REF-1664 · van Melick et al., 2016 · British Journal of Sports Medicine, · Paper · PubMed

The Dutch physiotherapy guideline for rehabilitation after ACL reconstruction, built on 90 studies and multidisciplinary consensus, sets a prehabilitation phase and then three phases each entered on criteria (impairment-based, sport-specific training, return to play), with strength, hop, movement-quality and psychological tests guiding each step and postoperative rehabilitation lasting 9-12 months

Main caveat: The quality and grading of the 90 studies are not reported in the abstract, so how much of each recommendation rests on consensus is unknown.
moderate evidenceMeasured on a mixed groupRead from the abstract only

The Royal Dutch Society for Physical Therapy (KNGF) asked a multidisciplinary group of Dutch ACL experts for an evidence statement on rehabilitation after ACL reconstruction.

A working group and a steering group searched MEDLINE and the Cochrane Library over January 1990 to June 2015 for meta-analyses, systematic reviews, randomised trials and prospective cohorts, and wrote the guideline.

A study had to address one of nine set topics: preoperative predictors of outcome after surgery, the effectiveness of physical therapy, open versus closed kinetic chain quadriceps exercise, strength and neuromuscular training, electrostimulation and EMG feedback, cryotherapy, measures of functional performance, return to play, and the risk of reinjury.

Ninety studies formed the basis of the statement. The guideline recommends a prehabilitation phase before surgery and three postoperative phases, each entered on criteria: impairment-based, sport-specific training, and return to play. Moving from one stage to the next should be guided by strength and hop tests together with tests of movement quality and psychological tests.

Rehabilitation after surgery should last 9-12 months, and a test battery of strength tests, hop tests and movement quality should be used to judge readiness to return to play and the risk of reinjury.

Participants

Not in the abstract: the number, sex and sports of the people in the 90 included studies. The guideline addresses patients after ACL injury and reconstruction.

Methods

Commissioned by the KNGF; a multidisciplinary working group and a steering group reviewed the literature and wrote the guideline.
Search: MEDLINE and the Cochrane Library, January 1990 to June 2015.
Designs: meta-analyses, systematic reviews, randomised controlled trials, prospective cohort studies.
Inclusion: one of 9 predetermined clinical topics (listed in the Summary).
Included: 90 studies.
Quality assessment and evidence grading: not reported in the abstract. Recommendations combine the evidence with expert consensus.

Key Results

ElementRecommendation, per the abstract
StructurePrehabilitation, then 3 criterion-based postoperative phases: impairment-based; sport-specific training; return to play
Moving between phasesA battery of strength and hop tests, movement quality and psychological tests
DurationPostoperative rehabilitation 9-12 months
Return to play and reinjury riskA test battery: strength tests, hop tests, movement quality

Practical Application

Expect rehabilitation after ACL reconstruction to take most of a year, with tests, not the calendar, moving the athlete on. The guideline sets 9-12 months of postoperative rehabilitation in phases entered on criteria. The physiotherapist runs the tests and decides each step, the surgeon and physiotherapist decide the return, and the assistant builds the endurance plan around their decisions; it does not diagnose or set phases.
Rehabilitation starts before surgery. The guideline includes a prehabilitation phase. Inference, not tested here: an athlete waiting for surgery can ask the physiotherapist what to do in that phase rather than simply stopping.
Inference, not tested here: 9-12 months covers most of a season, so race goals in that window are provisional and set with the physiotherapist; sport-specific work returns in the second phase, on the physiotherapist's call.
Not settled by this design / not from this paper: test thresholds, exercise doses, how the evidence was graded (not in the abstract), and how to combine rehabilitation with endurance training.

Limitations

The quality and grading of the 90 studies are not reported in the abstract, so how much of each recommendation rests on consensus is unknown.
Literature to June 2015; later work, including the Aspetar guideline (REF-1663), is newer.
The abstract gives no test thresholds, doses or criterion values.
Written from the abstract and the PubMed record; full text not read.
How this entry was checked and changed
Why this level

risk of bias not read (abstract only): a guideline built on a systematic review, but the abstract reports no quality or certainty assessment of the 90 studies, and the rubric's A for a guideline needs a graded review read in full

Content correction 2026-11-07
2026-11-07: added from the abstract and the PubMed record; level B+ (guideline built on a systematic review; risk of bias not read, abstract only).