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Variability in Terminal Phase Timing and Return-to-Sport Criteria in ACL Reconstruction Rehabilitation Protocols: A Scoping Review of U.S. Academic Institutions.

Hailey Calkins,Audrey Lotulelei,Megan L. Pales Taylor,D. Bennion,Alison Granger,Scott Behjani,Stephan G. Bodkin

Published 2026 in International Journal of Sports Physical Therapy

ABSTRACT

Background Rehabilitation following anterior cruciate ligament reconstruction (ACLR) plays a critical role in patient recovery and return to sport (RTS). However, substantial variability exists in how rehabilitation is prescribed, particularly in the terminal phases when insurance coverage often wanes and patients face decisions regarding RTS without consistent medical guidance. Purpose To characterize the variability in publicly accessible ACLR rehabilitation protocols from U.S. academic medical centers, with a focus on terminal phase timing and RTS criteria. Study Design: Scoping review. Methods Following PRISMA-ScR guidelines, a comprehensive search was conducted across 190 Association of American Medical Colleges (AAMC) institutions to identify publicly available ACLR rehabilitation protocols. Data points extracted included timing of the terminal rehabilitation phase and RTS criteria prescribed. Results Of 184 protocols identified, 119 isolated ACLR protocols were included. Among isolated ACLR protocols, the terminal phase began on average at 5.42 ± 1.79 months and ended at 7.38 ± 2.73 months post-ACLR, though 44% had no defined end point. Only 45% of protocols included RTS criteria, with an objective measure of strength (79%) and hopping (91%) being most frequently reported. However, wide variation existed in thresholds for limb symmetry index (LSI) used for these measures, which ranged from 80% to 100% LSI. Less than 40% of protocols included patient-reported outcomes or psychological readiness criteria. Conclusion Significant variability exists among publicly available ACLR rehabilitation protocols from U.S. academic institutions regarding terminal phase timing and RTS criteria. Many protocols lack clear endpoint definitions or specific, evidence-based RTS benchmarks. Given the critical role of late-phase rehabilitation in optimizing outcomes and minimizing reinjury risk, these findings highlight the need for ongoing review and refinement of rehabilitation protocols. Enhancing the consistency and clarity of terminal phase goals, particularly around functional testing and psychological readiness, may better support patients and providers in navigating the transition from rehabilitation to sport participation. Level of Evidence 3.

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