Supervised rehab boosts recovery after ACL surgery

Clinical takeaway: For young adults who continue to have knee problems 9 months or more after ACL reconstruction, consider referral for supervised exercise therapy; a structured education visit with self-directed exercise may be a reasonable alternative when supervised rehabilitation is unavailable.

Persistent problems after ACL reconstruction are common: about half of patients report ongoing knee pain 2 years after surgery, and roughly half of young adults with prolonged symptoms develop posttraumatic knee osteoarthritis within a decade. Yet evidence to guide care after the usual rehabilitation period has been limited.

In the SUPER-Knee randomized trial, researchers enrolled 184 adults aged 18 to 40 with persistent knee problems 9 to 36 months after ACL reconstruction. Participants received either 4 months of twice-weekly, physiotherapist-supervised strengthening and neuromuscular exercise plus education or a single physiotherapist-led education session and self-directed exercise program.

At 4 months, the supervised group had a 14.1-point improvement in the composite Knee injury and Osteoarthritis Outcome Score (KOOS4), versus 9.4 points with the control intervention. Although the 4.8-point between-group difference fell short of the prespecified 9-point threshold for clinical importance, 74% of supervised-therapy participants achieved an improvement of at least 9 points, compared with 51% of controls, corresponding to a number needed to treat of 4.

Patients receiving supervised therapy were also more likely to report improved pain (73% vs 40%), improved function (83% vs 43%), and satisfaction with their knee (70% vs 48%). They had greater gains in knee extensor and flexor strength, while MRI showed no between-group differences in cartilage thickness or composition.

By 12 months, differences in the main outcome had largely disappeared as the control group continued to improve, although advantages in patient-reported improvement and muscle strength persisted. The authors said the results strengthen evidence that progressive, supervised knee loading “is not harmful for articular cartilage” and concluded that supervised exercise therapy and education “should be recommended” for patients with persistent knee problems after ACL reconstruction.

In an accompanying editorial, Jeffrey B. Driban and Matthew S. Harkey described the years after rehabilitation as potential “lost decades” of care. “We should not allow these young adults with symptoms that limit daily activities and impair quality of life to fall through the cracks,” they wrote, urging clinicians at routine visits to ask patients with previous ACL reconstruction about persistent symptoms and refer symptomatic patients for supervised exercise or further evaluation.

Source: Culvenor AG, et al. (2026 Sep 29) Ann Intern Med. Exercise therapy and education for young adults with persistent knee problems after anterior cruciate ligament reconstruction: a randomized clinical trial