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. 2025 Apr 3;7(3):101142. doi: 10.1016/j.asmr.2025.101142

Disagreement Persists on Optimal Rehabilitation Goals and Timelines for Weight-Bearing Restriction, Knee Brace Use, and Return to Sports After Posterolateral Corner Reconstruction

Ilan Y Mitchnik a,b, Tomer Mimouni b, Loren S Haichin b, Suzana Bayyouk a,b, Gilbert Moatshe c,d, Dror Lindner a,b, Jorge Chahla e, Yiftah Beer a,b, Ron Gilat b,f,∗
PMCID: PMC12276552  PMID: 40692928

Abstract

Purpose

To assess the variability of rehabilitation protocols for both isolated posterolateral corner (PLC) reconstructions and those with a concomitant anterior cruciate ligament (ACL)/posterior cruciate ligament (PCL) reconstruction, to construct uniform rehabilitative protocol recommendations, and to propose rehabilitative outcome measures for future PLC-related clinical studies.

Methods

A Google search was conducted for online PLC reconstruction rehabilitation protocols, categorizing them into isolated PLC reconstructions or PLC with concomitant ACL/PCL reconstructions. Rehabilitative goals and timelines were described and agreement rates among protocols were calculated. Comparisons were made between groups and before/after 2019, when a global consensus was published. Common rehabilitative goals with high agreement rates were used to form a recommended protocol.

Results

Thirty-seven protocols were analyzed (19 isolated PLC, 9 PLC + PCL, and 9 PLC + ACL). Overall, 31% of rehabilitative goals and timelines had good-to-excellent agreement rates. Post-2019 consensus, adherence to a stepwise rehabilitative approach significantly improved, especially for initiating strength exercises after muscular endurance exercises (P = .009) and initiating power exercises after strength exercises (P = . 031). However, there was no significant change in overall agreement rates (P = . 735). Most disagreements involved postoperative weight-bearing restrictions, with one half of protocols recommending non−weight-bearing and one half partial-weight-bearing; the period of time a knee brace is required after 6 weeks; and return to sports timing, which differed with concomitant ACL (later return) and PCL (earlier return) reconstructions.

Conclusions

There is disagreement about optimal rehabilitative goals and timelines for weight-bearing restriction, knee brace use, and return to sports after PLC reconstructions. Rehabilitative outcomes that warrant further research were identified, and a suggested rehabilitation protocol was constructed.

Clinical Relevance

Rehabilitation after PLC reconstruction lacks standardization, with significant variation in key milestones such as weight-bearing, knee bracing, and return-to-sport timelines. This study provides an analysis of current rehabilitation protocol inconsistencies and offers a structured recommendation that may assist clinicians and physiotherapists in patient counseling and protocol development.

The posterolateral corner (PLC) of the knee is a complex structure, comprising ligaments, tendons, and muscles, all of which play a role in lateral and rotational knee stabilization.1 PLC injuries usually occur as the result of contact injuries that involve a varus or externally rotated tibia with the knee hyperextended.1 Isolated PLC injuries are rare, estimated to occur in 2% of knee injuries.2 More often, these injuries occur in conjunction with other ligament injuries such as the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL).3 Other structures that may be injured include the medial collateral ligament, the menisci, and the common peroneal nerve.3 This complex injury pattern presents significant diagnostic and treatment challenges. Although low-grade isolated injuries may be managed with nonoperative care, most injuries require surgical intervention to restore normal knee alignment kinematics.1 The choice of operative treatment depends on injury chronicity. High-grade acute injuries typically are treated by either anatomical repair or reconstruction, whereas high-grade chronic injuries are treated with anatomical ligamentous reconstruction, soft-tissue augmentations or advancements, or varus corrective osteotomies.1 Rehabilitation protocols after PLC reconstructions generally depend on various factors such as the type of PLC injury, its concomitant injuries, and the surgical technique used.4

Although postoperative rehabilitation after ligamentous reconstructions is critical, studies have found high degrees of variability in rehabilitative protocols after surgical knee procedures.5, 6, 7, 8, 9 Such lack of consensus in rehabilitation protocols may consequently influence patient outcomes.10 Most rehabilitation protocols focus on a stepwise rehabilitative process, including weight-bearing restrictions, range of motion (ROM) protections, physical exercises, and gradual return to sports (RTS). However, a lack of consensus regarding specific restrictions, exercises, or the timing of each of the steps could lead to confusion among patients and therapists about the expected rehabilitative milestones.

Clinical experience in treating PLC injuries is scarce, as only 13% of orthopaedic surgeons treat these injuries, mostly up to 4 cases per year.11 This poses a challenge to achieving a wide consensus on the management of PLC injuries.11 In 2019, Chahla et al.7 placed efforts into establishing an international consensus on PLC injury management, from diagnosis to rehabilitation. This consensus recommended protecting the knee in an extension brace and avoiding full weight-bearing, and it proposed a stepwise rehabilitative approach, including early ROM exercises, structured endurance, strength, and power exercise progression, followed by functional testing before returning to sports. However, whether this consensus affected global PLC rehabilitation protocols has not been assessed. In addition, a clear differentiation between rehabilitation protocols for isolated PLC injuries rather than PLC injuries with other concomitant injuries has yet to be made.

The purposes of this study were to assess the variability of rehabilitation protocols for both isolated PLC reconstructions and those with a concomitant ACL/PCL reconstruction, to construct uniform rehabilitative protocol recommendations, and to propose rehabilitative outcome measures for future PLC-related clinical studies. The hypothesis of this study was that there will be low rates of agreement about many aspects of rehabilitation after treatment of PLC injuries and that the 2019 consensus would have improved these agreement rates.

Methods

Study Design and Data Collection

This was an observational study of PLC reconstruction rehabilitation protocols published online and that are publicly available. Because this was a literature review study, ethical approval was required. Two independent researchers (T.M. and L.S.H.) searched the first 100 results on Google for the search terms: “posterolateral corner reconstruction rehabilitation.” This search engine and key words were chosen to replicate what a patient undergoing PLC reconstruction or their physiotherapist would search online. We assumed that rehabilitation protocols published in scientific journals would appear in a publicly available manner on the websites that would be screened, in which case the publicly available protocol was used instead. This approach aligns with similar studies conducted for analogous procedures.5,12,13 The initially identified protocols were screened and duplicate results were removed. We excluded protocols that were not specific for PLC injuries. The included protocols were then reviewed by an orthopaedic surgeon and a physical therapist (I.Y.M. and S.B.), and a spreadsheet table was populated with the collected data.

Variables and Measures

The collected data included affiliation with academic orthopaedic surgery societies, the year of online publication, the exact injury type for which the protocol was intended, rehabilitative weight-bearing and ROM restrictions, and rehabilitation exercises and their suggested timelines. Affiliations were determined on the basis of acknowledgments, scientific publications, or first author online profiles. To resolve any discrepancies in collected variables, a third researcher (R.G.) reviewed respective protocols in cases of mismatch in order to reach agreement.

Bike and isometric squats exercises were considered as muscular endurance exercises; closed kinetic chain exercises such as leg press, lunges, and steps as strength exercises; and jumping was considered as a power exercise. Weight-bearing restrictions were categorized to non−weight-bearing (NWB), or full weight-bearing. Toe-touch weight bearing was considered as a type of partial weight-bearing (PWB).

Statistical Analysis

The rehabilitation protocols were categorized into groups of injury types, such as isolated PLC reconstructions and nonisolated PLC reconstructions, with the latter category including PLC reconstructions with a concomitant ACL or PCL reconstruction. The means, standard deviations, medians, and interquartile ranges (IQR) for the collected rehabilitative recommendations were calculated. To measure agreement rates between different protocols, the coefficient of variation (CoV; also known as the relative standard deviation) was used. The greater the CoV, the more variability, or disagreement, there is. Thus, to measure agreement, the formula |1 – CoV| was used and the resultant rates were ranked similarly to other common reliability measures (0.00-0.49 is poor agreement, 0.50-0.74 is moderate agreement, 0.75-0.89 is good agreement, and 0.90-1.0 is excellent agreement).14 Uniform protocol recommendations were planned to be constructed on the basis of good-to-excellent agreement rates.

Isolated PLC reconstruction rehabilitation recommendations were compared with the gold standard 2019 consensus.7 χ2 tests were used to compare adherence to the consensus before and after its publication. The differences in rehabilitation protocols as the result of concomitant ACL or PCL reconstructions were compared using Mann-Whitney U tests. A χ2 test was used to compare difference in agreement rates between different rehabilitation protocol groups. A P of < .05 was used as a measure of statistical significance. For statistically significant differences, a 95% confidence interval (95% CI) was reported. All tests were performed using either Microsoft Excel 2019 or IBM SPSS, version 25 computer programs.

Results

Overall, 61 protocols were identified using our search method. We excluded 24 protocols, of which 22 were journal publications that also appeared in the other protocols (treated as duplicates), 1 a book chapter, and 1 a posteromedial corner reconstruction rehabilitation protocol (see Fig 1 for flowchart). Of the 37 remaining protocols15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51 (Table 1), orthopaedic surgical society affiliations were present in 29 protocols (78%). Nineteen protocols (50%) addressed isolated PLC reconstructions, 9 (24%) addressed a concomitant ACL reconstruction, and 9 (24%) addressed a concomitant PCL reconstruction (Table 1).

Fig 1.

Fig 1

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Study flow diagram. (ACL, anterior cruciate ligament; PCL, posterior cruciate ligament; PLC, posterolateral corner.).

Table 1.

Included Reviewed Rehabilitation Protocols

Author Year Affiliation Author Year Affiliation
Isolated PLC injury rehabilitation protocols PLC with ACL injury rehabilitation protocols
Wulf et al.15 2019 AOSSM Forsythe34 2017 AOSSM
Noyes et al.16 2019 AOSSM Bravman35 2018 AOSSM
Watson et al.17 2020 AOSSM Messamore36 2021 AOSSM
Bush et al.18 2020 AOSSM McNicholas37 2016 AANA
Sisk et al.19 2020 AOSSM Syal and Soswa38 2019 AANA
Gregory et al.20 2020 AOSSM Barrow39 2013 ISAKOS
Levenda et al.21 2021 AOSSM Tucson Orthopedic Institute40 2018 Unaffiliated
Kremen et al.22 2021 AOSSM The Christ Hospital41 2020 Unaffiliated
Taylor et al.23 2021 AOSSM Sanford Health42 2021 Unaffiliated
Cole et al.24 2023 AOSSM PLC with PCL injury rehabilitation protocols
Duerr et al.25 2023 AOSSM Jazrawi43 2011 AOSSM
Myer et al.26 2017 AANA Alaia44 2013 AOSSM
Ayzenberg et al.27 2020 AANA Brockmeier45 2015 AOSSM
Evangelista and Evangelista28 2020 AANA Bert46 2018 AOSSM
Murray et al.29 2021 AANA Mithoefer47 2021 AOSSM
Burnham30 2023 AANA MacLean48 2022 AOSSM
Van Thiel31 2016 Unaffiliated Chahla49 2019 AANA
Sports Medicine Division Brown University32 2017 Unaffiliated Athletic Orthopedics and Knee Center50 2015 Unaffiliated
Washington Orthopedic Center33 2018 Unaffiliated McGonigle51 2019 Unaffiliated
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AANA, Arthroscopy Association of North America; ABJS, Association of Bone and Joint Surgeons; ACL, anterior cruciate ligament; AOSSM, American Orthopaedic Society for Sports Medicine; ESSKA, European Society of Sports Traumatology, Knee Surgery & Arthroscopy; ISAKOS, International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine; PCL, posterior cruciate ligament; PLC, posterolateral corner.

Variability and Agreements in PLC Reconstruction Rehabilitation Protocols

Appendix Table 1 (available at www.arthroscopyjournal.org) describes the distributions, reporting rates, and agreement rates for the different protocols analyzed in this study. For isolated PLC reconstruction, 44% of items had poor agreement rates, 26% were moderate, 19% were good, and 12% had excellent agreement rates. These agreement rates were not significantly different from rehabilitation protocols for concomitant ACL and PCL reconstruction (P = .239). In addition to the rehabilitation recommendations from the 2019 consensus, other commonly (n > 50%) reported rehabilitative items included the range of degrees for early passive mobilization, ranging from 0° (with complete agreement) and 90° (high agreement); the use of assisted extension, knee extension, hip flexion/extension exercises and patellofemoral stretching, all initiated as soon as the first week (with poor agreement on timing); the use of swimming exercises, treadmill walking, and elliptical training was commonly recommended for weeks 9, 11, and 12, respectively, with moderate agreement rates. Furthermore, there was a common recommendation to avoid hamstring activation for 7 weeks (with moderate agreement on timing) and also to incorporate open and closed kinematic chain hamstring exercises starting on weeks 12 and 16, respectively, with a moderate agreement rate for both.

Adherence to the Isolated PLC Reconstruction Rehabilitation Consensus

Most (15/19) of the isolated PLC reconstruction protocols were published after the 2019 consensus. The only significant differences we found between pre- and postconsensus protocols was in a step wise approach to initiating strength exercises after muscular endurance exercises (preconsensus 95% CI 0.00-0.67, postconsensus 95% CI 0.69-1.00, P = .009) and initiating power exercises after strength exercises (preconsensus 95% CI 0.00-0.00, postconsensus 95% CI 0.51-0.96, P = .031). The comparison of pre- and postconsensus protocols is presented in Table 2.

Table 2.

Comparison of Isolated PLC Reconstruction Rehabilitation Protocol Recommendations

2019 Consensus Recommendations Preconsensus Protocols (n = 4) Postconsensus Protocols (n = 15) P Value
Early mobilization for range of motion 3 (75%) 13 (87%) .851
Muscular endurance after range of motion 2 (50%) 7 (47%) .993
Strength after muscular endurance 1 (25%) 13 (87%) .009
Power after strength 0 (0%) 11 (73%) .031
Knee bracing at least 6 weeks 4 (100%) 15 (100%) 1.000
Partial/non-weight bearing at least 6 weeks 1 (25%) 8 (53%) .445
Functional testing before return to sports 1 (25%) 7 (47%) .504
Running with cutting before return to sports 1 (25%) 7 (47%) .504
Return to sports no sooner than 9 months 0 (0%) 3 (20%) .576
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NOTE. Comparison of the number (percentage) of rehabilitation protocols with matching 2019 consensus recommendations. Two recommendations (Strength exercises after muscular endurance exercises, and Power exercises after strength exercises) had a significant change in adherence by protocols following the 2019 consensus.

From Chahla et al.7

Postconsensus agreement rates averaged 57% compared with preconsensus 53%. The postconsensus agreement rates were 44% poor, 37% moderate, 14% good, and 16% excellent (P = .735 when compared with pre-consensus agreement rate distribution). The greatest agreement rates (good-to-excellent) were for beginning lunge exercises on median week 12.5 (IQR = 12 to 13) with |1 − CoV| = 0.956. The poorest agreement rates were for the timing to remove knee bracing (|1 − CoV| = 0.053) on median week 6 (IQR = 6 to 12). We also found moderate agreement rates for weight-bearing restriction recommendations (|1 − CoV| = 0.547) and timing for weight-bearing advancement (|1 − CoV| = 0.533), with 7/15 (47%) protocols recommending initial NWB and the same number of 7 of 15 (47%) allowing initial PWB, advancing with weight bearing on median week 6 (IQR = 2 to 6). On the basis of these findings, we have compiled a chart describing the expected rehabilitative milestones patients may expect (Fig 2).

Fig 2.

Fig 2

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Expected timelines for isolated posterolateral corner reconstruction rehabilitation. Bars represent the median time period after which the rehabilitative milestone is expected to begin. Error bars represent the interquartile range measured across the included protocols in our study.

Concomitant ACL or PCL Reconstruction Effects on Rehabilitation Recommendations

Upon comparing the rehabilitation protocols of isolated PLC reconstruction with PLC and concomitant ACL or PCL reconstructions, we found a statistically significant difference in only 3 items. First, the timing for beginning closed kinetic chain hamstring exercises was different across protocols (P = .004). It was earlier with concomitant ACL reconstruction (median = 6; IQR 3-6; 95% CI 1.00-8.00) and concomitant PCL reconstructions (median = 7; IQR 7-10; 95% CI 5.00-11.00), whereas later with isolated PLC reconstructions (median = 13; IQR 7-13; 95% CI 6.50-13.00). These recommendations had moderate agreement rates (Appendix Table 1). Second, the timing for functional testing and RTS was different (P = . 042, and P = .008, respectively). Isolated PLC reconstruction rehabilitation protocols recommended timelines with a median of 24 (95% CI 12.00-28.00) and 26 weeks (95% CI 24.00-28.00), respectively, with good agreement rates (Appendix Table 1). Rehabilitative protocols for concomitant ACL reconstructions recommended later timelines (median = 28 with 95% CI 13.00-40.00, and 30 weeks with 95% CI 23.00-38.00, respectively), with moderate agreement rates (Appendix Table 1); whereas concomitant PCL reconstructions recommended earlier timelines (median = 17 with 95% CI 4.00-25.00, and 21 weeks with 95% CI 18.50-25.00, respectively), with moderate agreement rates for functional testing and excellent agreement rates for RTS (Appendix Table 1).

Summary of Expected Rehabilitative Goals

On the basis of the results described, we constructed recommendations for the rehabilitative goals expected after PLC reconstructions with or without concomitant ACL or PCL reconstructions. These recommendations rely on the 2019 consensus, recommended by at least 75% of protocols or with good-to-excellent agreement rates (|1 − CoV|) across the different protocols analyzed. The strongest consensus for rehabilitative goals, determined on the basis of the rate of protocol recommendations and greatest agreement rates, are for a ROM of 0 to 90° for the first week of early passive ROM, beginning bike riding on week 7, beginning running on week 17, and returning to sports on week 21 after a concomitant PCL reconstruction or week 30 after a concomitant ACL reconstruction.

Discussion

The main finding of this study is a relatively low (31%) good-to-excellent agreement rate by rehabilitation protocols for both isolated PLC reconstructions and those concomitant with ACL/PCL reconstructions. More specifically, there is significant variability and disagreement regarding the best time to begin knee and hip active exercises, the maximal period of time that a knee brace is needed, and postoperative weight bearing recommendations. After publication of the 2019 consensus, there has been some improvement in adherence to a step-wise rehabilitative approach but there was no significant improvement in rehabilitative protocols agreement rates. The main rehabilitative protocol difference when a concomitant ACL/PCL reconstruction is performed involves the timing for hamstring activation and timing for RTS. On the basis of these findings, a suggested rehabilitation protocol after PLC reconstructions was constructed (Table 3).

Table 3.

Consensus for Expected Rehabilitative Goals After PLC Reconstructions

Timing Rehabilitative Goal Recommendations Agreement
Week 1 Early mobilization
 Begin early passive ROM 100% Moderate
 Passive ROM of 0 to 90° 87% Good-excellent
 Perform knee extensions 84% Poor
 Knee extension ROM of 10 to 100° 26% Moderate-excellent
Week 1 Stretching
 Patellofemoral joint stretching 79% Poor
Core
Week 1  Hip flexors and extensors 74% Poor
Week 3  Hip adductors and abductors 74% Poor
Weight-bearing
Week 6  Advance weight-bearing to PWB/FWB 95% Poor
Knee bracing
Week 7  Remove knee brace 100% Poor
ROM
Week 7  Achieve full ROM 84% Moderate
Muscular endurance
Week 7  Begin bike riding 89% Good
Strength
Week 12  Lunges 37% Good
Power
 Hamstrings closed-kinetic chain
Week 8  With concomitant ACL reconstruction 89% Moderate
Week 9  With concomitant PCL reconstruction 100% Moderate
Week 13  For isolated PLC reconstruction 84% Moderate
week 17  Jumping exercises 58% Good
Return to sports
Week 17  Running 84% Good
 Preemptive functional testing
Week 17  With concomitant PCL reconstruction 89% Moderate
Week 24  For isolated PLC reconstruction 42% Good
Week 28  With concomitant ACL reconstruction 67% Moderate
 Active return to sports
Week 21  With concomitant PCL reconstruction 89% Excellent
Week 26  For isolated PLC reconstruction 100% Moderate
Week 30  With concomitant ACL reconstruction 84% Good
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NOTE. This table outlines the expected rehabilitative goals after PLC reconstructions, by postoperative week numbers that were calculated on the basis of the median week reported across all studied protocols. For each week, the table lists the rehabilitative goals, the percentage of protocols reporting these goals, and the level of agreement on the timeline of these goals between the protocols.

ACL, anterior cruciate ligament; FWB, full weight-bearing; PCL, posterior cruciate ligament; PLC, posterolateral corner; PWB, partial weight-bearing; ROM, range of motion.

The low agreement rates in rehabilitation protocols found in this study call for more standardization and research about optimal rehabilitative protocols for PLC injuries. The 2019 consensus was developed using the Delphi method, relying primarily on expert opinion rather than biomechanical research into PLC injuries.7 Other than the rehabilitative goals stated by the 2019 consensus, most rehabilitative protocols also focus on the exact degrees of early passive ROM (with high agreement on achieving full extension and up to 90° flexion). In addition, many recommend incorporating assisted knee extension exercises, hip flexion/extension exercises, and patellofemoral stretching during the first post operative week. Avoidance of hamstring activation is also a common recommendation, especially when isolated PLC reconstruction with or without a PCL reconstruction is performed. This is likely attributable to prevent stress on the newly reconstructed ligaments during initial healing.52 However, there is a lack of agreement on the exact timing and there is limited effect on the restrictions when a PCL reconstruction is added (Appendix Table 1). Also, whether there was a need for biceps femoris repair may also affect timing of hamstrings activation and is not accounted for in the rehab protocols. Further studies are needed to validate the effectiveness of specific rehabilitation exercises used in PLC reconstruction to ensure that current recommendations are supported by empirical evidence.

Unfortunately, despite our findings indicating that the 2019 consensus improved adherence to a step wise approach to PLC rehabilitation, lack of standardization in rehabilitative protocols persists as seen in our report of unchanged agreement rates. Furthermore, the improvement in adherence to a standardized protocol was only partial, and some recommendations are not yet as common as the consensus would have hoped (Table 2). For example, only about one half (53%) of postconsensus protocols recommending PWB/NWB for at least 6 weeks after PLC reconstruction. In addition, about one half (47%) recommended functional testing, figure-of-eight running, or cutting exercises before RTS and only 20% recommended RTS from the ninth postoperative month. The disagreement about RTS timing is especially evident when examining PLC reconstructions with concomitant ACL reconstructions (later RTS) or PCL reconstructions (earlier RTS). These observations call for future research to provide more accurate guidelines for return to sports after PLC reconstructions. Studies to compare postoperative PWB with NWB should be conducted because weight-bearing restrictions have important implications for patients, both for risk of deep vein thrombosis,53 and for patient expectations such as dependency on walking aids and potential limitations to activities of daily living. Although studies about functional testing before RTS have shown its benefits,54,55 future studies may wish to test the recommended timing of RTS after PLC reconstructions.

The suggested protocol derived from this study (Table 3) follows the 2019 consensus, which emphasized the importance of a sequential staged rehabilitation approach, encompassing ROM, muscular endurance, strength, and power.8 Early mobilization is a common principle in all protocols as a means to prevent joint stiffness and arthrofibrosis, with moderate agreement on timing (some protocols for PLC and concomitant PCL reconstruction recommended initiating early ROM as late as the third postoperative week, see Appendix Table 1). Brace immobilization to protect the reconstructed ligaments is also a common recommendation, but with poor agreement rates for how long it is necessary (Appendix Table 1). Our suggested protocol also shows some variability from the recommended consensus. Although both the consensus7 and these findings agree on a cautious approach to RTS, on the basis of objective functional tests such as running with cutting movements or figure-of-eight running, there are disagreements on the expected timeline. The 2019 consensus recommends a minimum period of 9 months before RTS,7 while the findings of the present study show that most protocols recommend, with a moderate agreement rate, an earlier RTS at week 26, equivalent to 6 months postsurgery. Furthermore, RTS timelines are different when PLC reconstruction is performed together with ACL/PCL reconstructions.

The implications of this study’s findings are substantial for both future research and clinical practice. First, these findings can guide future research to focus on important rehabilitative outcomes and provide a baseline for comparison of timelines. Second, our recommended protocol can provide health care professionals with a foundation for making informed decisions about brace immobilization, early motion, and expected RTS for patients.

Limitations

This study has several limitations. The use of Google as the primary search engine, rather than scientific databases, may have limited the comprehensiveness of protocol identification. In addition, the sample size for some injury types, particularly PLC and ACL reconstruction protocols, was relatively small, which might limit the generalizability of findings. Selection bias also may be present, as protocols published in scientific journals were excluded under the assumption that their recommendations were incorporated into the identified protocols. Furthermore, only English-language rehabilitation protocols were included, potentially omitting variations in rehabilitation guidelines across different healthcare systems. Finally, concomitant pathologies such as medial collateral ligament or meniscal injuries could not be analyzed in detail due to a lack of specific combined rehabilitation protocols.

Conclusions

There is disagreement about optimal rehabilitative goals and timelines for weight-bearing restriction, knee brace use, and return to sports after PLC reconstructions. Rehabilitative outcomes that warrant further research were identified and a suggested rehabilitation protocol was constructed.

Disclosures

All authors (S.B., Y.B., J.C., R.G., L.S.H., D.L., T.M., I.Y.M., G.M.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix

Appendix Table 1.

Comparison of Rehabilitation Protocols After Isolated and Nonisolated PLC Reconstruction

Isolated PLC Reconstruction (n = 19)
 PLC + ACL Reconstruction (n = 9)
 PLC + PCL Reconstruction (n = 9)
M (IQR) n (%) 1 − CoV M (IQR) n (%) 1 − CoV M (IQR) n (%) 1 − CoV P Value
Prehabilitation N/A 4 (21%) N/A N/A 2 (22%) N/A N/A 2 (22%) N/A N/A
 Initial weight-bearing restriction 2 (1-2) 18 (95%) 0.563 2 (2-2) 8 (89%) 0.658 1 (1-2) 9 (100%) 0.480 .742
 NWB 0 (0-0) 8 (42%) N/A 0 (0-0) 2 (22%) N/A 0 (0-0) 5 (56%) N/A N/A
 PWB 0 (0-0) 10 (53%) N/A 0 (0-0) 6 (67%) N/A 0 (0-0) 3 (33%) N/A N/A
Early mobilization
Early passive ROM, wk 1 (1-1) 19 (100%) 0.319 1 (1-1) 9 (100%) 0.455 1 (1-3) 9 (100%) 0.266 .401
 Minimum, ° 2 (8) 16 (84%) 1.000 0 (0) 7 (78%) 1.000 0 (0) 5 (56%) 1.000 .459
 Maximum, ° 86 (17) 17 (89%) 0.801 70 (21) 7 (78%) 0.705 81 (18) 7 (78%) 0.779 .121
 Assisted extension, wk 1 (1-1) 11 (58%) 0.162 2 (1-4) 6 (67%) 0.239 1 (1-1) 5 (56%) 0.484 .387
 Minimum, ° 7 (15) 7 (37%) 1.000 24 (20) 4 (44%) 0.169 10 (20) 4 (44%) 1.000 .260
 Maximum, ° 90 (0) 7 (37%) 1.000 87 (6) 3 (33%) 0.933 90 (0) 4 (44%) 1.000 .160
 Knee extensions, wk 1 (1-1) 16 (84%) 0.159 1 (1-2) 8 (89%) 0.269 1 (1-1) 7 (78%) 0.118 .829
 Minimum, ° 16 (18) 5 (26%) 0.135 10 (20) 4 (44%) 1.000 10 (20) 4 (44%) 1.000 .702
 Maximum, ° 99 (20) 5 (26%) 0.797 96 (28) 4 (44%) 0.714 90 (0) 3 (33%) 1.000 .813
 Early active ROM, wk 6 (3-12) 5 (26%) 0.254 1 (1-7) 6 (67%) 0.065 1 (1-7) 7 (78%) 0.025 .327
 Minimum, ° 0 (0) 0 (0%) N/A 10 (0) 1 (11%) 1.000 0 (0) 1 (11%) 1.000 .317
 Maximum, ° 103 (46) 2 (11%) 0.552 83 (12) 3 (33%) 0.861 90 (0) 2 (22%) 1.000 .832
Core
 Hip flexors extensors, wk 1 (1-7) 14 (74%) 0.112 1 (1-1) 5 (56%) 1.000 1 (1-4) 5 (56%) 0.315 .193
 Hip adductors abductors, wk 3 (1-7) 14 (74%) 0.109 1 (1-1) 7 (78%) 1.000 1 (1-4) 7 (78%) 0.148 .055
 Abdomen, wk 3 (1-7) 11 (58%) 0.202 7 (1-7) 3 (33%) 0.307 1 (1-4) 3 (33%) 0.213 .487
Stretching
 PFJ stretching, wk 1 (1-1) 15 (79%) 0.058 1 (1-1) 7 (78%) 1.000 1 (1-1) 5 (56%) 1.000 .436
 Calves stretching, wk 1 (1-1) 8 (42%) 0.414 1 (1-1) 5 (56%) 0.118 1 (1-1) 1 (11%) 1.000 .892
 Quadriceps stretching, wk 2 (1-5) 4 (21%) 0.085 8 (8-8) 1 (11%) 1.000 2 (1-6) 4 (44%) 0.188 .458
 Hamstrings stretching, wk 2 (1-7) 6 (32%) 0.016 1 (1-3) 4 (44%) 0.067 1 (1-9) 3 (33%) 0.260 .715
 ITB stretching, wk 3 (1-9) 3 (16%) 0.039 0 (0-0) 0 (0%) N/A 0 (0-0) 0 (0%) N/A N/A
 Scar massage, wk 3 (2-7) 5 (26%) 0.054 1 (1-1) 1 (11%) 1.000 3 (2-4) 2 (22%) 0.529 .412
Weight-bearing advancement, wk 6 (2-6) 18 (95%) 0.488 6 (2-6) 8 (89%) 0.483 5 (2-6) 8 (89%) 0.482 .755
Full ROM, wk 7 (3-7) 16 (84%) 0.561 7 (6-7) 6 (67%) 0.845 7 (6-9) 4 (44%) 0.716 .430
Remove knee brace, wk 7 (6-12) 19 (100%) 0.012 6 (6-6) 9 (100%) 0.706 6 (6-6) 9 (100%) 0.561 .066
Hamstrings avoidance, wk 7 (6-16) 13 (68%) 0.505 8 (6-12) 9 (100%) 0.426 8 (8-10) 8 (89%) 0.661 .920
Muscular endurance
 Isometric squats, wk 5 (3-6) 9 (47%) 0.321 7 (1-8) 3 (33%) 0.287 4 (2-5) 8 (89%) 0.465 .431
 Bike riding, wk 7 (7-7) 17 (89%) 0.792 7 (6-7) 8 (89%) 0.773 7 (4-7) 8 (89%) 0.604 .362
Strength exercises
 Pumps, wk 7 (1-10) 13 (68%) 0.177 7 (2-10) 8 (89%) 0.307 1 (1-6) 7 (78%) 0.050 .128
 Steps, wk 7 (7-10) 8 (42%) 0.585 7 (7-7) 5 (56%) 0.901 7 (6-9) 6 (67%) 0.513 .353
 Leg press, wk 9 (7-13) 12 (63%) 0.687 7 (6-7) 5 (56%) 0.626 7 (2-9) 5 (56%) 0.209 .201
 Lunges, wk 12 (12-13) 7 (37%) 0.817 13 (13-13) 1 (11%) 1.000 7 (2-13) 3 (33%) 0.197 .359
Power exercises
 Limited OKC, wk 12 (12-12) 1 (5%) 1.000 7 (7-7) 2 (22%) 1.000 3 (2-4) 2 (22%) 0.529 .150
 Full OKC, wk 13 (13-13) 2 (11%) 1.000 15 (4-26) 2 (22%) 0.037 10 (10-10) 1 (11%) 1.000 .729
 CKC hamstrings, wk 13 (7-13) 16 (84%) 0.540 6 (3-6) 8 (89%) 0.510 7 (7-10) 9 (100%) 0.515 .004
 OKC hamstrings, wk 12 (8-16) 12 (63%) 0.533 14 (12-15) 5 (56%) 0.718 11 (10-14) 4 (44%) 0.720 .948
 Jumping, wk 17 (17-21) 11 (58%) 0.785 17 (16-24) 9 (100%) 0.588 15 (13-21) 9 (100%) 0.629 .409
Endurance
 Swimming, wk 9 (7-13) 11 (58%) 0.678 12 (8-12) 5 (56%) 0.740 7 (6-8) 2 (22%) 0.798 .428
 Treadmill walking, wk 11 (8-16) 13 (68%) 0.620 12 (7-13) 7 (78%) 0.673 14 (8-17) 8 (89%) 0.540 .451
 Elliptical training, wk 12 (9-13) 13 (68%) 0.662 9 (7-16) 7 (78%) 0.476 9 (4-11) 3 (33%) 0.566 .344
Return to sports
 Running, wk 17 (14-20) 16 (84%) 0.754 15 (13-25) 8 (89%) 0.652 17 (12-19) 8 (89%) 0.757 .645
 Cutting, wk 17 (17-25) 10 (53%) 0.469 18 (15-22) 8 (89%) 0.579 19 (13-21) 6 (67%) 0.689 .907
 Functional testing, wk 24 (20-27) 8 (42%) 0.753 28 (22-38) 6 (67%) 0.636 17 (15-21) 8 (89%) 0.618 .042
 Full return, wk 26 (24-28) 16 (84%) 0.783 30 (24-38) 9 (100%) 0.718 21 (20-22) 8 (89%) 0.909 .008
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NOTE. Degrees are reported and compared as means and standard deviations; % indicates the percentage of all protocols.

1 − CoV, agreement rates; ACL, anterior cruciate ligament; CKC, closed kinetic chain; IQR, interquartile range; M, median; N, number of published recommendations; N/A, not available; NWB, non−weight-bearing; OKC, open kinetic chain; P, P value for difference between medians of groups; PCL, posterior cruciate ligament; PLC, posterolateral corner; PWB, partial weight-bearing.

References

Articles from Arthroscopy, Sports Medicine, and Rehabilitation are provided here courtesy of Elsevier

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