Achieving optimal outcomes for teen athletes with ACL injury

Feb. 16, 2024

Teens playing basketball Teens playing basketball

Teens play a basketball game, a sport in which cutting and pivoting can put the ACL at risk.

Perhaps counterintuitively for their young age, teen athletes are at highest risk of anterior cruciate ligament (ACL) injury and reconstruction plus recurrence compared with other age groups, according to Adam J. Tagliero, M.D., sports medicine specialist and orthopedic surgeon at Mayo Clinic in Minnesota.

These individuals' risk levels have everything to do with exposure: Teen athletes may have many remaining years of cutting and pivoting in sports played multiple days a week. Also, high-caliber young athletes may participate in multiple sports.

"Of all population groups, teens are often doing the most high-risk activity most frequently," says Dr. Tagliero.

Beyond formal sports environments, teens often are more active than adults. Even after an ACL injury is reconstructed, teen athletes typically return to high exposure with activities that may endanger this ligament. Their exposure frequently is vastly different from adults' exposure, who may play basketball on Saturdays or pass a football in the yard. ACL injury risk also may be increased by an underlying cause, including genetic or anatomic factors, or sometimes "just bad luck," says Dr. Tagliero. Generalized ligamentous laxity also may pose an ACL tear risk. Being a female teen athlete also places the individual at high risk of an ACL tear.

"Data on these injuries indicate higher risk for females," says Dr. Tagliero. "It may be landing mechanics, neuromuscular factors or other causes."

Though people often think of teens' bodies as bouncing back easily, Dr. Tagliero says this does not apply to ACL injury. He indicates a ligament healing on its own is rare. Most commonly, teens with an ACL injury require surgery, without which return to cutting and pivoting activities may lead to further injury, he says.

The dangers of delayed treatment

He describes a period following an ACL injury in which the swelling at the injury site decreases, and the patient's knee can feel better. Yet, he indicates that this perceived improvement in the knee is really a false sense of healing. A 2021 article published in The American Journal of Sports Medicine found that a surgical delay over 12 weeks increased meniscal injury risk while lessening the surgeon's ability to successfully repair it.

"At this point, the orthopedic surgeon often has to explain to the athlete the rationale for surgery," says Dr. Tagliero. "This often means missing the rest of the sports season and can be a difficult discussion."

Dr. Tagliero highlights that in this same article, delayed ACL reconstruction still led to a stable knee again postsurgically for the patients.

"But I don't want to see patients miss the opportunity to fix the meniscus or sustain further damage," says Dr. Tagliero.

The same article pointed to decreased return to sports for patients who did not have ACL surgery, compared with peers who had surgery for the same injury. This was likely due to ongoing problems with cutting and pivoting athletic activity, says Dr. Tagliero. He states that the ability to avoid surgery altogether is rare for young athletes with ACL injuries, because reconstruction restores the ability to cut and pivot in sports. Even outside of sports, he indicates that young athletes need skills such as pivoting for daily activities.

A Mayo Clinic study published in 2016 found 40% of patients who waited to have ACL reconstruction experienced a secondary meniscal tear by the time of surgery.

Another Mayo Clinic study published in 2019 found that delayed or nonoperative treatment most often led to these secondary meniscal tears, which frequently were categorized as medial meniscus complex tears. This type of tear prompted high partial meniscectomy rates — which Dr. Tagliero characterizes as a suboptimal outcome — in these patients.

More than an ACL injury

ACL injury often occurs with concomitant knee injuries.

"It's less likely a patient will just have an ACL injury," Dr. Tagliero says. "It's more common to find additional injuries to the ACL tear."

If the meniscus tears during ACL injury, treatment ranges from nonoperative therapy, such as injections, to surgical repair or resection. ACL specialists now often repair meniscal tears when able rather than simply removing damaged tissue to retain the meniscal role as a shock absorber and secondary stabilizer for the knee. Meniscus functional loss can speed cartilage breakdown and arthritis formation rates, he says.

Additionally, if the surgeon also repairs the meniscus with an ACL reconstruction, the patient's healing rates are favorable and durable in the long term, according to a 2018 publication by Dr. Tagliero and Mayo Clinic colleagues in The American Journal of Sports Medicine. They found clinical success for meniscal repair performed with ACL reconstruction in 72% of pediatric and adolescent patients.

Referral for teens with ACL injury

When considering ACL reconstruction for a teen athlete, where you send the patient is crucial to ensure an optimal and durable outcome. Surgery performed by ACL specialists with deep knowledge of the anatomy and reconstruction techniques can contribute to that endpoint. Although revision surgery is a possibility if needed, the outcomes are more likely to be unsatisfactory than in the primary setting. Thus, Dr. Tagliero suggests referring a teen athlete to a surgeon in whom you feel confident.

Mayo Clinic ACL specialists possess this high level of knowledge and experience with reconstructing torn ACLs and welcome referrals from physicians outside of Mayo Clinic.

For more information

James EW, et al. Early operative versus delayed operative versus nonoperative treatment of pediatric and adolescent anterior cruciate ligament injuries: A systematic review and meta-analysis. The American Journal of Sports Medicine. 2021;49:4008.

Sanders TL, et al. Incidence of and factors associated with the decision to undergo anterior cruciate ligament reconstruction 1 to 10 years after injury. The American Journal of Sports Medicine. 2016;44:1558.

Hagmeijer MH, et al. Secondary meniscal tears in patients with anterior cruciate ligament injury: Relationship among operative management, osteoarthritis, and arthroplasty at 18-year mean follow-up. The American Journal of Sports Medicine. 2019;47:1583.

Tagliero AJ, et al. Seventeen-year follow-up after meniscal repair with concomitant anterior cruciate ligament reconstruction in a pediatric and adolescent population. The American Journal of Sports Medicine. 2018;46:3361.

Refer a patient to Mayo Clinic.