ACL Reconstructions: Who Needs Them? 

Anterior cruciate ligament (ACL) injuries once were career-ending for athletes. With the advent of ACL reconstruction, elite athletes have been able to continue to compete at the highest level. But a question remains regarding recreational athletes and their need for reconstruction following ACL injury. Literature has shown that there are “copers” who are able to deal with an “ACL-deficient” knee, but are these individuals destined to participate in only low-impact activities without cutting and twisting? 

In the latest issue of JBJS, Pedersen et al. shed new light on this important topic, reporting the 5-year outcomes of the Delaware-Oslo ACL Cohort Study, a longitudinal study of patients who had been active in cutting, jumping, and pivoting sports before sustaining a unilateral ACL injury. The original cohort underwent 5 weeks of rehabilitation and then participated in a shared decision-making process to determine their treatment path. Inclusion criteria included involvement in level-I sports (such as soccer, football, handball, or basketball) or level-II activities (such as tennis, skiing, softball, baseball, or gymnastics) at least 2 times per week prior to injury.  

Treatment status at 5 years was known for 262 of the original 276 patients: 167 (64%) underwent early ACL reconstruction, 30 (11%) underwent delayed ACL reconstruction after having tried the path of rehabilitation only, and 65 (25%) opted for progressive rehabilitation alone. The patients who chose progressive rehabilitation alone were significantly older, less likely to participate in level-I sports preinjury, and less likely to have injuries to the medial meniscus compared with patients in the 2 reconstruction groups.  

Interestingly, at 5 years, no significant differences were found between the 3 groups in terms of clinical, functional, or physical activity outcomes as assessed by several measures.   

There were narrow indications for inclusion in the study, including no substantial concomitant knee injuries, and patients needed to have full resolution of acute impairments before being enrolled. That being said, at follow-up, 95% to 100% of patients across groups were still active in some kind of sports. This gives hope to older guys like me that maybe we don’t need to fear an ACL injury ending our weekend careers of showing our kids “how it’s really done.” Maybe former athletes like myself would fall into that group of “copers” who can still be relatively active with an “ACL-deficient” knee? 

Click here for the related JBJS video summary of this article. 

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media