Surgeons are adding more lateral extra-articular procedures to ACL reconstructions, especially in young cutting and pivoting athletes. On paper, it sounds great—tighten up the anterolateral side, improve stability, protect the graft. But what does that actually mean for clinical outcomes and for how we manage rehab?
A new Level 1 systematic review and meta-analysis just pulled together the randomized trials comparing isolated ACL reconstruction to ACL reconstruction plus a lateral extra-articular procedure. The results raise important questions: Are these athletes truly more stable? Do we see fewer graft ruptures? And are we quietly trading those benefits for more pain, stiffness, or long-term joint issues?
In this week’s podcast, we break down what the data really show, how it should influence your decision-making as a sports physical therapist, and what to watch for when an athlete walks in with a LET on their op note. Check out the full episode to hear how (and when) this should change your rehab approach.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 381: ACLR + LET: Overkill or the New Gold Standard?
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Show Notes
• Master the Evaluation and Treatment of the Knee
• Does the Addition of a Lateral Extra-articular Procedure to a Primary Anterior Cruciate Ligament Reconstruction Result in Superior Functional and Clinical Outcomes? A Systematic Review and Meta-analysis of Randomized Controlled Trials
Transcript
Mike Reinold:
Welcome back everybody to the latest episode of the Ask Mike Reinold Show. We are here with another journal article review for you. Let’s see. We have the crew from Champion PT and Performance here. Brendan Gates, Anthony Videtto, Diwesh Poudyal, Dave Tilley, Mike Scaduto, and Dan Pope, and we’re going to be talking about a study from AJSM in 2025 out of Australia that Lenny is going to review. He’s going to grace us with his wisdom. But basically, they talk about: does adding a lateral extraarticular procedure to an ACL reconstruction enhance outcomes? Lenny, what did they find?
Lenny Macrina:
They found an interesting finding. So yeah, it was in this past year, 2025, out of AJSM, so a very reputable journal, one of our top journals that we refer to. It was out of Australia. And ironically, it was four physical therapists and a PhD. And I had to look up what the other author was. He was a… I think it was a he. Yes. He’s the Bachelor of Surgery, which is apparently a degree you get in English, like Australia or Great Britain type country. So it’s a Bachelor of Surgery, so four PTs. So it’s interesting that four PTs and one Bachelor of Surgery and a PhD put this study together on adding LET or ALL.
So what they’re talking about is, in a traditional ACL reconstruction, you do patellar tendon graft, hamstring graft. Now the surgeons are trying to be better. They’re trying to control for re-tears. So they wanted to look at this study. They looked at 10. It’s a systematic review and meta-analysis to see if the addition of these extraarticular procedures helps to decrease re-tear rates during ACL surgery. So you had groups of people that had just a standard ACL reconstruction, which again, this study’s out of Australia. So primarily, one of the weaknesses, in my opinion, because I am a patellar tendon guy, this was mainly done on hamstring autografts. So noted.
Mike Reinold:
Interesting.
Lenny Macrina:
So a lot of hamstring autografts, and they wanted to see the outcomes over a period of time. And they followed these patients over a period of time. So it was a Cochrane database review. They used certain criteria to find these studies, randomized controlled studies, all level one studies. So very powerful, strong studies that we highly respect and are the most powerful to influence our practice. Low heterogeneity. So they all kind of give similar type… There’s not a lot of randomness in the study, in the studies that were in the 10 studies that were included.
And they showed a significant difference in re-tear rates using the LEAP. So the lateral extraarticular procedures that included LET, so lateral extraarticular tenodesis or ALL, anterior longitudinal ligament. So two different procedures. So you got to be cautious there because you get two different types of procedures being done during these ACL reconstructions of hamstring autografts. There was a low representation of females. Only about 33% of the people in the study were female, and the average age was 26 years old.
So you get an older group of people versus the younger crowd that’s more likely to retear their ligament or benefit from the addition of this procedure. So you want to see that female, younger than 20 years old, more included in these studies, and it wasn’t. The studies that were included did not have that age group as strongly included. And so I think some of the takeaways are going to be that adding it in a certain population may help. On the short term, there’s more pain, the strength is compromised early on, but it all kind of goes equal about a year out of surgery.
And so for me, personally, if I’m seeing patients… I just had a kid who had a left ACL reconstruction. He tore the right side, and the surgeon and I were going back and forth because the surgeon included me, whether or not to include an LET or not. Primarily, I’m seeing LETs, not ALLs, as that extra procedure being done. So that extraarticular tenodesis of the IT band being done. And he chose to do the surgery because I think the surgeon was freaking out that this kid already had a history of a tear. Let’s really lock him down and prevent that extra rotatory instability that this procedure does do, and let’s do the LET.
So I don’t know. I’m curious to hear everybody’s thoughts on these papers. Again, it was biased toward men, older, 26 years old. They didn’t control for PT. I think that was another important finding, was it was just physical therapy was done based off of you, the person. There was no protocol to kind of progress these patients appropriately. And so I think that’s a little disappointing as well, but that’s what we commonly see in the research. So I’m just going to open up to you guys. That’s kind of the 35,000-foot view of this paper. Curious what you guys think. Would you recommend an LET to your patients based off of this data?
Dave Tilley:
Yeah, I can jump in. And Lenny just definitely stole the thunder. Unfortunately, those are my notes as well. I think I read the whole paper, and I was like, “Oh, this is great.” And then I’m like, “Wait a minute, they’re seeing mostly males who are older, and they’re doing hamstring grafts. That is literally the opposite of what I see in the clinic.” And I could be biased because I see a lot of gymnasts, dancers, and a lot of soccer players. My primary ACL is, looking through my patient list, is a 16 to 17 year old female with a bone, patellar bone graft, and they’re not super lax, but most of them are really lax.
And the LET, in my mind, from what I’ve learned from learning other papers, is we’re trying to control some of that excessive genetic laxity that they have. So if we’re thinking about doing something that’s going to maybe be more painful in short term and make it harder to get back, maybe some longer term quad type stuff with the swelling, when you recommend that, it’s like you want to make sure that person is going to go through something that gives them a lot of extra stability and is good.
So I read the whole paper, and I was like, “Oh, this is cool. This is good to see.” But man, this couldn’t be farther away from the person that I’m seeing. 10 years older, opposite gender, hamstring graft. And I was a little nervous to maybe automatically say everyone gets an LET. Whereas I think where my clinical brain goes is for someone who is younger, lax, type one. They had a lot of type one pivoting sports, which I guess would say is definitely a plus. But a jumping and landing sport, I think volleyball, I think basketball, I think gymnastics.
In someone who’s young and lax, that’s when I’m thinking about like, “Okay, maybe this person is more appropriate for this.” And the other piece of it too is that surgeons are the ones who I think are suggesting this or dictating this. It’s not really a choice that we make, but it’s good to know upfront that if someone is getting an LET… I had a kid with a LET, meniscus, lateral, and medial, and a BTB. That kid’s quad was mushy. It took so hard to get his leg so swollen, so cranky, so angry that it took a long time. And I had to educate him a lot on like, “Listen, this is going to go a lot slower than maybe you want because you had so much work done. Your leg is very, very… The joint is angry right now,” as they say. So those are kind of my takeaways.
Mike Reinold:
Dave, can I just ask, to your point though, we’re never going to have a perfect study. You guys have great limitations. You bring up good limitation. We can’t have a perfect study. It’s so impossible to do a study like that. Dave, you think your people in your avatar that you just described right there, wouldn’t this be helpful for them?
Dave Tilley:
Yes. And that is kind of where I think it’s… We had this discussion around bracing. Like bracing, when is that appropriate? When’s it not? And I think it’s something that if a surgeon is already thinking about the fact that this person’s young and lax and they’re going back to a really high-risk sport, they have long-term college goals, they’re 16, they want to play at least six more years and get a scholarship.
In my mind, I’m trying to be like, “Yeah, this is the perfect person who might do well with that extra stability if we forfeit some quad activation or swelling or discomfort in the beginning.” But the thing that’s really hard is you get somebody who has a quad tenant repair and LET. Holy moly, those things are hard to get going. They’re really cranky and angry, and the quad is really rough. So that’s the hard thing, is that the more you do on top of a meniscus and an ACL, I think that middle two, six weeks to 10 weeks, is really hard to get somebody stronger, less swollen, less painful, whatever. So…
Lenny Macrina:
LET. The LET…
Mike Reinold:
Are you guys educating on that?
Lenny Macrina:
Oh, sorry. Go ahead.
Mike Reinold:
So I was just going to ask, are you educating people on that?
Dave Tilley:
Yeah. Yeah.
Mike Reinold:
So when you say, “Look…”
Lenny Macrina:
I am, yeah.
Mike Reinold:
“A pre-op, you’re getting this procedure. Get ready. We’re going to have a little bit more work to do at the beginning.”
Dave Tilley:
Yeah. Exactly.
Mike Reinold:
Okay.
Dave Tilley:
Yeah.
Lenny Macrina:
Yeah. I think a general rule of thumb is lateral structures tend to get more swollen. I think we’ve talked about this before on the podcast. So when you do… And they’re painful. Versus a medial structure. Like an MCL sprain, the knee gets stiff or grade two, grade three, like a repair or reconstruction of the MCL, they get stiff. With a LET or a lateral-sided injury, they get more swollen and painful, but they don’t necessarily get as stiff.
So the protocols don’t change much. And they said that in the paper too. Range of motions don’t change much with the addition of the LAT, but there’s just more swelling and pain, which is probably why the quad didn’t come back as quickly in that group. But everybody kind of normalized at a year plus out of surgery. So you’ll get there. It’s just a tougher road to get there, but you have a more, maybe relatively stable knee with the decreased risk of a tear.
There was one paper that did talk about OA in the knee, and that was quickly squashed that the paper wasn’t strongly powered and there was some bias in the paper, but there has been discussion in the orthopedic world that the addition of these procedures, the LET or ALL can lead to some wearing in the knee because of the extra stress on the knee and the stability in the knee that is afforded from the surgery, that it may wear the knee down quicker in the patellofemoral joint. So I would kind of be cautious interpreting that, but keep an eye on that because that may pull itself out in the future as we see more of these done and we study these procedures more.
Mike Reinold:
I wish somebody would tell the Tommy John surgeons that concept.
Lenny Macrina:
Right. Right. Exactly.
Mike Reinold:
Maybe tighter is not better, but anyway.
Lenny Macrina:
Right. Yeah.
Mike Reinold:
You know what scares me? Here’s what scared me about this, because I think you could summarize this article in a sentence that said adding this makes you more stable with better outcomes. With just some short-term increases in some stuff that subsides. But here’s what scares me. So I just recently recorded a presentation for Dan Pope, Kevin Coughlin, and I’s upcoming return to sport course, a little…
Lenny Macrina:
Plug.
Mike Reinold:
A little plug. A little teaser in there. And some of these articles blew my mind. Two studies published in the last couple of years. Why don’t you guys guess? What is the average amount of PT visits? Dan, if you know the answer, if you saw my presentation, what is the average amount of PT visits for ACLs in the United States? Guess.
Mike Scaduto:
12.
Lenny Macrina:
I was going to say 12.
Mike Reinold:
I was going to say, I threw up with this number. So I kind of led you to go low. So 12. Anybody else?
Anthony Videtto:
24.
Dan Pope:
Six.
Diwesh Poudyal:
16.
Mike Reinold:
$1. $1. So the part that blew my mind, two studies, one published in 2021 in OJSM, 17. Recently in Arthroscopy this year, 21. And by the vast majority of these are at the beginning.
Lenny Macrina:
Right.
Mike Reinold:
So what? Let’s say 18, 18 PT visits after ACL? I mean, no wonder why the outcomes suck and no one’s strong.
Lenny Macrina:
And you’re probably doing twice a week for six weeks. So the majority of them are the first six weeks, and then you kind of…
Mike Reinold:
Oh, I did the math.
Lenny Macrina:
You cherry-pick the visits for the next six weeks.
Mike Reinold:
I did the math, trying to break it down, because they broke it down. 52% of those visits are in the first six weeks. So essentially, nine visits are 1.5 times a week. And then for the next month, it was just once a week. And then after that, you just saw somebody three other times after that. 90% of people are done within the first 16 weeks.
Lenny Macrina:
So you wonder why re-tear rates are so high. They’re not strong enough. They’re not getting the PT they need, and they just declared because of a time base. Six months out, “Oh, your knee looks good enough. You got Lachmans. Let’s start doing some soccer stuff or something like that.” And then… But this is where we come in. This is where education comes in.
This is where our business comes in. We have people like Diwesh and our coaching staff that can handle this. And I think that’s what critical, in these surgeries and surgeries that involve what we talked about, is you need to have a good relationship with a strength coach or PT gym that has the facilities to provide what they need. And it’s hugely beneficial. And I think our re-tear rates are significantly lower in our population than what the research is saying for that reason. So I think that’s a strong point, not of this paper, but I think that comes out of this stuff in our discussions.
Mike Reinold:
That’s the only thing that makes me more nervous about a procedure like this, that might be better in the long run. But to me, I think you almost argue it requires more PT, and you could argue that’s a huge problem with our profession right now.
Lenny Macrina:
And talking to the surgeons, people that I trust locally in Boston and in Birmingham where I used to work, they say the LET is good, but I think it’s overused, and a good patellar tendon, a PTG, and for most of the athletes, is sufficient and good. It’s a stable knee. You get their quads back. It’s a very reproducible surgery and rehab. You understand what’s going on. You don’t have the hiccups that you get from a quad tendon.
Don’t even get me going with quad tendon grafts. Remember, when they do an LET, when they do these surgeries, there’s more time in the surgery ward, there’s more anesthesia going on, there’s more pain, there’s more time that there… It’s more stress for the body. So it should be done in a patient that really would benefit it, like the ones that Dave sees. That gymnast who’s very lax, trying to get back to a high level, level one pivoting, cutting sport, I think would be the take-home in my opinion.
Mike Reinold:
Yeah. So if you’re more statistically likely to re-injure it.
Lenny Macrina:
Yes.
Mike Reinold:
So you’re less than whatever, 21, 23 years old. I know there’s a cutoff in there. You’re less than that. You’re going back to high-level sport, you’re female.
Lenny Macrina:
You’re very lax. Your Baiting score is off the chart. You’re positive for everything, you’re…
Mike Reinold:
Right.
Lenny Macrina:
Or however you say, biting, baiting, whatever that scale is.
Mike Reinold:
I mean, I’m Reinold. It’s an I. EI’s I.
Lenny Macrina:
Right. Right.
Mike Reinold:
So anybody that says otherwise is wrong, but yeah, just saying. But yeah, it’s just science.
Lenny Macrina:
Yeah.
Mike Reinold:
But so let’s put this and a couple weeks ago’s episode together. I don’t know about you guys. You tear your ACL, I’m getting an NMES unit to use at home. Based on a couple weeks ago.
Lenny Macrina:
Right.
Mike Reinold:
I’m getting a Game Ready. Why wouldn’t you get a Game Ready? Are you bananas not to get a Game? What does that cost? 100 bucks to rent? Just rent a Game Ready. Getting a Game Ready. I’m probably going to get a CPM after ACL for me. I got a thumbs up from Brendan. That’s what I would do if it was my knee. What are you taking by chance? You spent more money on golf training aids, Len, than people spend on stuff to help them with their ACL rehab at home.
Lenny Macrina:
Right. Our doctors use all that stuff, and I think it’s very beneficial to them. And I think we’re kind of biased because we see that side. And I’ve seen the other side too, where you don’t. It’s just a little easier. Those first few weeks are a little easier for the person physically, mentally, and it just helps so much in the long run, in my opinion. So yeah.
Mike Reinold:
Awesome. Great article. Thanks, Len. Good review. Again, another good article. This is fun. I’m enjoying these. I think we’re all… I know. I see everybody here. I think everybody’s enjoying it here, too. So if you like it, please let us know. Send me an email on the website or comment on our social medias. DM me, it’d be great to hear from you. And please keep subscribing, rating, reviewing these on Apple Podcasts and Spotify, and we’ll see you on the next episode. Thank you so much.
