A meta-analysis was recently published, suggesting that outcomes may be the same between nonoperative and surgical reconstruction after ACL injury.
Obviously, social media has been buzzing.
But are outcomes really the same? We discuss in this episode.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 372: Are the Outcomes Really the Same Between Nonoperative and Surgical Treatment of ACL Injuries?
Listen and Subscribe to Podcast
You can use the player below to listen to the podcast or subscribe. If you are enjoying the podcast, PLEASE click here to leave us a review in iTunes, it will really mean a lot to us. THANKS!
Show Notes
• No Difference in Return-to-Sport Rate or Activity Level in People with Anterior Cruciate Ligament (ACL) Injury Managed with ACL Reconstruction or Rehabilitation Alone: A Systematic Review and Meta-Analysis
• Evaluation and Treatment of the Knee online course
Transcript
Mike Reinold:
Welcome back, everybody, to the latest episode of the podcast. We are here answering your questions, but also reviewing some journal articles. So, we’re working on some new formats here, and we’re almost at the 10-year mark of this podcast, which is crazy. I don’t think anybody really listens to it anymore, but we enjoy recording it for those very few people that are still listening, thank you for that.
We are here at Champion PT and Performance up in Boston. We have another journal article to review today. We have Kevin Coughlin, Lisa Lowe, Brendan Gates, Anthony Videtto, Dave Tilley, Lenny Macrina, and Mike Scaduto here. And we’re going to be going over another journal article review for your pleasure today. So, what do we have today? We have… This one was just published in July of 2025 in Sports Medicine. And Len, you’re more on Twitter than me here, but I’m going to say that this one was discussed quite a bit on social media recently. But the article is “No Difference in Return to Sport Rate or Activity Level in People with ACL Injury Managed with Reconstruction or Just Rehab Alone.”
Lenny Macrina:
Right.
Mike Reinold:
Len, what do you think of this article? What’s your review?
Lenny Macrina:
Yeah, when this article first came out, it kind of hit a lot of areas of common conversations that we have on social media. It’s one of those like, “Oh, okay, what we got going on here?” Because there is obviously a population of people that could probably get away with not having a surgery. And so, this paper came out and was like, “Oh, maybe we can expand that group, and maybe surgery is not as viable as we have said and believe and promote.”
And so, you look at the paper, and I appreciate what the authors have done. I don’t know the authors at all. I think Stephanie’s out of Australia. She’s put other papers out on cross-bridge nonsurgical interventions after ACL. So, take it with a grain of salt. I tend to have biases as well. And so the paper, when we dive into it, is a little… I think there’s some flaws to it that I think once you dive into it, you’re like, all right, maybe the conclusions that were drawn, I would take it with a grain of salt. Because they were able to whittle it down to about 18 studies of about 1,600 participants. So again, it’s a meta-analysis and a systematic use. They did a big lit search and they whittled it down to what met their conclusion and exclusion criteria. And a big thing was that the paper had to compare surgical versus non-op rehab, and then see if the groups had a significant difference in all those papers, and then bring it down into a clean meta-analysis and systematic review.
And so, their conclusion was there was no significant difference in the groups that had ACL rehab or rehab alone. If you look at their return to sport injury or return to pre-injury rates, it’s only about 45 to 50% in the studies included. If my ACL patients had a 45% chance of getting back to sport, I don’t know if I’d still be in business. So, those numbers seem low in general.
I think another thing that they looked at as well was the lack of… We don’t know the pre-op status or the pre-injury status of the participants. They were… Seems to be an older group, not all athletes, definitely there were no elite athletes. And they say that in their conclusions, that you cannot generalize this to elite or higher level athletes. So, we’re generalizing it, I think, to basically an adult population. I think you can maybe say, could do a trial of non-op rehab, but they can’t say that with certainty.
Most of the studies had significant confounding biases and had very low and serious uncertainty and risk bias associated with them. And I’m talking almost all of them. So when you start looking at… If you take studies that have biases associated with them and try to come up with a conclusion, your conclusion is going to be biased. I think that’s what we’re coming up with here, is all these meta-analyses and systematic reviews seem to have what they determine as serious biases associated with them. So I would say the conclusions have serious biases as well.
So, I think take it with a grain of salt that you compile all this data. And again, I appreciated what they did. I don’t think this is swaying me. Again, I have my internal biases that I treat all post-op patients. I’ve spoken to numerous PTs, we met about this in one of our Sports Medicine Society meetings, and most people that have read it say that they appreciate the research, but there needs to be more work to be done to compare apples to apples. So, I open it up to you guys and who read the article and just curious what you guys had to say as well.
Mike Reinold:
What do you got, Dave?
Dave Tilley:
Yeah, I think for me personally, when I read articles like this, it’s a pretty bold statement to say there’s comparable rates and you maybe don’t need an ACLR, stuff like that. So as someone who also does research, you try very hard to make sure that when you say something that’s a little bit more spicy, you’re really having a lot of pretty solid evidence to back that up.
So the only parallel I can say is we worked on a paper where we talked about elbow OCD in weight-bearing gymnasts, and we were recommending that people start weight-bearing at earlier than maybe the recommendation was. We had to spend years digging through papers to defend why biologically we thought that, what the surgeons thought, whatever. So that’s always for me, is like, wow, okay, to Lenny’s point, if I’m going to make a discussion point about this, I got to really make sure that all these studies are pretty hardcore methodology, they’re long-term.
And for me, I highlighted it to read it, but it says at the very end of the discussion, it says, “However, it is known that some individuals managed non-surgically will not regain the knee stability required for taking part in cutting and pivoting sports. For individuals with persistent knee instability after trialing nonsurgical management, ACL reconstruction is recommended.” So for, me as a clinician, the ultimate goal is what? Safely get them back to sports and then not get that dreaded text that, like, “Hey, I was playing last night. Something went really quick. I felt a pop. I’m getting an MRI,” and your heart sinks.
So for me, that’s always the end goal of, “I need to make sure this person gets back.” Saying you got back to sports is one thing, but are you successful at sports for many, many months, many years after? And for me, I need a one, two, five-year follow-up on really long prospective studies to say someone got back to full level, they didn’t get hurt again, they didn’t have a reconstruction later down the road or a meniscus tear. And that’s where I started to feel a little bit on the fence about this and how hard you can lean on these results, because I think that’s what matters the most. If someone is one, two, five years out, they didn’t have another knee injury, they didn’t feel unstable, they didn’t tweak their knee, then take a month off, then tweak their knee, then take a month off.
That, for me, is always what I think we see a lot of, is that people who are ACL deficient, if they’re going back to really high level sports, there’s always this kind of instability, fear, even with the brace, even with great strength conditioning, whatever. You never know. Cutting, pivoting, field contact, especially like you’ve got people running into you all the time, you’ve got girls trying to kick your legs for the ball and stuff. So, that’s always what I think about when I read a paper like this, is you got to have some pretty hard legs to stand on from a research point of view to start making these claims.
Mike Reinold:
Yeah, I thought it was funny, just to add to that a little bit too. I was like, “What is return to sport?” You return to sport without an ACL. So yeah, you play one game and then the next week you blow out. But I’m not saying that happens to everybody, but if that were the case, that person returned to sport, I believe in the criteria of even the study, which I thought was kind of crazy. So, very interesting.
I want to hear other people. I saw a bunch of hands go. Lenny, just real quick. 48% of the ACL reconstruction group returned at 12 months. How does that stand to the norm? 48% of the ACL reconstruction group at 12 months return to sport. That seems low and slow.
Lenny Macrina:
Right, and that was the point that I made earlier. It’s 45 to 50% in the study return to sport at 12 months, and then we’re missing something. And again, there’s no standardized protocol. There’s so many different variables that are associated with this. What are the graph choices? Who, what are the patient populations? Male, female, the ages? How old were they? What sport did they play? The last sentence of the paper, literally before the final conclusion, section five is, “Studies included mostly adult participants and no studies included elite athletes.” So the findings cannot be generalized for children, adolescents, or elite athletes. So again, pump the brakes with the conclusions, but again, an adult population, maybe you talk about it or you talk about an allograft or something like that. Again, that’s surgical.
So, we have to be careful because the conclusions that are drawn that are spoken in this are that the outcomes are the same with surgical versus non-surgical treatment, but then you can’t say that to everybody. It’s just literally, you got to read the paper carefully and look at the limitations of the paper, and maybe an adult could get away with it if they’re going back to a relatively sedentary lifestyle, which the Tegner scale, which is used throughout the paper, looks at work and activities like sporting activities. It’s not an ACL specific or it’s not athlete specific. It’s… Did they get back to work or a job or something like that? And so, that’s another flaw of the paper, is the scale that they were often using in these papers was not necessarily ACL specific and sports related specific.
Mike Reinold:
Mike, what are you at?
Mike Scaduto:
Yeah, I mean, I don’t know if I even want to say this. As someone who doesn’t have a Twitter, I don’t know if I take issue or I think that the title of the paper itself was very purposely made, I think to garner a lot of attention. But they kind of hedge the bet in the name of the title because it says Return to Sport or Activity Level. And sounds like, based on what Lenny was talking about, that maybe this paper is really looking more at the activity level, it’s not really looking at return to sport. But if you want to get people to talk about it on Twitter, I think return to sport and ACL is the hottest topic. So, I don’t know. I think, again, I don’t have a Twitter, so you can’t find me, but I think that was maybe a little misleading on my end.
Mike Reinold:
I’m just going to add to that a little bit, too. If you dig into some of these papers, they talked about that the rehab was performed on low-level activity people that did not want to return to sport, and some were told not to return to sport.
Lenny Macrina:
Right, exactly.
Mike Reinold:
So yeah, no wonder why the rates are so low. I mean, that is an interesting one. But Brendan, what do you got?
Lenny Macrina:
I’m thankful that they mentioned that in the paper.
Mike Reinold:
Yeah. Brendan, what do you got?
Brendan Gates:
Yeah, I too just shudder thinking about the TikToks and Instagram videos that are going to be made with this headline without really looking at the population that they’re talking about. So, I feel like they should just add on “in middle-aged people” at the end of that title. And yeah, it just worries me. People take this and they look at the title and they just say, “Well, hey, my 17-year-old soccer player maybe doesn’t need surgery.” I just feel like we need to really highlight some of those differences, like Lenny said.
Lenny Macrina:
And I’m hearing that as well. I’m getting an uptick, definitely. And not because of this paper, not blaming this paper, not at all. It was before this paper came up, but I’m hearing an uptick of parents coming in and trying to convince me that their 16, 17, 18-year-old son or daughter does not need surgery. I got a kid right now, actually walked in the door this past week or late last week, who is going to not do a revision surgery after his primary ACL reconstruction. For other reasons, for numerous reasons. The doctor said, “Let’s just go non-op and see how it goes. Let’s try to get you through your fall season.”
And he’s going to strength train with us. I’ve spoken to the kid a bunch, let him know the risks, he understands everything, and he’s going to try to not do a revision surgery and try to get through his soccer season his high school year this fall. And fingers are crossed, but he understands the risks and I’ve talked to him and even training with us and all that. So we’ll see, but there is… There’s been a little uptick in parents wanting to discuss non-op rehab for their high school child.
Mike Reinold:
Well, you could tell them, Len, based on this paper, if you don’t want to return a sport, you have a 48% chance of returning a sport, which is great.
Lenny Macrina:
Right, right, right.
Mike Reinold:
I mean, that’s kind of what it says. If you don’t want to or were told not to, you still have a chance, I guess is what it is.
Lenny Macrina:
Yeah, let’s flip a coin.
Mike Reinold:
Yeah. Can I stir the pot with one other thing? This is interesting here. Did you notice that the definition of the surgical group could have included up to 30% repairs and allografts?
Lenny Macrina:
Yeah, I meant to mention that. I had that highlighted as well, yes.
Mike Reinold:
Holy smokes that… So, all right, so what’s the percentage of allografts that repair versus an autograft? Just an example, that would increase the ACL reconstruction group a lot higher, even if you just standardized that a little bit better. Because yeah, if you do a repair, an allograft, you’re already saying this person probably isn’t a D-1 collegiate football running back
Lenny Macrina:
Yeah, low activity, yeah, yeah.
Mike Reinold:
Yeah. You know what I mean? It’s almost inherent that that was in there. But, what else? Who else wants to jump in on anything? Anthony, what do you got?
Anthony Videtto:
Yeah, I was just going to go back to what Brendan said about these screen grabs, putting on TikTok and all these kids are saying, “Oh, maybe I don’t need ACL surgery.” Well, what about clinicians who don’t read the paper or don’t have access to the paper, whatever it may be? They just see the headline, and now they’re recommending to their 16, 17, 18-year-old patients, “Well, maybe we try non-op and then maybe down the road if it doesn’t work, we get ACL surgery.” It’s like these kids don’t have enough time in their high school career, college career to take four or five months to trial non-op and then go through 12 to 14 months, whatever it is, of a surgical protocol. So, that’s just a tough situation to put a 16, 17-year-old kid in when they just don’t have the time to do that.
Mike Reinold:
And the follow-up paper could be the incidence of OA and total knee replacements in these groups five to 10 years from now, which is a whole other conversation of what you’re doing. That’s high enough alone in ACL, I can’t imagine the percentage compared to reconstruction versus a non-operative rehab. I don’t know. Does that exist, Len?
Lenny Macrina:
That is tough. I feel like there are people that are arguing that there’s no difference if you have surgery or not, so why do the surgery? So yeah, I mean, that’s the other side’s argument, but I tend to be more surgical. I guess I grew up with that. I’m biased in that and who I treat. So, I treat high school, college athletes, and adults, but they are active adults. And if you’re active, it seems like this study is not helping me convince my patients to try non-op. But sorry, people online, I know there is a whole world that wants this, including some of our friends. Yeah.
Mike Reinold:
No, again, I think we can say, if you don’t want to return to sport, then your chance of returning to sport is similar. That’s kind of my takeaway from this study. It’s kind of a weird way of saying it. But Kev, what do you have?
Kevin Coughlin:
Yeah, I definitely agree with all the points that have been made so far. The other thing I’d say is that a study like this just needs to be put into context with all the other studies that have come out. Because I remember looking at some of this stuff with Dan, and there’s plenty of research to show that if you’re a higher activity level and a younger age and you play a type-one cutting sport, your chances of successfully rehabbing without surgery are very low. So, we can’t look at one paper that, I think Mike Scaduto said, if you have a catchy headline, and like Brendan and Anthony said, you might run with that and think that, “Oh, there’s new evidence emerging that we don’t need to do surgery in these athletes.” Well, it needs to be looked at in the context of all the other papers.
So, maybe it’s an interesting thing to keep an eye on and see if there are new randomized controlled trials of higher quality that come out and show this. But you can’t forget all the other good research that has already been published that has answered this question in certain populations. So, that’s just the only other thing I’d say is, try to keep that stuff in mind as well.
Mike Reinold:
Yeah, I’m going to go off-topic here. I was deciding if I wanted to do this or not, but I can’t tell you how much it pains me to see clickbait and these misinformation, misleading type titles in our mainstream media. This is going into our research now and our journal articles. You cannot do clickbaity stuff in a research article here. We are medical professionals. This is scientific. And this is nothing against the authors here, this is not an authorship thing. This is the journals. This is everybody doing this, and it’s not right. I just think we have to be very careful here, because what I’ve learned over my career is the majority of people don’t read research. The few people that do don’t get past the title. The very few people that get past the title don’t get past the abstract. So that’s part of why we’re kind of doing this here.
But I think this is a really good example of if you start getting into debates about this online, you got to know all the details. There’s some merits to this study. This is a good study that shows some things like rehab on low level people. I think it actually opened my eyes that, and I say low activity level, low, like what do they want to return to? It’s actually opened my eyes that it may not be a bad option for some people that don’t want to go through it. So, there are definitely merits to this whole thing, but man, trying to get people to debate this online and those contrarian social media accounts that just want to say all these things, you have to put it in context, just like everything else. One ACL is not the same as another ACL, and one patient’s not the same as another patient. So you got to be really careful with that. So, little soapboxy, man, but I hate to see that this is where we’re going in that direction.
But anyway, appreciate it. Great review. Thanks, Len, for going over that. Again, if you like this sort of stuff, the journal article reviews and hearing us a little bit here and how we’re thinking through these studies, let us know. Send us some messages, email me, DM us on social media, because we want to know if you like the new format. And please, rate, review, subscribe. We’ll see you on the next episode, thanks so much.
