Current views on preoperative rehabilitation practice after anterior cruciate ligament injury among licensed physical therapists in Saudi Arabia: An online-based cross-sectional survey

Abstract

Preoperative rehabilitation is an important stage to both physically and mentally prepare patients for anterior cruciate ligament reconstruction (ACLR) and postoperative rehabilitation. This study aimed to investigate the current preoperative rehabilitation practice after anterior cruciate ligament injury among licensed physical therapists in Saudi Arabia. This was an online-based cross-sectional survey. A total of 114 physical therapists completed the survey. The survey consisted of 16 mandatory questions about management strategies, prescribed exercises, patients’ physical and psychological concerns, and discussions about nonoperative management. The majority of the respondents used the following preoperative interventions: education (89.5%), closed kinetic chain exercises (66.7%), stretches (63.2%), open kinetic chain exercises (61.4%), proprioceptive exercises (59.6%), cold (56.1%), and activity modification advice (52.6%). More than half of the respondents would recommend patients awaiting ACLR to complete the exercises 2 to 4 times weekly (56.1%) for up to 8 weeks (80.7%) before ACLR. The respondents (73.7%) reported that patients awaiting ACLR did not receive preoperative rehabilitation due to 2 primary factors: the orthopedic team did not refer patients to rehabilitation specialists, and there was a lack of awareness about preoperative rehabilitation. Most therapists (86%) would discuss conservative management if a patient returned to their preinjury level of function before surgery. The surveyed physical therapists reported using various interventions and preoperative rehabilitation lengths with patients awaiting ACLR. The majority of the therapists indicated that patients awaiting ACLR did not receive preoperative rehabilitation. Future studies are needed to establish a consensus on the optimal preoperative rehabilitation program.

1. Introduction

The anterior cruciate ligament (ACL) injury is one of the most common and devastating knee injuries, especially among athletes who participate in sports that involve sudden stops, changes in direction, and pivoting.^[1,2] ACL injury can cause pain, swelling, instability, and difficulty walking or bearing weight on the affected leg.^[3] Treatment for ACL injury depends on the patient’s age and level of athleticism and may include nonoperative or surgical treatments.^[4] Surgical reconstruction of the ACL (ACLR) is generally recommended treatment for restoration of knee stability in young and active patients, particularly those who are planning to return to pivoting sports.^[4]

The prevalence of ACL injury in Saudi Arabia varies depending on the population being studied, with rates reported to be as high as 26.2%.^[5–8] Recent data for the average wait time for ACLR in Saudi Arabia was reported to be 6 months in 45.9% of patients (n = 39) to more than 6 months in 32.9% (n = 28).^[8] However, the optimal timing for ACLR is still a matter of debate, and there is no consensus on the ideal time for surgery.^[9] A recent systematic review and meta-analysis found that ACLR performed more than 3 months after injury was associated with a higher rate of medial meniscal tears when compared to ACLR performed within 3 months of injury.^[10] Similarly, ACLR performed more than 6 months after injury was associated with a higher rate of medial meniscal tears compared with ACLR performed within 6 months of injury.^[10]

Preoperative rehabilitation is recognized in the literature as an important stage to both physically and mentally prepare patients for ACLR and postoperative rehabilitation.^[11–13] However, the optimum preoperative rehabilitation program after ACL injury is lacking, and clinical practice for this stage of treatment varies.^[11,12] The recommended preoperative rehabilitation program should at least include strengthening knee muscles, increasing range of motion, and improving balance and proprioception.^[11] A recent review found that preoperative rehabilitation exercises improved postoperative neuromuscular, self-reported knee function, and return to sports success. Another review found that quadriceps strength, psycho-vitality, patients’ estimation of their ability to return to their preinjury level, and graft type were preoperative predictors for return to physical activity following ACLR.^[12]

This study aimed to investigate the current preoperative rehabilitation practice for patients awaiting ACLR among licensed physical therapists in Saudi Arabia. We anticipate that the findings of this study will enhance our understanding of physical therapists’ current views and practices with patients awaiting ACLR. Furthermore, the information gathered could serve as a valuable resource for future research on preoperative rehabilitation.

2. Materials and methods

This study was conducted using an online-based cross-sectional survey. The main questions of the survey were adopted from a previously published study after obtaining permission from the lead author.^[14] Before accessing the survey, respondents were provided with a written statement that explained the purpose of the study and the eligibility for participation. It was stated that participation in the survey was voluntary, no personal information was collected, and eligible participants must be licensed physical therapists who are working in Saudi Arabia and are actively treating patients with ACL injury and/or ACLR. Participants who chose to take part in the study were granted access to the survey questions. If a participant chose not to participate, the survey would end. This study was approved by the Research Ethics Committee at Taibah University, Saudi Arabia (approval number: CMR-PT-2023-08).

Google Forms was used to construct the survey. The survey consisted of 2 main sections: one on preoperative rehabilitation practice and the other on postrehabilitation practice. The current study focused solely on preoperative rehabilitation questions. Questions about postoperative rehabilitation have been previously published.^[15] The first section of the survey consisted of 16 mandatory questions that focused on preoperative rehabilitation following ACL injury (Table 1). The response formats included multiple choice, checkbox, and Likert scale options. The survey began with 2 qualifying questions: “Are you a licensed physical therapist currently practicing in Saudi Arabia?” and “Are you actively treating patients with ACL injuries and/or undergoing ACLR?.” These questions were designed to ensure that the responses were exclusively from licensed physical therapists in Saudi Arabia who are actively treating patients with ACL injuries and/or ACLR. Respondents answering “No” to either question would be unable to proceed with the survey. The section on preoperative rehabilitation encompassed questions about management strategies, prescribed exercises, patients’ physical and psychological concerns, and discussion about nonoperative management.

Table 1.

Preoperative rehabilitation management: survey responses from 114 licensed physical therapists in Saudi Arabia.

Questions	n (%)
1. What is your primary area of expertise for the purpose of this survey?
All musculoskeletal conditions (including orthopedics)	80 (70.2)
Primarily lower limb	16 (14)
Primarily upper limb	0 (0)
Other subspecialty, but I still see some patients after anterior cruciate ligament injury/surgery	18 (15.8)
Other	0 (0)
2. How long have you been qualified as a physical therapist?
≤2 years	4 (3.5)
>2 years but ≤ 5 years	26 (22.8)
>5 years but ≤ 10 years	30 (26.3)
>10 years but ≤ 15 years	32 (28.1)
> 15 years	22 (19.3)
3. Approximately, how many patients awaiting ACLR would you see per year?
1–5	44 (38.6)
6–20	46 (40.4)
21–50	14 (12.3)
>51	10 (8.8)
4. What interventions do you use with patients awaiting ACLR?
Activity modification advice	60 (52.6)
Education	102 (89.5)
Heat	18 (15.8)
Cold	64 (56.1)
Closed kinetic chain exercises	76 (66.7)
Open kinetic chain exercises.	70 (61.4)
Stretches	72 (63.2)
Taping	32 (28.1)
Bracing	42 (36.8)
Electrotherapy	58 (50.9)
Manual therapy	58 (50.9)
Plyometric exercises (e.g., jumping, running, hopping)	46 (40.4)
Proprioceptive exercises	68 (59.6)
Imagery training	12 (10.5)
Other	16 (14.0)
5. How often would you recommend patients awaiting ACLR to complete the exercise(s) you have prescribed?
Once a week	0 (0)
2–4 times per week	64 (56.1)
5–6 times per week	16 (14.0)
Daily	34 (29.8)
I would not prescribe exercises	0 (0)
6. For how long would you typically see patients for rehabilitation before ACLR? (i.e., preoperative rehabilitation length)
≤ 4 weeks.	52 (45.6)
> 4 weeks but ≤ 8 weeks	40 (35.1)
> 8 weeks but ≤ 12 weeks	14 (12.3)
> 12 weeks but ≤ 16 weeks	4 (3.5)
> 16 weeks but ≤ 24 weeks	2 (1.8)
> 24 weeks	2 (1.8)
7. What contributes to your decision to how long you see patients for rehabilitation before their ACLR?
Pain	70 (61.4)
Muscular strength	80 (70.2)
Psychological well-being	26 (22.8)
Proprioception	28 (24.6)
Swelling	58 (50.9)
Weight bearing ability.	38 (33.3)
Range of movement.	66 (57.9)
Patient preference.	34 (29.8)
Perceived readiness for surgery.	24 (21.1)
Surgery waiting list.	20 (17.5)
Surgeon request.	34 (29.8)
Self-efficacy score (obtained from appropriate screening tool).	6 (5.3)
Appointment availability within your department.	6 (10.5)
Other	2 (1.8)
8. Do you think all patients on the waiting list for ACLR receive preoperative rehabilitation in your area?
Yes.	30 (26.3)
No.	84 (73.7)
9. You previously answered “No” to: “Do you think all patients on the waiting list for ACLR receive preoperative rehabilitation in your area?,” why do you think this might be?
Patients were not referred by the orthopedic team (e.g., surgeon, physician).	68 (81.0)
Patients choice not to undertake preoperative rehabilitation and they prefer surgery.	28 (33.3)
Lack of awareness of preoperative rehabilitation.	72 (85.7)
Lack of research to support completion of preoperative rehabilitation.	10 (11.9)
Lack of resources (cost of preoperative rehabilitation, availability of services, and insurance allowance).	24 (28.6)
Other	1 (2.4)
10. Have you had experience of patients reporting concerns regarding their readiness for surgery?
Yes.	90 (78.9)
No.	24 (21.1)
11. You previously answered “Yes” to: “Have you had experience of patients reporting concerns regarding their readiness for surgery?” Did you feel confident to manage these concerns?
Strongly agree.	34 (37.8)
Agree	36 (40.0)
Somewhat agree	14 (15.5)
Neither agree nor disagree	2 (2.2)
Somewhat disagree	0 (0)
Disagree	2 (2.2)
Strongly Disagree	2 (2.2)
12. You previously answered “Yes” to: “Have you had experience of patients reporting concerns regarding their readiness for surgery?” What concerns have commonly been reported to you?
Surgical risk and outcome (short and long-term).	64 (71.1)
The need for surgery over a nonoperative approach.	42 (46.7)
Lack of understanding of surgery and postoperative rehabilitation.	54 (60.0)
Psychosocial factors such as fear, anxiety, and time off work.	42 (46.7)
Not enough time for preoperative rehabilitation (e.g., needing more time to prepare the knee).	12 (26.7)
Other	1 (2.2)
13. Have you had experience of patients reporting concerns regarding their ability to return to their pre-injury level of physical activity following ACLR?
Yes	98 (86.0)
No	16 (14.0)
14. You previously answered “Yes” to: “Have you had experience of patients reporting concerns regarding their ability to return to their pre-injury level of physical activity following ACLR?” Did you feel confident to manage these concerns?
Strongly agree.	48 (48.9)
Agree	32 (32.6)
Somewhat agree	10 (10.2)
Neither agree nor disagree	2 (2.0)
Somewhat disagree	0 (0)
Disagree	2 (2.0)
Strongly Disagree	4 (4.1)
15. You previously answered “Yes” to: “Have you had experience of patients reporting concerns regarding their ability to return to their pre-injury level of physical activity following ACLR?” What concerns have commonly been reported to you?
Re-rupture and/or ACL injury in the contralateral limb.	50 (50.0)
Long-term outcomes of surgery including pain, stiffness, swelling, reduced strength and the development of osteoarthritis (OA)	56 (57.1)
Time to return to pre-injury levels.	70 (71.4)
Ability to perform at pre-injury level.	60 (61.2)
Burden and uncertainty of postoperative rehabilitation.	10 (10.2)
Other	6 (6.1)
16. If a patient had returned to their pre-injury level of ability prior to surgery, would you discuss conservative management?
Yes	98 (86.0)
No	16 (14.0)

This study adopted an exploratory research approach. Although no formal sample size calculation was conducted, our primary objective was to achieve a diverse recruitment pool. This diversity ensured external validity of our findings and allowed for variation across specific characteristics, including area of practice and length of qualification.

Information about the study, along with the survey link, was disseminated across various social media platforms such as X platform (Formerly Twitter). The link remained active for 2 months, specifically March and April 2023. Following the conclusion of the survey, the data were exported from Google Forms into Microsoft Excel format (Microsoft Corporation, Redmond, WA). The data underwent both descriptive and proportional analysis.

3. Results

The survey was completed by 114 physical therapists. The majority of the respondents (70.2%) reported that their primary area of expertise was musculoskeletal conditions. Most respondents (96.5%) had been qualified as physical therapists for more than 2 years. Nearly 40% of the respondents reported treating 6 to 20 patients awaiting ACLR annually, followed by 38.6% who were treating 1 to 5 patients per year. The results of the survey are summarized in Table 1.

The results showed that the surveyed respondents used different preoperative interventions with patients awaiting ACLR. More than half of the respondents reported using the following interventions: education (89.5%), closed kinetic chain exercises (66.7%), stretches (63.2%), open kinetic chain exercises (61.4%), proprioceptive exercises (59.6%), cold (56.1%), and activity modification advice (52.6%). Only 40.4% of the participants utilized plyometric exercises in their preoperative management strategies. The majority of the respondents (56.1%) recommended patients to complete prescribed exercises 2 to 4 times per week. When asked about the length of preoperative rehabilitation, 45.6% of the therapists stated that they would treat patients awaiting ACLR for 4 weeks or less. Meanwhile, 35.1% of the therapists would treat patients for a period between 4 to 8 weeks before the surgery. The respondents identified a variety of factors influencing their decisions regarding the length of preoperative rehabilitation. These included muscular strength (cited by 70.2% of respondents), pain levels (61.4%), range of motion (57.9%), and the presence of swelling (50.9%).

Most respondents (73.7%) reported that not all patients on the waiting list for ACLR receive preoperative rehabilitation. A large proportion of the respondents indicated that the common reasons for patients not receiving preoperative rehabilitation included patients not being referred by the orthopedic team (81%) and lack of awareness of preoperative rehabilitation (85.7%). Approximately 80% of physical therapists stated that they had experience with patients reporting concerns regarding their readiness for surgery. The most commonly reported concerns were surgical risk and outcome (71.1%) and lack of understanding of surgery and postoperative rehabilitation (60%). Most therapists (77.8%) felt confident in managing these concerns.

Most of the physiotherapists (86%) had experience with patients reporting concerns regarding their ability to return to their pre-injury level of physical activity following ACLR. Of these respondents, 81.5% strongly agreed or agreed that they felt confident managing patients’ concerns. The respondents indicated that the common concerns reported by patients included time to return to pre-injury levels (71.4%), ability to perform at pre-injury level (61.2%), and long-term outcomes of surgery including pain, stiffness, swelling, reduced strength, and the development of osteoarthritis (57.1%). Most therapists (86%) reported discussing conservative management with patients who had returned to their pre-injury level of ability before surgery.

4. Discussion

The goal of this survey was to explore the current preoperative management strategies after ACL injury among licensed physical therapists in Saudi Arabia. Most of the surveyed therapists were qualified as physical therapists for more than 2 years and were treating up to 20 patients awaiting ACLR per year. The therapists reported using several types of interventions and preoperative rehabilitation lengths with patients awaiting ACLR.

The commonly used interventions reported by the therapists were education, closed and open kinetic chain exercises, stretches, proprioceptive exercises, cold, and activity modification advice. More than half of the respondents would recommend patients awaiting ACLR to complete the exercises 2 to 4 times weekly for up to 8 weeks before the surgery. These findings are aligned with a systematic review of presurgery or post-injury training protocols.^[13] Furthermore, the surveyed physical therapists in Saudi Arabia showed comparable results to those reported by a previous worldwide survey of physiotherapy practice on their current preoperative physiotherapy management strategies for patients awaiting ACLR.^[14] Further research is needed to establish a consensus on the optimal preoperative rehabilitation program, including its frequency and length.

The therapists in the current study reported several factors that contribute to the decision on the preoperative rehabilitation length. Commonly reported factors include muscular strength, pain, range of motion, and swelling management. In a recent study, bilateral quadriceps strength deficits have been detected early after a primary ACL injury.^[16] Therefore, it is imperative that patients after ACL injury should receive an early preoperative rehabilitation program that aims to at least maintain quadriceps strength. A recent systematic review found that 4 to 16 weeks of preoperative rehabilitation exercise increased quadriceps strength prior to ACLR.^[17] This review indicated that preoperative open kinetic chain exercise produced significantly stronger preoperative quadriceps when compared to closed-kinetic chain exercise.^[17] Another systematic review found that a preoperative exercise program that includes strength, control, and balance and perturbation training for a period between 3 to 6 weeks (10 to 24 sessions) before the surgery offered a small benefit to quadriceps strength and single leg hop scores 3 months after ACLR when compared with no preoperative rehabilitation.^[18]

ACL rupture not only leads to physical consequences for the injured patients but also has psychological implications.^[12] Growing evidence suggests that many patients did not return to sports, despite adequate restoration of knee function, due to psychological factors associated with their injury.^[19] Moreover, fear of reinjury after ACL rupture can result in poor rehabilitation outcomes.^[20–22] In the current study, less than a quarter of the respondents (22.8%) considered the psychological well-being of patients as a factor in deciding the preoperative rehabilitation length, compared to 47.5% in a previous study conducted in other countries.^[14] Therefore, it is crucial for physical therapists in Saudi Arabia to address psychological factors when treating patients awaiting ACLR. Preoperative psychological evaluation plays a significant role in identifying patients with fear of reinjury.^[22,23] This evaluation may enable clinicians to provide targeted interventions to address this issue early in the rehabilitation process.^[22,23]

The importance of preoperative rehabilitation to postoperative rehabilitation has been discussed in the literature.^[24] Patients who received preoperative rehabilitation are likely to have better postoperative functional and psychological outcomes when compared to patients with no or limited preoperative rehabilitation.^[24] In the current study, a majority of the respondents (73.7%) reported that patients awaiting ACLR did not receive preoperative rehabilitation. These respondents identified 2 primary factors contributing to this issue: the orthopedic team did not refer patients to rehabilitation specialists, and there was a lack of awareness about preoperative rehabilitation. These findings are also reported by other therapists in other countries.^[14] A recent study conducted among Australian orthopedic surgeons revealed that only 11% of the surgeons considered preoperative rehabilitation as essential for postoperative rehabilitation outcomes.^[25] However, it remains unclear whether this perspective is shared by surgeons from different countries, necessitating further research on this subject.

Nearly 80% of the respondents revealed that they had experience with patients reporting concerns regarding their readiness for surgery. Of these respondents, 78% felt confident managing these concerns. The common concerns reported to the therapists by patients included surgical risk and outcome (71.1%) and lack of understanding of surgery and postoperative rehabilitation (60%), Moreover, 81.5% of the respondents felt confident addressing patients concerns regarding their ability to return to their pre-injury level of physical activity following ACLR. These concerns included time to return to pre-injury levels (71.4%), ability to perform at pre-injury level (61.2%), and long-term outcomes of surgery including pain, stiffness, swelling, reduced strength, and the development of osteoarthritis. A recent study highlighted that patients often have a limited understanding of ACL injuries and the surgical procedures involved, which can lead to unrealistic expectations and potential dissatisfaction with treatment outcomes.^[26] These patients frequently rely on unreliable internet sources for information, further contributing to misconceptions.^[26] Therefore, it is important to provide patients with thorough education regarding their injury, treatment options, and prognosis for managing expectations and ensuring patients feel well-informed throughout the treatment process.^[26]

The consideration of operative or nonoperative management after ACL injury has been discussed extensively in the literature.^[4] In a recent consensus study, there was unanimous agreement that ACLR is usually the preferred treatment for young and active patients who want to restore knee stability, especially those who plan to return to jumping/cutting/pivoting sports.^[27] On the other hand, nonoperative management can be considered for older and less active patients, or those who only participate in straight-plane activities.^[27] However, ACLR is indicated for patients who show persistent functional instability or episodes of giving way.^[27] In our study, most therapists (86%) reported that they would discuss conservative management if a patient returned to their pre-injury level of function before surgery. Clinicians can use the criteria that identify patients who can return to sports without ACLR.^[28] These criteria include objective knee function testing, patient-reported outcomes, and episodes of functional instability.^[28]

While we acknowledge that the lack of control over who is completing the survey is a limitation of this study, we have taken several steps to ensure that the survey is completed only by licensed physical therapists who are working in Saudi Arabia and are actively treating patients with ACL injury and/or ACLR. We have clearly stated in the study description that this survey is specifically designated for this group of professionals. Additionally, we have included 2 questions at the beginning of the survey to ensure that only licensed physical therapists who meet our criteria can complete the survey. Answering “No” to either of these questions would end the survey.

Although free text-style response options to some of the survey questions would have allowed the respondents to provide valuable information that justifies their responses, we chose not to use these kinds of open-ended questions. We were concerned that these questions would require deep and careful thinking, which could make the survey long and lead to respondents abandoning it in between. Instead, we opted for closed-ended questions that were easier to answer and provided us with more structured data.

5. Conclusions

The surveyed physical therapists provided insight into their current preoperative rehabilitation after ACL injury. These therapists reported using different types of interventions and preoperative rehabilitation lengths. A key finding from this survey is that the majority of the surveyed therapists indicated that patients awaiting ACLR did not receive preoperative rehabilitation. These respondents identified 2 primary factors contributing to this issue: the orthopedic team did not refer patients to rehabilitation specialists, and there was a general lack of awareness about preoperative rehabilitation. Further research is needed to explore the current views of orthopedic physicians or surgeons in Saudi Arabia on the importance of preoperative rehabilitation to patients’ postoperative outcomes.

Author contributions

Conceptualization: Yasir S. Alshehri.

Data curation: Yasir S. Alshehri.

Formal analysis: Yasir S. Alshehri.

Investigation: Yasir S. Alshehri.

Methodology: Yasir S. Alshehri.

Project administration: Yasir S. Alshehri.

Resources: Yasir S. Alshehri.

Software: Yasir S. Alshehri.

Supervision: Yasir S. Alshehri.

Visualization: Yasir S. Alshehri.

Writing – original draft: Yasir S. Alshehri.

Writing – review & editing: Yasir S. Alshehri.