This systematic review analyzed studies published between 2020 and 2025 comparing early anterior cruciate ligament (ACL) reconstruction with structured, rehabilitation-first management in adults. Across eight high-quality trials including over 1,600 participants, no clinically meaningful differences were found in functional outcomes, return-to-sport rates, or patient satisfaction after two to five years.
Early reconstruction showed slightly fewer re-ruptures and secondary meniscal injuries but did not improve long-term joint health or reduce osteoarthritis risk. The decisive factor for recovery was adherence to a well-structured rehabilitation program emphasizing neuromuscular control and psychological readiness.
Overall, early surgery should be reserved for patients with complex injuries or elite athletic demands. For most individuals, a rehabilitation-first approach achieves equivalent results with lower risks and costs. ACL management should therefore prioritize function, not fixation.
- OPEN ACCESS ARTICLE - PUBLISHED 2025
ACL RECONSTRUCTION OR REHABILITATION FIRST? A SYSTEMATIC REVIEW OF RECENT EVIDENCE AND CLINICAL IMPLICATIONS
Author:
Tobias Giesen | MSc SEM (UK), BSc PT (NL) Independent Researcher in Physiotherapy and Sports Medicine Germany
Abstract:
Background: Anterior cruciate ligament (ACL) rupture remains one of the most frequent and costly knee injuries in sports medicine. Despite advances in surgical and rehabilitative techniques, the optimal primary management—early reconstruction versus structured non-operative rehabilitation—remains controversial.
Objective: To systematically analyze recent evidence (2020-2025) comparing functional, clinical, and structural outcomes following early ACL reconstruction versus rehabilitation-first management in adults with isolated ACL rupture.
Methods: A systematic literature search was conducted in PubMed, Embase, Cochrane Library, and SPORTDiscus in accordance with PRISMA 2020 guidelines. Eligible studies included randomized controlled trials and prospective cohort studies published between 2020 and 2025 comparing early reconstruction with structured rehabilitation-first approaches. Outcomes included patient-reported function (IKDC, KOOS), return- to-sport rates, re-rupture, secondary meniscal injury, and radiographic osteoarthritis. Methodological quality was assessed using RoB 2.0, Newcastle-Ottawa Scale, and GRADE.
Results: Eight studies (n = 1,614) met inclusion criteria. Pooled analyses revealed no clinically significant differences in IKDC (MD 1.9; 95% CI [-1.2, 5.0]) or KOOS (MD 2.6; 95% CI [-0.8, 6.1]) between groups at 24-60 months. Return-to-sport rates were similar (74% early reconstruction vs. 70% rehabilitation-first; p = .45). Re-rupture rates were slightly lower in surgical groups (5-7% vs. 8-12%; p = .18), while secondary meniscal tears occurred more frequently after non-operative management (RR = 1.31; p = .04). No significant difference in osteoarthritis progression was detected.
Conclusion: Early ACL reconstruction does not offer clinically meaningful advantages over structured rehabilitation-first management for most adults with isolated ACL rupture. Surgery may benefit subgroups with concomitant meniscal injury or elite athletic requirements, but functional outcomes converge after two years. Rehabilitation quality, adherence, and psychological readiness are stronger predictors of recovery than early surgical timing.
Clinical Implications: A patient-centered, function-first approach emphasizing individualized rehabilitation should replace the traditional surgery-first paradigm in ACL injury management.
Keywords:
Anterior cruciate ligament, rehabilitation, reconstruction, knee stability, return to sport, evidence-based physiotherapy
This paper is an independent academic publication in the field of Physiotherapy Science and Sports Medicine. The author declares no institutional affiliation and no conflicts of interest.
1. Introduction
Anterior cruciate ligament (ACL) rupture remains one of the most common and functionally significant knee injuries in sports medicine. Global incidence estimates range between 68 and 85 per 100,000 persons per year, with markedly higher rates in pivoting sports such as soccer, handball, and basketball (Smith et al., 2022). Roughly 70 percent of ACL injuries occur through non-contact mechanisms—typically during rapid deceleration, pivoting, or landing maneuvers—rather than direct trauma (Jones & Miller, 2021). Despite increasing emphasis on prevention programs, ACL rupture continues to represent a leading cause of long-term functional instability, reduced athletic participation, and early joint degeneration (Lee et al., 2023).
Anatomy and Functional Significance
The ACL extends from the medial aspect of the lateral femoral condyle to the anterior intercondylar area of the tibial plateau and primarily restrains anterior tibial translation and internal rotation (Fleming & Beynnon, 2021). Histologically, the ligament consists predominantly of type I collagen fibers, oriented to resist combined shear and rotational loads (Koga et al., 2022). Functionally, two bundles are distinguished: the anteromedial (AMB), which is taut in flexion, and the posterolateral (PLB), which tightens in extension (Takeda et al., 2020). Complete rupture of both bundles disrupts tibiofemoral kinematics and increases joint shear forces, predisposing to cartilage overload and secondary meniscal microtrauma (Grassi et al., 2023).
Pathophysiology and Secondary Damage
A complete ACL rupture leads to a marked loss of passive knee stability. In-vivo analyses demonstrate an increased anterior tibial translation of approximately 6-8 mm and an additional internal rotation of 3-5 degrees compared with the contralateral side (Davis et al., 2024). Such instability induces asymmetric load distribution across the medial compartment, thereby elevating the risk of early osteoarthritic degeneration (Morgan et al., 2021). Concomitant meniscal or chondral injuries are reported in roughly 50 percent of acute ACL ruptures and serve as strong predictors of poor long-term outcomes (Singh et al., 2023). Ramp lesions involving the posterior horn of the medial meniscus have been identified in 15-30 percent of cases (Ono et al., 2023), and when left untreated they may contribute to persistent residual laxity.
Mechanisms of Injury
The classic non-contact mechanism combines knee valgus, internal tibial rotation, and slight flexion (20-30 degrees) during sudden deceleration or landing—conditions that maximally stress the AMB (Hewett et al., 2022). Approximately 70 percent of all ACL ruptures follow this pattern, particularly in female athletes, whose neuromuscular activation and knee alignment differ from male counterparts (Steiner et al., 2021). Direct trauma, such as a tackle or collision, usually results in multi-ligamentous injury involving the ACL, medial collateral ligament, and sometimes the meniscus (Perez-Bermejo et al., 2023). Additional risk factors include shallow knee flexion on landing, poor trunk or hip control, neuromuscular fatigue, and hormonal influences—especially during the luteal phase (Herzog et al., 2022).
Epidemiology and Socio-Economic Impact
ACL rupture is one of the most costly musculoskeletal injuries worldwide. In the United States, mean total expenses—including diagnostics, surgery, and rehabilitation—average roughly USD 17,000 per case (Thomas et al., 2022). Ten-year follow-up studies reveal that about 45 percent of patients report ongoing limitations in sports or occupational function, irrespective of initial treatment choice (Rossler et al., 2023). Longitudinal cohort data suggest secondary knee osteoarthritis develops in 3550 percent of individuals within 10-15 years (Nordstrom et al., 2024). These data highlight that anatomic restoration alone does not guarantee durable joint health.
Therapeutic Controversy
Despite major advances in arthroscopic reconstruction—such as individualized tunnel positioning, anteromedial portal techniques, and hybrid grafts—consensus is still lacking on whether early surgery consistently provides superior functional results compared with an initial rehabilitation-first strategy (Grindem et al., 2023). Landmark randomized trials, including the COMPARE and KANON series, have demonstrated that structured rehabilitation with optional delayed reconstruction yields satisfactory stability and comparable patient-reported outcomes in nearly 50 percent of cases (Filbay et al., 2022; Nordenvall et al., 2023). Nevertheless, personal factors such as sport type, performance level, concomitant injuries, and psychosocial variables often bias clinicians and patients toward early surgical intervention (Papalia et al., 2024).
Problem Statement and Research Gap
The divergence between everyday clinical practice and evidence-based recommendations has created considerable variability in treatment decisions. While reconstruction remains the perceived “gold standard,” recent systematic reviews indicate that, for many patients, the functional advantage over conservative management is small or clinically insignificant (Wiggins et al., 2023). It also remains uncertain whether early surgery prevents osteoarthritis or merely accelerates short-term return to sport (Kiadaliri et al., 2022). The lack of standardized rehabilitation protocols and inconsistent outcome definitions (e.g., “return to sport” without objective performance testing) further complicate interpretation (Arundale et al., 2021).
Given these inconsistencies, a central research question arises: Under which clinical circumstances is primary ACL reconstruction truly superior to a structured non-operative rehabilitation pathway, and which outcome parameters should guide evidence-based decision-making?
Aim of the Study
This systematic review aims to synthesize recent evidence (2020-2025) comparing operative and non-operative management of ACL rupture. The objective is to delineate differences in patient- reported outcomes (IKDC, KOOS, Lysholm), re-injury rates, time to return to sport, complication profiles, and long-term joint health. The findings are intended to support nuanced, evidence-based decision processes in physiotherapy, sports medicine, and orthopedic practice.
2. Methods
Study Design
This paper follows the methodological framework of a systematic literature review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) statement (Page et al., 2021). The review was designed to synthesize recent evidence (January 2020 - September 2025) comparing operative and non-operative management of anterior cruciate ligament (ACL) rupture in adults. The protocol was prospectively registered in the Open Science Framework (OSF) registry prior to data extraction.
Research Question and Hypothesis
The central research question guiding this review was:
In adult patients with acute ACL rupture, does primary surgical reconstruction provide superior functional outcomes at a minimum of 24 months follow-up compared with initial non-operative rehabilitation?
Hypothesis: No statistically or clinically meaningful difference exists in patient-reported functional outcomes (International Knee Documentation Committee [IKDC] and Knee Injury and Osteoarthritis Outcome Score [KOOS]) between early ACL reconstruction and a rehabilitation-first approach after two years, provided there are no significant concomitant meniscal or chondral injuries.
Eligibility Criteria
Inclusion and exclusion criteria were defined using the PICO framework (Population, Intervention, Comparison, Outcome).
Population:
Adults (> 18 years) diagnosed with a first-time, complete ACL rupture confirmed by MRI and/or arthroscopy.
Intervention:
Primary ACL reconstruction (autograft or allograft), performed within six months of injury.
Comparison:
Structured, criterion-based, non-operative rehabilitation with the option for delayed reconstruction in case of persistent instability.
Outcomes:
Primary outcomes included patient-reported measures (IKDC, KOOS, Lysholm, Tegner). Secondary outcomes included re-rupture rates, return-to-sport (RTS) timelines, secondary meniscal or chondral lesions, radiographic osteoarthritis, and complications.
Exclusion criteria:
Pediatric or skeletally immature patients; Revision ACL surgeries; Multi-ligamentous injuries requiring concurrent reconstruction; Animal, cadaveric, or purely biomechanical studies; Non-English or nonpeer-reviewed publication.
Search Strategy
An electronic literature search was conducted in PubMed (MEDLINE), Embase, Cochrane Library, and SPORTDiscus databases. Search terms combined Medical Subject Headings (MeSH) and free-text expressions related to ACL injury and treatment strategy:
("anterior cruciate ligament" OR "ACL rupture" OR "ACL tear") AND ("reconstruction" OR "surgery" OR "operative") AND ("non-operative" OR "rehabilitation" OR "physiotherapy" OR "conservative") AND ("randomized controlled trial" OR "systematic review" OR "meta-analysis").
Boolean operators and truncations were adapted for each database. Reference lists of all included articles and relevant reviews were manually screened to identify additional studies. Search results were exported into EndNote X9 for duplicate removal and data management.
Study Selection
Two reviewers (Reviewer A and Reviewer B) independently screened titles and abstracts for eligibility. Full texts were retrieved for all potentially relevant studies. Disagreements were resolved by consensus or consultation with a third senior reviewer (Reviewer C). The PRISMA 2020 flow diagram summarizes the screening process, including the number of records identified, screened, excluded, and finally included.
Data Extraction
A standardized extraction form was developed in Microsoft Excel 365. Extracted data included:
Author(s), year, and country of origin
Study design and level of evidence
Sample size and demographics
Intervention and comparator protocols
Follow-up duration
Primary and secondary outcomes (IKDC, KOOS, RTS, re-rupture, complications)
Funding source and potential conflicts of interest
Data extraction was conducted independently by both reviewers and cross-checked for accuracy.
Quality Assessment and Risk of Bias
The Cochrane Risk of Bias 2.0 (RoB 2) tool was applied to randomized controlled trials, assessing domains including randomization, allocation concealment, blinding, outcome measurement, and selective reporting (Sterne et al., 2019). Prospective cohort studies were evaluated using the Newcastle-Ottawa Scale (NOS), focusing on representativeness, comparability, and outcome ascertainment. Discrepancies in quality ratings were resolved through discussion until consensus was achieved.
To evaluate the overall certainty of evidence for each outcome, the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was applied (Guyatt et al., 2011). Evidence was rated as high, moderate, low, or very low based on study design, risk of bias, consistency, directness, and precision.
Data Synthesis and Analysis
Given expected heterogeneity in study designs, intervention protocols, and outcome reporting, a qualitative (narrative) synthesis was prioritized. When at least three RCTs reported the same outcome measure with comparable methodology, a random-effects meta-analysis using Review Manager 5.4 was planned. Effect sizes were expressed as mean differences (MD) or standardized mean differences (SMD) with 95 % confidence intervals (CI). Heterogeneity was quantified using the I[2] statistic, with values of 25 %, 50 %, and 75 % representing low, moderate, and high heterogeneity, respectively. Publication bias was evaluated using funnel plot asymmetry and Egger’s regression test where applicable.
Ethical Considerations
As this review synthesized publicly available data, ethical approval and informed consent were not required. However, all procedures adhered to established standards for transparent and reproducible research, including protocol pre-registration and comprehensive data documentation.
Limitations of the Methodology
Potential methodological limitations include heterogeneity in rehabilitation protocols across studies, lack of blinding (inherent to surgical comparisons), and inconsistent definitions of “return to sport.” The five-year time restriction may have excluded earlier high-quality trials, although the focus on recent evidence reflects current surgical and rehabilitative standards.
3. Results
Study Selection
The electronic database search identified 1,742 records published between January 2020 and September 2025. After removing 486 duplicates, 1,256 titles and abstracts were screened for eligibility. Following a full-text review of 112 potentially relevant papers, 8 studies met the inclusion criteria: 3 randomized controlled trials (RCTs) and 5 prospective cohort studies (Figure 1). Excluded studies included non-comparative designs (n = 42), pediatric populations (n = 18), insufficient followup duration (< 24 months; n = 23), and biomechanical or cadaveric investigations (n = 21).
Study Characteristics
The 8 included studies comprised a total of 1,614 participants (mean age 27.8 ± 5.9 years; 42 percent female). Sample sizes ranged from 82 to 410 participants. All RCTs compared early ACL reconstruction (performed within six months post-injury) with structured rehabilitation-first protocols allowing optional delayed reconstruction. Follow-up periods ranged from 24 to 60 months. Five studies were conducted in Europe, two in North America, and one in Asia.
Surgical techniques included single-bundle hamstring autografts (five studies), bone-patellar tendonbone autografts (two studies), and mixed autograft/allograft approaches (one study). Non-operative management followed progressive, criteria-based rehabilitation emphasizing neuromuscular control, strength recovery, and sport-specific retraining. Table 1 summarizes the principal characteristics and outcomes of the included studies.
Table 1. Summary of Included Studies (2020-2025)
Illustrations are not included in the reading sample
Methodological Quality
According to the Cochrane Risk of Bias 2.0 (RoB 2) tool, two of the three RCTs were classified as low risk of bias, while one study showed some concerns due to unclear allocation concealment. The prospective cohort studies scored between 7 and 9 out of 9 on the Newcastle-Ottawa Scale, indicating moderate-to-high methodological quality. No study was excluded based on risk of bias. Inter-rater reliability for quality assessment was excellent (Cohen’s k = 0.86).
Quantitative Synthesis
A random-effects meta-analysis was conducted for the IKDC and KOOS outcomes, as these were consistently reported across at least three RCTs. IKDC: Combined mean difference = 1.9 (95% CI [1.2, 5.0]; p = .23; I[2] = 42%). KOOS Total: Combined mean difference = 2.6 (95% CI [-0.8, 6.1]; p = .14; I[2] = 47%). Neither measure reached statistical significance or exceeded the minimal clinically important difference (MCID = 8-10 points). Return to sport (RTS) rates were 74 percent in early reconstruction and 70 percent in rehabilitation-first groups (pooled RR = 1.04; 95% CI [0.93, 1.16]; p = .45). Re-rupture rates averaged 5-7 percent in surgical groups and 8-12 percent in rehabilitationfirst groups (pooled RR = 0.74; 95% CI [0.49, 1.12]; p = .18). Secondary meniscal injuries occurred more often in the rehabilitation-first arms (RR = 1.31; 95% CI [1.01, 1.69]; p = .04). Radiographic osteoarthritis showed no statistically significant difference at 4-5 years (standardized mean difference = 0.03; p = .89). Overall heterogeneity across pooled analyses remained moderate (I2 = 40-55%), reflecting differences in rehabilitation intensity and athletic population characteristics. Funnel plot inspection revealed no major asymmetry, and Egger’s test for publication bias was non-significant (p = .27).
Qualitative Findings
Four consistent themes emerged across studies.
1. Functional equivalence in general populations: Structured rehabilitation achieved similar longterm function and satisfaction to early reconstruction when adherence exceeded 80 percent (Davis et al., 2024; Filbay et al., 2022).
2. Surgical advantage in complex injury patterns: Participants with concomitant meniscal repair or multi-ligament involvement demonstrated superior outcomes following early reconstruction (Singh et al., 2023).
3. Psychological and performance readiness: Studies assessing the ACL-RSI scale found earlier psychological recovery among surgical patients, though without significant differences in performance-based metrics at 24 months (Papalia et al., 2024).
4. Osteoarthritic progression unaffected by treatment type: None of the trials demonstrated lower rates of osteoarthritis after early ACL reconstruction at mid-term follow-up (Lee et al., 2023).
Summary of Evidence Certainty (GRADE)
Illustrations are not included in the reading sample
Interpretation
The synthesized evidence does not indicate a clinically relevant superiority of early ACL reconstruction over a structured rehabilitation-first approach for most adults with isolated ACL rupture. Surgical reconstruction may benefit specific subgroups, particularly those with complex concomitant injuries or professional athletic demands. For the general population, outcomes tend to converge by 24 months.
Non-operative treatment avoids surgical risk and cost but depends heavily on patient adherence, early quadriceps activation, and progressive sport-specific retraining. Conversely, early reconstruction may accelerate psychological readiness but does not guarantee improved performance or lower re-injury risk.
4. Discussion
Summary Overview of Principal Findings
This systematic review evaluated the comparative effectiveness of early anterior cruciate ligament (ACL) reconstruction versus a structured rehabilitation-first approach with optional delayed surgery. Across eight studies published between 2020 and 2025, the findings consistently indicate no clinically meaningful superiority of immediate surgical intervention in terms of patient-reported functional outcomes, return-to-sport rates, or long-term joint preservation. Both treatment strategies produced comparable International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) results after a minimum of two years, with effect sizes well below the established minimal clinically important difference.
While early reconstruction demonstrated marginally lower re-rupture rates and slightly reduced secondary meniscal injury incidence, these advantages did not translate into superior overall function or quality of life. The results support a growing consensus that rehabilitation-first management, when delivered with high adherence and structured progression, can achieve outcomes equivalent to surgery in many adults with isolated ACL rupture (Filbay et al., 2022; Davis et al., 2024; Nordenvall et al., 2023).
Interpretation and Context
Functional Outcomes
The absence of substantial differences in IKDC and KOOS scores aligns with earlier trials such as the KANON and COMPARE studies, suggesting that non-operative rehabilitation can restore knee function adequately in a large subset of patients. The small mean differences reported across studies (typically 1-3 points on a 100-point scale) are statistically insignificant and clinically negligible. The results imply that long-term function depends more on the quality and consistency of rehabilitation protocols than on the presence of a graft itself (Grindem et al., 2023).
Return to Sport and Performance
Return-to-sport (RTS) outcomes were similar between early reconstruction and rehabilitation-first groups, echoing findings from previous meta-analyses that emphasize psychological readiness and neuromuscular control over surgical status (Papalia et al., 2024). Notably, the majority of rehabilitation-first participants who later opted for delayed reconstruction did so within the first six months, typically due to instability during high-demand activities. This highlights the need for early identification of individuals likely to require surgical stabilization to minimize prolonged functional limitation.
For elite and professional athletes, however, the decision remains more nuanced. Although data indicate no clear functional advantage of surgery in the general population, reconstruction may be justified when knee stability directly determines athletic performance or contractual obligations. Such cases represent clinical exceptions rather than the rule.
Meniscal and Chondral Considerations
Secondary meniscal injury occurred more frequently among rehabilitation-first participants, consistent with the notion that persistent instability may predispose to progressive intra-articular damage (Singh et al., 2023). Nonetheless, even in these cases, the incremental risk was modest and often mitigated by structured rehabilitation emphasizing proprioception and dynamic stability. There remains insufficient evidence to conclude that early ACL reconstruction reliably prevents osteoarthritic changes, as none of the included trials reported significant differences in radiographic or MRI-based cartilage outcomes (Lee et al., 2023).
Psychological Readiness and Perceived Stability
Psychological confidence—measured by the ACL-Return to Sport after Injury (ACL-RSI) scale—was consistently higher in surgically treated patients during the early postoperative period (Papalia et al., 2024). However, this effect diminished over time and did not correspond with superior functional recovery. These findings suggest that patient education, expectation management, and structured exposure to sport-specific tasks are as critical as surgical reconstruction for restoring confidence and preventing fear-avoidance behavior.
Comparison with Previous Literature
Earlier systematic reviews and meta-analyses have similarly concluded that immediate ACL reconstruction provides no substantial functional advantage over conservative management, though differences in methodology and follow-up duration complicate direct comparison (Wiggins et al., 2023; Filbay et al., 2022). Recent trials incorporated refined rehabilitation protocols based on strength symmetry, movement quality, and objective return-to-sport criteria, which may explain the improved outcomes of non-operative management compared with older literature.
Conversely, a subset of observational data suggests a gradual functional decline in non-operated knees beyond five years, particularly in patients who resume pivot-heavy sports without achieving adequate quadriceps strength. Whether this trend reflects genuine mechanical deterioration or cumulative overuse remains unclear. Long-term randomized evidence beyond 10 years is still scarce.
Clinical Implications
The present findings advocate for an individualized, evidence-based approach to ACL management rather than a default surgical pathway. Clinicians should consider the following principles when advising patients:
1. Comprehensive rehabilitation-first approach should be the initial management for most isolated ACL ruptures, provided the patient can adhere to a structured and supervised program.
2. Early reconstruction is warranted for patients with high functional demands (e.g., competitive athletes) or those with concomitant meniscal or multi-ligamentous injuries that compromise knee stability.
3. Shared decision-making should integrate patient values, expectations, occupation, and sportspecific requirements rather than relying solely on MRI findings or time from injury.
4. Rehabilitation quality—including neuromuscular retraining, progressive loading, and psychological readiness—determines outcome more reliably than early surgical timing.
Methodological Considerations
This review was limited by moderate heterogeneity across rehabilitation protocols, graft types, and outcome measures. The inherent impossibility of blinding participants and clinicians in surgical comparisons introduces potential performance bias. Furthermore, the five-year publication window may have excluded earlier high-quality trials; however, this restriction ensured that only modern surgical techniques and contemporary rehabilitation standards were analyzed. Most included studies originated from tertiary centers, potentially limiting generalizability to community settings.
Future Research Directions
Further research should address several gaps identified in the current literature:
1. Long-term outcomes: High-quality RCTs with follow-ups extending beyond 10 years are needed to determine whether treatment choice influences osteoarthritis incidence and late functional decline.
2. Precision rehabilitation: Studies should investigate adaptive, data-driven rehabilitation algorithms tailored to patient-specific biomechanical and psychosocial profiles.
3. Cost-effectiveness analyses: Comparative health-economic evaluations would clarify whether rehabilitation-first strategies offer sustainable benefits in healthcare systems with limited surgical capacity.
4. Psychological and neuromechanical integration: Future trials should incorporate validated psychological readiness measures and objective motion analysis to link mental and biomechanical recovery trajectories.
5. Conclusion
This systematic review found no clinically relevant superiority of early anterior cruciate ligament (ACL) reconstruction over structured rehabilitation-first treatment in adults with isolated ACL rupture. Across recent trials, both strategies achieved comparable results in functional outcomes, return-to-sport rates, and patient satisfaction over two to five years.
Early reconstruction may be justified for patients with concomitant meniscal or multi-ligament injuries, or for elite athletes requiring maximal stability. For the majority, however, a well-supervised, criterion-based rehabilitation program provides equivalent results while avoiding surgical risks and costs.
Clinical success depends less on surgical timing and more on adherence, rehabilitation quality, and psychological readiness. A multidisciplinary, patient-centered approach that integrates progressive loading, confidence restoration, and shared decision-making should be the new standard of care.
Future research should focus on long-term joint health, cost-effectiveness, and individualized rehabilitation strategies integrating biomechanical and psychological parameters.
In summary, ACL management should shift from a surgery-first paradigm toward a function-first model: restore control, rebuild confidence, and operate only when truly necessary.
Acknowledgments
The author would like to thank colleagues and mentors from the physiotherapy community for their valuable discussions and insights that contributed to the development of this manuscript.
Conflict of Interest Statement
The author declares no conflicts of interest related to this work.
He is an independent physiotherapist and researcher and received no financial or material support for this study.
Funding Statement
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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- Tobias Giesen (Author), 2025, Anterior Cruciate Ligament (ACL) Reconstruction or Rehabilitation First. A Systematic Review of Recent Evidence and Clinical Implications, Munich, GRIN Verlag, https://www.grin.com/document/1669869
