There is limited evidence to support non-surgical management for less active patients with less laxity.

Rationale
This recommendation is based on one moderate-strength, one low strength and three very low strength studies .24, 31, 71, 93, 29 Patients were classified based on activity level and knee laxity at initial injury. The following three groups were considered particularly low risk: (1) Patients participating in less than 50 hours of jumping or cutting sports and less than 5 mm of side to side difference based on KT-1000 or manual maximal testing, (2) Patients participating in 50-199 hours of jumping or cutting sports with less than 5 mm of side to side difference based on KT-1000 or manual maximal testing, and (3) Patients participating in less than 50 hours of jumping or cutting sports with 5-7 mm of side to side difference based on KT-1000 or manual maximal testing.31 Collectively, these low risk groups were found to have lower rates of late meniscal surgery and ACL reconstruction than patients in the high risk groups treated non-operatively.31 Thus, low risk patients may do well with non-operative treatment. However, 25% of the low risk patients ultimately required surgery, including ACL reconstruction or meniscal surgery.31

Benefits of Implementation
Lower risk patients, based on activity and/or index laxity criteria, may tolerate an ACL deficient knee, and therefore may be spared exposure to the risks of surgical intervention such as infection, risks of anesthesia, arthrofibrosis, etc.

Possible Harms of Implementation
Despite being categorized as low risk, these patients may still require late ACL reconstruction and/or meniscal surgery and could sustain further damage to the ACL deficient knee

Future Research
Future research should attempt to define which patients may be safely treated conservatively after ACL injury, and what specific risk factors contribute to this decision making process.

 
  1. (24) Daniel DM, Stone ML, Dobson BE, Fithian DC, Rossman DJ, Kaufman KR. Fate of the ACL-injured patient. A prospective outcome study. Am J Sports Med 1994;22:632-644.
  2. (29) Fink C, Hoser C, Hackl W, Navarro RA, Benedetto KP. Long-term outcome of operative or nonoperative treatment of anterior cruciate ligament rupture--is sports activity a determining variable? Int J Sports Med 2001;22:304-309.
  3. (31) Fithian DC, Paxton EW, Stone ML et al. Prospective trial of a treatment algorithm for the management of the anterior cruciate ligament-injured knee. Am J Sports Med 2005;33:335-346.
  4. (71) Mihelic R, Jurdana H, Jotanovic Z, Madjarevic T, Tudor A. Long-term results of anterior cruciate ligament reconstruction: a comparison with non-operative treatment with a follow-up of 17-20 years. Int Orthop 2011;35:1093-1097.
  5. (93) Richter M, Bosch U, Wippermann B, Hofmann A, Krettek C. Comparison of surgical repair or reconstruction of the cruciate ligaments versus nonsurgical treatment in patients with traumatic knee dislocations. Am J Sports Med 2002;30:718-727.