Optimizing surgical readiness and recovery in anterior cruciate ligament reconstruction: A narrative review

Eligibility criteria

Articles were considered eligible when they discussed ACL injury, ACL reconstruction, pre-operative rehabilitation, post-operative rehabilitation, return-to-sport criteria, quadriceps strength, ROM, neuromuscular control, or complications relevant to ACL reconstruction. Clinical reviews, consensus statements, clinical commentaries, systematic reviews, cohort studies, and relevant foundational biomechanical or rehabilitation studies were included. Articles not focused on ACL reconstruction preparation or rehabilitation were excluded.

Information sources

The literature used for this narrative review was identified from biomedical databases and reference lists, with emphasis on PubMed-indexed orthopaedic, sports medicine, rehabilitation, and arthroscopy literature. The manuscript prioritized recent and clinically relevant evidence while retaining older foundational studies when they supported key rehabilitation principles.

Search

A representative PubMed search strategy was: (anterior cruciate ligament OR ACL) AND (reconstruction OR repair) AND (prehabilitation OR pre-operative rehabilitation OR post-operative rehabilitation OR return to sport OR quadriceps strength OR neuromuscular control). Additional terms included knee stability, ROM, arthrofibrosis, effusion, and criterion-based rehabilitation.

Study selection

Titles, abstracts, and full texts were screened for relevance to pre-operative and post-operative preparation for ACL reconstruction. Studies were selected when they contributed clinically applicable information to diagnosis, surgical preparation, prehabilitation goals, post-operative phases, strength progression, or return-to-sport decision-making. Because this is a narrative review, a formal Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram and meta-analysis were not performed.

Data collection process

Data were extracted narratively from included sources and organized into clinically relevant themes: ACL anatomy and injury mechanism, ACL reconstruction principles, pre- operative preparation, post-operative rehabilitation phases, and return-to-sport readiness.

Data items

Extracted variables included target population, intervention type, pre-operative goals, rehabilitation phase, weight- bearing and range-of-motion guidance, strengthening parameters, neuromuscular-control measures, functional testing, complications, and return-to-sport criteria.

Risk of bias in individual studies

A formal risk-of-bias assessment was not performed because the article was designed as a narrative review. The strength of evidence was interpreted qualitatively according to study design, clinical relevance, consistency of findings, and agreement with consensus recommendations.

ACL injury and reconstruction principles

The ACL stabilizes the knee by resisting anterior tibial translation and contributing to rotational control. Injury commonly occurs during pivoting, cutting, deceleration, or landing activities and may be associated with meniscal or chondral damage. Diagnosis relies on history, examination, tests such as Lachman, anterior drawer, and pivot-shift testing, and magnetic resonance imaging to confirm the tear pattern and associated pathology [Figure 1]. ACL reconstruction is generally considered for complete rupture with functional instability, young or high-demand patients, selected partial tears with instability, and cases in which activity modification is impractical. Surgical goals [Figure 2] are to restore anterior and rotational stability, protect the meniscus and cartilage, and support return to desired activity while minimizing stiffness and complications.^{[1,2,5,6,8-12]}

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Figure 1: Schematic illustration of the anteromedial and posterolateral bundles of the anterior cruciate ligament. PL: Posterolateral, AM: Anteromedial.

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Figure 2: Arthroscopic anterior cruciate ligament (ACL) reconstruction showing graft placement and fixation principles.

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Graft selection and rehabilitation implications

Graft choice should be individualized because each graft has advantages, limitations, and donor-site considerations. Bone-patellar tendon-bone (BPTB), hamstring tendon (HT), quadriceps tendon (QT), allograft, and selected alternatives such as peroneus longus tendon (PLT) may be considered according to patient age, sport demand, occupation, kneeling requirement, baseline symptoms, graft size, surgeon experience, and concomitant pathology. Recent studies support individualized decision-making: HT and BPTB autografts have shown comparable short-term clinical and functional outcomes, hamstring graft diameter may vary and affect planning, accelerated rehabilitation evidence remains heterogeneous, and PLT may provide comparable knee stability with acceptable donor-site recovery in selected high- demand patients.^[13-21]

Rehabilitation should account for graft-specific morbidity without abandoning common ACL principles. BPTB grafts require monitoring for anterior knee pain, kneeling pain, patellofemoral symptoms, and quadriceps inhibition. HT grafts require progressive hamstring and posterior-chain strengthening before sprinting, cutting, and deceleration. QT grafts require focused quadriceps activation, knee-extension strength recovery, and attention to extensor-mechanism symptoms. Allografts require caution in young- or high-demand patients because of incorporation and failure concerns, and PLT grafts require assessment of ankle strength and donor-site symptoms.^[13-21]

Pre-operative preparation

Prehabilitation should begin after diagnosis and aims to create a quiet, mobile, and strong knee before reconstruction. Core goals are reduction of pain and effusion, restoration of full passive and active ROM, especially full extension, normalization of gait, quadriceps activation, and ideally at least 90% quadriceps strength symmetry before surgery. Exercises commonly include range-of-motion work, quadriceps sets, straight-leg raises, heel slides, progressive closed-chain strengthening, balance training, and neuromuscular control [Supplementary Table]. Psychological readiness, self-efficacy, patient education, and communication among the surgeon, rehabilitation clinician, and patient are also important because they influence adherence and functional recovery.^[12,22-28]

Post-operative rehabilitation

Post-operative rehabilitation should be progressive and criterion-based. Early rehabilitation focuses on graft protection, pain and effusion control, full extension, progressive flexion, patellar mobility, quadriceps activation, and non-antalgic gait. Weight-bearing and bracing are adjusted according to graft type, fixation, surgeon preference, and concomitant meniscal or chondral procedures. Progression should be delayed when swelling, pain, extension loss, or poor quadriceps control persists.^[20,29-34]

The middle phases emphasize endurance, strength, neuromuscular control, and movement quality. Training progresses from bilateral to unilateral tasks, low-load endurance work to heavier strengthening, and controlled patterns to more complex functional tasks. Running is generally introduced only when pain and effusion are minimal, ROM is near symmetric, gait is normalized, and objective strength criteria are acceptable. Later rehabilitation adds plyometrics, agility, acceleration, deceleration, change- of-direction drills, and sport-specific tasks while maintaining strength work.^{[20,29,34-39]}

Return to sport should not be based on time alone. A shared decision among the patient, surgeon, and therapist should consider graft type, concomitant procedures, sport demand, psychological readiness, strength symmetry, hop performance, movement quality, swelling response, and confidence. Commonly used benchmarks include quadriceps and hamstring strength symmetry, limb symmetry on hop tests, balance and movement-quality testing, absence of effusion, full ROM, and sport-specific tolerance.^{[20,29,34,37-39]}

Limitations

This narrative review did not include a formal meta-analysis or risk-of-bias scoring. The included evidence varies in design, rehabilitation exposure, follow-up duration, and outcome definitions; therefore, recommendations should be interpreted as a clinically oriented synthesis rather than protocol-level proof.