Guided Prehabilitation Before ACL Reconstruction Shows Small Benefit

Key Takeaways

• Guided, criteria-based prehabilitation was associated with a more pronounced preoperative KOOS improvement, with reported differences extending to surgery day and 60 days after surgery.
• Several secondary measures did not differ between groups over time, while selected functional tests and KOOS subscales favored different groups at specific intervals.
• Engagement was broadly similar, no serious adverse events were reported, and the investigators urged caution because baseline KOOS values differed and attrition was substantial.

In a randomized trial of guided prehabilitation before ACL reconstruction, 114 participants showed somewhat greater gains in self-reported knee function than those using self-directed home training. Patients were followed from hospital assessment to 180 days after surgery, with the clearest difference seen in the KOOS primary outcome. The advantage was modest rather than definitive.

This monocentric, prospective, single-blinded randomized controlled trial used 1:1 block randomization. Participants were 16 to 60 years old, had unilateral complete primary ACL rupture confirmed clinically and by MRI, and were scheduled for arthroscopically assisted anatomic reconstruction using hamstring or quadriceps tendon autograft. The guided arm received individually tailored, adaptive, criteria-based prehabilitation with two 60-minute supervised sessions each week in a medical rehabilitation centre plus weekly home exercises. The comparator arm used a six-exercise brochure for self-administered training three times weekly, and both groups later received the same standardized postoperative rehabilitation. The comparison centered on preoperative supervision intensity rather than postoperative care, which was standardized in both groups.

KOOS sum score was the primary outcome, and secondary outcomes included range of motion, knee flexor and extensor strength, calf raise testing, Y-Balance, countermovement jump, ACL-RSI, and Tegner score. Assessments took place at hospital anamnesis, 1 to 7 days before surgery, on surgery day, and at 30, 60, 90, and 180 days after surgery, with at least three weeks of preoperative training. In the guided arm, baseline KOOS was 46.04 and increased to 58.52 before reconstruction, while the comparator moved from 51.01 to 59.18. In the KOOS findings after ACL reconstruction, group-by-time interactions differed for change to surgery day and 60 days postoperatively, both p=0.039. The separation remained small and was harder to interpret because the guided group started with lower KOOS scores.

No significant effects were found for extension deficit, flexion deficit, ACL-RSI, countermovement jump, or isokinetic testing, and psychological readiness did not differ between groups over time. Selected interaction effects pointed in different directions, with calf raise and the symptoms subscale favoring the comparator, while Y-Balance, activity, and several quality-of-life intervals favored the guided arm. Supervised-session adherence averaged 6.38 sessions, compared with 6.75 self-administered sessions, although the home program showed a far wider range of participation. Overall, 58 participants discontinued intervention or dropped out, and age and gender influenced some outcomes. Completion and engagement were uneven across both groups.

No serious adverse events were reported during the trial. Meniscus repair surgery led to exclusion in 7 participants, while acute infections, a fall, and pain-related inability to complete some assessments contributed to interruptions or missed visits. The investigators described the effects as small and noted that lower baseline KOOS values gave the guided group more room to improve. They also noted that added clinical contact, high dropout, and travel burden complicated interpretation. The randomized comparison suggested modest preoperative KOOS gains with guided training, while imbalance and attrition limited any stronger superiority claim.