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ACL rehabilitation after reconstruction: Evidence‐based consensus recommendations from the German Knee Society—Part IV

German Knee Society (DKG) · 2026 · Europe

Source and licence

Authors
Martin Häner, Wolf Petersen, Arthur Praetorius et al.
Title
ACL rehabilitation after reconstruction: Evidence‐based consensus recommendations from the German Knee Society—Part IV
Journal
Journal of Experimental Orthopaedics, 2026
DOI
10.1002/jeo2.70875
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC13431688

Licence statement of the original publication

This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

Open the original publication →Full text on Europe PMC

Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

RESULTS

  • 1Partial weight bearing for 2 weeks after isolated ACL reconstructionLevel of evidence: B2; Certainty: Moderate
  • 2Extended partial weight bearing in presence of concomitant injuriesLevel of evidence: C; Certainty: Low
  • 3Unsupervised rehabilitationLevel of evidence: B2; Certainty: Moderate
  • 4Combination of supervised and unsupervised rehabilitationLevel of evidence: A2; Certainty: Moderate
  • 5Rehabilitation duration of at least 9 monthsLevel of evidence: A1; Certainty: High
  • 6Completion of rehabilitation based on functional criteriaLevel of evidence: A1; Certainty: Moderate
  • 7Postoperative psychological and social interventionsLevel of evidence: E; Certainty: Very low
  • 8Hard‐frame knee braces after isolated ACL‐RxLevel of evidence: B1; Certainty: Moderate
  • 9Hard‐frame knee braces with concomitant meniscus injuryLevel of evidence: C; Certainty: Low
  • 10Kinesiotaping (KT) in early phaseLevel of evidence: B2; Certainty: Low
  • 11Cryotherapy during first 3 daysLevel of evidence: A2; Certainty: Moderate
  • 12Continuous passive motionLevel of evidence: A2; Certainty: Moderate
  • 13Extracorporeal shockwave therapyLevel of evidence: B2; Certainty: Low
  • 14Digital applications for rehabilitationLevel of evidence: B1; Certainty: Moderate
  • 15Neuromuscular electrical stimulation (NMES)Level of evidence: A1; Certainty: Moderate
  • 17Blood flow restriction with low‐load resistance trainingLevel of evidence: A1; Certainty: Moderate
  • 18Whole‐body vibration trainingLevel of evidence: B2; Certainty: Low
  • 19Dry needling in early rehab phaseLevel of evidence: C; Certainty: Very low
  • 20Early open kinetic chain exercises from Week 4Level of evidence: A2; Certainty: Moderate
  • 23High‐intensity trainingLevel of evidence: B2; Certainty: Moderate
  • 24Proprioceptive trainingLevel of evidence: B2; Certainty: Moderate
  • 26Cross‐education trainingLevel of evidence: C; Certainty: Low
  • 27Core stability exercisesLevel of evidence: C; Certainty: Low
  • 29Neurocognitive trainingLevel of evidence: C; Certainty: Low

Postoperative weight bearing

  • Statement 1Based on moderate‐certainty evidence, partial weight bearing for 2 weeks is reasonable due to a trend toward increased tunnel widening, while revision rates are not significantly elevated.GRADE Evidence category: B2
  • Statement 2Based on low‐certainty evidence, extended partial weight bearing (>2 weeks) may be considered in the presence of concomitant injuries, such as cartilage, collateral ligament or meniscus lesions.GRADE Evidence category: C

Unsupervised versus supervised rehabilitation

  • Statement 3Based on moderate‐certainty evidence, unsupervised rehabilitation might be equivalent to supervised rehabilitation.GRADE Evidence category: B2
  • Statement 4Based on moderate‐certainty evidence, a combination of supervised and unsupervised rehabilitation likely improves outcomes.GRADE Evidence category: A2

Rehabilitation duration

  • Statement 5Based on moderate‐certainty evidence, rehabilitation programmes should last at least 9 months, depending on patient intensity and progress.GRADE Evidence category: A1
  • Statement 6Based on moderate‐certainty evidence, completion of rehabilitation should be based on functional criteria rather than time alone.GRADE Evidence category: A1

Psychological and social interventions

  • Statement 7Based on very low‐certainty evidence, postoperative psychological and social interventions might improve outcomes, but cannot be generally recommended.GRADE Evidence category: E

Knee braces

  • Statement 8Based on moderate‐certainty evidence, hard‐frame knee braces are generally not required after isolated ACL reconstructionGRADE Evidence category: B1
  • Statement 9Based on low‐certainty evidence, hard‐frame braces may be considered after ACL reconstruction with concomitant meniscus injury.GRADE Evidence category: C

Kinesiotaping (KT)

  • Statement 10Based on low‐certainty evidence, KT may reduce pain and swelling in the early phase after ACL reconstruction, but effects are inconsistent.GRADE Evidence category: B2

Cryotherapy/Compressive cryotherapy

  • Statement 11Based on moderate‐certainty evidence, cryotherapy is recommended during the first 3 days after ACL reconstruction; compressive cryotherapy may be more effective.GRADE Evidence category: A2

Continuous passive motion (CPM)

  • Statement 12Based on moderate‐certainty evidence, CPM cannot be routinely recommended after ACL reconstruction.GRADE Evidence category: A2

Extracorporeal shockwave therapy (ESWT)

  • Statement 13Based on low‐certainty evidence, ESWT cannot be recommended for rehabilitation after ACL reconstruction.GRADE Evidence category: B2

Digital applications

  • Statement 14Based on moderate‐certainty evidence, digital applications can effectively support pre‐ and postoperative rehabilitation after ACL reconstruction and likely improve KOOS scores and pain outcomes.GRADE Evidence category: B1

Neuromuscular electrical stimulation (NMES)

  • Statement 15Based on moderate‐certainty evidence, NMES can be recommended after ACL reconstruction.GRADE Evidence category: A1

Electromyographic biofeedback (EMG FB)

  • Statement 16Based on moderate‐certainty evidence, EMG biofeedback can be recommended after ACL reconstruction.GRADE Evidence category: A1

Blood flow restriction training (BFR)

  • Statement 17Based on moderate‐certainty evidence, BFR combined with low‐load resistance training can be recommended after ACL reconstruction.GRADE Evidence category: A1

Whole‐body vibration training

  • Statement 18Based on low‐certainty evidence, whole‐body vibration training cannot be generally recommended after ACL reconstruction.GRADE Evidence category: B2

Trigger point dry needling (TrP‐DN)

  • Statement 19Based on very low‐certainty evidence, dry needling might improve early quadriceps function and can be considered as an adjunct therapy.GRADE Evidence category: C

Open and closed kinetic chain exercises (OKC and CKC exercises)

  • Statement 20Based on moderate‐certainty evidence, early OKC exercises from Week 4 likely improve quadriceps strength after ACL reconstruction.GRADE Evidence category: A2

Eccentric training

  • Statement 21Based on moderate‐certainty evidence, eccentric exercises may be incorporated as part of rehabilitation after ACL reconstruction.GRADE Evidence category: B2

Isokinetic training

  • Statement 22Based on moderate‐certainty evidence, isokinetic training can be recommended for strength recovery, especially in the early and mid rehabilitation phases after ACL reconstruction.GRADE Evidence category: B2

Low‐ versus high‐intensity resistance training

  • Statement 23Based on moderate‐certainty evidence, high‐intensity training can be used during rehabilitation and likely improves muscle strength without compromising joint stability.GRADE Evidence category: B2

Proprioceptive training (PT)

  • Statement 24Based on moderate‐certainty evidence, proprioceptive training should be included in rehabilitation as it likely improves strength and sensorimotor function.GRADE Evidence category: B2

Plyometric training

  • Statement 25Based on moderate‐certainty evidence, plyometric training can be integrated into rehabilitation after ACL reconstruction.GRADE Evidence category: B2

Cross‐education training (CE)

  • Statement 26Based on low‐certainty evidence, CE cannot currently be recommended due to conflicting results.GRADE Evidence category: C

Core stability training

  • Statement 27Based on low‐certainty evidence, core stability exercises can be integrated into rehabilitation after ACL reconstruction.GRADE Evidence category: C

Aquatic therapy

  • Statement 28Based on moderate‐certainty evidence, aquatic therapy can be used in the early phase after wound healing to likely improve subjective knee function.GRADE Evidence category: B1

Neurocognitive training

  • Statement 29Based on low‐certainty evidence, neurocognitive training can be integrated as an additional intervention in ACL reconstruction rehabilitation.GRADE Evidence category: C

Abstract

Purpose: The aim of this consensus was to provide evidence‐based recommendations for individual rehabilitation interventions following anterior cruciate ligament reconstruction. These recommendations are intended to complement, rather than replace, comprehensive criterion‐based rehabilitation protocols.

Methods: A modified Delphi process conducted by the German Knee Society evaluated 29 rehabilitation topics. Evidence from systematic reviews, randomized controlled trials and prospective cohort studies (A1‐C) was summarized and rated by an expert panel. Consensus was defined as ≥80% agreement between raters. Statements were graded using the Grading of Recommendations Assessment, Development and Evaluation framework, specifying the certainty of evidence.

Results: Consensus was achieved for 25 topics (86%). Moderate‐certainty evidence (B2) indicates that early weight bearing likely results in safe functional recovery. Supervised and unsupervised exercise (A2–B2) likely results in improved strength and function. Rehabilitation lasting ≥9 months (A1) likely results in optimal recovery guided by functional progress. Neuromuscular training (A1) and proprioceptive training (B2) likely improve sensorimotor control and functional outcomes. Plyometric (B2) and eccentric exercises (B2), as well as blood flow restriction (A1), likely result in enhanced quadriceps strength and muscle mass. Core stability exercises (C) and aquatic therapy (B1) likely improve knee function and facilitate early return to activity. Adjunctive modalities, such as cryotherapy (A2), likely reduce pain and swelling; KT (C) and digital applications (B1) may improve early‐phase outcomes. Interventions such as whole‐body vibration training (B2) and cross‐education (C) showed inconsistent or insufficient benefits. Rehabilitation should be individualized according to patient‐specific factors, concomitant injuries and functional progress.

Conclusion: These consensus recommendations provide a multimodal, evidence‐based framework for anterior cruciate ligament rehabilitation. Following these recommendations likely reduces variability in clinical practice, supports safe return to sport and might lower the risk of re‐injury.

Level of Evidence: Level V, expert consensus.

Contents of the original publication

The section headings of the original.

  • INTRODUCTION
  • MATERIALS AND METHODS
  • Statistical analysis
  • RESULTS
  • A. General aspects of rehabilitation
  • B. Assistive devices
  • C. Exercise‐based training therapy
  • DISCUSSION
  • CONCLUSION

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