Young adults experiencing persistent knee pain 9 to 36 months after anterior cruciate ligament (ACL) repair surgery achieve significantly greater functional relief from a structured, physiotherapist-supervised physical therapy program than from self-directed rehabilitation, according to a randomized trial published in the Annals of Internal Medicine.
Supervised Rehab Program Improves KOOS Scores at Four Months
The 184-patient trial demonstrated that a supervised exercise and education program improved Knee Injury and Osteoarthritis Outcome Score (KOOS) values by 14.1 points after 4 months. In comparison, patients in the self-managed control group achieved a 9.4-point improvement, establishing a mean difference of 4.8 points with a 95% confidence interval ranging from 1.4 to 8.2. Adam Culvenor, PhD, of La Trobe University in Bundoora, Australia, and his research colleagues led the study, which evaluated patients aged 18 to 40 who had undergone ACL surgery between 9 and 36 months prior and registered baseline KOOS scores below 80 on a 100-point scale where higher values indicate better joint health.
The intervention protocol required participants to complete physiotherapist-led leg and neuromuscular exercises for 30 to 60 minutes twice weekly during the first 4 months, supplemented by a once-weekly unsupervised session. The program also incorporated 45- to 60-minute education sessions at weeks 1 and 4. Conversely, the control group received a single 30-minute education session at baseline along with an instructional booklet detailing home exercises. Control participants were permitted one phone call to a physiotherapist to ask questions but received no further medical staff assistance.
Twelve-Month Follow-Up Shows Convergence Between Treatment Groups
By month 12, the performance gap between the cohorts narrowed as the self-managed control group largely caught up with the supervised participants. Researchers documented a change from baseline KOOS scores of 15.8 points for the supervised group and 14.5 points for the control group at the 1-year mark. Despite the convergence at 12 months, a greater proportion of patients in the supervised program achieved clinically significant functional relief.
All patients assigned to the supervised program completed the initial 4-month intervention, whereas six participants in the control group were lost to follow-up. An additional five patients from each group were lost by month 12. Statistical analyses utilized an intention-to-treat approach incorporating all available data. The study population averaged approximately 30 years of age, with women accounting for just under 40% of the cohort. Baseline KOOS scores averaged 64, and a mean of 2.3 years had elapsed between the original surgery and study enrollment.
Clinical Implications for Post-Surgical ACL Care
Reconstruction remains the standard of care for severe ACL tears. While the procedure is effective, persistent pain, activity limitations, and early-onset osteoarthritis remain common among younger patients. Prior to this trial, clinical guidelines lacked evidence-informed recommendations for managing patients who continued to experience disability months after their procedure, a window defined as the transition period to posttraumatic osteoarthritis when it may still be prevented.
With the 4-month results designated as the primary efficacy measure, the study authors concluded that physiotherapist-supervised exercise therapy and education is safe and should be recommended to improve knee health in individuals suffering from persistent problems following ACL repair. An accompanying editorial written by Jeffrey Driban, PhD, of the UMass Chan Medical School in Worcester, Massachusetts, and Matthew Harkey, PhD, of Michigan State University in East Lansing, supported these findings, emphasizing that the trial provides a low-risk intervention strategy that aligns with independent consensus recommendations for patient education and supervised exercise.