Background: Reconstruction is considered to provide the best opportunity for return to sports (RTS) after anterior cruciate ligament (ACL) rupture. However, recent studies report that <50% of athletes return to preinjury sporting levels and that RTS rates at 1 year after injury are the same for athletes undergoing reconstruction and nonoperative management. Long-term studies are essential to confirm these findings and guide decisions regarding surgery.
Purpose: First, to compare long-term sports participation after ACL reconstruction and nonreconstruction and, second, to relate RTS level to strength and stability.
Study design: Cohort study; Level of evidence, 3.
Method: Patients with ACL deficiency (n = 101) who were referred for physical therapy at the time of diagnosis were followed long term: 56 were treated surgically 2.5 years (interquartile range [IQR], 1-4) after injury and 45 were treated nonoperatively. At long-term follow-up, the reconstructed group was at 9 years (IQR, 7-11) after injury and aged 33.3 ± 6.2 years (mean ± SD, 70% male; 61% meniscal injury), and the nonreconstructed group was at 11 years (IQR, 7-14) after injury and aged 38.7 ± 8.3 years (67% male; 58% meniscal injury). Measures of objective stability, subjective stability, and quadriceps/hamstring strength were compared between groups using independent-samples t tests. Current RTS level, scored on a 6-point scale, was compared between groups using chi-square tests. Spearman rho correlated RTS with outcome measures.
Results: Of the total group of patients, 96% with reconstruction and 93% without continued to play sports. In the reconstructed and nonreconstructed groups, 4% and 7% did not RTS, and 8% and 17% returned to safe sports, respectively: 13% and 12% to running, 20% and 26% to sports involving limited twisting, 12% and 24% to recreational pivoting sports, and 43% and 14% to competitive pivoting sports. The only significant difference was in return to competitive pivoting sports (P = .003). Five patients with reconstruction ruptured the contralateral ACL, and 1 ruptured his graft. Most patients treated nonoperatively modified their sports participation. Their RTS levels correlated significantly with quadriceps strength (r = 0.65; P < .001), hamstring strength (r = 0.721; P < .001), and subjective stability (r = 0.405; P = .01).
Conclusion: Surgically treated patients returned to competitive pivoting sports at 3 times the rate of those managed nonoperatively, confirming that reconstruction provides the best opportunity for continued participation in competitive pivoting sports. Regardless of grouping, RTS correlated with modifiable factors, including strength and stability. Higher rates of subsequent injuries observed after reconstruction may result from increased participation in competitive pivoting sports.
Keywords: anterior cruciate ligament; long-term outcomes; nonoperative management; reconstruction; return to sport.