Anterior Cruciate Ligament Rehabilitation for the 10- to 18-Year-Old Adolescent Athlete: Practice Guidelines Based on International Delphi Consensus
Authors: van Melick Nicky , Dietvorst Martijn , van Oort Maaike I.A.M. , Claessens Remco L.A. , Janssen Rob P.A. , Bogie Rob ,   the Adolescent ACL Rehabilitation Group, Claussen William , Greenberg Elliot M. , Grindem Hege , Kearney Sharon , van Keulen Matthijs , Lips Martijn , Macrina Lenny , McWilliam David , Moksnes Håvard , Norris Richard , Paterno Mark V. , Picot Brice , Piskulic David , Prato Luis F. , Sayer Timothy A. , Sethi Faraz , Silvers-Granelli Holly , Truong Linda , Whalan Matthew , Witvrouw Erik 
Published: July 2023

Background:

There are 2 treatment options for adolescent athletes with anterior cruciate ligament (ACL) injuries—rehabilitation alone (nonsurgical treatment) or ACL reconstruction plus rehabilitation. However, there is no clear consensus on how to include strength and neuromuscular training during each phase of rehabilitation.

Purpose:

To develop a practical consensus for adolescent ACL rehabilitation to help provide care to this age group using an international Delphi panel.

Study Design:

Consensus statement.

Methods:

A 3-round online international Delphi consensus study was conducted. A mix of open and closed literature-based statements were formulated and sent out to an international panel of 20 ACL rehabilitation experts. Statements were divided into 3 domains as follows: (1) nonsurgical rehabilitation; (2) prehabilitation; and (3) postoperative rehabilitation. Consensus was defined as 70% agreement between panel members.

Results:

Panel members agreed that rehabilitation should consist of 3 criterion-based phases, with continued injury prevention serving as a fourth phase. They also reached a consensus on rehabilitation being different for 10- to 16-year-olds compared with 17- and 18-year-olds, with a need to distinguish between prepubertal (Tanner stage 1) and mid- to postpubertal (Tanner stages 2-5) athletes. The panel members reached a consensus on the following topics: educational topics during rehabilitation; psychological interventions during rehabilitation; additional consultation of the orthopaedic surgeon; duration of postoperative rehabilitation; exercises during phase 1 of nonsurgical and postoperative rehabilitation; criteria for progression from phase 1 to phase 2; resistance training during phase 2; jumping exercises during phase 2; criteria for progression from phase 2 to phase 3; and criteria for return to sports (RTS). The most notable differences in recommendations for prepubertal compared with mid- to postpubertal athletes were described for resistance training and RTS criteria.

Conclusion:

Together with available evidence, this international Delphi statement provides a framework based on expert consensus and describes a practice guideline for adolescent ACL rehabilitation, which can be used in day-to-day practice. This is an important step toward reducing practice inconsistencies, improving the quality of rehabilitation after adolescent ACL injuries, and closing the evidence-practice gap while waiting for further studies to provide clarity.