Variability in rehabilitation protocols following pediatric anterior cruciate ligament (ACL) reconstruction

Objectives: The objective of this study was to assess the variability of publicly available pediatric anterior cruciate ligament (ACL) reconstruction rehabilitation protocols produced by academic orthopedic surgery departments and children's hospitals. Methods: A web-based search was performed to identify rehabilitation protocols. Protocol and literature review guided the development of a comprehensive scoring rubric that was used to assess protocols for the presence and timing of postoperative adjunctive therapy and physical therapy recommendations. Results: A search of 180 academic orthopedic surgery programs and 250 children's hospitals identified 21 rehabilitation protocols. A majority of these protocols (90%) recommended postoperative adjunctive therapies such as bracing (81%), cryotherapy (43%), electrical muscle stimulation (24%), and/or continuous passive motion (14%). Several protocols (57%) recommended a specific weight-bearing status in the immediate postoperative period, but there was minimal consensus on that status. Conversely, there was more agreement amongst protocols that recommended strength exercises (52%); a majority of protocols suggested quad sets (91%), ankle pumps (73%), leg press (64%), and/or double-leg squats (55%). Ten protocols (48%) recommended initiation of stretches in the first week following surgery, and most commonly suggested patella mobilizations start at an average of 1.9 weeks postop (range 0-8 weeks). Twelve protocols (57%) discussed return to play, with an average recommended return to play at 7.5 months (range 3-11 months) postoperatively. However, few protocols recommended that patients get approval from their surgeon (19%) or pass specific tests (24%) prior to return to play. Conclusion: Few academic departments of orthopedic surgery or children's hospitals publish pediatric ACL reconstruction protocols online. Given the substantial variability observed amongst these protocols and recent findings that patients increasingly turn to the internet for medical information, this study suggests that standardization of pediatric ACL reconstruction rehabilitation has the potential to further optimize patient care.