The rehabilitation of patients undergoing anterior cruciate ligament (ACL) reconstruction requires symmetry in bilateral quadriceps strength and adequate proprioception capabilities prior to return to preoperative level of activity or sport. This is the limiting factor and can delay the time that patients can return to play. There is little literature on pre-operative physiotherapy or prehabilitation of patient with ACL injury. This paper discusses the anatomy, biomechanics, surgical decision making, and the current knowledge of preoperative training or “prehabilitation” in patients awaiting ACL reconstruction. 1. Introduction Anterior cruciate ligament injuries are significant when they involve a complete intrasubstance tearing of the anterior cruciate ligament (ACL) in the knee. The injury is characterized by joint instability that leads to pain, decreased activity and function, poor-knee-related quality of life, and an increased risk of osteoarthritis of the knee. Relatively few studies have examined the effects of preoperative strengthening of the ACL injured patient. Most studies on ACL rehabilitation in the recent past have mainly investigated (i) the coping mechanisms of the patients treated conservatively, (ii) the effects of balance training preoperatively, (iii) the outcomes of accelerated rehabilitation postoperatively, (iv) and the types of rehabilitation programmes that should be employed. Prehabilitation has been defined as “the process of enhancing functional capacity of the individual to enable them to withstand the stressor of inactivity” [1], preparing a patient before a stressful event. The term “prehabilitation” is not commonly used in the context of ACL injury rehabilitation. It is, however, used in relation to patients preparing for other orthopaedic procedures [1] and in prevention of injury in the healthy population [2]. For example, prehabilitation is commonly used prior to total knee replacements [3], spine surgery [4], cardiac procedures [5], and colectomies [6]. Noyes et al. were the first to propose the use of physiotherapy prior to ACL surgery to increase muscle strength and improve recovery rates [7]. However, to date, very few studies examined the effects of preoperative physiotherapy in this condition. There has been a paradigm shift from Noyes’s rule-of-one-third in relation to ACL injuries, where a third improved, another third deteriorated, and the final third had no significant changes following rehabilitation and activity modification. The pathway of ACL injuries is shown in Figure 1. With the advent of MRI
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