# Substantial variability and inconsistent quality of publicly available rehabilitation protocols after quadriceps tendon anterior cruciate ligament reconstruction: A cross‐sectional analysis of academic orthopaedic surgery programmes

## TL;DR

Rehab protocols for quadriceps tendon ACL surgery vary widely and often lack specific guidance, leading to inconsistent care.

## Contribution

The study reveals substantial variability and lack of QT-specific rehabilitation guidelines in academic orthopaedic programs.

## Key findings

- Most protocols use a hinged brace locked in extension for 2–4 weeks.
- Exercise prescriptions, adjunctive therapies, and return-to-sport criteria show significant variability.
- Many protocols are not tailored to QT-specific considerations and resemble those for other graft types.

## Abstract

Quadriceps tendon (QT) autograft is increasingly used for anterior cruciate ligament reconstruction (ACLR), yet rehabilitation guidelines remain extrapolated from patellar tendon (PT) or hamstring tendon (HT) protocols. This cross‑sectional study evaluated publicly available postoperative rehabilitation protocols from academic orthopaedic programmes to describe their content, assess variability and identify key trends.

Accredited orthopaedic residency programmes were identified through the Electronic Residency Application Service (ERAS) and Canadian Resident Matching Service (CaRMS). A three‐step systematic web‐based search was conducted to identify publicly available QT‐ACLR rehabilitation protocols. Protocols were included if specific to QT autografts and excluded if addressing concomitant meniscal repairs. Two independent reviewers extracted data on rehabilitation components and timelines. The proportion of protocols including each component and the median initiation time were calculated.

Of 219 programmes screened, 16 eligible protocols were identified. Nine were QT‐specific and seven were general ACLR protocols. Key trends included: (1) use of a hinged brace locked in extension for 2–4 weeks (86.7%); (2) initiation of icing, cryotherapy and patellar mobilizations immediately postoperatively (68.8%); (3) neuromuscular electrical stimulation use within the first 4 weeks (56.2%); (4) target of full extension by 2–4 weeks and flexion by 3–4 months (100%); (5) strengthening, balance and proprioceptive training beginning between 1–3 months (93.8%–100%) and (6) return‑to‑sport (RTS) testing between 5 and 9 months, using time‐based and/or criterion‐based recommendations (100%). Substantial variability existed in exercise prescriptions, adjunctive therapy use and RTS criteria.

Publicly available QT‐ACLR rehabilitation protocols from academic programmes emphasize early weight‐bearing, range of motion restoration and progressive strengthening but reveal considerable variability in timing, adjunctive therapies and RTS guidelines. Many protocols mirror those for PT and HT autografts rather than being tailored to QT‐specific considerations. Standardized, evidence‐based rehabilitation guidelines that address graft‐specific risks, psychological readiness and telehealth delivery are needed to optimize outcomes following QT‐ACLR.

Level IV.