Purpose: The postoperative use of a rehabilitative knee brace after isolated primary anterior cruciate ligament (ACL) reconstruction (ACLR) using a hamstring tendon (HT) autograft is controversial. A knee brace may provide subjective safety but can cause damage if applied incorrectly. The aim of this study is to evaluate the effect of a knee brace on clinical outcomes following isolated ACLR using HT autograft. Methods: In this prospective randomised trial, 114 adults (32.4 ± 11.5 years, 35.1% women) underwent isolated ACLR using HT autograft after primary ACL rupture. Patients were randomly assigned to wear either a knee brace (n = 58) or no brace (n = 56) for 6 weeks postoperatively. An initial examination was performed preoperatively, and at 6 weeks and 4, 6, and 12 months. The primary endpoint was the subjective International Knee Documentation Committee (IKDC) score to measure participants’ subjective perceptions. Secondary endpoints included objective knee function assessed by IKDC, instrumented knee laxity measurements, isokinetic strength tests of the knee extensors and flexors, Lysholm Knee Score, Tegner Activity Score, Anterior Cruciate Ligament—Return to Sport after Injury Score, and quality of life determined by Short Form-36 (SF36). Results: There were no statistically significant or clinically meaningful differences in IKDC scores between the two study groups (3.29, 95% confidence interval (CI) −1.39 to 7.97, p = 0.03 for evidence of non-inferiority of brace-free compared with brace-based rehabilitation). The difference in Lysholm score was 3.20 (95% CI −2.47 to 8.87); the difference in SF36 physical component score 0.09 (95% CI −1.93 to 3.03). In addition, isokinetic testing did not reveal any clinically relevant differences between the groups (n.s.). Conclusions: Brace-free rehabilitation is non-inferior to a brace-based protocol regarding physical recovery 1 year after isolated ACLR using HT autograft. Consequently, the use of a knee brace might be avoided after such a procedure. Level of Evidence: Level I, therapeutic study.

Background/Objectives: Anterior cruciate ligament (ACL) injuries continue to present significant clinical and rehabilitative challenges. Despite advances in surgical techniques and rehabilitation protocols, persistent reinjury rates and increased pressure for early return to sport require a critical reassessment of current practices. This narrative review provides a comprehensive overview of the evolution, current standards, and future directions of ACL surgery and rehabilitation. Content: The literature search was conducted primarily in PubMed/MEDLINE and Web of Science using ACLRelated keywords, with emphasis on systematic reviews, randomized controlled trials, registry data, and consensus guidelines published within the past two decades. The evolution of ACL treatment is shaped by the transition from open to arthroscopic and anatomic reconstructions, as well as the refinement of fixation and augmentation techniques. In parallel, rehabilitation concepts shifted from rigid, time-based schedules to criteria-driven, individualized approaches. Key aspects include early mobilization, prehabilitation, and the integration of innovative tools such as anti-gravity treadmill and blood flow restriction training. Evidence on bracing suggests no routine benefit, while structured prevention programs have proven effective. Return-to-play strategies now emphasize objective functional criteria and psychological readiness. Conclusions: ACL therapy has evolved toward personalized, function-oriented rehabilitation. Future developments—including markerless motion analysis, AI-supported rehabilitation, and digital health applications promise for further individualization of care and optimization of long-term outcomes.

Background: The lateral ankle sprain (LAS) is the most common injury in the field of everyday and sports-related activities. There is a high rate of patients with LAS who will develop chronic ankle instability (CAI). A possible explanation for this high rate is an insufficient rehabilitation and/or a premature return to intense exercise and workloads. Currently, there are general rehabilitation guidelines for LAS but there is a lack of standardized evidenced-based rehabilitation concepts for LAS, which effectively reduce the high CAI rate. The primary aim of the study is to investigate the effectiveness of a 6-week sensorimotor training intervention (SMART-Treatment, SMART) in contrast to standard therapy (Normal Treatment, NORMT) after an acute LAS on perceived ankle joint function. Methods: This study will be a prospective, single-center, interventional randomized controlled trial with an active control group. Patients (14–41 years) with an acute LAS and a MRI confirmed lesion or rupture of at least one ankle ligament will be included. Exclusion criteria are acute concomitant injuries of the ankle, pre-injuries of the ankle, serious lower-extremity injuries of the last 6 months, lower-extremity surgery, and neurological diseases. The primary outcome measure will be the Cumberland Ankle Instability Tool (CAIT). Secondary outcomes include the Foot and Ankle Ability Measurement (FAAM), isokinetic and isometric strength diagnostics, joint repositioning sense, range of motion, measurements of postural control, gait and run analysis, and jump analysis. This protocol will follow the SPIRIT guidance. Discussion: Current management of LAS rehabilitation lacks since there is a high rate of patients developing a CAI. It has been shown that exercise therapy improves ankle function in acute LAS as well as in patients with CAI. It is further recommended to address specific impairment domains in ankle rehabilitation. However, empirical data for such a holistic treatment algorithm is missing. Therefore, this study has the potential to improve the healthcare for LAS patients and might be used for a future standardized evidence-based rehabilitation concept. Trial registration: “Prospectively registered” ISRCTN – ISRCTN13640422 17/11/2021; DRKS (German Clinical Trials Register) – DRKS00026049.

Background/Objectives: Anterior cruciate ligament (ACL) injuries continue to present significant clinical and rehabilitative challenges. Despite advances in surgical techniques and rehabilitation protocols, persistent reinjury rates and increased pressure for early return to sport require a critical reassessment of current practices. This narrative review provides a comprehensive overview of the evolution, current standards, and future directions of ACL treatment and rehabilitation. Additionally, we present original data evaluating the effectiveness of brace-free rehabilitation following ACL reconstruction (ACL-R). Methods: The review synthesizes developments in surgical techniques and rehabilitation strategies, including blood flow restriction training, anti-gravity treadmill use, and return-to-play criteria. Complementary to the literature, we report results from a controlled, longitudinal study (n = 137) comparing isokinetic strength and functional outcomes between brace-based and brace-free early rehabilitation after ACL-R using hamstring grafts. Results: The literature reflects a shift from time-based to criteria-driven rehabilitation, emphasizing individualization and functional readiness. Our original data revealed no significant differences in quadriceps and hamstring torque production between groups at 16, 26, and 52 weeks postoperatively. Statistical parametric mapping confirmed the non-inferiority of brace-free rehabilitation in terms of isokinetic performance. Conclusions: ACL therapy has evolved toward personalized, function-oriented rehabilitation. Our findings suggest that postoperative bracing may be unnecessary in many cases, supporting a more progressive approach. Future developments may include markerless motion analysis, AI-supported rehabilitation, and digital health tools to further individualize care.

The aim of this study was to establish a consensus-based classification of postoperative events following anterior cruciate ligament reconstruction (ACLR), clearly distinguishing no complication/normal clinical course, minor complication, major complication, and failure, using a structured Delphi methodology among international experts in anterior cruciate ligament (ACL) surgery. A three-round modified Delphi process was conducted involving international high-volume ACL surgeons. An initial set of statements addressing potential postoperative events after ACLR was developed by a working group based on clinical expertise and contemporary literature. Panelists classified each statement as no complication/normal clinical course, minor complication, major complication, or failure. Consensus was predefined as ≥75% agreement within a single category. Statements reaching consensus were retained, whereas non-consensus statements were revised and re-evaluated in subsequent rounds. Thirty-nine experts completed the first and second Delphi rounds, and 30 (76.9%) completed the third round. The initial 52 statements were expanded to 67 in round two and refined to 46 in round three. Consensus was achieved for 14 statements (26.9%) in round one, 21 statements (31.3%) in round two, and 20 statements (43.5%) in round three. Overall, consensus was reached for 55 statements, forming the final classification framework. The panel clearly distinguished graft failure-defined as graft insufficiency or symptomatic instability-from major complications requiring surgical intervention or associated with substantial morbidity, and from minor complications or expected postoperative findings. Notably, traumatic graft rupture following a clearly documented new injury was not considered a postoperative complication. This international Delphi consensus establishes a standardized and clinically meaningful classification of postoperative events following ACLR. By clearly distinguishing no complication, minor complication, major complication, and failure, this framework provides a shared language that may improve consistency in outcome reporting, facilitate comparison across studies, and enhance the interpretability of clinical research and registry data. V, expert consensus.