Nonsurgical vs Surgical ACL Care: Knee Function and Return to Sport

Key Takeaways

• No statistically significant between-group difference appeared in IKDC-SKF at any measured time point, and scores improved over time in both groups.
• Seventy-five percent of the cohort returned to sport within 24 months, with similar 24-month rates across groups and earlier return in the non-ACLR pathway.
• Older age, female sex, and new serious knee injury were associated with lower IKDC-SKF scores, and among patients aged 26 to 40 years, ACLR was associated with a higher risk of not returning than non-ACLR.

Across 272 patients with acute ACL injury in the NACOX cohort, knee-function scores did not separate significantly between non-ACLR and ACLR pathways over 24 months. In this Swedish multicenter study, treatment choice reflected routine shared decision-making rather than randomization. Return-to-sport patterns differed mainly in timing, while 24-month participation rates were broadly similar between groups.

This multicenter prospective cohort from Sweden enrolled 272 patients across 7 sites, including public and private clinics, and included patients aged 15 to 40 years within 6 weeks of injury. Mean age was 25.5 years, and 52% were female. Investigators measured patient-reported knee function with the International Knee Documentation Committee Subjective Knee Form at baseline and at 3, 6, 12, and 24 months after injury or ACLR, depending on group. Return to sport meant reaching the preinjury Tegner level or higher, and the ACLR group was younger and had higher preinjury activity levels at baseline, which shaped the comparison.

No statistically significant between-group difference in IKDC-SKF was observed at follow-up time points, and scores rose over time in both treatment groups. The mixed-effects analysis adjusted for age, sex, preinjury activity level, and new serious knee injury. Older age, female sex, and a new serious knee injury were each associated with lower IKDC-SKF scores, with P values of .003, .004, and less than .001. Knee-function scores improved across both care pathways during the 24-month follow-up.

In the IKDC-SKF and return-to-sport analysis, 75% of the cohort returned to sport within 24 months. The 24-month return rates were 72% in the non-ACLR group and 77% in the ACLR group, with no statistically significant difference between groups at P = .286. Among those who returned, mean time to return was 6.3 months overall from index ACL injury or ACLR, depending on group. The non-ACLR group returned earlier than the ACLR group, at 3.5 versus 8.1 months, with P less than .001. The main between-group difference was timing rather than 24-month participation.

Among patients aged 26 to 40 years, ACLR was associated with a 3.15-fold higher risk of not returning to sport at 24 months than non-ACLR, with P = .015. By 24 months, 170 patients had undergone ACLR, and mean time from index injury to reconstruction was 5.6 months. The cohort was observational and nonrandomized, baseline characteristics differed between groups, and missing questionnaire data were more common in the ACLR group. Age, sex, reinjury status, and treatment pathway were all associated with the outcome patterns seen in routine practice.