REF-1663 · Kotsifaki et al., 2023 · British Journal of Sports Medicine, · Paper · PubMed

The Aspetar guideline on rehabilitation after ACL reconstruction makes exercise the core of rehabilitation and physical therapy modalities an early adjunct for pain, swelling and lost range of motion, but finds little evidence on how much exercise is needed, no evidence on which criteria should govern progression, return to running or discharge, and very low certainty for most components; most recommendations were agreed by expert clinicians

Main caveat: Read from the abstract only: the recommendations, their GRADE ratings, the trials reviewed and their risk of bias are not in it.
moderate evidenceMeasured on a mixed groupRead from the abstract only

Kotsifaki and colleagues at Aspetar wrote a clinical practice guideline for rehabilitation after reconstruction of the anterior cruciate ligament (ACLR), following the AGREE II appraisal instrument and grading the evidence with GRADE.

A Guideline Development Group searched for and reviewed randomised clinical trials and systematic reviews on the interventions available to a physiotherapist, alone or combined, such as exercise, physical therapy modalities and objective progression criteria, to guide what an optimal rehabilitation protocol should contain.

Exercise came out as the mainstay of rehabilitation, but evidence on how the volume or intensity of exercise relates to outcomes was scarce. Modalities can help in the early phase, while pain, swelling and restricted range of motion are present, and adding them may let exercise start earlier without pain.

Return to running and return to training or activity are key milestones, yet there is no evidence on which criteria should decide progression or discharge. Certainty was very low for most components of rehabilitation, and most recommendations were agreed by expert clinicians.

The authors add that the guideline raises several elements of ACLR management not reported before; the abstract does not name them.

Participants

Not in the abstract: the number of trials and reviews, the number, sex and sports of the patients in them. The guideline addresses patients in rehabilitation after ACL reconstruction.

Methods

Development to the AGREE II instrument; evidence graded with GRADE.
Guideline Development Group; systematic search and review of randomised clinical trials and systematic reviews.
Question: the effectiveness of rehabilitation interventions available to the physiotherapist, alone or in combination (for example exercise, modalities, objective progression criteria).
Not in the abstract: databases, dates, number of studies, risk-of-bias results.
Certainty: very low for most components (abstract). Recommendations: mostly agreed by expert clinicians.

Key Results

Exercise: the mainstay of rehabilitation after ACLR; little evidence on the dose-response relation between exercise volume or intensity and outcomes.
Physical therapy modalities: helpful as an adjunct in the early phase, when pain, swelling and limited range of motion are present; adding them early may allow exercise to start earlier without pain.
Return to running and to training or activity: key milestones; no evidence on which progression or discharge criteria to use.
Certainty: very low for most components; most recommendations agreed by expert clinicians.
Several new elements of ACLR management are highlighted (not named in the abstract).

Practical Application

After ACL reconstruction the physiotherapist's exercise programme is the treatment; the assistant fits endurance training around it and does not change it. The guideline makes exercise the mainstay, and the surgeon and physiotherapist decide its content, its progression and when running or training return. The assistant does not diagnose, set milestones or override the rehabilitation plan.
There is no well-tested dose or test threshold to copy. The guideline found little evidence on how much exercise is needed and none on which criteria should gate return to running or discharge; the numbers an athlete is given (sessions a week, strength targets, weeks to running) are the clinician's prescription, with little or no trial evidence behind them (inference from the abstract).
Early on, pain, swelling and lost range of motion are the signals. Modalities are an early adjunct for them. Inference, not tested here: in an endurance plan, a session that raises pain or swelling goes back to the physiotherapist before it is repeated.
Inference, not tested here: stationary cycling is a common early carrier of aerobic work and strained the ACL little in a laboratory study of patients' own ligaments, not grafts (REF-1666); the start date and limits on the bike come from the surgeon and physiotherapist.
Not settled by this design / not from this paper: the guideline's specific recommendations, criteria and timelines (not in the abstract), how to combine rehabilitation with endurance training, and care without surgery.

Limitations

Read from the abstract only: the recommendations, their GRADE ratings, the trials reviewed and their risk of bias are not in it.
Very low certainty for most components; most recommendations were agreed by expert clinicians.
Physiotherapy-led rehabilitation after reconstruction; care without surgery and endurance-specific questions are outside its scope as the abstract describes it.
Written from the abstract and the PubMed record; full text not read.
How this entry was checked and changed
Why this level

capped, full text not read (abstract only): a guideline built on a GRADE-assessed systematic review reaches A only when read in full; the abstract itself reports very low certainty for most components and says most recommendations were agreed by expert clinicians

Content correction 2026-11-07
2026-11-07: added from the abstract and the PubMed record; level B+ (guideline built on a GRADE-assessed systematic review, read from the abstract only).