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.

Researchers systematically reviewed 18 articles covering 15 studies to compare outcomes between people who had ACL (anterior cruciate ligament) reconstruction surgery and those who completed structured exercise rehabilitation alone after ACL injury. The main finding was surprising: return-to-sport rates were not significantly different between the two groups. The surgery group showed a small advantage on activity level measures, but this difference was so small it fell below what would be considered clinically meaningful.

The evidence quality was rated as low or very low, largely because many studies had design problems that likely made surgery look better than it actually was, and because the results varied considerably across different studies.

Many people believe that ACL surgery is the only way to get back to playing sport or staying active. This review of research suggests that belief may not match what actually happens.

People who completed structured, supervised exercise rehabilitation alone returned to sport at similar rates to those who had surgery. Some people in the surgery group did show slightly higher activity levels overall, but the difference was quite small and may not have felt noticeable in daily life. It is worth knowing that the available research has significant limitations.

Some studies were not well-designed in ways that could have favored the surgery group unfairly. The studies also looked at different kinds of outcomes and populations, which made it hard to draw a single clear picture.

This means that while the current evidence suggests surgery is not essential for returning to activity, your own situation, goals, and what your healthcare team recommends should guide your decision.

This is a summary of research, not medical advice. Talk to your own healthcare provider about anything affecting your care.

This meta-analysis challenges a common clinical assumption by finding no difference in return-to-sport rates between ACL reconstruction and structured, supervised rehabilitation alone. The pooled odds ratio for return to sport was 1.5 with a wide confidence interval crossing 1.0, suggesting no meaningful superiority of surgery.

A small difference favoring reconstruction appeared on Tegner Activity Scale scores (mean difference 0.7 points), but this fell below the minimal detectable change threshold and disappeared when high-bias studies were excluded. The evidence certainty is low to very low, driven by substantial heterogeneity in results and high risk of confounding bias in ten of fifteen studies, particularly regarding group allocation and differences in return-to-sport advice between surgical and non-surgical cohorts. Only two randomized controlled trials were included; most evidence came from observational comparisons.

The authors noted insufficient data on time to return to sport and physical activity volume. This body of evidence suggests that rehabilitation alone is not obviously inferior for return-to-sport outcomes, though the methodological limitations prevent drawing strong conclusions.