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

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.