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Improving the quality of rehabilitation following anterior cruciate ligament reconstruction surgery, in an outpatient physiotherapy department
  1. Michael Henning1,
  2. Rose Henning2,
  3. Joe Dummett2
  1. 1Orthopaedic Interface, Royal Devon University Healthcare NHS Foundation Trust, Barnstaple, UK
  2. 2Physiotherapy Outpatients, Royal Devon University Healthcare NHS Foundation Trust, Barnstaple, UK
  1. Correspondence to Michael Henning; mike.henning{at}


Anterior cruciate ligament reconstruction (ACLR) is a type of orthopaedic knee surgery and physiotherapy rehabilitation is undertaken for several months postoperatively, often with the aim of returning the patient to sport. Variations in postoperative protocols to guide rehabilitation exist between National Health Service (NHS) Trusts. Although there is no single guideline to guide clinicians, strong evidence does support several clinical measures to be included post-ACLR, to improve outcomes and reduce the need for revision surgery. This project aimed to align our NHS Trust’s ACLR physiotherapy care with best-evidence.

A literature review was completed to establish key quality standards for ACLR rehabilitation. A retrospective notes audit was then undertaken to quantify the baseline quality of care, measured against these standards. Quality improvement methods were used to improve the quality of care and postoperative rehabilitation processes for ACLR patients. A new evidence-based, postoperative rehabilitation protocol was created, a core group of clinicians was formed to see ACLR patients and a rehabilitation class, solely for ACLR patients was also implemented.

The key process measure for the project was patients engaging in ‘criteria-driven progressions of rehabilitation’. This ‘criteria-driven progressions’ rate increased from 0% at baseline to 100% during the project period. Overall, non-attendance rates maintained at a similar level from 5.4% at baseline to a final rate of 4.8%. There was also an increase in mean ‘return to sport’ times, from 6 to 9.9 months, which is in line with best-evidence recommendations.

The previous rehabilitation provided in our trust was not aligned with current evidence. This quality improvement project has led to improvements in patient care and lessons from the project will allow other trusts to learn from the changes made, to improve their own care pathways.

  • Clinical practice guidelines
  • Outpatients
  • PDSA
  • Quality improvement
  • Rehabilitation

Data availability statement

Data are available upon reasonable request. Data is available within the study itself or on request from the lead author.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • For optimal anterior cruciate ligament reconstruction (ACLR) care, evidence shows that outcomes are improved by a period of preoperative rehabilitation and criteria-driven postoperative rehabilitation. There was a lack of evidence demonstrating successful and reproducible examples of the process of such care being implemented in clinical practice, specifically in a National Health Service (NHS) setting.


  • Best-evidenced ACLR care can be successfully implemented in an NHS outpatient physiotherapy setting. This study outlines the steps taken to align our Trust’s ACLR care with best evidence, as well as the outcome and process measures we used as part of a quality improvement approach to the project.


  • The study highlights successes and challenges that can be expected on such a project. The study can be used as a guide on how to implement service changes for ACLR care.


Physiotherapy rehabilitation is paramount to a successful recovery from an anterior cruciate ligament reconstruction (ACLR) and for a return to sport.1 2 This project was based in the Royal Devon University Healthcare National Health Service (NHS) Foundation Trust (Northern) Musculoskeletal physiotherapy service. The service offers approximately 25 000 appointments per year and employs approximately 25 whole time equivalent outpatient physiotherapists.

Initially, feedback from an ACLR patient dissatisfied with their rehabilitation and perceived early discharge from our physiotherapy team prompted us to audit the current practices for ACLR patients. Discussions with the local orthopaedic knee consultant also highlighted concerns around the physiotherapy care of ACLR patients within our department. In addition, conversations within team meetings identified the rehabilitation of ACLR patients as an area where many clinicians lacked confidence.

An initial audit of ACLR patients from the previous 2 years revealed inconsistent advice on return to sport timing and a lack of outcome measures. Specifically, only 20% of patients had undergone a period of ‘prehabilitation’ before surgery, and 77% had achieved full knee extension by 4 weeks postoperation. Additionally, no patients had completed a psychological screening or readiness for return-to-sport questionnaire. Moreover, postoperative rehabilitation for ACLR patients was entirely time-based, with patients advancing to more challenging rehabilitation exercises according to preset time intervals, rather than based on evidence-based clinical criteria.

The aim of this project was:

To use evidence-based criteria-driven rehabilitation progressions for at least 75% of ACLR patients within 12 months.


Rupture of the anterior cruciate ligament (ACL) is a common knee injury in sporting populations.3 Conservative management should be trialled following ACL ruptures, with ACLR surgery being reserved for patients with persistent knee instability.4 In the UK’s NHS, approximately 15 000 ACLRs are performed each year, at a cost of £63 million.5 For most ACLR patients, the ultimate goal is to return to sport, and a criteria-driven approach to rehabilitation, rather than a time-based one, can improve these return-to-sport rates.6

In ACLR rehabilitation, there is no single protocol for clinicians to follow, and clinicians are often bound by local consultant-led protocols.2 However, though variations exist between different best-practice guidelines for ACLR rehabilitation, there is consensus on several key factors to be included in a postoperative rehabilitation programme.2

The duration of ACLR rehabilitation has been shown to affect the outcome, with guidelines recommending at least 6–9 months of physiotherapy following the surgery to improve return-to-sport rates, reduce the rates of graft failure and decrease the chances of long-term joint problems.2 Compliance with such a lengthy programme of postoperative rehabilitation has been previously highlighted,7 8 so ‘did not attend’ (DNA) rates could be expected to rise if rehabilitation periods are extended.

To the authors’ knowledge, no UK-based studies have investigated the confidence of physiotherapists in ACLR rehabilitation or conducted a quality improvement project to enhance ACLR care.


Initial data collection focused on key clinical standards, agreed after the project group had reviewed current evidence and best-practice guidelines. Baseline data was collected by requesting all ACLR operation details from the orthopaedic team in the trust, and auditing the physiotherapy notes for those that were referred to our department prior to ACLR surgery or immediately postoperatively. We chose to audit ACLR patients from 2018 to 2019. Prior to this, there was a different orthopaedic consultant and postoperative protocol used. Additionally, staffing turnover means that notes taken prior to 2018 would likely not reflect current practice. In this period, 30 complete sets of notes were available for audit. All baseline data is shown in table 1.

Table 1

Baseline data

Research has shown that rates of re-injury are reduced if return to sport is delayed until at least 9 months postoperation9 and therefore the time the patient returned to sport was also chosen as the outcome measure for this project. DNA rates and compliance with rehabilitation are associated with clinical outcomes.7 8 If the rehabilitation process was likely to increase, in line with the aforementioned research, then DNA rates may also have been expected to increase.

The key focus of the project was to improve our rehabilitation of ACLR patients, particularly in terms of progressing the rehabilitation based on evidence-based criteria, rather than time since surgery. Criteria-driven rehabilitation is recommended to improve clinical outcomes and the criteria set in the programmes use batteries of strength and function tests to help determine appropriateness for exercise progressions.1 2 This means key clinical criteria must be met, before moving on to the next, more challenging, stage of rehabilitation. This criteria includes factors such as range of motion, performance on specific agility tests and symmetry on strength testing.

One specific example of this ‘criteria driven’ rehabilitation is ‘restoration of full knee extension by 4 weeks postoperation’ which has been shown to be a key factor associated with a successful clinical outcome.10–12

An additional measure was whether patients had engaged in a period of ‘prehabilitation’, to improve flexibility and strength prior to surgery, as this has also been shown to affect clinical outcomes.2 13

As well as clinical objective measures, there is also strong evidence that psychological factors such as fear avoidance, kinesiophobia and also patient-reported readiness to return to sport are all shown to be associated with outcome.2 14 15


A project team consisted of the two lead authors as representative of the physiotherapy outpatient team, along with another senior outpatient physiotherapist, the lead orthopaedic consultant, the orthopaedic interface clinical lead, as well as representatives from the Trust’s quality improvement (QI) team. The whole group met at project initiation and again 6 months later. In between, the key group of three physiotherapists met on a six weekly basis to monitor the change processes.

The focus of the project centred around the development of a new postoperative rehabilitation protocol, to guide patients and clinicians in ACLR management. This was to be more in line with the current evidence-base and be focused on criteria-driven rehabilitation.

The primary process measure for the project was:

Additionally, the following secondary process measures were audited:

  • Period of prehabilitation.

  • Completion of psychological screening and readiness for return to sport questionnaires.

The main outcome measures for the project were:

  • Time for return to sport.

  • Full extension by 4 weeks postoperation.

As the proposed rehabilitation process was longer than preintervention, DNA percentage was the balance measure for this project.


The project aimed to improve the quality of care for new ACLR patients by implementing evidence-based criteria-driven progressions for at least 75% of patients within 12 months. The project used a plan, do, study, act (PDSA) cycle approach to test different change ideas.

Baseline audit

Our initial objective was to complete a review and appraisal of the research and best-practice guidelines. This would provide the key measures used to audit quality of care. It was also aid in the development of a new post-ACLR rehabilitation protocol focused around criteria-driven progressions.

PDSA cycle 1

A team of core clinicians within the department was chosen, from expressions of interest. This was a group of six clinicians, across four outpatient sites within the trust (included the initial three project physiotherapists). Given the relatively low number of ACLR surgeries done locally, the perceived lack of confidence in the wider team and the fact clinicians saw ACLR patients so infrequently, the decision was made that all ACLR patients would only be referred for their rehabilitation with one of the core team. There was an improvement in our primary process measure after this change, with 50% of ACLR patients engaging with criteria-driven progressions.

At this point, some clinicians were still using the old postoperative protocol. It was also clear due to our referral vetting procedures, that some patients were still being seen by clinicians outside of the core team. Following this, we made greater efforts to periodically liaise with the Orthopaedic secretaries to update us with any planned ACLR procedures so we could pre-empt any referral and mark them for one of the core team. We also reminded the outpatient team of the importance of highlighting any ACLR patients to be seen only by the core team on the electronic vetting system. Finally, working with the admin team to update them on the project and the role of the core team, improved the process further.

PDSA cycle 2

Once the ACLR protocol was signed off by all relevant stakeholders and officially replaced the previous protocol, the project group completed a training session to help explain key components of the protocol and answer any questions from the team. Ultimately, following this change, 67% of ACLR patients were observed to be completing criteria-driven progressions. On discussion with the core team, it seemed some clinicians were still using the old time-driven protocol and still lacked confidence in implementing the new protocol.

PDSA cycle 3

For our final test cycle, two classes were set up at the two biggest outpatient departments, exclusively for ACLR patients. This was partly in response to patient feedback and partly for capacity reasons. Given the longer than average duration of rehabilitation for ACLR patients, seeing them on a one-to-one basis for 6–9 months would significantly impact on department capacity. We anticipated that this would further standardise the quality of care for ACLR patients and we expected to see a further improvement in our process measure. This cycle also involved further communication about the class with physiotherapy administrative staff, the orthopaedic teams and also fellow physiotherapy clinicians. This was to reinforce the pathway and also encourage referrals, ideally preoperatively for prehabilitation. Following this change, the rate of ACLR patients engaging with criteria-driven progressions increased to 100%.


Our main process measure and the focus of the whole project was to align with best-evidence for ACLR rehabilitation and specifically criteria-driven progressions of rehabilitation. The changes implemented led to significant improvements in this (now 100% engaging in criteria-driven progressions), compared with our baseline, and these changes have been sustained.

As figure 1 shows, the primary ‘criteria-driven progressions’ measure improved significantly, although two secondary measures; ‘prehabilitation’ and ‘psychological screening and readiness for return to sport questionnaires’ only improved to 50%. Time constraints was the main reason given for this modest increase in questionnaire completion by our core team of ACLR clinicians, as the questionnaires take a few minutes each to complete. Regarding ‘prehabilitation’, our processes are still quite manual, in the sense that the core team relies on an orthopaedic secretary flagging appropriate planned ACLR patients to us. Going forwards, more automated processes will hopefully improve this score.

Figure 1

Run chart for process measures. PDSA, plan, do, study, act.

One of the outcome measures for the project was mean return to sport time after ACLR. Mean return to sport time increased from a mean of 6 months to 9.9 months. These have maintained since then, at approximately 9.5 months, which is in line with best-practice guidelines.1 2 The other outcome measure, ‘full extension by 4 weeks’ increased from a baseline of 77%–100%.

The balance measure for the project was DNA rates, which maintained at a similar level from baseline (5.4%), to a final level of 4.8%. This is in line with the average DNA rate of the department, and lower than we expected given the long and arduous nature of the rehabilitation process following ACLR. There is no data available for regional or national benchmarks for this figure.

Lessons and limitations

The overall aim of the project was to align our post-ACLR rehabilitation with the best current evidence. Overall, the project has been a success with improvements in all quantitative measures. Using PDSA cycles ensured we stopped to reflect on each small change idea, to ensure it was contributing to the overall purpose of the project. The sample of patients is low (n=16), largely because elective surgeries such as ACLR were cancelled or delayed for such long periods of this project period due to the COVID-19 pandemic.

We observed similar DNA rates prechange and postchange. However, on reflection, we feel we could have been more creative with solutions to tackle this problem. For example, using more patient-initiated follow ups towards the late stages of rehabilitation, when DNAs were more frequent. Alternatively, using virtual appointments or using text-reminders routinely, could have improved this score further. Anecdotally, DNA rates have been higher in patients not wanting to return to competitive sport; this is something we want to investigate with data analysis. If correct, then for these particular patients, better education on the long-term implications (specifically joint health) of rehabilitation compliance, may also improve DNA rates.

As part of our second PDSA cycle, a training session was completed. Subjectively, feedback was positive for the session in terms of understanding around the new protocol. However, no formal evaluation, either through survey feedback or through an objective measure of knowledge, was completed.

We met as a group every 6–8 weeks and continue to do so, although this has reduced to quarterly on average; somewhat because of waitlist and operational pressures. This has been helpful to continue, for support and advice, as well as keeping momentum for the project.

In terms of data collection, a frustration of the team has been having to manually complete outcome measures and questionnaires on paper with patients and then get them scanned on to our IT system, which is time consuming. This may explain the modest improvement in completion rates of psychological screening and readiness for return to sport questionnaires. Additionally, all the core clinicians are asked to input as much of the quantitative data (ie, as per baseline measures) at the point of discharging their ACLR patients, which again is onerous. Digital solutions, such as electronic outcome measure collection and smarter IT audit capability would have reduced these burdens for the clinicians. Additionally, more admin/clerical support for such tasks would also improve the process.

It was extremely helpful to identify key stakeholders at the start of the project and engage them with the motivation for the project. As the project progressed, it would have been helpful to have updated certain stakeholders, for example, orthopaedic team, both for their information, but also for their feedback and advice. Our current system does not feel robust, in that it very much depends on the orthopaedic secretary flagging planned ACLR patients to us in advance. Going forward, we want to work with our IT support teams to identify any ACL patient (whether they are conservatively or surgically managed) automatically on our electronic medical record, to make the process more reliable and seamless.

Adapting the ACLR process, so these patients are exclusively seen by a core group of clinicians led to improvements in our key measures, as already discussed. However, while the improvements have been sustained to date, this model of working potentially leaves us vulnerable for the future. For example, if one or two of such a small team leaves, then the pathway for these patients is significantly impacted. Going forwards, it may be better to rotate some of the core clinicians, to gradually train more of the wider team, to provide a more resilient and robust system.

We managed to get patient feedback and advice when writing the postoperative ACLR protocol and again with our ACL class design/structure. However, it would have been helpful to have sought patient and public involvement throughout the whole project, for example, when prioritising the next change idea. Furthermore, another important balance measure for ACLR patients is re-injury and revision surgery rates, which we did not and currently do not audit.

The very process of collecting data and completing patient-recorded outcome measures is progress in itself for the group, and for the department. At baseline, we collected no outcome measures, screening tools or questionnaires. Therefore, we did not have a clinical outcome scores to use as a comparison for this project, which is another limitation. However, we now collect and record much more quantitative clinical data, which can be used more meaningfully in the future.

Overall, the project has been engaging for the team, and satisfaction within the core team is high. However, the scope of the project was bound somewhat by our initial lack of data. Specifically, we initially wanted to audit and subsequently improve the care of all ACL patients, whether conservatively or surgically managed. However, as our department did not code any patient records by diagnosis, we had no way knowing what ACLs had been seen in our department. The only data we could get was ACLR patients, as the orthopaedic and theatre teams had lists of these. Thus, this became the focus of the project. Nevertheless, in reality, all ACL patients, whether managed surgically or conservatively, have ended up being seen and managed by the core team anyway, but for the purpose of the project we only ever had the baseline data on ACLR patients. In 2022, the trust has implemented a new electronic patient record, and so going forwards searches by diagnosis and baseline audits should be much easier to undertake.


High quality, recent evidence has shown that patient outcomes after ACLR are significantly improved by engaging for 6–9 months postsurgery, in criteria-driven rehabilitation.2 Our initial audit had shown that our practice prior to the project did not align with this best-practice recommendation. Our overall aim was to deliver criteria-driven rehabilitation progressions for 75% of ACLR patients by 12 months, which we successfully achieved. Data collection continues on an ongoing basis thanks to the work of the core ACL team and shows that this target is still being met.

Our project lacked formal patient and staff satisfaction questionnaires, although anecdotal evidence for both factors has strongly suggested a positive response to the project.

Though detailed cost analysis was not undertaken, we were able to demonstrate that a longer period of evidence-based rehabilitation is possible, without impacting on whole-service capacity. The rate of one-to-one appointments per patient has not changed from the baseline period; the baseline 30 patients had on average six one-to-one appointments each and just over three class appointments each. The comparator 16 patients also had 6 one-to-one appointments each, but almost 11 class appointments. Thus, the project has largely been delivered by increased use of classes and optimising class sizes.

Overall, a significant improvement in the quality of care for ACLR patients has been demonstrated, with tangible benefits to patient care evident. The project has also improved communication between different professional groups in our trust; for example, the orthopaedic consultant and physiotherapy outpatient team. This will hopefully lead to more collaboration in the future, and the skills developed within the project team will cascade down to other team members in other projects going forward.

Work is being done to improve the efficiency of our processes. For example, we are looking into software that can integrate with our trust’s electronic patient record, to automatically send, collect and analyse outcome measures and screening questionnaires, used by the whole department not just the core ACL team.

Up to this point, we are not aware of any other similar published ACLR rehabilitation quality improvement projects. This project, in terms of structure and processes, represents a sustainable and successful intervention that may be replicated in other trusts.

In the future, locally the project would benefit from expanding to encompass ACL patients from the point of diagnosis and through their management, whether that is conservative or surgical. Coproduction of any changes, alongside patients, will also ensure that future changes are meaningful and relevant at a patient level.

Data availability statement

Data are available upon reasonable request. Data is available within the study itself or on request from the lead author.

Ethics statements

Patient consent for publication

Ethics approval

Royal Devon University Healthcare NHS Foundation Trust approved completion of the project and for submission of this report.


The authors would like to thank the other clinicians who worked as part of the wider project team: Jon Ballaman, Laura Davis, Ros Hebard, Archie Baker and Karan Plank; all based at Royal Devon University Healthcare NHS Foundation Trust, Physiotherapy Outpatients, North Devon District Hospital Barnstaple, Devon, UK EX31 4JB. The authors are grateful for the project support and guidance from Rebecca Fox, Therapy Research and Innovation Lead, Royal Devon University Healthcare NHS Foundation Trust, North Devon District Hospital Barnstaple, Devon, UK EX31 4JB. Finally, the authors would like to thank Will Griffiths-Jones (Orthopaedic Consultant), Darren West (Physiotherapy Outpatients Clinical Lead) and Gethin Lynch (MSK Consultant Physiotherapist) for their ongoing support for the project (all based at Royal Devon University Healthcare NHS Foundation Trust, North Devon District Hospital Barnstaple, Devon, UK EX31 4JB).



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  • Contributors MH conceptualised the project, performed the data analysis and prepared the manuscript. MH is the guarantor and accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish. RH and JD validated the data and reviewed the manuscript. RH and JD were the lead supervisors for the project and implementation of the changes.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.