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

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.