# Is operative approach to ACL rupture better than conservative on athletes coming back to sports?

> 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.

## Evidence-Based Physiotherapy Course
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 an International Course in Spain, A Coruña, in the Faculty of Physiotherapy at the University of Coruña about EBP. 

More than 30 physiotherapy students and 9 teachers from six universities participated:
* Savonia University of Applied Sciences, Finland
* Universidade da Coruña, Spain
* Charles University, Czech Republic
* CERRFF, France
* École D´Assas, France
* Escola de Santa María de O Porto, Portugal

## Background on ACL Injuries
The number of anterior cruciate ligament (ACL) injuries has doubled over the past 20 years. This trend is evident across different age groups and levels of sport. For example, among European football players, the annual incidence is 1.42%, whereas among young professional players, it reaches approximately 2%, increasing with age and level of competition.

## Methodology
Our group consisted of four students from Finland, Spain, France, and the Czech Republic. We conducted a targeted literature search 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.”

**Inclusion Criteria:**
* Male athletes with clinically or MRI-confirmed ACL ruptures.
* Comparison of surgical ACL reconstruction with structured conservative rehabilitation.
* Reported outcomes related to return to sport, knee function, or activity levels.
* Original RCTs published in English.

**Exclusion Criteria:**
* Studies with female participants only or mixed-sex samples without separate male analysis.
* Case reports and reviews.
* Studies not reporting sport-related outcomes.

## Findings
Four randomized controlled trials (RCTs) were eligible for this review: Reijman et al. (2021), van Yperen et al. (2018), Frobell et al. (2010), and Meuffels et al. (2009).

* **Reijman et al. (2021):** Compared early ACL reconstruction with structured rehabilitation. After two years, both groups improved significantly with no clinically meaningful difference in IKDC scores. About half of the rehabilitation group never required surgery.
* **Van Yperen et al. (2018):** A 20-year follow-up of high-level athletes. No significant differences were observed in osteoarthritis, knee function, or meniscal damage between operative and nonoperative groups.
* **Frobell et al. (2010):** Investigated young, active adults. Approximately 60% of patients initially managed conservatively avoided surgery entirely, achieving similar improvements in function and quality of life.
* **Meuffels et al. (2009):** A 10-year follow-up of high-level athletes. Surgical patients had better knee stability, but no differences were found in osteoarthritis rates, activity levels, or functional scores.

## Conclusion
The evidence indicates that both early ACL reconstruction and structured conservative rehabilitation can result in good long-term functional outcomes. Neither approach clearly outperforms the other in terms of functional outcomes or long-term joint health. While surgery provides slightly better knee stability, structured conservative rehabilitation can achieve comparable levels of activity and return to sport. The strongest evidence supports a rehabilitation-first approach with the option for delayed surgery.

## 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.
* Mazza D, et al. (2022). Impact of Anterior Cruciate Ligament Injury on European Professional Soccer Players. Orthop J Sports Med.
* Astur, D. C., et al. (2023). The incidence of anterior cruciate ligament injury in youth and male soccer athletes. Knee surgery, sports traumatology, arthroscopy.
* Reijman, M., et al. (2021). Early surgical reconstruction versus rehabilitation with elective delayed reconstruction for patients with anterior cruciate ligament rupture: COMPARE randomised controlled trial. BMJ.
* Frobell, R. B., et al. (2010). A randomized trial of treatment for acute anterior cruciate ligament tears. The New England journal of medicine.
* Meuffels, D. E., et al. (2009). Ten year follow-up study comparing conservative versus operative treatment of anterior cruciate ligament ruptures. British journal of sports medicine.
* van Yperen, D. T., et al. (2018). Twenty-Year Follow-up Study Comparing Operative Versus Nonoperative Treatment of Anterior Cruciate Ligament Ruptures in High-Level Athletes. The American journal of sports medicine.