Extended Preoperative Rehabilitation: Does It Influence Return to Sport After Surgery?

Preoperative rehabilitation refers to a period of extended rehabilitation prior to surgery that goes beyond basic impairment resolution to improve outcomes after surgery. Successful post-surgical outcomes are influenced by the functional status of the knee joint prior to surgery. Clinicians and researchers from the Delaware-Oslo cohort implement a progressive, extended preoperative rehabilitation program that focuses on neuromuscular training, progressive strengthening, and plyometric and agility training. The program consists of a series of 10 rehabilitation sessions, at least two times per week, with a goal of achieving specific preoperative milestones prior to anterior cruciate ligament reconstruction (ACLR). After extended preoperative rehabilitation and ACLR, athletes should progress through criterion-based postoperative rehabilitation milestones and meet stringent, performance-based measures (at least 90% quadriceps index, 90% limb symmetry index (LSI) on four hop tests, and 90% on Knee Outcome Survey Activities of Daily Living Scale and Global Rating of Perceived Function) prior to receiving return to sport (RTS) clearance. We recommend delaying return to level I sports, those involving jumping, cutting, or pivoting, until at least 9 months after ACLR to reduce the risk of reinjury. Our research from the Delaware-Oslo cohort indicates that extended preoperative rehabilitation plus criterion-based postoperative rehabilitation, compared to criterion-based postoperative rehabilitation alone, results in higher patient-reported outcomes and RTS rates 2 years after ACLR. Extended preoperative rehabilitation, described in detail in this chapter, may be a critical component to improve functional and RTS outcomes as well as reduce secondary injury rates after ACLR.