Optimising Rehabilitation in Reducing the Risk of Post-Traumatic Osteoarthritis Following ACL Injury

Abstract

Abstract  Background: Anterior cruciate ligament (ACL) injuries are common and disabling, with many patients developing post-traumatic osteoarthritis (PTOA) within 5-20 years regardless of surgery. PTOA significantly affects mobility and quality of life, yet rehabilitation practices have not been explicitly developed with PTOA prevention as a primary goal.  Aims: This study explored how rehabilitation can be optimised to reduce the risk of PTOA following ACL injury, by examining patient and physiotherapist perceptions, identifying barriers and enablers, and generating recommendations for practice.  Methods: Fourteen participants were recruited: six patients who had undergone ACL reconstructions and rehabilitation within the past six years, and eight experienced physiotherapists. Semi-structured interviews were conducted between May and September 2025. Data were transcribed, coded, and analysed thematically using Braun and Clarke’s six-phase framework.  Results: Five themes were identified: (1) limited patient education and awareness of PTOA, (2) barriers in access and coordination of care, (3) psychological challenges including fear of reinjury and low confidence, (4) rigid, time-based rather than criterion-driven protocols, (5) absence of long-term follow-up, with telerehabilitation seen only as a partial adjunct.  Discussion: Findings highlight persistent gaps between evidence and practice. Optimisation should prioritise structured education, psychological support, criterion-based progression, interdisciplinary communication, and extended follow-up supported by digital tools. These insights emphasise that PTOA risk is influenced by biomechanical, biological, and behavioural factors extending beyond rehabilitation. This research contributes new qualitative evidence from the UK on optimising ACL rehabilitation with a specific focus on PTOA prevention. These findings also align with the constructivist epistemology underpinning the study, recognising that patients and professionals construct meaning differently based in lived experiences an approach essential for interpreting

variations in awareness, adherence, and perceived barriers. While these findings are valuable, they are based on modest sample and self-reported experiences, which may limit wider transferability.  Ethics: Ethical approval was obtained from the University of Nottingham Faculty of Medicine and Health Sciences Research Ethics Committee (Ref: UNSEM-J15).