What is the recommended nonoperative and post-operative rehabilitation for ACL injuries in skeletally immature children?

To answer this question, a comprehensive search of the PubMed database (June 2013) was performed. 1, 3

At time of review, available evidence included 2 prospective trials (2,3), 2 reviews (1,5), clinical commentary (6), and case report (4).

Incidence of ACL injury among skeletally immature youth is increasing due to greater sports participation and improved awareness (1). Nonoperative treatment has been suggested to decrease risk of chronic instability and subsequent meniscal and/or chondral injuries, while operative treatment may cause physeal damage and eventual growth disturbances such as leg length discrepancies or angular deformities (1,5,6).

Moksnes et al evaluated nonoperative rehab program for ACL injury among 36 skeletally immature children with 2 yr follow-up and concluded that knee function remained adequate despite no surgical treatment (3,6). However, 13 children reported that their main sporting activity was no longer pivoting sport (3). Next, authors evaluated incidence of concomitant injuries and found that only 1 new meniscal injury occurred during 1-2 yr period post-injury in 28 ACL deficient knees (2).

Greenberg provided case report of 8 yr old boy who showed readiness for return to sport by 6 mos following all-epiphyseal reconstruction. Patient continued to participate in competitive sports at 2 yr follow-up (4). Authors noted several considerations for ACL rehab among youth, including slower progression to weight bearing, importance of parent education and assessment of emotional maturity, and use of specific, performance based criteria to guide rehab progression (4). Fabricant and Moksnes also recommend performance based outcomes, such as hop tests and isokinetic strength testing, to guide rehab progression and to assess readiness for return to sport (1,6).

Based on articles reviewed, current guidelines for rehab of ACL injuries in skeletally immature children are limited (5). Prospective outcomes suggest that initial nonoperative management of these individuals may be appropriate without increased risk of secondary meniscal damage.


  1. Fabricant PD, Jones KJ, Delos D, Cordasco FA, Marx RG, Pearle AD, Warren RF, Green DW. Reconstruction of the anterior cruciate ligament in the skeletally immature athlete: a review of current concepts: AAOS exhibit selection. J Bone Joint Surg Am. 2013 Mar 6;95(5):e28. doi: 10.2106/JBJS.L.00772. Review. PubMed PMID: 23467876.

Moksnes H, Engebretsen L, Risberg MA. Prevalence and incidence of new meniscus and cartilage injuries after a nonoperative treatment algorithm for ACL tears in skeletally immature children: a prospective MRI study. Am J Sports Med. 2013 Jun 14. [Epub ahead of print] PubMed PMID: 23771955