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Contents lists available at ScienceDirect

Journal of Science and Medicine in Sport

journal homepage: www.elsevier.com/locate/jsams

Review

Intensive supervised rehabilitation versus less supervised

rehabilitation following anterior cruciate ligament reconstruction? A
systematic review and meta-analysis
Andrew R. Gamble a,∗ , Evangelos Pappas a , Mary O’Keeffe b,c , Giovanni Ferreira b ,
Christopher G. Maher b , Joshua R. Zadro b
a
Discipline of Physiotherapy, Faculty of Medicine and Health, The University of Sydney, Australia
b
Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Australia
c
School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Ireland

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: To investigate whether intensive supervised rehabilitation following ACL reconstruction leads
Received 29 October 2020 to superior self-reported function and sports participation compared to less supervised rehabilitation.
Received in revised form 1 March 2021 Design: Systematic review and meta-analysis.
Accepted 3 March 2021
Methods: We included randomised controlled trials (RCTs) comparing supervised rehabilitation to
Available online xxx
rehabilitation with a similar protocol that used less supervised sessions for athletes following ACL recon-
struction. Two reviewers independently screened studies and extracted data. The Physiotherapy Evidence
Keywords:
Database (PEDro) scale was used to evaluate methodological quality and GRADE to evaluate overall qual-
Rehabilitation
Function
ity of evidence. Self-reported function and sports participation were the primary outcomes. Data were
Remote pooled using random effects meta-analyses.
Home Results: Our search retrieved 4075 articles. Seven articles reporting on six RCTs were included (n = 353).
Supervision Very-low to low-certainty evidence suggests intensive supervised rehabilitation is not superior to less
ACL surgery supervised rehabilitation following ACL reconstruction for improving self-reported function, sports par-
ticipation, knee flexor and extensor strength, range of motion, sagittal plane knee laxity, single leg hop
performance, or quality of life.
Conclusion: Based on uncertain evidence, intensive supervised rehabilitation is not superior to less super-
vised rehabilitation for athletes following ACL reconstruction. Although high-quality RCTs are needed to
provide more certain evidence, clinicians should engage athletes in shared decision making to ensure
athletes’ rehabilitation decisions align with current evidence on supervised rehabilitation as well as their
preferences and values.
© 2021 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

Practical implications • There is a need for large, high-quality randomised controlled

• Physiotherapists managing athletes following ACL reconstruc-
tion could focus less on regular supervised sessions and more
on education to support independence with rehabilitation.
• Physiotherapists could provide supervised sessions on an ‘as
needed’ basis to ensure athletes are competent performing their
exercises independently and are able to identify “warning signs”
of inappropriate rehabilitation such as poor progress, loss of
range of motion or substantial knee joint edema after activity.
∗ Corresponding author.
E-mail address: Andrew@lifestylephysio.com.au (A.R. Gamble).
trials implementing progressive rehabilitation protocols to inves-
tigate the value of intensive supervised rehabilitation following
ACL reconstruction.
1. Introduction
The anterior cruciate ligament (ACL) is one of the most fre-
quently injured knee ligaments.1 Most ACL ruptures occur during
non-contact cutting and change of direction movements in sport.2
The annual incidence of ACL ruptures is estimated at 68.6 per
100,000 person-years in the United States1 with females at 2–10
times higher risk of rupturing their ACL during pivoting and cut-
ting sports (e.g. basketball, football) compared to males.3 ACL

https://doi.org/10.1016/j.jsams.2021.03.003
1440-2440/© 2021 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

Please cite this article as: Gamble AR, et al,Intensive supervised rehabilitation versus less supervised rehabilitation following anterior
cruciate ligament reconstruction? A systematic review and meta-analysis, J Sci Med Sport, https://doi.org/10.1016/j.jsams.2021.03.003
G Model
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A.R. Gamble et al.
reconstruction surgery followed by rehabilitation is recommended
for most athletes wishing to return to sport, particularly athletes
involved in sports that require pivoting and cutting.4 Although
there is evidence that some athletes can return to sport without
surgery following an ACL rupture,5 the use of ACL reconstruction
continues to rise.3 Following ACL reconstruction, 65% of athletes
will return to their pre-injury level of sports participation and 1 in
4 of those who return to sport will experience a subsequent ACL
rupture.6
Rehabilitation following ACL reconstruction aims to return ath-
letes to their previous level of function and sports participation
while reducing the risk of re-injury. Maximising strength, func-
tional performance, and addressing psychological factors such as
fear of re-injury are key targets of rehabilitation.7 Achieving the
right balance between training and rest during rehabilitation is also
important because both under- and over-loading may increase the
risk of injury.8 Guidelines recommend using a battery of tests to
ensure important deficits in strength and functional performance
are addressed.9 For example, achieving >90% of quadriceps strength
and single leg hop performance compared to the unaffected limb
(i.e. Limb Symmetry Index, LSI > 90%) can reduce the risk of re-injury
by 84%.10
There is currently no consensus on the ‘best’ rehabilitation
protocol. Many aspects of rehabilitation are of unknown value,
such as the need for intensive supervision by a health profes-
sional. Numerous randomised controlled trials and systematic
reviews have demonstrated that intensive supervised rehabilita-
tion is not superior to less supervised or primarily home-based
rehabilitation for a range of orthopaedic and musculoskeletal pre-
sentations, including post-lumbar disc surgery,11 post-knee12 and
hip arthroplasty,13 and rotator cuff tendinopathy.14 A systematic
review by Papalia et al. – the most recent review on this topic –
found that intensive supervised rehabilitation was not superior to
less supervised rehabilitation following various knee operations,
including ACL reconstruction.15 However, several methodological
issues with this review warranted an update of the evidence on
this topic (specifically following ACL reconstruction). The review
by Papalia et al.15 did not use meta-analysis, did not evaluate the
overall quality of the evidence (e.g. using the GRADE approach), it
included non-randomised trials (which is inappropriate for assess-
ing the effectiveness of interventions as per Cochrane guidelines16 ),
and only provided a brief description of the rehabilitation protocols.
The aim of this systematic review was to investigate whether
intensive supervised rehabilitation following ACL reconstruction
leads to superior self-reported function, sports participation and
various secondary outcomes (strength, range of motion, sagittal
plane knee laxity, single leg hop performance and quality of life)
compared to less supervised rehabilitation.
2. Methods
2.1. Protocol and registration
This systematic review was prospectively registered on PROS-
PERO (CRD42020163007) and conducted in accordance with the
PRISMA statement17 and AMSTAR-2 checklist (Appendix A). Two
deviations from the protocol were made. We did not restrict par-
ticipants’ age to 16 years and older as we wanted to capture all
trials on this topic. We used the Physiotherapy Evidence Database
(PEDro) scale to assess risk of bias instead of the Cochrane Risk of
Bias tool as the authors had more experience using the PEDro scale.
2.2. Study selection
We only included randomised controlled trials (RCTs).
2
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We included trials enrolling recreational and elite athletes aged
15 years or older following ACL reconstruction.
The included trials had to compare two post-operative rehabil-
itation protocols that only differed by the number of supervised
(or clinic-based) sessions athletes received. The protocol that had
fewer number of supervised sessions was defined as ‘less super-
vised rehabilitation’. Trials evaluating rehabilitation protocols with
the same number of supervised sessions or evaluating rehabili-
tation protocols with different intervention parameters between
groups (e.g. type of exercises, intensity, duration) were excluded.
Self-reported knee function (e.g. Lysholm scale) and sports
participation (e.g. Tegner scale) were our primary outcomes. Sec-
ondary outcomes included knee muscle strength (e.g. assessed
isometrically, eccentrically or concentrically using a dynamome-
ter), knee flexion and extension range of motion, sagittal knee plane
laxity (e.g. assessed using an arthrometer), single leg hop perfor-
mance (e.g. assessed using the LSI for single leg hop for maximum
distance, single leg timed hop for 6 m and single leg vertical hop for
maximum height), and quality of life.
2.3. Data sources and searches
The following electronic databases and clinical trial registries
were searched using terms synonymous with “ACL”, “surgery” and
“rehabilitation” from the earliest record to April 2020: MEDLINE,
Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE,
CINAHL, SPORTDiscuss, Scopus Web of Science, ClinicalTrials.gov,
The Australian New Zealand Clinical Trials Registry (ANZCTR)
(www.anzctr.org.au) and The World Health Organisation (WHO)
International Clinical Trials Registry Platform (ICTRP) (https://apps.
who.int/trialsearch/). Our search strategy is in Appendix B. Two
researchers (AG and JZ) independently performed the selection
of studies by screening titles and abstracts, followed by full-text
articles according to the inclusion criteria. All disagreements were
resolved by discussion. To ensure no eligible trials were missed
from the above searches, these authors hand-searched reference
lists of included trials and relevant reviews,15,18 performed cita-
tion tracking, and contacted investigators known to be involved in
trials that were yet to be published.
2.4. Data extraction and quality assessment
Using a standardised data collection form, two researchers (AG
and JZ) independently extracted data on trial characteristics (e.g.
setting, country, sample size, intervention, comparison) and out-
come measures (i.e. baseline and follow-up time points) for each
trial. Disagreements were resolved by discussion and re-checking
the trial report. Intervention details were extracted according to the
TIDieR checklist (see Appendix C).19 We extracted four time points
for outcome data in this review: up to 3 months post-operatively
(or time point closest to 3 months), 3–6 months (or time point clos-
est to 6 months), 6–12 months (or time point closest to 12 months)
and >12 months (or last time point beyond 12 months). When rele-
vant outcome data was missing, we extracted data from published
plots using WebPlotDigitizer (version 4.1) and contacted authors
to clarify if needed.
Methodological quality was assessed using the PEDro scale
(0−10, where higher scores indicate higher methodological
quality). Trials indexed in PEDro are independently rated for
methodological quality by two trained evaluators, with a third eval-
uator arbitrating any disagreements. We extracted these scores for
each trial report from PEDro (https://www.pedro.org.au/).20 Trials
scoring ≥7 were considered to have high methodological quality.
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2.5. Data synthesis and analysis
All outcome data were converted to mean (SD) and entered in
Review Manager (version 5.3) for analysis. Outcome data expressed
using mean (range), median (interquartile range, IQR) and median
(range) were converted to mean (standard deviation, SD) using the
calculator by Wan et al.21 Standard errors (SE) were converted to
SD using the Review Manager calculator.22 For studies that did not
report a SD and it could not be calculated using the above methods,
we used the SD from the trial with the highest PEDro score in that
analysis (in accordance with Cochrane).16 If two or more trials had
identical PEDro scores, we took the SD from the trial with the largest
sample size.
We used random effects meta-analyses to summarise the mean
intervention effect of intensive supervised rehabilitation (rela-
tive to less supervised rehabilitation) on self-reported function,
sports participation and all secondary outcomes. Two measures
of self-reported function were assessed by trials in our review:
the Lysholm score and International Knee Documenting Commit-
tee (IKDC) score. We only pooled data using the Lysholm score
because it was reported in more trials than the IKDC score and no
trial reported the IKDC score without reporting a Lysholm score.
Based on previous research, we defined the minimally important
clinical difference (MCID) as 10 on a 0−100 scale for the Lysholm
score.23 Pooled estimates were reported using weighted mean
difference (MD) and 95% confidence intervals (CI). Heterogeneity
was assessed using the I2 statistic and interpreted as follows: (a)
0–40%, unlikely to be important heterogeneity; (b) 30–60%, mod-
erate heterogeneity; (c) 50–90%, substantial heterogeneity; and
(d) 75–100%, considerable heterogeneity.24 Since no meta-analysis
included more than 10 trials, we did not assess publication bias.
We were unable to perform a sensitivity analysis restricted to tri-
als with high methodological quality (i.e. PEDro score ≥7) because
only one trial had high methodological quality.25 Due to a limited
number of trials, we were unable to perform sub-group analy-
ses investigating whether trial characteristics influenced our main
findings.
The Grading of Recommendations Assessment, Development
and Evaluation (GRADE) approach was used to evaluate the over-
all quality of evidence and strength of recommendations.26 Quality
of evidence was rated as high, moderate, low, or very low. Quality
of evidence started at “high” (due to the inclusion of RCTs only)
and was downgraded for each of the following issues encountered:
limitations in the study design, imprecision, inconsistency, indi-
rectness, and publication bias. Quality of evidence was downgraded
by one level if the limitation was judged as ‘serious’ or by two levels
if it was judged as ‘very serious’. Criteria on how we judged each
domain are available in Appendix D.
2.6. Role of the funding source
The authors received no funding for conducting this review.
3. Results
3.1. Search results
Our database searches retrieved 4075 articles. After removing
duplicates and screening titles and abstracts, we reviewed the full
text of 30 articles (Fig. 1). Seven articles reporting on six two-arm
RCTs were included (n = 353 participants). A list of excluded arti-
cles is in Appendix E. The findings of one Canadian-based trial was
reported as a 3 month25 and 2−4-year follow-up.27 Across the six
trials, the mean age of participants ranged from 15 to 48 years old,
3
Journal of Science and Medicine in Sport xxx (xxxx) xxx–xxx
the percentage of females from 19 to 48%, and the sample size was
26−145.
3.2. Trial characteristics
The included trials were conducted in the United States
(n = 2),28,29 Canada (n = 1),25 Australia (n = 1),30 United Kingdom
(n = 1),31 and Sweden (n = 1).32 Three trials reported funding,25,29,31
while three reported no funding28,30,32 (Appendix F).
3.2.1. ACL reconstruction details
Time from ACL rupture to reconstruction was a minimum of
6 weeks in two trials,25,28 less than 3 months in two trials,30,32
and between 12 and 132 months in one trial.31 One trial did
not report time since ACL rupture for participants.29 ACL graft
types included bone-patella tendon-bone autograft (n = 3),25,29,31
bone-patella tendon-bone, not specified as autograft or allograft
(n = 1),30 bone-patella tendon-bone autograft or allograft (n = 1),28
bone-patella tendon-bone or semitendinosus autograft (n = 1)32
(Appendix F).
3.2.2. Setting
Participants saw a physiotherapist at an outpatient orthopaedic
clinic in two trials,31,32 an outpatient physical therapy department
in one trial,30 a University physical therapy clinic in one trial29
and a University sports medicine clinic in one trial.25 One trial
did not provide details on the setting.28 In four trials,29–32 partici-
pants in both groups (i.e. intensive vs. less supervised groups) were
seen by the same physiotherapist. In one trial,25 participants in the
intensive supervised group were able to choose their own physio-
therapist, while participants in the less supervised group saw the
same physiotherapist at a University sports medicine clinic. One
trial did not specify whether participants in the intensive super-
vised and less supervised groups saw the same physiotherapist28
(Appendix F).
3.2.3. Rehabilitation protocols
Duration of prescribed rehabilitation for both the intensive and
less supervised groups was 6 weeks in one trial, 29 3 months
in one trial,25 6 months in three trials,28,31,32 and 9 months in
one trial.30 Rehabilitation began immediately post-operatively in
five trials.25,29–32 One trial did not specify when rehabilitation
commenced.28 Rehabilitation protocols were largely comparable
across trials. All protocols transitioned participants through range
of motion exercises, aerobic exercises, muscle strengthening exer-
cises (with increasing range of motion and stability demands) and
sport-specific activities (Appendix F).
3.2.4. Level of supervision
Level of supervision (i.e. the number of supervised sessions)
was the only difference in rehabilitation protocols between groups
in each trial. Four trials provided participants in the intensive
supervised group a greater number of one-on-one physiotherapy
sessions to differentiate between the intensive and less supervised
protocols.25,28–30 The mean (SD) total number of physiotherapy
sessions in the intensive vs. less supervised group was 14.4 vs. 2.85
(no SD) visits over 6 weeks in one trial,29 14 (1) vs. 3 (1) visits over
3 months in one trial,25 19.9 vs. 5 (no SD) over 6 months in one
trial, 28 and 18 vs. 4 (no SD) visits over 9 months in one trial.30
Two trials provided participants in the intensive supervised group
an additional supervised exercise class to differentiate between the
intensive and less supervised protocols.31,32 One trial implemented
the exercise class at 4–6 weeks post-operatively and provided
participants in the intensive supervised group an additional 24
supervised sessions,31 and one implemented the exercise class at
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Fig. 1. PRISMA flow diagram.
6 weeks post-operatively and provided participants in the inten-
sive supervised group with 13–36 additional supervised sessions.32
The exercise class ran until 6 months post-operatively in both trials
(Appendix F).
3.2.5. Outcomes
To assess self-reported function, five trials used the Lysholm
Scale28–32 and two used the IKDC.31,32 One trial measured func-
tion using the Lysholm Scale showing no significant difference
between groups at 12 months but did not report the preoper-
ative data or SD.29 Three trials used the Tegner scale to assess
sports participation.30–32 Knee flexion and extension strength
were assessed in four trials.25,30–32 Two trials measured isometric
strength,30,32 three measured concentric strength,25,30,31 and one
measured eccentric strength30 using the LSI. Flexion and exten-
sion range of motion was assessed in three trials.25,28,32 One trial
measured flexion in supine (active assisted), extension in prone
(passive) and flexion and extension during walking using video-
analysis. 25 One trial measured active flexion without specifying
the position,28 and one measured active flexion and extension in
supine.32 Sagittal plane knee laxity was measured in three tri-
als using an arthrometer.25,29,31 One trial did not report mean
scores for laxity but reported graft failures (defined as side-to-side
differences in laxity of >4 mm).29 Three trials measured func-
tional performance using Limb Symmetry Index of single leg hop
tests.28,30,32 One trial reported that it measured hop testing but
their assessment method was not specified and they did not report
their results.28 Two trials measured single leg hop for maximum
distance,30,32 and one also measured single leg timed hop for 6 m
and single leg vertical hop for maximum height.30 For quality of
life, one trial used an ACL-specific measure of quality of life25 and
one used the Sickness Impact scale29 (Appendix F).
3.3. Methodological quality
PEDro scores ranged from 4 to 7 across the trials (Table 1). The
two articles by Grant et al. that report on the same trial had dif-
ferent PEDro scores (n = 7 and 4, respectively) and were considered
4
Journal of Science and Medicine in Sport xxx (xxxx) xxx–xxx
separately in this section.25,27 All trials used true randomization to
allocate participants to groups and reported point measures and
variability measures. Six trials reported between-group statisti-
cal comparisons,25,27,28,30–32 five blinded outcome assessors25,29–32
and five specified the eligibility criteria.25,28–30,32 Baseline charac-
teristics were similar between groups in three trials.25,27,30 Two
trials had low loss to follow up,28,29 two used intention to treat
analyses,25,31 and one used concealed allocation.25 No trial blinded
participants or therapists.
3.4. Effects of intervention
3.4.1. Primary outcomes
There was low-certainty evidence that intensive supervised
rehabilitation following ACL reconstruction did not improve self-
reported function compared to less supervised rehabilitation at 3
months (MD −1.24, 95% CI: −6.09 to 3.61; 3 trials, n = 114) and 3–6
months (MD 1.80, 95% CI: −0.91 to 4.50; 4 trials n = 149), and very-
low-certainty evidence at 6–12 months (MD −0.92, 95% CI: −3.73
to 1.88; 3 trials n = 114) (Table 2; Appendix G).
Similar results were found for sports participation, with low-
certainty evidence at 3 months (MD 0.50, 95% CI: −0.35 to 1.35; 1
trial n = 40), 3–6 months (MD 0.52, 95% CI: −0.01 to 1.04; 3 trials
n = 96), and 6–12 months (MD 0.91, 95% CI: −1.04 to 2.86; two trials
n = 77) (Table 2; Appendix H).
3.4.2. Secondary outcomes
Compared to less supervised rehabilitation, intensive super-
vised rehabilitation did not improve concentric, eccentric and
isometric knee extension (low-certainty; Appendix I–K) or flex-
ion strength (low-certainty; Appendix L–N), flexion (very-low to
low-certainty; Appendix O) and extension range of motion (low-
certainty; Appendix P), sagittal plane knee laxity (low-certainty;
Appendix Q), single leg hop for maximum distance (low-certainty;
Appendix R), single leg timed hop for 6 m (low-certainty; Appendix
S), single leg vertical hop for maximum height (low-certainty;
Appendix T) and quality of life (low-certainty; Appendix U) at any
time point, except for eccentric knee extension strength at 3–6
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months (low-certainty; Appendix K and Table 2). A summary of

129
21
53

88

37
37
40
the data entered in Review Manager (version 5.3) for each meta-

n
analysis is in Appendix V.
Total score
(/10)a 4. Discussion

5
4
7
4
5
4
4
measures and 4.1. Summary of main findings and key implications
Report point

Very-low to low-certainty evidence suggests there is no differ-

variability
measures

ence in self-reported function, sports participation, strength, range

100
Y of motion, sagittal plane knee laxity, single leg hop performance
Y
Y
Y
Y
Y
Y
or quality of life between athletes who have intensive supervised
comparisons

rehabilitation following ACL reconstruction and those who have

statistical

less supervised rehabilitation. This evidence is based on seven

between
-group
Report

small trials at high risk of bias which may not have implemented
86
N contemporary rehabilitation protocols. Although there is a need
Y
Y
Y
Y
Y
Y

for high-quality RCTs using progressive rehabilitation protocols to

treat analyses
Intention to

investigate the value of intensive supervised rehabilitation follow-

ing ACL reconstruction, these findings may have some potential
implications for how physiotherapists can approach the reha-
29
N

N
N
N
N
Y

bilitation of athletes following ACL reconstruction. For example,

instead of supervising the performance of all exercises, physiother-
Low loss to

apists may be able to offer supervised sessions on an ‘as needed’

follow-up

basis to ensure athletes are competent performing their exercises

independently and to identify “warning signs” of inappropriate
29
N

N
N
N
N
Y

rehabilitation such as slow progress, loss of range of motion or

substantial knee joint edema after activity.29
Blinding of

assessors
outcome

4.2. Strengths and limitations of this review

71
N

N
Y

Y
Y
Y

Key strengths of this review include that it was conducted

according to recommendations from PRISMA17 and Cochrane,16
Blinding of
therapists

fulfils most of the AMSTAR-2 criteria (Appendix A), and two review-
ers independently performed the selection of studies and extracted
n = number of participants included in meta-analysis; N: no; PEDro: Physiotherapy Evidence Database; Y: yes.

data. The main limitation is that our conclusions are based on very
N
N
N
N
N
N
N
0

low- to low-certainty evidence and 6 of the 7 included studies

had poor methodological quality (i.e. PEDro scores of 4 or 5 out
Blinding of
subjects

of 10). The RCTs included were small, likely underpowered and

poorly reported their rehabilitation protocols (see TIDieR checklist
N
N
N
N
N
N
N
0

in Appendix C). Key elements commonly not reported were compo-

nents of exercise volume and intensity (e.g. repetitions, sets, load,
stics similar
characteri-

rate of perceived excretion) and progression criteria. This makes

between
Baseline

groups

replication and comparison to evidence-based rehabilitation guide-

lines difficult.
43
N
N

N
N
Y
Y
Y

Other limitations include that only one study reported data on

Item one (‘eligibility criteria’) is not counted in the PEDro total score.

patients who had a hamstring graft which is by far the most popu-
Concealed
allocation

lar graft,33–36 and no trial investigated a home-exercise program

Physiotherapy Evidence Database scale score of included studies.

without supervision so it is possible the difference in the num-

14

ber of supervised sessions (ranged from 2 to 5 times between

N
N

N
N
N
N
Y

groups across trials) was not enough to show significant differ-

Randomised

ences between groups. It is also possible the number of supervised

sessions was not high enough to make a difference. Differing time
groups
PEDro scale checklist

periods from ACL rupture to reconstruction across trials and the

100
Y
Y
Y
Y
Y
Y
Y

fact that the number of supervised sessions may vary in clinical

practice should also be considered when interpreting these results.
Furthermore, only one trial included elite athletes, no trial assessed
Eligibility
specified

adherence to home-exercise, we do not know whether partici-

pants in the less supervised groups performed their exercises at
71
N

N
Y
Y

Y
Y
Y

home or a gym, and athletes willing to participate in trials testing a

% of Studies fulfilling

less supervised approach might have more motivation to perform

home-exercise than athletes in the general population.
Hohmann (2011)
Revenas (2009)
Schenck (1997)
Fischer (1998)
Author (year)

Beard (1998)

Grant (2005)
Grant (2010)

each item

4.3. Meaning of the study

Table 1

Based on uncertain evidence, intensive supervised rehabili-

a

tation is not superior to less supervised rehabilitation for any

5
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Table 2
Summary of findings for comparisons between intensive supervised and less supervised rehabilitation following anterior cruciate ligament reconstruction.

No. of participants (studies) Between-group effects Certainty of evidence

Self-reported function (Lysholm score, 0−100) MD (95% CI) GRADE

Up to 3 months 114 (3 RCTs) −1.24 (−6.09 to 3.61) Lowa,b ⊕⊕
3–6 months 149 (4 RCTs) 1.80 (−0.91 to 4.50) Lowa,b ⊕⊕
6–12 months 114 (3 RCTs) −0.92 (−3.73 to 1.88) Very-lowa,b,c ⊕

Sports Participation (Tegner score, 0−10) MD (95% CI) GRADE

Up to 3 months 40 (1 RCT) 0.50 (−0.35 to 1.35) Lowa,b ⊕⊕
3–6 months 96 (3 RCTs) 0.52 (−0.01 to 1.04) Lowa,b ⊕⊕
6–12 months 77 (2 RCTs) 0.91 (−1.04 to 2.86) Lowa,b ⊕⊕

Concentric quadriceps strength (LSI) MD (95% CI) GRADE

Up to 3 months 190 (3 RCTs) −0.56 (−4.98 to 3.86) Lowa,b ⊕⊕
3–6 months 59 (2 RCTs) 4.58 (−3.53 to 12.70) Lowa,b ⊕⊕
6–12 months 40 (1 RCT) 3.20 (−9.26 to 15.66) Lowa,b ⊕⊕
12–24 months 88 (1 RCT) 7.00 (−2.33 to 16.33) Lowa,b ⊕⊕

Concentric hamstring strength (LSI) MD (95% CI) GRADE

Up to 3 months 190 (3 RCTs) −0.03 (−3.98 to 3.91) Lowa,b ⊕⊕
3–6 months 59 (2 RCTs) 6.31 (−0.81 to 13.42) Lowa,b ⊕⊕
6–12 months 40 (1 RCT) 5.10 (−9.91 to 20.11) Lowa,b ⊕⊕
12–24 months 88 (1 RCT) −1.10 (−7.66 to 5.46) Lowa,b ⊕⊕

Eccentric quadriceps strength (LSI) MD (95% CI) GRADE

Up to 3 months 40 (1 RCT) 3.00 (−7.03–13.03) Lowa,b ⊕⊕
3–6 months 40 (1 RCT) 9.40 (2.37–16.43) Lowa,b ⊕⊕
6–12 months 40 (1 RCT) 5.20 (−2.26–12.66) Lowa,b ⊕⊕

Eccentric hamstring strength (LSI) MD (95% CI) GRADE

Up to 3 months 40 (1 RCT) 5.60 (−6.18 to 17.38) Lowa,b ⊕⊕
3–6 months 40 (1 RCT) −4.20 (−12.89 to 4.49) Lowa,b ⊕⊕
6–12 months 40 (1 RCT) −2.10 (−13.20 to 9.00) Lowa,b ⊕⊕

Isometric quadriceps strength (LSI) MD (95% CI) GRADE

Up to 3 months 40 (1 RCT) −14.70 (−24.86 to −4.54) Lowa,b ⊕⊕
3–6 months 77 (2 RCTs) 3.08 (−11.23 to 17.39) Lowa,b ⊕⊕
6–12 months 77 (2 RCTs) 6.18 (−1.14 to 13.51) Lowa,b ⊕⊕

Isometric hamstring strength (LSI) MD (95% CI) GRADE

Up to 3 months 40 (1 RCT) −0.20 (−13.96 to 13.56) Lowa,b ⊕⊕
3–6 months 40 (1 RCT) −2.70 (−10.65 to 5.25) Lowa,b ⊕⊕
6–12 months 40 (1 RCT) 3.70 (−1.01–8.41) Lowa,b ⊕⊕

Flexion range of motion (degrees for between-limb difference or surgical limb) SMD (95% CI) GRADE
Up to 3 months 182 (2 RCTs) 0.03 (−1.06 to 1.13) Very-lowa,b,c ⊕
3–6 months 90 (2 RCTs) −0.31 (−0.84 to 0.23) Lowa,b ⊕⊕
6–12 months 37 (1 RCT) 0.00 (−0.67 to 0.67) Lowa,b ⊕⊕
12–24 months 88 (1 RCT) 0.20 (−0.22 to 0.62) Lowa,b ⊕⊕

Extension range of motion (degrees for between-limb difference or surgical limb) MD (95% CI) GRADE
Up to 3 months 129 (1 RCT) −1.00 (−1.81 to −0.19) Lowa,b ⊕⊕
3–6 months 37 (1 RCT) 0.00 (−1.99 to 1.99) Lowa,b ⊕⊕
6–12 months 37 (1 RCT) 0.00 (−2.02 to 2.02) Lowa,b ⊕⊕
12–24 months 88 (1 RCT) 1.00 (−0.09 to 2.09) Lowa,b ⊕⊕

Sagittal plane knee laxity (mm) MD (95% CI) GRADE

Up to 3 months 150 (2 RCTs) −0.91 (−3.02 to 1.19) Lowa,b ⊕⊕
3–6 months 19 (1 RCT) −2.50 (−5.75 to 0.75) Lowa,b ⊕⊕
6–12 months 37 (1 RCT) 0.00 (−1.71 to 1.71) Lowa,b ⊕⊕
12–24 months 88 (1 RCT) 0.90 (−0.03 to 1.83) Lowa,b ⊕⊕

Single leg hop for maximum distance (LSI) MD (95% CI) GRADE
Up to 3 months 40 (1 RCT) −0.40 (−15.34 to 14.54) Lowa,b ⊕⊕
3–6 months 77 (2 RCTs) −0.56 (−7.18 to 6.06) Lowa,b ⊕⊕
6–12 months 77 (2 RCTs) 0.29 (−5.74 to 6.31) Lowa,b ⊕⊕

Single leg timed hop for 6 m (LSI) MD (95% CI) GRADE

Up to 3 months 40 (1 RCT) 7.90 (−6.81 to 22.61) Lowa,b ⊕⊕
3–6 months 40 (1 RCT) 0.10 (−9.77 to 9.97) Lowa,b ⊕⊕
6–12 months 40 (1 RCT) −4.70 (−22.27 to 12.87) Lowa,b ⊕⊕

Single leg vertical hop for maximum height (LSI) MD (95% CI) GRADE
Up to 3 months 40 (1 RCT) 10.20 (−5.50 to 25.90) Lowa,b ⊕⊕
3–6 months 40 (1 RCT) 8.90 (−4.48 to 22.28) Lowa,b ⊕⊕

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Table 2 (Continued)

No. of participants (studies) Between-group effects Certainty of evidence

6–12 months 40 (1 RCT) 1.30 (−0.37 to 2.97) Lowa,b ⊕⊕

Quality of life (ACL QoL or SIP, 0−100) MD (95% CI) GRADE

6–12 months 37 (1 RCT) −0.10 (−0.21 to 0.01) Lowa,b ⊕⊕
12–24 months 88 (1 RCT) −10.10 (−18.10 to −2.10) Lowa,b ⊕⊕

GRADE Working Group grades of evidence

High certainty (⊕⊕⊕⊕): We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty (⊕⊕⊕): We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is
a possibility that it is substantially different.
Low certainty (⊕⊕): Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty (⊕): We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of
effect.

ACL: anterior cruciate ligament; CI: confidence interval; LSI: limb symmetry index; MD: mean difference; SMD: standardised mean difference; QoL: quality of life; RCT:
randomised controlled trial; SIP: sickness impact profile.
a
Downgraded by one level because >25% of the trials, weighted by their sample size, were at high risk of bias (i.e. scored <7 on the PEDro scale).
b
Downgraded by one level because there is only one study, or where there is more than one study the total sample size is less than 400 (imprecision).
c
Downgraded by one level because I2 ≥ 80% (inconsistency).

outcome, despite 2–5 times more supervised sessions across the
six trials. There were also no clinically relevant effects sizes. For
example, between-group differences for self-reported function
(a primary outcome) were well-below the MCID of 10 (range:
0.9–1.8).23
Since all groups with less supervision in our review had some
level of physiotherapist supervision, we cannot recommend home-
exercise without any physiotherapy oversight. Nevertheless, a key
implication of these findings is that large amounts of supervised
rehabilitation may not be necessary following ACL reconstruction,
particularly for recreational athletes (as only one trial included
elite athletes). This finding is good news for athletes who cannot
afford supervised rehabilitation, have poor access to physiotherapy
or have high motivation to perform their rehabilitation inde-
pendently. It is also comforting considering the effects of the
COVID-19 pandemic, where individual and social circumstances
have changed access to attend clinic-based appointments. Since
intensive supervised rehabilitation does not demonstrate superior
outcomes compared to less supervised rehabilitation, clinicians
should involve athletes in shared decision making to ensure ath-
letes’ rehabilitation decision align with their preferences and
values.
Goal setting, pre-operative assessment and education with peri-
odic assessment of objective measures post-operatively could be
vital for athletes undergoing ACL reconstruction, particularly those
who prefer to perform most of their rehabilitation with less super-
vision. Goal setting could help individualise programs and increase
athlete motivation to rehabilitate independently. Pre-operative
education on the use of crutches, importance of early loading and
exercise (e.g. weight bearing, range of motion, quadriceps exer-
cises) with advice on preventing flares in symptoms or jeopardising
the integrity of the graft could improve athletes’ confidence and
self-efficacy.9 Pre-operative assessment could be used to iden-
tify range of motion or strength deficits that an athlete could try
to address before surgery.9 A systematic review of eight RCTs
(n = 451 athletes) found that pre-operative education and exercise
was superior to usual care for improving self-reported function
and quadriceps strength following ACL surgery.37 Finally, periodic
assessment of objective measures such as knee strength and hop
performance could be used throughout rehabilitation to ensure
athletes reach performance milestones that are associated with a
reduced risk of re-injury.38
4.4. Comparison to existing literature
Our review adds to the findings of numerous RCTs and sys-
tematic reviews which suggest intensive supervised rehabilitation
might not be necessary for a variety of musculoskeletal and
orthopaedic presentations.39 For example, intensive supervised
rehabilitation is not superior to less supervised rehabilitation
or primarily home-based rehabilitation following knee and hip
arthroplasty (systematic reviews that both include 5 RCTs,
n = 524 and n = 234 participants, respectively),12,13 following lum-
bar disc surgery (systematic review of 5 RCTs, n = 272),11 for the
management of rotator cuff tendinopathy (one RCT, n = 86),14
following arthroscopic rotator cuff repair (RCT, n = 117),40 and post-
immobilization of ankle fractures (Cochrane review of 4 RCTs,
n = 366)41 and upper limb fractures (systematic review of 3 RCTs,
n = 167).42
Guidelines for rehabilitation following ACL reconstruction vary
in their recommendations for the use of intensive supervised
rehabilitation.43 Some guidelines recommend intensive supervised
physiotherapy for some people,44 some recommend home-based
protocols for motivated athletes,45 and others highlight the uncer-
tainty of the evidence on this topic (similar to our study).9 Some
cohort studies suggest intensive clinic-based rehabilitation might
be superior to primarily home-based programs.46 However, rig-
orous RCTs are needed to confirm these findings before strong
recommendations supporting intensive supervision are made.
4.5. Implications for research and unanswered questions
Very low- to low-certainty evidence in this review highlights the
need for large, methodologically rigorous RCTs investigating the
effectiveness of intensive supervised rehabilitation compared to
less supervised rehabilitation following ACL reconstruction. Since
trials were published between 1997 and 2011 and rehabilitation
protocols were poorly reported, there is also a need to investi-
gate the value of intensive supervised rehabilitation following ACL
reconstruction with rehabilitation protocols that are adequately
reported (e.g. adhere to the Consensus on Exercise Reporting Tem-
plate (CERT) or TIDieR checklist) and reflect contemporary practice
(i.e. progressive rehabilitation, goal-based progression). Only one
trial assessed long-term outcomes (i.e. > 12 months)27 . Long-term
data is needed to understand whether intensive supervised reha-
bilitation has any long-term benefits (e.g. reduced injury risk,
increased sports participation, more optimal progression of exer-
cises). Another important gap in the literature is whether intensive
supervision is needed for elite athletes. Elite athletes may have
more advanced rehabilitation needs compared to recreational ath-
letes and require intensive supervision from a physiotherapist. On
the other hand, they might have higher motivation to complete
rehabilitation with less supervision or might already be working
with strength and conditioning coaches.

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A.R. Gamble et al.
There is currently no consensus on the ‘best’ rehabilita-
tion protocol or optimal progression of exercises and training
parameters during rehabilitation (e.g. volume, intensity, duration,
frequency) following ACL reconstruction. Some physiotherapists
use pre-specified rehabilitation protocols, while others base pro-
gression and training parameters on objective assessment (e.g.
range of motion, swelling and functional testing). Protocols of
different intensities and durations appear to be equally effica-
cious for improving function, balance, quality of life and sports
participation.9 As such, rehabilitation protocols varied across tri-
als included in this review, with progression of exercises and
training parameters largely determined by the treating physio-
therapist. This variation may explain some of the heterogeneity
observed in the meta-analyses. More research is needed to iden-
tify the optimal progression of exercises and training parameters
used during rehabilitation following ACL reconstruction, or to iden-
tify the best strategies for tailoring rehabilitation protocols (e.g.
exercises informed by performance testing, psychological readi-
ness, and goals). More research is also a needed to investigate the
optimal number of supervised sessions during rehabilitation, as our
review suggests there becomes a point where additional supervised
sessions are of limited value.
No trial in this review reported data on adherence to unsuper-
vised exercise. To better understand how much attention clinicians
should pay to adherence, future trials should investigate the rela-
tionship between adherence to home-exercise and outcomes. If a
strong positive relationship exists, research could investigate the
effectiveness of various strategies to increase adherence such as
the use of a digital or App-based exercise diary. Qualitative data
suggesting athletes desire more education, goal setting and assess-
ment throughout rehabilitation47,48 could be promising strategies
to explore to increase adherence to home-exercise. Compliance
to supervised sessions was discussed in all trials but reporting
was poor. For example, only four trials reported the proportion
of athletes in each group that attended prescribed supervised
sessions.25,28,31,32 Better reporting of compliance is needed to
explore whether certain characteristics of athletes are predictors
of poor compliance.
5. Conclusion
Very-low to low-certainty evidence suggests intensive super-
vised rehabilitation following ACL reconstruction is not superior
to less supervised rehabilitation for improving self-reported func-
tion, sports participation, strength, range of motion, sagittal laxity,
single leg hop performance or quality of life. There is a need for
large, high-quality RCTs using contemporary rehabilitation proto-
cols to investigate the value of intensive supervised rehabilitation
following ACL reconstruction. Given the uncertainty of the cur-
rent evidence, clinicians should engage athletes in shared decision
making to ensure athletes’ rehabilitation decisions align with their
preferences and values.
Confirmation of ethical compliance
N/A.
Acknowledgement
Chris Maher is supported by a Principal Research Fellowship
from the National Health and Medical Research Council of Australia.
8
Journal of Science and Medicine in Sport xxx (xxxx) xxx–xxx
Appendix A. Supplementary data
Supplementary material related to this article can be found, in
the online version, at doi:https://doi.org/10.1016/j.jsams.2021.03.
003.
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