Comparative effectiveness of resistance training modalities after anterior cruciate ligament reconstruction: a network meta-analysis of randomized controlled trials.

BACKGROUND: After anterior cruciate ligament reconstruction (ACLR), resistance training is essential, yet the comparative effectiveness of specific approaches remains uncertain. The objective was to compare the effectiveness of commonly used resistance training modalities after ACLR on quadriceps strength, quadriceps mass, knee function, and health-related quality of life (QoL). METHODS: PubMed, Embase, Cochrane CENTRAL, Web of Science, and Google Scholar were searched to 30 September 2025 for randomized controlled trials in adults or adolescents after primary ACLR. Eligible studies compared modality-dominant resistance-based rehabilitation with standard multimodal postoperative rehabilitation or other resistance approaches and reported quadriceps strength, quadriceps mass, knee function, or QoL. The standard multimodal rehabilitation comparator was interpreted as usual rehabilitation practice rather than absence of exercise or resistance training. A random-effects network meta-analysis estimated standardized mean differences (SMDs) with 95% confidence intervals and ranked treatments using surface under the cumulative ranking curve (SUCRA). RESULTS: Twenty-two trials (n = 797) were included. For quadriceps strength, blood flow restriction training (BFRT) ranked first (SUCRA 81.7) and exceeded standard multimodal rehabilitation (CON) (SMD 0.40; 95% CI 0.07 to 0.73). For quadriceps mass, BFRT ranked first (SUCRA 79.1) and exceeded CON (SMD 0.82; 95% CI 0.11 to 1.53). For knee function, isokinetic training (IKT) had the highest-ranking probability (SUCRA 87.7), but pairwise differences among active modalities were not statistically significant, indicating no clear evidence of clinical superiority. For QoL, eccentric training (ET) ranked first (SUCRA 87.4) and improved QoL versus CON (SMD 1.31; 95% CI 0.01 to 2.63). CONCLUSION: Post-ACLR resistance prescription should be outcome-oriented. BFRT may be considered when the primary target is recovery of quadriceps strength and mass, particularly compared with usual standard multimodal rehabilitation. IKT may be considered when aiming to improve knee function, but current evidence does not confirm its superiority over other active modalities. ET may be considered when improving QoL is a major rehabilitation goal, although this finding should be interpreted cautiously given the limited certainty of evidence. These findings should be understood as comparisons between modality-dominant programs and standard multimodal rehabilitation, and may help inform individualized rehabilitation planning following ACLR. SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/prospero/, identifier CRD420251182456.