Introduction

Evidence-Based Physical Therapy (EBP) uses the best research evidence with clinical expertise and user’s preferences to produce the most appropriate and effective care. At week 44 in 2025, we had International Course in Spain, A Coruna, in the Faculty of Physiotherapy at University of Coruña about EBP. The program was opened with welcome words of the president of The European Network of Physiotherapy in Higher Education (ENPHE) and followed with the basis of EBP and teachers who highlighted the main challenges at different Physical Therapy fields. More than 30 physiotherapy students and 9 teachers from six universities (Savonia University of Applied Sciences, Finland, Universidade da Coruña, Spain, Charles University Czech Republic, CERRFF and École D´Assas, France, and Escola de Santa María de O Porto, Portugal), actively participated this week and shared experiential group dynamics and social activities. The students collaborated and wrote articles on a range of topics, including evidence-based neurology, respiratory and musculoskeletal disorders, geriatric and pediatric care, as well as sports injuries and related issues. This blog article presents a group work on a sports topic (Picture 1).

Background

The number of anterior cruciate ligament (ACL) injuries has doubled over the past 20 years (AranDule, Silvers-Granelli, Myklebust, 2022). This trend is evident across different age groups and levels of sport. For example, among European football players, the annual incidence is 1.42% (Mazza et al., 2022), whereas among young professional players, it reaches approximately 2%, increasing with age and level of competition (Astur et al., 2023).

We are participating in an international Evidence-Based Physiotherapy course held in A Coruña, Spain, lasting one week. Our group consists of four students from Finland, Spain, France, and the Czech Republic, working together on a mini systematic review. The purpose of this assignment is to critically analyse current research evidence related to physiotherapy and rehabilitation. In our project, we specifically focused on the topic of anterior cruciate ligament (ACL) injuries, with particular attention to evaluating the effectiveness of operative versus conservative treatment approaches in athletes returning to sport.

Methods

For our mini systematic review, we conducted a targeted literature search to identify randomized controlled trials (RCTs) comparing operative and non-operative treatment approaches for anterior cruciate ligament (ACL) rupture in male athletes. The search was performed in PubMed and PEDro using keywords such as “ACL,” “anterior cruciate ligament,” “rupture,” “injury,” “sports,” “male,” “surgical,” “operative,” “non-operative,” “conservative,” and “return to sport.” Only peer-reviewed studies published in English were considered.

The research question guiding this review was: “Is an operative approach to ACL rupture more effective than a conservative approach for athletes returning to sports?” Studies were included if they involved male athletes with clinically or MRI-confirmed ACL ruptures, compared surgical ACL reconstruction with structured conservative rehabilitation (including physiotherapy, neuromuscular training, and functional strengthening), and reported outcomes related to return to sport, knee function, or activity levels. Only original RCTs were eligible.

Exclusion criteria included studies with female participants only, mixed-sex samples without separate male analysis, case reports, reviews, studies not reporting sport-related outcomes, and studies not published in English. The methodological quality of the included studies was assessed using the PEDro scale, ensuring that the evidence was reliable and robust. Scores ranged from 6/10 to 9/10, with an average of 7.5/10, allowing us to focus on high-quality trials comparing early ACL reconstruction with structured rehabilitation.

Results

According to the established inclusion criteria, four randomized controlled trials (RCTs) were eligible for this mini systematic review, comparing operative and conservative management of anterior cruciate ligament (ACL) rupture. (Reijman et al., 2021; van Yperen et al., 2018; Frobell et al., 2010; Meuffels et al., 2009). The selected studies span different time periods, with follow-up durations ranging from two to twenty years.

Overall, the evidence indicates that both early ACL reconstruction and structured conservative rehabilitation can result in good long-term functional outcomes. While early surgical reconstruction may offer a somewhat faster recovery of knee stability and confidence in certain athletes, many patients managed conservatively are able to avoid surgery without compromising long-term knee function. The findings from these studies highlight that treatment decisions should be individualized, taking into account the athlete’s activity level, symptoms, and personal goals.

Across all four studies, both operative and nonoperative approaches led to positive long-term outcomes, with no clear superiority of one method over the other in terms of function, pain, or return to sport.

Reijman et al. (2021) conducted a multicentre randomized controlled trial comparing early ACL reconstruction with structured rehabilitation and optional delayed surgery in 167 adults. After two years, both groups improved significantly. The surgical group had slightly higher IKDC scores (mean 84.7 vs. 79.4), but the difference was not clinically meaningful. Importantly, about half of the rehabilitation group never required surgery, showing that many athletes can recover effectively with nonoperative care.

Van Yperen et al. (2018) followed 50 high-level athletes for 20 years after ACL rupture, comparing operative and nonoperative treatment. No significant differences were observed in osteoarthritis (OA), knee function, or meniscal damage. Although surgical patients demonstrated better mechanical stability, this did not translate into improved long-term outcomes. The study concluded that nonoperative management remains a valid long-term strategy, even for elite athletes.

Frobell et al. (2010) investigated 121 young, active adults with ACL rupture, comparing early reconstruction with structured rehabilitation plus optional delayed surgery. Approximately 60% of patients initially managed conservatively avoided surgery entirely, achieving similar improvements in function and quality of life. Knee stability was slightly better in the surgical group, but subjective outcomes were equivalent.

Meuffels et al. (2009) conducted a 10-year follow-up of 50 high-level athletes treated either surgically or conservatively. Surgical patients had better knee stability, but no differences were found in osteoarthritis rates, activity levels, or functional scores. Both groups showed similar reductions in activity compared with pre-injury levels, indicating that structured rehabilitation can be equally effective without surgery.

PEDro scores across the studies ranged from 6 to 9 out of 10, indicating overall good methodological quality. The strongest evidence came from Reijman et al. (2021), supporting a rehabilitation-first strategy with the option of delayed surgery if instability persists.

Conclusion

Based on the evidence from the four studies, neither approach—operative nor conservative—clearly outperforms the other in terms of functional outcomes or long-term joint health for high-level athletes. Surgical treatment offers improved knee stability, which may be particularly beneficial for elite athletes or those participating in pivoting sports. Conservative treatment can be equally effective for others, avoiding surgical risks while still allowing a return to sport, especially when paired with high-quality rehabilitation.

Overall, the studies consistently show no significant difference in long-term functional outcomes between operative and conservative treatment of ACL rupture in male athletes. Surgery provides slightly better knee stability, but structured conservative rehabilitation can achieve comparable levels of activity and return to sport when executed effectively. The strongest evidence supports a rehabilitation-first approach with the option for delayed surgery. Treatment decisions should therefore be individualized based on the athlete’s sport, knee stability, and personal goals.

Reflections on Teamwork and Collaboration

The international team’s collaboration was marked by effective communication, mutual respect, and shared responsibility. Despite differences in cultural and educational backgrounds, the group worked cohesively in English as a common language, enabling clear exchange of ideas and smooth coordination. Each member contributed according to their strengths, ensuring a balanced workload and collective ownership of the final work. Through open discussion and constructive feedback, the team refined their research question and methodology, learning the value of flexibility and precision in academic collaboration. This cross-cultural teamwork not only enhanced the quality of their project but also enriched their overall learning experience.

---

Authors:

Sulo Aalto, physiotherapy student, Savonia University of Applied Sciences, Kuopio, Finland

Younes Benhammou, physiotherapy student, CERRFF, France

Magdalena Flašíková, physiotherapy student, Charles University, Czech Republic

Noa Rivada López, physiotherapy student, University of A Coruña, Spain

Dagmar Pavlu, Physiotherapist, Assoc. Prof. Charles University, Czech Republic

Ivana Vláčilová, PhD., PT. Charles University, Czech Republic.

Marja Äijö, PT, PhD Principal Lecturer of gerontology and rehabilitation, Savonia University of Applied Sciences, Kuopio, Finland.

Veronica Robles García, PhD. PT. OT. Associate Professor, University of A Coruña, A Coruña, Spain.

Zeltia Naia Entonado, PhD. PT. University of A Coruña, A Coruña, Spain.

María Vilanova Pereira, PhD., PT. University of A Coruña, A Coruña, Spain.

Adrien Pallot, PT, MSc, Lecturer at École D´Assas, France.

Aurel Bellaïche, PT, Lecturer at CEERRF, France.

---

References:

Arundale A.J.H, Silvers-Granelli H.J., Myklebust G. (2022). ACL injury prevention: Where have we come from and where are we going? J Orthop Res. Jan;40(1):43-54. doi: https://doi.org/10.1002/jor.25058

Mazza D, Viglietta E, Monaco E, Iorio R, Marzilli F, Princi G, Massafra C, Ferretti A. (2022). Impact of Anterior Cruciate Ligament Injury on European Professional Soccer Players. Orthop J Sports Med. Feb 22; 10(2):23259671221076865. doi: https://doi.org/10.1177/23259671221076865.

Astur, D. C., Margato, G. F., Zobiole, A., Pires, D., Funchal, L. F. Z., Jimenez, A. E., Freitas, E. V., & Cohen, M. (2023). The incidence of anterior cruciate ligament injury in youth and male soccer athletes: an evaluation of 17,108 players over two consecutive seasons with an age-based sub-analysis. Knee surgery, sports traumatology, arthroscopy: offi-cial journal of the ESSKA, 31(7), 2556–2562. https://doi.org/10.1007/s00167-023-07331-0.

Reijman, M., Eggerding, V., van Es, E., van Arkel, E., van den Brand, I., van Linge, J., Zijl, J., Waarsing, E., Bierma-Zeinstra, S., & Meuffels, D. (2021). Early surgical reconstruction versus rehabilitation with elective delayed recon-struction for patients with anterior cruciate ligament rupture: COMPARE randomised controlled trial. BMJ (Clinical re-search ed.), 372, n375. https://doi.org/10.1136/bmj.n375

Frobell, R. B., Roos, E. M., Roos, H. P., Ranstam, J., & Lohmander, L. S. (2010). A randomized trial of treatment for acute anterior cruciate ligament tears. The New England journal of medicine, 363(4), 331–342. https://doi.org/10.1056/NEJMoa0907797

Meuffels, D. E., Favejee, M. M., Vissers, M. M., Heijboer, M. P., Reijman, M., & Verhaar, J. A. (2009). Ten year fol-low-up study comparing conservative versus operative treatment of anterior cruciate ligament ruptures. A matched-pair analysis of high level athletes. British journal of sports medicine, 43(5), 347–351. https://doi.org/10.1136/bjsm.2008.049403

van Yperen, D. T., Reijman, M., van Es, E. M., Bierma-Zeinstra, S. M. A., & Meuffels, D. E. (2018). Twenty-Year Fol-low-up Study Comparing Operative Versus Nonoperative Treatment of Anterior Cruciate Ligament Ruptures in High-Level Athletes. The American journal of sports medicine, 46(5), 1129–1136. https://doi.org/10.1177/0363546517751683