Rehabilitation following surgical reconstruction for anterior cruciate ligament insufficiency: What has changed since the 1960s?—State of the art

Anterior cruciate ligament (ACL) insufficiency can be disabling, given the physical and sports activity constraints that negatively impact the quality of life. Consequently, surgery is the main approach for most active patients. Nonetheless, ACL reconstruction (ACLR) cannot be successful without adequate preoperative and postoperative rehabilitation. Since the 1960s, post-ACLR rehabilitation has evolved, mainly from advances in surgery, coupled with a better understanding of the biological concepts of graft revascularization, maturation and integration, which have impacted ACL postoperative rehabilitation protocols. However, new technologies do involve a definite learning curve which could affect rehabilitation programs and produce inconsistent results. The development of rehabilitation protocols cannot be defined without an accurate diagnosis of ACL injury and considering the patient's main physical demands and expectations. This article discusses how postoperative rehabilitation following ACLR has changed from the 1960s to now, focussing on surgical technique (type of tendon graft, fixation devices, and graft tensioning), biological concepts (graft maturation and integration), rehabilitation protocols (prevention of ACL injuries, preoperative rehabilitation, postoperative rehabilitation), criteria to return to sports, patient's reported outcomes and outcome. Although rehabilitation plays an essential role in managing ACL injuries, it cannot be fully standardised preoperatively or postoperatively. Preoperative and postoperative rehabilitation should be based on an accurate clinical diagnosis, patients' understanding of their injury, graft tissue biology and biomechanics, surgical technique, the patient's physical demands and expectations, geographical differences in ACL rehabilitation and future perspectives.