Journal of Sport Rehabilitation, 2023, 32, 884-893

https://doi.org/10.1123/jsr.2022-0343
© 2023 Human Kinetics, Inc. ORIGINAL RESEARCH REPORT

The Effect of Staged Versus Usual Care Physiotherapy on Knee

Function Following Anterior Cruciate Ligament Reconstruction
Kestrel McNeill,1 Hana Marmura,2,3,4 Melanie Werstine,2,3 Greg Alcock,2,3 Trevor Birmingham,2,3,4,5
Kevin Willits,3,6 Alan Getgood,3,6 Marie-Eve LeBel,3,6 Robert Litchfield,3,6 Dianne Bryant,1,2,3,6
and J. Robert Giffin3,5,6
1
Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; 2School of Physical
Therapy, Faculty of Health Sciences, Western University, London, ON, Canada; 3Fowler Kennedy Sport Medicine Clinic, Western University, London, ON, Canada;
4
Bone and Joint Institute, Western University, London, ON, Canada; 5Wolf Orthopedic Biomechanics Lab, Western University, London, ON, Canada;
6
Division of Orthopedics, Department of Surgery, The Schulich School of Medicine and Dentistry, Western University, London, ON, Canada

Context: The long duration and high cost of anterior cruciate ligament reconstruction (ACLR) rehabilitation can pose barriers to
completing rehabilitation, the latter stages of which progress to demanding sport-specific exercises critical for a safe return to
sport. A staged approach shifting in-person physiotherapy sessions to later months of recovery may ensure patients undergo the
sport-specific portion of ACLR rehabilitation. Design/Objective: To compare postoperative outcomes of knee function in
patients participating in a staged ACLR physiotherapy program to patients participating in usual care physiotherapy through a
randomized controlled trial. Methods: One hundred sixty-two patients were randomized to participate in staged (n = 80) or usual
care physiotherapy (n = 82) following ACLR and assessed preoperatively and postoperatively at 2 weeks, 6 weeks, 3 months, and
6 months. The staged group completed the ACLR rehabilitation protocol at home for the first 3 months, followed by usual care in-
person sessions. The usual care group completed in-person sessions for their entire rehabilitation. Outcome measures included
the Lower Extremity Functional Scale, International Knee Documentation Committee Questionnaire, pain, range of motion,
strength, and hop testing. Results: There were no statistically significant between-group differences in measures of knee function
at 6 months postoperative. Patients in the usual care group reported significantly higher International Knee Documentation
Committee scores at 3 months postoperative (mean difference = 5.8; 95% confidence interval, 1.3 to 10.4; P = .01). Conclusion:
A staged approach to ACLR rehabilitation does not appear to impede knee function at 6 months postoperative but may result in
worse patient reported outcomes at early follow-ups.

Keywords: rehabilitation, return to sport, randomized controlled trial

Young athletic patients who undergo anterior cruciate liga- can be both barriers and facilitators to ACL rehabilitation adher-
ment (ACL) reconstruction (ACLR) have high expectations of a ence and participation.12 These factors include length of rehabili-
normally functioning knee and a successful return to their preinjury tation/commitment, cost, insurance, activity restrictions, type and
sports or activities after surgery.1 Unfortunately, these patients progression of exercises, patient control, enjoyment, and assess-
experience low rates of return to their preinjury level of sport (less ment of progress.12
than 50%)2,3 and high rates of secondary injury (up to 30%)4 Adherence is a multifactorial concept influenced by personal
resulting in further declines in knee function. schedules, income, housing location, and access to physiotherapy
Evidence-based ACLR rehabilitation protocols are instrumental clinics.13 Moderate or full adherence to supervised rehabilitation
in preventing secondary injury and are critical to a successful recovery following ACLR has been shown to improve patient-reported and
and return to sport (RTS).5,6 ACL rehabilitation protocols commonly functional measures of knee function, and increase patients’
span 6 to 9 months and are divided into phases, beginning with early chances of returning to sport.14 However, patients may experience
range of motion (ROM), and weight-bearing and progressing to sport- rehabilitation fatigue due to the high frequency of required ap-
specific training.7–9 Participation in the sport-specific phase of reha- pointments during early ACLR physiotherapy protocols. For these
bilitation is critical for patients to obtain the strength, endurance, reasons, patients may not adequately adhere to their rehabilitation
coordination, and psychological readiness required to safely RTS.9 to return to preinjury sport or activity levels.
The extensive rehabilitation process following ACLR is not Some level of clinician contact is important for successful
without difficulties such as cost and adherence-related issues. rehabilitation, but continuous supervision may not be neces-
Although most insurance plans cover a portion of rehabilitation sary.15,16 We propose that a staged approach could offer a solution
costs, it is not uncommon for patients to reach their coverage limits to issues surrounding traditional in-person and fully supervised
before 6 months, requiring out of pocket payment to complete the physiotherapy. In a staged model, patients see their physiothera-
entirety of their rehabilitation program.10,11 Care delivery factors pists’ in-person for assessment at specified milestones but complete
weekly exercises and the prescribed protocol on their own, with
McNeill https://orcid.org/0000-0002-4374-6510 more regular in-person sessions initiated at the sport-specific stage
Marmura https://orcid.org/0000-0002-8648-870X of rehabilitation. Shifting the frequency of in-person visits from
Birmingham https://orcid.org/0000-0002-3300-7677 early to late phase rehabilitation may ensure that patients undergo
Giffin (rgiffin@uwo.ca) is corresponding author. more advanced rehabilitation and achieve the knee function
884
Unauthenticated | Downloaded 04/30/25 05:07 PM UTC
 Staged Versus Usual Care Physiotherapy 885

required to safely RTS. Previous research has evaluated the therapist reviewed the first 6 weeks of the program with the patient
effectiveness of different home-based or semisupervised rehabili- to confirm understanding of all exercises. Patients in the staged
tation models and has suggested no significant differences in group then only returned to the clinic at 6 weeks and 3 months to be
postoperative outcomes compared with clinic-based physio- assessed by a physiotherapist and their surgeon, and were encour-
therapy.10,15,17 aged to perform the protocol at home. At 6 weeks postoperatively,
Therefore, the purpose of this study was to compare postop- the patient was evaluated using the previously described clinical
erative measures of knee function in patients participating in a assessment. If they passed, the physiotherapist reviewed the struc-
staged physiotherapy program versus patients participating in usual ture of the final 6 weeks of the home-based component of the staged
care physiotherapy following ACLR. We hypothesized that there program. In the staged group, if a patient had not completely met
would be no differences between groups at 3 or 6 months postop- the objectives of the first 6 weeks, the therapist reassigned the
erative in the primary outcome of knee function or secondary exercises from the first 6 weeks and demonstrated and assigned the
outcomes of knee-related quality of life, ROM, pain, strength- and final 6 weeks of the program. The patient was then encouraged to
performance-based measures. work on the entire program at home. Patients for whom there was a
significant delay in expected progress were encouraged to attend
additional supervised physiotherapy visits as dictated by clinician
Methods expertise and patient needs. This would not be considered a
Study Design and Participants crossover to usual care, as the majority of the program would
continue to be home based for the first 3 months. A patient would
This study was a 2 group, parallel design randomized controlled trial be considered a crossover if they opted to attend the same fre-
that took place through the practices of 5 orthopedic surgeons at the quency of in-person physiotherapy sessions as the usual care group
Fowler Kennedy Sport Medicine Clinic. All patients between the within the first 3-month period of the program (1–2 times per
ages of 15 and 40 who were scheduled to undergo ACLR using a week), or if it was deemed necessary by clinicians due to delays in
hamstring autograft were invited to take part in the study. The progress. After 3 months, patients in the staged group began to
exclusion criteria were as follows: (1) previous ACLR on either progress through the ACLR protocol with regularly scheduled in-
knee; (2) repair or reconstruction of the posterior cruciate ligament or person visits as per usual care.
medial collateral ligament was required; (3) history of metabolic Patients in the usual care group followed the same ACLR
bone, collagen crystalline, degenerative joint or neoplastic disease; protocol but attended in-person clinic physiotherapy sessions 1 to
(4) chondral defect requiring treatment; (5) femoral, tibial or patellar 2 times per week. This schedule was determined through discus-
fracture (apart from Segond fractures); (6) bilateral ACLR required; sions between the physiotherapist and patient to schedule physio-
(7) the patient did not speak, understand, or read the English therapy visits according to the therapist’s usual practice and the
language; (8) impairment or illness that precluded informed consent patient’s funding, family, school, and work situation (usual de-
or rendered the patient unable to complete questionnaires; (9) no terminants of physiotherapy frequency and duration following
fixed address or means of contact; or (10) major medical illness ACL reconstruction).
where life expectancy was less than 2 years. Consenting patients
were enrolled at their preoperative clinic visit by a research assistant. Procedures: Outcome Measures
This study was granted ethics approval by the University of Western
Ontario Research Ethics Board. Baseline preoperative assessments were conducted 1 week before
surgery, and included patient reported outcomes and functional
Procedures: Interventions measures. Follow-up activities were completed at 2 weeks, 6 weeks,
3 months, and 6 months postoperatively (Figure 1). The primary
Patients in both groups attended their first consultation with a outcome measure was knee function at 6 months postoperatively,
physiotherapist at approximately 2 weeks postoperatively. The as measured by the Lower Extremity Functional Scale (LEFS). The
Fowler Kennedy ACLR rehabilitation protocol9 was provided to LEFS is a valid self-reported measure of function for patients with
all patients (Supplementary Material S1 [available online]). Both lower extremity orthopedic conditions that is responsive to change,
groups of patients were seen by their orthopedic surgeon postop- and highly reliable.18
eratively at 2 weeks, 6 weeks, and 3 months. All surgeons were Secondary outcome measures included knee-specific quality
blinded to group allocation. At 6 weeks and 3 months, the surgeon of life, pain, ROM, strength, and performance-based functional hop
completed a clinical assessment to evaluate each patient’s progress testing. Knee-specific quality of life was measured by the Interna-
by answering yes or no to the following questions: does the patient tional Knee Documentation Committee (IKDC) Subjective Ques-
demonstrate an inability to (1) bend their knee at least 80 degrees tionnaire, an 18-item knee-specific questionnaire designed to detect
(knee flexion), (2) straighten their knee by greater than 10 degrees change in patients with a variety of knee conditions.19 The 4-Item
(knee extension), (3) contract and hold their quadriceps muscle, Pain Intensity Measure (P4) was used to evaluate pain for parti-
(4) perform a straight leg raise, and (5) displays quads avoidance cipants over the 2 days prior to their visit.20 ROM was measured
gait pattern? If the surgeon answered “yes” to any of these through passive knee extension and active-assisted knee flexion
questions the patient increased the frequency of their in-person tests using a universal goniometer. Side-to-side difference (surgical
physiotherapy appointments. knee – contralateral knee) was calculated for active-assisted knee
Patients randomized to the staged physiotherapy group flexion and passive knee extension.
received a copy of a 12-week home-based program at their 2-week Hop testing was used as a performance-based outcome mea-
initial consultation which included education on the home-based sure to evaluate neuromuscular control, strength, and confidence in
rehabilitation purpose, commitment, stages, and progressions in both limbs. This involved a combination of 4 hop tests (single hop
addition to detailed exercise instructions, pictures, dosage, and for distance, timed 6-m hop, triple hop for distance, and crossover
progressions (Supplementary Material S2 [available online]). The hop for distance).21 All tests were performed twice per leg and the
JSR Vol. 32, No. 8, 2023
Unauthenticated | Downloaded 04/30/25 05:07 PM UTC
886 McNeill et al

Figure 1 — Timing of outcome assessments and trial activities. *LEFS was not administered at the preoperative timepoint. ACL indicates anterior
cruciate ligament; IKDC, International Knee Documentation Committee Subjective Questionnaire; LEFS, Lower Extremity Functional Scale; LSI, limb
symmetry index; ROM, range of motion.

average of the 2 trials was included in the analysis. Limb Symmetry by surgeon, presence of meniscal repair, and physiotherapy loca-
Index was calculated for all hop tests, and was performed as per tion (Fowler Kennedy Sport Medicine Clinic or other).
Reid et al.21 The total Limb Symmetry Index was calculated by
taking an average of the 4 scores. Statistical Analyses
Quadriceps (knee extension) and hamstring (knee flexion)
strength were measured preoperatively and 6 months postopera- All statistical analyses were performed using SPSS Statistics
tively using an isokinetic dynamometer. Peak torque (in newton (version 26). Descriptive statistics were calculated for baseline
meters), average peak torque (in newton meters), and average demographics and clinical characteristics with t tests used to
power (in Watts) were recorded on the surgical limb and expressed determine any significant differences between the groups.
as a percentage of the contralateral limb. Assessors consisted of As the primary analysis, LEFS scores were examined using an
surgeons, kinesiologists, and physiotherapists, all of whom were analysis of covariance to examine the difference between the usual
trained to administer the evaluations employed within this study, care and staged physiotherapy groups at 3 and 6 months postoper-
in a standardized manner. All assessors were blinded to patient atively while adjusting for 2-week postoperative scores. Post hoc
allocation. tests were adjusted for multiple comparisons using the Bonferroni
correction. Secondary outcome measures were compared at 3 and 6
months postoperatively using an analysis of covariance to adjust
Procedures: Randomization
for preoperative scores. Assumptions of normality, linearity,
Patients were randomized postoperatively on a 1:1 basis to either homogeneity of variance, and regression slopes were confirmed
(1) usual care physiotherapy or (2) staged physiotherapy. Ran- using Levene test and visual inspection of Q-Q plots and scat-
domization was in permuted mixed block sizes and was stratified ter plots.
JSR Vol. 32, No. 8, 2023
Unauthenticated | Downloaded 04/30/25 05:07 PM UTC
 Staged Versus Usual Care Physiotherapy 887

As a secondary exploratory analysis, the proportions of pa- respectively. No crossovers between groups were documented,
tients who reached acceptable levels for selected outcomes at 3 and and 5 participants in each group experienced delays in progress at
6 months were calculated for both groups and compared using 6 weeks (P = .94, insignificant difference between groups). There
Fischer Exact test. Acceptable values for the outcome measures of were 67 patients in the staged physiotherapy group and 70 patients
knee function are presented in Table 1 and are based on criteria in the usual care group remaining at 6 months. Participant baseline
from previous literature and clinical expertise.22–25 A 2-sided P demographics and clinical characteristics are presented in Table 2.
value of <.05 marked statistical significance for all analyses.
Missing midpoint data were addressed through multiple impu-
tation using 50 iterations. All missing data were assumed to be
Primary Analysis
missing at random, as no important differences were observed Between-group differences for our primary and secondary outcome
between participants missing and not missing data points based on measures at 3 and 6 months postoperatively are displayed in Table 3
Little test performed across all variables with missing data. We and Figure 3. LEFS scores did not display significant mean
followed the intention-to-treat principle for all analyses. differences between the usual care and staged physiotherapy
Sample size was calculated based on a 2-sided alpha error of groups at 3 months (2.6; 95% confidence interval [CI], −0.8 to
(.05) and a power of 80% to detect a moderate effect size of 0.5, or 6.1; P = .14), or 6 months postoperatively (0.8; 95% CI, −1.0 to 3.7;
8.5 points on the LEFS.26 Thus, a total of 61 participants were P = .52) after adjusting for 2-week postoperative measurements.
required for each group. The sample size was increased to 71 IKDC scores were significantly higher in the usual care group
patients per group to allow for a 15% dropout rate, requiring 142 (68.3 [1.6]) when compared with the staged physiotherapy group
patients total. (62.4 [1.6]) at 3 months following surgery (5.8; 95% CI, 1.3 to
10.4; P = .01). The remaining secondary outcome measures dis-
played no significant differences between groups. At 6 months
Results following surgery, no significant differences were observed
between groups for any secondary outcome including IKDC
Participants (Table 3).
The flow of patients is presented in Figure 2. Of the 899 patients
assessed for eligibility, 522 did not meet the inclusion criteria, Secondary Analysis
54 refused to participate, and 171 were either missed during the
recruitment period or cancelled their surgery. A total of 162 The proportion of patients that reached acceptable values for select
patients were randomized, with 80 allocated to the staged physio- outcome measures at 3 and 6 months postoperatively are presented
therapy group and 82 to the usual care group. Two participants in Table 1. At 6 months postoperative, less than 50% of patients in
were excluded postrandomization. Loss to follow-up was 16% both groups showed acceptable strength values and less than 75%
and 12% for the staged physiotherapy and usual care groups, of patients in both groups showed acceptable ROM and hop testing

Table 1 Proportion of Acceptable Values at 3 and 6 Months

Usual care, Staged physiotherapy,
Outcome measure Acceptable valuea n (%) n (%) P
3 mo
LEFS (0–80 points) 55 51 (72.9) 44 (65.7) .46
ROM, °
Active-assisted flexion Within 5° contralateral leg 41 (58.6) 49 (73.1) .11
Passive extension Equal to contralateral leg 56 (80.0) 63 (94.0) .02*
6 mo
LEFS (0–80 points) 61 60 (85.7) 49 (73.1) .09
ROM, °
Active-assisted flexion Equal to contralateral leg 49 (70.0) 49 (73.1) .71
Passive extension Equal to contralateral leg 54 (77.1) 50 (74.6) .68
Hop testing LSI, % >90% 45 (64.3) 47 (67.1) .47
Strength testing, N·m or W
Quadriceps peak torque ≥90% contralateral leg 28 (40.0) 30 (44.8) .61
Quadriceps average power (all strength 27 (38.6) 29 (43.3) .61
measures)
Quadriceps average peak torque 26 (37.1) 29 (43.3) .49
Hamstring peak torque 34 (48.6) 23 (34.3) .12
Hamstrings average power 18 (25.7) 16 (23.9) .85
Hamstring average peak torque 26 (37.1) 24 (35.8) 1.00
Abbreviations: LEFS, Lower Extremity Functional Scale; LSI, limb symmetry index (surgical leg/contralateral leg); ROM, range of motion.
a
Acceptable outcome measure values were determined based on criteria from previous literature and clinical expertise.22–25
*P < .05.

JSR Vol. 32, No. 8, 2023

Unauthenticated | Downloaded 04/30/25 05:07 PM UTC
888 McNeill et al

Assessed for eligibility

(n = 899)
Excluded (n = 737)
Not meeting inclusion criteria (n = 512)
Refused to participate (n = 54)
Other (missed, no surgery) (n = 171)

Randomized (n = 162)

Usual care (n = 82) Staged physiotherapy (n = 80)

Excluded postrandomization (n = 2)* Excluded postrandomization (n = 0)

Lost to follow-up (n = 10) Lost to follow-up (n = 13)

Unable/unwilling to return (n = 2) Unable/unwilling to return (n = 4)
Unable to reach/contact (n = 8) Unable to reach/contact (n = 9)

6 months post-op (n = 70) 6 months post-op (n = 67)

Figure 2 — Patient flow diagram. *One patient was excluded postrandomization due to a previously unreported contralateral anterior cruciate ligament
tear, and one due to an additional intraarticular procedure as per surgeon direction.

values. At the 3-month timepoint, there was a significantly larger program to ensure appropriate progress is being made and to avoid
proportion of patients with acceptable passive knee extension adverse events.
ROM in the staged physiotherapy group (94%) than the usual Notably, the majority of patients in both groups did not have
care group (80%; P = .02). There were no other significant differ- acceptable outcomes to indicate safe ability to RTS, which aligns
ences between groups. with the recommendation to delay RTS for 9 to 12 months
postoperatively.23,27 Flexibility in the level of supervision and
Discussion location of physiotherapy may allow for optimization of late stage
ACL rehabilitation and enable more patients to achieve a success-
This study revealed that using a staged approach to ACLR reha- ful recovery and RTS.
bilitation does not appear to alter short-term knee function (ROM, There were no significant differences in any measures of
hamstring and quadricep strength or hop testing performance) up to postoperative knee function between the staged physiotherapy and
6 months postoperative, when compared to usual care physiother- usual care groups at 6 months following surgery. Overall, both
apy rehabilitation. This could present opportunities for an individ- groups showed significant improvements in IKDC scores from
ualized approach to physiotherapy following ACLR, in which preoperative to 6 months postoperative that surpassed the minimal
patients can choose a home based or supervised in clinic model clinically important difference of 11.5 (staged physiotherapy: 20.3,
for their rehabilitation during the first 3 postoperative months of usual care: 14.1) indicating meaningful change.27 Secondary anal-
recovery based on their preferences and situational context. Ulti- yses showed significant differences in IKDC scores which favored
mately, patients should be given the choice as to their preferred usual care at the 3-month timepoint. This is notable considering the
model. It is important to note that assessments with a physiothera- rehabilitation protocols of our 2 study groups differed for only the
pist during the acute stage are still necessary in a home-based first 3 months (in-person vs home-based exercises). The change in
JSR Vol. 32, No. 8, 2023
Unauthenticated | Downloaded 04/30/25 05:07 PM UTC
 Staged Versus Usual Care Physiotherapy 889

Table 2 Baseline Demographic and Clinical Characteristics

Usual care Staged physiotherapy
Characteristic (N = 80) (N = 80) P
Sex, n (%)
Male 36 (52.9) 44 (61.1) .39
Female 32 (47.1) 28 (38.9)
Age, y, mean (SD) 22.8 (6.3) 24.0 (6.7) .25
Height, m, mean (SD) 1.7 (0.2) 1.8 (0.1) .61
Weight, kg, mean (SD) 76.1 (17.4) 78.9 (18.3) .37
Leg dominance, n (%)
Right 63 (94.0) 71 (98.6) .20
Left 4 (6.0) 1 (1.4)
Injured leg, n (%)
Right 29 (43.3) 43 (60.6) .08
Left 38 (56.7) 28 (39.4)
Meniscal repair, n (%)
Yes 20 (25.0) 19 (23.8) .85
No 60 (75.0) 61 (76.3)
IKDC (0–100), mean (SD) 62.7 (15.8) 58.6 (15.2) .89
P4 (0–40), mean (SD) 6.2 (7.0) 8.5 (8.4) .14
ROM, °, mean (SD)
Active-assisted flexion
Surgical 137.0 (8.5) 136.9 (9.4) .67
Contralateral 140.1 (8.4) 141.0 (8.4) .99
Side-to-side difference −3.1 (7.3) −4.1 (9.2) .51
Passive extension
Surgical −3.5 (3.2) −3.1 (3.0) .55
Contralateral −4.1 (2.6) −3.9 (3) .78
Side-to-side difference 0.6 (2.9) 0.9 (2.1) .46
Hop testing (LSI), mean (SD)
Single hop 82.6 (24.6) 70.2 (36.1) .03*
6M hop 113.0 (47.8) 97.2 (59.0) .04*
Triple hop 77.8 (26.0) 69.0 (38.1) .28
Cross hop 74.6 (30.9) 68.5 (37.7) .28
Total 87.0 (23.0) 76.2 (37.3) .09
Strength testing, %, mean (SD)
Quadriceps peak torque 77.8 (18.6) 79.7 (17.7) .54
Quadriceps average power 82.0 (23.3) 82.9 (18.2) .77
Quadriceps average peak torque 78.0 (19.0) 79.3 (19.0) .70
Hamstring peak torque 85.5 (18.3) 87.7 (19.7) .48
Hamstrings average power 94.1 (20.3) 86.0 (22.2) .50
Hamstring average peak torque 85.2 (18.2) 86.9 (20.4) .57
Abbreviations: IKDC, International Knee Documentation Committee Subjective Questionnaire; LSI, limb symmetry index
(surgical leg/contralateral leg); ROM, range of motion; 6M, 6-meter.
*P < .05.

IKDC scores from preoperative to 3 months postoperative was including the upper limit of the 95% CI (10.4), and the difference
similar between groups (3.8 vs 5.6, respectively), and change from in mean change scores across timepoints (pre-op to 3 m: 1.8, 3 m to
3 months to 6 months and pre-op to 6 m was higher in the staged 6 m: 8.0, pre-op to 6 m: 6.2), did not reach the established minimal
physiotherapy group. These results may be partly due to the fact clinically important difference (11.5), minimally important change
that preoperative scores were lower in the staged physiotherapy (10.9), or minimum detectable change (11.5) of the IKDC subjec-
group compared with the usual care group (58.6 vs 62.7), although tive knee form.27 Therefore, we cannot be confident that these
this difference was not statistically significant. However, the mean results represent differences between groups beyond measurement
difference in IKDC scores between groups at 3 months (5.8), error. It is possible that the lack of regular physiotherapy
JSR Vol. 32, No. 8, 2023
Unauthenticated | Downloaded 04/30/25 05:07 PM UTC
890 McNeill et al

Table 3 Three- and Six-Month Follow-Up Functional Outcome Scores for Patients in Usual Care Physiotherapy
and Staged Physiotherapy Following ACL Reconstruction
Usual care, Staged physiotherapy, Mean difference
Outcome measure mean ± SE mean ± SE (95% CI) P
3 mo
LEFS score (0–80) 59.5 ± 1.2 56.9 ± 1.2 2.6 (−0.8 to 6.1) .14
IKDC score (0–100) 68.3 ± 1.6 62.4 ± 1.6 5.8 (1.3 to 10.4) .01*
P4 score (0–40) 5.9 ± 0.7 8.1 ± 0.7 −1.5 (−3.3 to 0.4) .13
ROM, °
Active-assisted flexion
Surgical 134.0 ± 1.0 135.7 ± 1.1 −1.8 (−4.6 to 1.1) .23
Contralateral 139.6 ± 0.7 139.8 ± 0.7 −0.3 (−2.3 to 1.8) .79
Side-to-side difference −5.8 ± 0.9 −4.2 ± 1.0 −1.6 (−4.2 to 1.1) .24
Passive extension
Surgical −2.67 ± 0.4 −3.2 ± 0.4 0.5 (−0.6 to 1.6) .36
Contralateral −4.3 ± 0.3 −5.3 ± 0.3 1.0 (0.2 to 1.9) .03*
Side-to-side difference 1.7 ± 0.3 2.2 ± 0.3 −0.5 (−1.2 to 0.2) .19
6 mo
LEFS score (0–80) 69.7 ± 1.0 68.9 ± 1.0 0.82 (−2.0 to 3.7) .52
IKDC score (0–100) 76.8 ± 1.5 78.9 ± 1.6 −2.0 (−6.4 to 2.3) .35
P4 score (0–40) 5.8 ± 0.6 6.2 ± 0.6 −0.4 (−2.1 to 1.3) .66
ROM, °
Active-assisted flexion
Surgical 136.5 ± 1.0 135.6 ± 1.0 1.0 (−1.9 to 3.8) .51
Contralateral 139.0 ± 0.7 139.6 ± 0.8 −0.6 (−2.7 to 1.5) .57
Side-to-side difference −3.5 ± 0.8 −4.3 ± 0.8 0.6 (−1.7 to 2.9) .63
Passive extension
Surgical −3.5 ± 0.4 −3.1 ± 0.4 −0.4 (−1.4 to 0.7) .52
Contralateral −5.2 ± 0.3 −4.6 ± 0.3 −0.6 (−1.5 to 0.3) .19
Side-to-side difference 1.5 ± 0.3 1.4 ± 0.3 0.1 (−0.8 to 1.0) .90
Hop testing (LSI)
Single hop 80.6 ± 3.2 85.8 ± 3.5 −4.2 (−11.8 to 3.4) .27
6M hop 95.7 ± 4.3 101.2 ± 4.4 −5.5 (−17.7 to 6.6) .37
Triple hop 78.5 ± 3.3 83.0 ± 3.3 −4.6 (−13.7 to 4.6) .33
Cross hop 80.4 ± 5.2 85.9 ± 4.4 −4.1 (−15.1 to 6.9) .46
Total 84.8 ± 3.3 88.3 ± 3.4 −3.5 (−12.9 to 5.9) .47
Strength testing, %
Quadriceps peak torque 79.0 ± 1.9 79.7 ± 1.9 −0.7 (−6.1 to 4.7) .80
Quadriceps average power 77.9 ± 1.8 78.1 ± 1.8 −0.1 (−5.1 to 4.8) .96
Quadriceps average peak torque 76.4 ± 2.1 79.1 ± 2.1 −2.7 (−8.6 to 3.2) .38
Hamstring peak torque 81.9 ± 1.9 79.4 ± 2.0 2.6 (−2.9 to 8.0) .36
Hamstrings average power 75.9 ± 1.8 72.8 ± 1.8 3.1 (−2.1 to 8.2) .24
Hamstring average peak torque 80.7 ± 1.9 78.4 ± 1.9 2.2 (−3.1 to 7.6) .41
Abbreviations: ACL, anterior cruciate ligament; CI, confidence interval; IKDC, International Knee Documentation Committee Subjective Questionnaire; LEFS, Lower
Extremity Functional Scale; LSI, limb symmetry index (surgical leg/contralateral leg); ROM, range of motion.
*P < .05.

appointments contributed to the difference between groups with measure than those in usual care if they had not switched to regular
less support provided during the acute phases of recovery. Social in-person appointments at 3 months, this would not be appropriate
support has been identified as an important factor affecting RTS for the individualized stage of the ACLR rehabilitation protocol
following ACL injury, which can come from a variety of sources and is not suggested in the staged rehabilitation approach. In the
(family, friends, teammates, coaches, physiotherapists, trainers, early stages of rehabilitation consisting of standard ROM and
etc).12,28 While it is possible that patients in the staged physiother- strength exercises, other sources of support are likely adequate
apy group may have continued to report worse outcomes on this and do not need to be physiotherapy specific. Patients involved in a
JSR Vol. 32, No. 8, 2023
Unauthenticated | Downloaded 04/30/25 05:07 PM UTC
 Staged Versus Usual Care Physiotherapy 891

Figure 3 — Unadjusted Lower Extremity Functional Scale (LEFS) scores at ACLR postoperative assessment timepoints in the staged physiotherapy
and usual care groups. ACLR indicates anterior cruciate ligament reconstruction; CI, confidence interval; LEFS, Lower Extremity Functional Scale.

staged rehabilitation program would likely benefit from education Interestingly, this model is reversed from that of the present study,
regarding utilizing these supports and active coping strategies for with the highest frequency of physiotherapy visits in the first 6 weeks
the early phase of recovery when physiotherapy would be less and the lowest frequency at the final stages of recovery. Despite this
involved. In terms of safety, complication rate in this population is difference, both studies showed no significant differences between
low and can be monitored effectively with milestone follow-up groups in patient reported or clinical outcomes. Grant et al22 con-
appointments with the surgeon and physiotherapist.29 Although ducted an adequately powered randomized controlled trial of 145
likely helpful at all stages, we hypothesize that support from a patients assigned to either home-based physiotherapy attending 4
physiotherapist may be most advantageous in the sport-specific late physical therapy sessions (0, 3, 6, and 12 wk postoperative) over the
stages of ACL rehabilitation to address psychological factors such first 3 months postoperative (n = 73) or to supervised physical
as confidence to RTS, fear of reinjury, kinesiophobia, and self- therapy attending 17 sessions (2 sessions per week for weeks
efficacy.28 2–7, weekly for weeks 8–12) over the first 3 months (n = 72). This
Our results are consistent with previous research suggesting is similar to the model of the present study, in which patients were
that there are no significant differences in outcomes between home- seen 3 times in the first 3 months (2, 6, and 12 wk postoperative)
based and supervised approaches to ACLR rehabilitation.22,30–32 A with the potential for an extra visit(s) if not progressing as expected.
2022 systematic review and meta-analysis by Uchino et al,31 In the study by Grant et al,22 all patients were provided an education
concluded that there were no significant differences in self-reported booklet including information on ACL injury, surgery, and exercise
knee function or knee muscle strength when comparing supervised instructions, pictures, progressions, and precautions. The trial out-
versus home-based rehabilitation following ACLR. However, this comes including ROM, ligament laxity, and strength were catego-
review included only 9 studies, 5 of which were included in the rized as clinically acceptable or unacceptable.22 At 3 months
meta-analyses, and the body of evidence was deemed of very low postoperative, the home-based group had a significantly higher
quality based on the Cochrane Collaboration’s Risk of Bias tool.31 proportion of patients with acceptable knee flexion and extension,
Most studies had very small sample sizes, with only 2 studies with no other significant differences between groups.22 At long-term
including more than 100 patients. follow-up of 2–4 years (mean = 38 mo), there were no significant
Ugutmen et al32 included 104 patients randomized to a home- differences between groups in knee extension or flexion, ligament
based (n = 52) or clinic-based rehabilitation program (n = 52) for 8 laxity, strength, or IKDC scores.30
months (5 phases). Patients were assessed weekly for the first 6 In the current study, the staged physiotherapy group showed a
weeks with ROM and strength exercise demonstrations at in-person significantly larger proportion of patients with acceptable passive
visits and a home exercise booklet provided. Patients were then seen knee extension (surgical leg equal to the contralateral leg) at 3
biweekly for the next 6 weeks and then monthly, concluding the months postoperative (94% vs 80%, respectively) compared with
study with a mean follow-up period of 31.1 months (range 12–66).32 the usual care group. However, the mean difference in passive knee
JSR Vol. 32, No. 8, 2023
Unauthenticated | Downloaded 04/30/25 05:07 PM UTC
892 McNeill et al

extension at this timepoint was only half a degree, providing little messaging is likely critical to establish buy-in from the patient and
clinical relevance. Additionally, while the staged physiotherapy a common understanding of the program progression, goals, and
group showed a significantly higher proportion of patients with expectations. These factors not being assessed is a limitation of the
acceptable passive extension at 3 months, our study was not present study and should be included in future research. Previous
powered to detect differences between groups for the dichotomized research in this area emphasizes the importance of a home exercise
outcomes and this difference was not seen at 6 months. booklet, careful selection of compliant patients, and periodic
In both the usual care and staged groups, less than half of follow-up with a physiotherapist as important ingredients for a
patients had acceptable strength values (surgical leg ≥ 90% contra- successful home program, however, the influence of these program
lateral leg), and less than 3 quarters had acceptable knee flexion components have not been formally assessed.31,32 The use of
(surgical leg equal to contralateral leg) to RTS at 6 months after patient factors will be critical to individualize the decision for a
surgery. A recent cohort study of 108 patients similarly reported that supervised or home-based rehabilitation program.
only 50% of patients passed RTS criteria at 6 months.24 Another Our study protocol included 6 months of rehabilitation, which
prospective study of 62 patients reported higher proportions (33%– we have concluded is too short to achieve functional outcomes.
80%) of patients meeting the individual criteria of Limb Symmetry Therefore, the effects of staged physiotherapy on long term (1–5 y
Index > 90% at 6 months for various strength measures.25 However, postoperative) functional and patient reported outcomes, RTS, and
when analyzed together, only 3% of patients passed all RTS criteria secondary injury rates remain unclear. More longitudinal research
at 6 months.25 The low proportion of patients meeting functional incorporating the aforementioned confounding patient factors and
performance goals and/or RTS criteria suggests that functional evaluating long-term outcomes is needed to determine if a staged
recovery is incomplete at 6 months and that this postoperative format for physiotherapy following ACLR is appropriate.
milestone is likely too early for RTS evaluations. In fact, the
Delaware-Oslo ACL Cohort Study showed a 51% reduction in Conclusion
reinjury risk for every month that RTS was delayed after surgery,
until 9 months.23 A recently published ACL injury RTS consensus A staged approach to rehabilitation (shifting the frequency of in-
statement also showed unanimous agreement among experts that the person visits from early to late phase rehabilitation) following
time-based RTS criteria should be abandoned in clinical practice.27 ACLR does not appear to influence patient reported or functional
The length of ACLR rehabilitation protocols and timing of RTS outcomes within the first 6-month postsurgery when compared
testing should be extended beyond the length of the protocol used in with usual care physiotherapy. More longitudinal and multicenter
this study 6 to 9, or 12 months postoperative to ensure patients meet research is needed to determine if a staged format for physiotherapy
appropriate criteria before RTS to reduce the risk of reinjury. following ACLR is appropriate for all patient groups and evaluate
The current body of evidence suggests that a home-based its impact on long-term functioning, including RTS.
rehabilitation program could be equally as reliable as a home-based
program, with the potential to save time and money.30–32 However, Acknowledgment
more high-quality and rigorous research is required to increase
confidence in this messaging. This study focused on rehabilitation This study was supported in part by the Fowler Kennedy Sport Medicine
supervision at 3 to 6 months post-ACLR, but the timing at which Clinic Internal Research Fund and the American Orthopedic Society for
supervision, support, and motivation is beneficial may be different Sports Medicine Sandy Kirkley Clinical Outcome Research Grant.
for individual patients. The willingness to be flexible in the delivery
of an ACLR rehabilitation programs and alter periods of supervi- References
sion and home-based care throughout one patient’s care based on
additional factors not addressed in this study such as self-efficacy, 1. Feucht MJ, Cotic M, Saier T, et al. Patient expectations of primary and
funding, patient goals, and recovery progression may increase the revision anterior cruciate ligament reconstruction. Knee Surg Sports
likelihood of a successful outcome. Traumatol Arthrosc. 2016;24(1):201–207. doi:10.1007/s00167-014-
3364-z
Strengths and Limitations 2. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport
following anterior cruciate ligament reconstruction surgery: a sys-
This study’s strengths lie in its rigorous methodology, including the tematic review and meta-analysis of the state of play. Br J Sports
randomization process and blinding procedures. To our knowledge, Med. 2011;45(7):596–606. doi:10.1136/bjsm.2010.076364
this trial of staged versus traditional supervised physiotherapy is the 3. Lefevre N, Klouche S, Mirouse G, Herman S, Gerometta A, Bohu Y.
largest to date. However, despite enrolling an adequate number of Return to sport after primary and revision anterior cruciate ligament
participants into the study for our primary analysis, missing mid- reconstruction. Am J Sports Med. 2017;45(1):34–41. doi:10.1177/
point data required addressing through multiple imputation. Finally, 0363546516660075
our secondary analysis was underpowered for the dichotomization 4. Webster KE, Feller JA, Leigh WB, Richmond AK. Younger patients
of select outcome measures into acceptable and unacceptable levels are at increased risk for graft rupture and contralateral injury after
but was exploratory in nature. Wide confidence intervals indicate anterior cruciate ligament reconstruction. Am J Sports Med. 2014;
imprecise results among some outcomes which prevent us from 42(3):641–647. doi:10.1177/0363546513517540
concluding with certainty, that a stage rehabilitation protocol pro- 5. Kyritsis P, Bahr R, Landreau P, Miladi R, Witvrouw E. Likelihood of
vides similar outcomes to in-person, supervised rehabilitation. ACL graft rupture: not meeting six clinical discharge criteria before
Psychological factors such as perceived support, self-efficacy, return to sport is associated with a four times greater risk of rupture. Br J
confidence, and motivation are often discussed as important con- Sports Med. 2016;50(15):946–951. doi:10.1136/bjsports-2015-095908
founding factors, which may influence how effective a home-based 6. Nawasreh Z, Logerstedt D, Cummer K, Axe M, Risberg MA, Snyder-
or supervised rehabilitation program is for an individual patient.30 Mackler L. Functional performance 6 months after ACL reconstruc-
If such an approach is chosen, effective early education with clear tion can predict return to participation in the same preinjury activity

JSR Vol. 32, No. 8, 2023

Unauthenticated | Downloaded 04/30/25 05:07 PM UTC
 Staged Versus Usual Care Physiotherapy 893

level 12 and 24 months after surgery. Br J Sports Med. 2018; 21. Reid A, Birmingham TB, Stratford PW, Alcock GK, Giffin RJ.
52(6):375. doi:10.1136/bjsports-2016-097095 Hop testing provides a reliable and valid outcome measure during
7. Cavanaugh JT, Powers M. ACL rehabilitation progression: where are rehabilitation after anterior cruciate ligament reconstruction. Phys
we now? Curr Rev Musculoskelet Med. 2017;10(3):289–296. doi:10. Ther. 2007;87(3):337–349. https://academic.oup.com/ptj/article/87/
1007/s12178-017-9426-3 3/337/2742133
8. de Mille P, Osmak J. Performance: bridging the gap after ACL 22. Grant JA, Mohtadi NGH, Maitland ME, Zernicke RF. Comparison of
surgery. Curr Rev Musculoskelet Med. 2017;10(3):297–306. doi: home versus physical therapy-supervised rehabilitation programs
10.1007/s12178-017-9419-2 after anterior cruciate ligament reconstruction: a randomized clinical
9. Werstine M. Physiotherapy following ACL reconstruction protocol; trial. Am J Sports Med. 2005;33(9):1288–1297. doi:10.1177/03635
2015. Accessed September, 2022. https://www.fowlerkennedy.com/ 46504273051
wp-content/uploads/2023/03/PHYSIOTHERAPY-FOLLOWING- 23. Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg
ACL-RECONSTRUCTION-PROTOCOL-November-2015.pdf MA. Simple decision rules reduce reinjury risk after anterior cruciate
10. Wright RW, Preston E, Fleming BC, et al. ACL reconstruction ligament reconstruction: the Delaware-Oslo ACL cohort study. Br
rehabilitation: a systematic review part I. J Knee Surg. 2008;21(3): J Sports Med. 2016;50(13):804–808. doi:10.1136/bjsports-2016-
217–224. 096031.SIMPLE
11. Zhang JY, Cohen JR, Yeranosian MG, et al. Rehabilitation charges 24. Nawasreh Z, Logerstedt D, Cummer K, Axe MJ, Risberg MA,
associated with anterior cruciate ligament reconstruction. Sport Snyder-Mackler L. Do patients failing return-to-activity criteria at
Health. 2015;7(6):538–541. doi:10.1177/1941738115606878 6 months after anterior cruciate ligament reconstruction continue
12. Walker A, Hing W, Lorimer A. The influence, barriers to and demonstrating deficits at 2 years? Am J Sports Med. 2017;45(5):
facilitators of anterior cruciate ligament rehabilitation adherence 1037–1048. doi:10.1177/0363546516680619
and participation: a scoping review. Sports Med Open. 2020;6(1): 25. Welling W, Benjaminse A, Seil R, Lemmink K, Zaffagnini S, Gokeler
7. doi:10.1186/s40798-020-00258-7 A. Low rates of patients meeting return to sport criteria 9 months
13. Argent R, Daly A, Caulfield B. Patient involvement with home-based after anterior cruciate ligament reconstruction: a prospective longitu-
exercise programs: can connected health interventions influence dinal study. Knee Surg Sports Traumatol Arthrosc. 2018;26(12):
adherence? JMIR mHealth uHealth. 2018;6(3):8518. doi:10.2196/ 3636–3644. doi:10.1007/s00167-018-4916-4
mhealth.8518 26. Abbott JH, Schmitt J. Minimum important differences for the patient-
14. Han F, Banerjee A, Shen L, Krishna L. Increased compliance with specific functional scale, 4 region-specific outcome measures, and
supervised rehabilitation improves functional outcome and return to the numeric pain rating scale. J Orthop Sports Phys Ther. 2014;
sport after anterior cruciate ligament reconstruction in recreational 44(8):560–564. doi:10.2519/jospt.2014.5248
athletes. Orthop J Sport Med. 2015;3(12):770. doi:10.1177/232596 27. Svantesson E, Hamrin Senorski E, Webster KE, et al. Clinical out-
7115620770 comes after anterior cruciate ligament injury: panther symposium
15. Gamble AR, Pappas E, O’Keeffe M, Ferreira G, Maher CG, Zadro JR. ACL injury clinical outcomes consensus group. Knee Surg Sports
Intensive supervised rehabilitation versus less supervised rehabilita- Traumatol Arthrosc. 2020;28(8):2415–2434. doi:10.1007/s00167-
tion following anterior cruciate ligament reconstruction? A system- 020-06061-x
atic review and meta-analysis. J Sci Med Sport. 2021;24(9):862–870. 28. Jenkins SM, Guzman A, Gardner BB, et al. Rehabilitation after anterior
doi:10.1016/j.jsams.2021.03.003 cruciate ligament injury: review of current literature and recommenda-
16. Risberg MA, Lewek M, Snyder-Mackler L. A systematic review of tions. Curr Rev Musculoskelet Med. 2022;15:170–179.
evidence for anterior cruciate ligament rehabilitation: how much and 29. Higgins J, Chang J, Hoit G, Chahal J, Dwyer T, Theodoropoulos J.
what type? Phys Ther Sport. 2004;5(3):125–145. doi:10.1016/j.ptsp. Conventional follow-up versus mobile application home monitoring
2004.02.003 for postoperative anterior cruciate ligament reconstruction patients: a
17. Kruse LM, Gray B, Wright RW. Rehabilitation after anterior cruciate randomized controlled trial. Arthroscopy. 2020;36(7):1906–1916.
ligament reconstruction a systematic review. J Bone Jt Surg. 2012; doi:10.1016/j.arthro.2020.02.045
94-A(19):1737–1748. doi:10.5792/jkks.2011.23.2.69 30. Grant JA, Mohtadi NGH. Two- to 4-year follow-up to a comparison
18. Mehta SP, Fulton A, Quach C, Thistle M, Toledo C, Evans NA. of home versus physical therapy-supervised rehabilitation programs
Measurement properties of the lower extremity functional scale: a after anterior cruciate ligament reconstruction. Am J Sports Med.
systematic review. J Orthop Sports Phys Ther. 2016;46(3):200–216. 2010;38(7):1389–1394. doi:10.1177/0363546509359763
doi:10.2519/jospt.2016.6165 31. Uchino S, Saito H, Okura K, Kitagawa T, Sato S. Effectiveness of a
19. Higgins LD, Taylor MK, Park D, et al. Reliability and validity of the supervised rehabilitation compared with a home-based rehabilitation
International Knee Documentation Committee (IKDC) subjective following anterior cruciate ligament reconstruction: a systematic
knee form. Jt Bone Spine. 2007;74(6):594–599. doi:10.1016/j. review and meta-analysis. Phys Ther Sport. 2022;55:296–304. doi:
jbspin.2007.01.036 10.1016/j.ptsp.2022.05.010
20. Spadoni GF, Stratford PW, Solomon PE, Wishart LR. The evaluation 32. Ugutmen E, Ozkan K, Kilincoglu V, et al. Anterior cruciate ligament
of change in pain intensity: a comparison of the P4 and single-item reconstruction by using otogeneous hamstring tendons with home-
numeric pain rating scales. J Orthop Sports Phys Ther. 2004; based rehabilitation. J Int Med Res. 2008;36(2):253–259. doi:10.
34(4):187–193. doi:10.2519/jospt.2004.34.4.187 1177/147323000803600206

JSR Vol. 32, No. 8, 2023

Unauthenticated | Downloaded 04/30/25 05:07 PM UTC