Rehabilitation after anterior cruciate ligament and meniscal injuries: a best-evidence synthesis of systematic reviews for the OPTIKNEE consensus

Abstract

Objective: Synthesise evidence for effectiveness of rehabilitation interventions following ACL and/or meniscal tear on symptomatic, functional, clinical, psychosocial, quality of life and reinjury outcomes.

Design: Overview of systematic reviews with Grading of Recommendations Assessment, Development and Evaluation certainty of evidence.

Data sources: MEDLINE, EMBASE, CINAHL, SPORTDiscus and Cochrane Library.

Eligibility criteria: Systematic reviews of randomised controlled trials investigating rehabilitation interventions following ACL and/or meniscal tears in young adults.

Results: We included 22 systematic reviews (142 trials of mostly men) evaluating ACL-injured individuals and none evaluating isolated meniscal injuries. We synthesised data from 16 reviews evaluating 12 different interventions. Moderate-certainty evidence was observed for: (1) neuromuscular electrical stimulation to improve quadriceps strength; (2) open versus closed kinetic chain exercises to be similarly effective for quadriceps strength and self-reported function; (3) structured home-based versus structured in-person rehabilitation to be similarly effective for quadriceps and hamstring strength and self-reported function; and (4) postoperative knee bracing being ineffective for physical function and laxity. There was low-certainty evidence that: (1) preoperative exercise therapy improves self-reported and physical function postoperatively; (2) cryotherapy reduces pain and analgesic use; (3) psychological interventions improve anxiety/fear; and (4) whole body vibration improves quadriceps strength. There was very low-certainty evidence that: (1) protein-based supplements improve quadriceps size; (2) blood flow restriction training improves quadriceps size; (3) neuromuscular control exercises improve quadriceps and hamstring strength and self-reported function; and (4) continuous passive motion has no effect on range of motion.

Conclusion: The general level of evidence for rehabilitation after ACL or meniscal tear was low. Moderate-certainty evidence indicates that several rehabilitation types can improve quadriceps strength, while brace use has no effect on knee function/laxity.

Keywords: anterior cruciate ligament; exercise; knee; rehabilitation.

Figure 1

Flow diagram of study selection. RCT, randomised controlled trial; SR, systematic review.

Figure 2

Heatmaps displaying the overlap of individual trials that evaluated interventions (with moderate-certainty evidence) included in more than one systematic review. Includes all eligible systematic reviews, irrespective of whether they were included or excluded from data synthesis. Grey boxes indicate that an RCT was not included in the respective systematic reviews. * indicates that an RCT was not included in our data synthesis because the systematic reviews that assessed it were excluded from our data synthesis due to high risk of bias. RCTs, randomised controlled trials.

Figure 3

Risk of bias (RoB) summary. (A) Individual systematic review RoB scores. (B) Breakdown of the RoB across the four domains and overall RoB score. * indicates that an RCT was not included in our data synthesis because the systematic reviews that assessed it were excluded from our data synthesis due to high RoB. RCT, randomised controlled trial.

Figure 4

Evidence map for ACL rehabilitation interventions. Only the four most consistent outcomes reported across systematic reviews presented for clarity. CKC, closed kinetic chain; CPM, continuous passive motion; NM, neuromuscular; NMES, neuromuscular electrical stimulation; OKC, open kinetic chain.