The Role of Patient Characteristics in the Success of Nonoperative Treatment of Anterior Cruciate Ligament Injuries

Am J Sports Med. 2020 Jun;48(7):1657-1664. doi: 10.1177/0363546520917386. Epub 2020 May 13.


Background: Anterior cruciate ligament (ACL) tears can either be treated nonoperatively with physical therapy and then treated operatively if persistent instability is present, or be directly treated operatively. Advantages of early ACL reconstruction surgery include shorter time from injury to surgery and potentially fewer meniscal injuries, but performing early ACL reconstruction in all patients results in surgery in patients who might not need ACL reconstruction. It is important to assess in which patients nonoperative treatment is successful and which patients will require ACL reconstruction and thus might be better treated surgically in an earlier phase.

Purpose: To identify patient characteristics that predict the success of nonoperative treatment.

Study design: Cohort study (Prognosis); Level of evidence, 2.

Methods: All patients with complete ACL injuries who were evaluated between 2014 and 2017 at our clinic were included. The minimum follow-up was 2 years. The initial treatment and ultimate ACL reconstruction were reviewed. Univariate analysis was performed using Mann-Whitney U tests and chi-square tests and multivariate analysis using binary logistic regression.

Results: A total of 448 patients were included with a median age of 26 years and median Tegner level of 7 and mean Tegner level of 6.4. At initial consultation, 210 patients (47%) were treated nonoperatively with physical therapy and 126 of these patients (60%) ultimately required ACL reconstruction. Nonoperative treatment failed in 88.9% of patients <25 years of age, 56.0% of patients 25 to 40 years, and 32.9% of patients >40 years (P < .001); and 41.9% of patients with Tegner level 3 to 6, and 82.8% of patients with Tegner level 7 to 10. Age <25 years (odds ratio [OR], 7.4; P < .001) and higher Tegner levels (OR, 4.2; P < .001) were predictive of failing nonoperative treatment in multivariate analysis. Patients in the failed nonoperative group had longer time from diagnosis to surgery than the direct reconstruction group (6.2 vs 2.2 months; P < .001), and more frequently had new meniscal injuries (17.4% vs 3.1%; P < .001) at surgery.

Conclusion: Nonoperative treatment of ACL injuries failed in 60% of patients and was highly correlated with age and activity level. In patients aged 25 years or younger or participating in higher-impact sports, early ACL reconstruction should be considered to prevent longer delay between injury and surgery, as well as new meniscal injuries.

Keywords: ACL reconstruction; activity level; age; anterior cruciate ligament; nonoperative treatment; predictors.

MeSH terms

  • Adolescent
  • Adult
  • Anterior Cruciate Ligament Injuries / complications
  • Anterior Cruciate Ligament Injuries / surgery
  • Anterior Cruciate Ligament Injuries / therapy*
  • Anterior Cruciate Ligament Reconstruction
  • Athletic Injuries / complications
  • Athletic Injuries / therapy
  • Female
  • Follow-Up Studies
  • Humans
  • Logistic Models
  • Male
  • Middle Aged
  • Odds Ratio
  • Physical Therapy Modalities*
  • Retrospective Studies
  • Tibial Meniscus Injuries / complications
  • Time-to-Treatment
  • Treatment Outcome
  • Young Adult