Reproducibility of the reporting of post-operative anterior cruciate ligament reconstruction rehabilitation programmes: a scoping review v1
Authors: Nutarelli Sebastiano , Van Dyk Nicol 
Published: May 2024

Rupture of the anterior cruciate ligament (ACL), the primary stabilizing ligament of the knee joint, is one of the most significant problems in orthopaedic sports medicine with an annual incidence of 71 to 91 per 100,000 persons reported in some European Union (EU) countries (Granan et al, 2009). Taking the population of the EU countries as 500,000,000 the annual incidence of ACL ruptures equates to approximately 450,000 per year in the EU, with an associated approximate direct medical cost of > €4 billion. This cost estimate does not take into account further economic sequelae such as lost productivity and medical costs associated with the development of post-traumatic knee joint osteoarthritis (OA). For athletes aiming to return-to-sport after ACL rupture, ACL reconstruction (ACL-R) is the recommended treatment of choice. The aim of ACL-R is to maximise the stability and functional capacity of the ACL-deficient knee, with an objective of facilitating return-to-sport. Clearance for return-to-sport indicates the medical team’s confidence in the athlete’s ability to participate in sporting activities that place large demands on knee joint sensorimotor control. However, the prevalence of ACL re-ruptures following primary ACL-R is increasing worldwide (Wright et al, 2011; Ratzlaff et al, 2010) with a prevalence of 6% to 25% being reported (Myklebust et al, 1997; Grassi et al., 2017). A conservative estimate of a re-rupture rate of 11.5% this would mean that there would be > 40,000 ACL re-ruptures per year in the EU, equating to an annual direct operative cost of €400,000,000. Surgical intervention and postoperative rehabilitation program concur to the final outcome following ACL-R, therefore they should both be evaluated. While details of different surgical ACL-R procedures and grafts options have been extensively described and weighted in the literature, postoperative rehabilitation protocols are poorly described; their actual level of replicability is unclear. Physical therapy following ACL-R is key to re-establish the pre-operative functional abilities and recover from the insult to the whole joint and lower limb complex associated with the combination of the initial injury and surgical procedure. This takes place with a peculiar neuromuscular control re-training, regaining the different muscle strength sub-components, functional stability, balance, psychological readiness through repetitively practicing sports-specific/athletic movements in a progressive ecologically valid environment, and testing for return to sport to eventually minimize the risk for re-injury. Regardless the recognized pivotal role of post-surgical rehabilitation, yet paradoxically there is no universally accepted rehabilitation paradigm following ACL-R which pinpoints the cornerstones of such a long and crucial journey. Despite multiple publications on this topic, studies are characterized by an average poor level of reporting possibly invalidating the possibility to replicate programs. The aggregation of data on this topic could establish whether there’s a sufficient and consistent level of evidence to guide practicing clinicians in replicating a postoperative rehabilitation protocol for patients following ACL-R or there’s need for further and more solid clinical research in order to empower clinicians to implement a solid Evidence-Based Practice after ACL-R. The study protocol (PRISMA-P) and a protocol table following Arksey & O’Malley (2005) and Levac et al (2010) have been completed.