The influence, barriers to and facilitators of anterior cruciate ligament rehabilitation adherence and participation: a scoping review

Key points

1. 01A longer duration of supervised rehabilitation is associated with more favourable post-operative outcomes.
2. 02The optimal frequency of supervised post-operative rehabilitation is unknown.
3. 03Moderately or minimally supervised rehabilitation appears at least as effective as high-frequency supervised rehabilitation.
4. 04Patients face psychological, environmental, personal and treatment-related barriers and facilitators, including fear of reinjury, self-motivation, social support and the therapeutic relationship.
5. 05Very few patients complete a full evidence-based programme, leaving many short of safe return-to-sport criteria.

How it was conducted

Design

Scoping review following PRISMA-ScR and the Arksey and O'Malley and Peters frameworks; no formal quality appraisal per scoping methodology

Search

PubMed, Embase, CINAHL, SPORTDiscus and Web of Science up to 18 July 2019; English-language articles only

Population

Patients undergoing ACL reconstruction with any graft type, across all rehabilitation timepoints

Screening

4532 citations, 1967 titles and abstracts and 180 full texts screened; single reviewer screening

Focus

Influence of adherence and participation on outcomes, plus barriers to and facilitators of rehabilitation

What they found

• 71 studies were included (19 reviews and 52 original studies), split into 44 on rehabilitation prescription and participation and 36 on barriers and facilitators.
• Across 20 original frequency studies (mean age 27.6), 13 of 20 found no significant difference by supervision frequency (7 RCTs, 5 retrospective, 1 prospective).
• 7 more recent studies associated moderate or high supervision with better patient-reported outcomes, proprioception, return to sport, Lysholm scores and satisfaction.
• 8 duration studies found that more than 6 months of supervised rehabilitation was associated with limb symmetry, return-to-sport criteria, hop symmetry, torque, agility and subjective outcomes; a delayed start of more than 1 month was negative.
• In patient-perspective themes, the therapeutic relationship was cited 4 times as a barrier and 7 as a facilitator (11 total), digital health 3 barrier and 8 facilitator (11 total), and group rehabilitation 3 barrier and 12 facilitator (15 total).

Limitations

• As a scoping review, no formal quality appraisal was done, and many included studies were of poor quality.
• Screening was carried out by a single reviewer and study categories were defined by the authors.
• No date limit was applied, so findings may not reflect contemporary practice, and outcome measures were highly heterogeneous.
• Most participants were over 25, activity levels were poorly reported, and there were no cost-benefit studies despite cost-effectiveness pressures.

Why it matters

For patients

Plan for a longer course of supervised rehab (well beyond the first few months) and expect that fear of reinjury, motivation and support from family and your therapist will strongly shape your recovery.

For clinicians

Prioritise duration and structured later-phase work (agility, landing, gym, on-field, return-to-sport) over chasing a specific session frequency, and actively address psychological and environmental barriers.

For readers

This is a broad map of the evidence rather than a graded recommendation: it shows longer supervised rehab is promising and the right frequency is still unsettled, calling for proper RCTs.