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Meta-Analysis
. 2025 Sep;55(9):2191-2205.
doi: 10.1007/s40279-025-02268-5. Epub 2025 Jul 2.

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

Stephanie R Filbay  1 , Garrett Bullock  2 , Scott Russell  3 , Frances Brown  3 , Wilson Hui  3 , Thorlene Egerton  4   3
Affiliations
Meta-Analysis

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

Stephanie R Filbay et al. Sports Med. 2025 Sep.

Abstract

Background: A common belief amongst patients and clinicians is that anterior cruciate ligament reconstruction is required to return to sport. It is not clear if this belief is supported by the best available research.

Objective: We aimed to compare return-to-sport and activity levels following anterior cruciate ligament rupture managed with anterior cruciate ligament reconstruction versus rehabilitation alone.

Methods: We performed a systematic review and meta-analysis. A comprehensive search was conducted across seven electronic databases for empirical studies published to July 2023. Articles were included if they assessed return-to-sport and/or activity levels in two groups where one underwent an anterior cruciate ligament reconstruction and the other had exercise-based rehabilitation that was standardised and/or supervised by a healthcare professional. In addition to narrative syntheses, random-effect meta-analyses were conducted for return-to-sport and activity participation (Tegner Activity Scale). The protocol was pre-registered (PROSPERO CRD42022313507).

Results: Eighteen articles reporting on 15 studies (two randomised controlled trials) met inclusion criteria. Ten studies had a high risk of confounding bias that was likely to favour anterior cruciate ligament reconstruction including biases in group allocation and differences in activity and return-to-sport advice between groups. The findings suggest that anterior cruciate ligament reconstruction was not associated with higher return-to-sport rates (odds ratio 1.5, 95% confidence interval 0.76-2.97) compared to rehabilitation alone. A small difference favouring anterior cruciate ligament reconstruction was observed for Tegner Activity Scale scores (mean difference 0.7, 95% confidence interval 0.16-1.24) that did not exceed the minimal detectable change and no difference was observed after excluding studies with a high risk of confounding bias. Insufficient data were available for time to return to sport and physical activity levels. The evidence is of low or very low certainty because of the heterogeneity of results and the high risk of bias in the included studies.

Conclusions: There was no difference in return-to-sport rates or activity levels when comparing anterior cruciate ligament reconstruction with rehabilitation alone for the management of anterior cruciate ligament injury.

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Conflict of interest statement

Declarations. Funding: Stephanie R. Filbay is funded through a National Health and Medical Research Council Investigator Grant (1194428). Conflicts of interest/competing interests: Stephanie R. Filbay, Garrett Bullock, Scott Russell, Frances Brown, Wilson Hui and Thorlene Egerton have no conflicts of interest that are directly relevant to the content of this article. Ethics approval: Not applicable. Consent to participate: Not applicable. Consent for publication: Not applicable. Availability of data and material: All data generated or analysed during this study are included in this published article and its supplementary information files. Code availability: Not applicable. Authors’ contributions: SF and TE conceived the study and provided supervision and mentoring to students SR, FB and WH who worked on the review for their Master’s theses. SR, FB, WH, GB, TE and SF all contributed to screening, data extraction, risk of bias assessment and data synthesis. SF and TE wrote the first complete draft of the manuscript and all authors contributed to the manuscript preparation and approved the final submitted version. SF is the guarantor for the study.

Figures

Fig. 1
Fig. 1
Preferred Reporting Items for Systematic Reviews (PRISMA) flow chart outlining article selection process and reasons for article exclusion
Fig. 2
Fig. 2
Random-effect meta-analysis depicting pooled odds of return to sport for all available studies, and according to the risk of confounding bias because of the study design. Studies were considered to have a high risk of confounding bias if they (a) recommended people with a low pre-injury activity level to choose non-surgical management, (b) allocated people to non-surgical management if they expressed they did not aim to return to pre-injury sport and/or (c) only advised people in the non-surgical group that they should limit activity or not return to sport. ACLR anterior cruciate ligament reconstruction, CI confidence interval, IV inverse variance, Rehab rehabilitation, ⊕ indicates an overall low risk of bias, ⊝ indicates an overall high risk of bias
Fig. 3
Fig. 3
Random-effect meta-analysis depicting pooled mean difference (95% confidence interval [CI]) in the Tegner Activity Scale (TAS) score for all studies with data, separated according to the risk of confounding bias. Studies were considered to have a high risk of confounding bias if they (a) recommended people with a low pre-injury activity level to choose non-surgical management, (b) allocated people to non-surgical management if they expressed they did not aim to return to pre-injury sport and/or (c) only advised people in the non-surgical group that they should limit activity or not return to sport. ACLR anterior cruciate ligament reconstruction, IV inverse variance, Rehab rehabilitation, SD standard deviation, ⊕ indicates an overall low risk of bias; ⊝ indicates an overall high risk of bias
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References

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