Outcomes following an optimised anterior cruciate ligament (ACL) reconstruction rehabilitation program in community-level athletes

Participants will complete the intervention as part of their regular clinical care post ACL reconstruction. The intervention will include two components: 1) physical and 2) contextual and patient-related. All interventions will be delivered at private outpatient physiotherapy clinics across the Gold Coast as part of clinical care by the lead author or a physiotherapist trained in the delivery of the intervention as determined by the lead author (experience level 1-6 years). The delivery of the intervention will be guided by our custom ACL Rehabilitation Guide, which will be provided to the participants. Physical intervention The physical intervention reflects a pragmatic rehabilitation program designed to address specific deficits following ACL reconstruction based on the results of preceding research and best practice rehabilitation principles. Treatment will commence at any time prior to surgery or within 3 weeks of reconstruction, continuing for a period of 12 months post the date of surgery. The intervention consists of five phases. 1. Prehabilitation (from the first consultation to surgery, patients may not have pre-surgery consultation)– rehabilitation focuses on settling pain and swelling, restoring range of motion, and commencing resistance exercise to improve function prior to surgery. Exercises may include inner range quads, extension sag, cycling, squats, steps ups, lunges and hopping activities when deemed appropriate. 2. Early (0-6 weeks) – rehabilitation focus on settling pain and swelling, restoring range of motion, , improving balance and proprioception, normalising gait and minimising quads atrophy. Exercises may include inner range quads, extension sag, cycling, squats, steps ups when deemed appropriate. 3. Mid (6 weeks to 5 months) - rehabilitation focus on building muscle mass, improving motor control, commencing jump training, prepare to run drills, and developing aerobic fitness. Participants are encouraged to commence gym-based resistance exercise to promote appropriate strength training stimulus. Exercises may include leg press, bridging variations, squat and deadlift variations, step ups, single leg squatting, cycling, cross trainer land and pool-based running technique drills. 4. Late (5-9 months) - rehabilitation focus on developing high level strength, power, technical proficiency, and fitness to achieve symmetry between limbs. This includes strength training, jump and plyometric training, field-based rehabilitation with a focus on cutting and lateral movement in pre-planned situations before progressing to reactive situations. Exercises may include squat and deadlift variations, lunge variations, single leg squat, box and hurdle jump variations, lateral shuffle drills, cone cutting and agility drills reacting to therapist signal or other player movement. 5. Return to sport (9-12 months) - rehabilitation will continue to build on the late phase training with a particular focus on single leg strength and control and reactive change of direction. This phase also entails developing a return to sport plan for transition back into practice and then game play as appropriate. Exercises may include single leg squat, single leg deadlift, Bulgarian split squat, reactive multi-directional hopping drills, reactive agility drills and small-sided games. The aim of the physical intervention is to expose the participant to a specific and intense training stimulus designed appropriately based on established exercise prescription principles (for example early phase daily low load exercises due to post-operative restrictions before progressing to 2-3 x week lower limb strength training at 12RM or heavier for total sets 8-10/muscle group per week int eh later phases). Exercise prescription will be adapted to the client and include exercises appropriate to the phase of rehabilitation. A physiotherapist will actively observe, correct, and progress exercises as deemed appropriate during and between sessions. All sessions will be delivered as per the clinical judgement of the treating physiotherapist, guided by an overarching rehabilitation protocol developed specifically for this study. Time frames for each phase are provided as a guide only as participants must pass a set of progression criteria before moving to the next phase of rehabilitation. As detailed below this may involve supervised, unsupervised, group and telehealth options, with the frequency and duration of the scheduled sessions to vary depending on the needs of the participant determined through consultation between the clinician and therapist. Group sessions are only available from the mid-phase onwards. To address the barriers identified during the initial studies regarding exercise delivery, patients will be provided with their exercise program via the online exercise prescription software "Physiotec" (https://physiotec.ca/ca/en/). The program also allows tracking of independent exercise completion. The frequency and duration of supervised and group based interventions can be monitored through the practice management software. Contextual and patient-related intervention The rehabilitation program will not only consider the physical components of rehabilitation but the contextual and patient-related factors. A key time point to address these factors will be at the commencement of each phase of rehabilitation. This process will involve an appointment (4-5 sessions, 30-60minutes, delivered face-face or via Zoom.) with the rehabilitation provider to develop a plan for the upcoming phase. This plan includes goal setting, discussion of service delivery, identification of barriers to rehabilitation and monitoring patient psychology. This process forms part of the five main contextual and patient-related target concepts detailed below: 1. Informational support – participants will subscribe to an email mail-out (1-2 per week, approx 2-5min reading time) detailing information relevant to the phase of rehabilitation. This provides a verified source of quality information. For example, during the recovery phase participants will receive information pertaining to managing swelling and pain post-operatively, strategies to minimise quadricep atrophy, how to regain knee extension and facilitate bending. 2. Goal setting and re-assessment – collaborative goal-setting sessions at the commencement of each phase of rehabilitation will facilitate the planning of appropriate ongoing rehabilitation. 3. Service delivery –The different modes of service delivery will be presented to participants, including supervised, unsupervised, group and telehealth options. This ensures the participants care can be optimised based on their circumstances and barriers to rehabilitation. 4. Identification of barriers to rehabilitation –the participant will be asked about and presented with a list of potential barriers to rehabilitation. Through discussion, solutions to the potential barriers will be determined and implemented to optimise rehabilitation participation for the individual. 5. Patient psychology – Participant expectations, activities they find challenging or are fearful will regularly be monitored and assessed. Rehabilitation can then be implemented to address these factors.