Prehabilitation prior to anterior cruciate ligament reconstruction is a safe and effective intervention for short‐ to long‐term benefits: A systematic review

PURPOSE: Comprehensively explore current practices in preoperative rehabilitation (prehabilitation) for anterior cruciate ligament reconstruction (ACLR) and assess corresponding clinical outcomes and complication rates. METHODS: A systematic search of EMBASE, MEDLINE, Cochrane and PubMed was conducted from inception to 1 November 2024. All studies reporting outcomes and/or complications following prehabilitation and ACLR were included. Screening and data abstraction were designed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Revised Assessment of Multiple Systematic Reviews guidelines. RESULTS: Thirty-six studies with 2326 patients undergoing prehabilitation and ACLR were included. Weighted averages of all clinical outcomes met or surpassed patient acceptable symptom state (PASS) thresholds and return to sports (RTS) criteria. There were no preoperative complications following prehabilitation. Major post-operative complications included graft failure (4.6%), contralateral ACL rupture (1.0%), surgical site infection (0.6%), deep infection (0.4%), non-ACL ligament injury (0.5%), reoperation for hardware removal (0.3%), muscle rupture (0.1%), patellar subluxation (0.1%) and patellar rupture (0.1%). CONCLUSION: Current prehabilitation practices for ACLR emphasize impairment resolution, ROM restoration, and neuromuscular exercises. Safety of current practices is supported by the absence of preoperative complications and similar post-operative complication rates compared to patients undergoing standard care. Clinical outcomes of patients undergoing prehabilitation were shown to meet and surpass PASS thresholds and RTS criteria, expedite post-operative recovery, and maintain functional improvements up to 10 years post-operation, suggesting that prehabilitation is a safe and effective intervention yielding short- to long-term benefits. There is a need for further high-quality randomized controlled trials and large prospective cohort studies comparing the effect of prehabilitation on post-operative outcomes, reporting specific exercise details and protocol progression. LEVEL OF EVIDENCE: Level II.