Management of ACL Injuries in Skeletally Immature Patients: Current Challenges and Treatment Options
DOI:
https://doi.org/10.12775/QS.2025.48.67330Keywords
Pediatric ACL injury, pediatric ACL tear, pediatric ACL treatment, pediatric ACL reconstructionAbstract
Background Injuries to the ACL are becoming increasingly common in pediatric and adolescent athletes, due to rising participation in high-demand sports. Managing ACL tears in patients who have not reached skeletal maturity is challenging because surgical reconstruction carries a risk of damaging open growth plates, while non-operative care may result in persistent instability and progressive joint damage.
Aim This work aimed to sum up the latest research on the epidemiology, diagnostic considerations and treatment options for ACL in patients who have not reached skeletal maturity, with a particular focus on achieving a balance between restoring knee stability and protecting the growth plates.
Material and methods This review draws on published clinical studies, epidemiological data, and systematic reviews, which are referenced throughout the text. The material covers findings on injury incidence, risk factors, the outcomes of non-operative and operative management, and the complication rates.
Results ACL injuries represent up to 50% of knee sports injuries, with an increasing incidence among young athletes. Non-operative treatment often results in persistent instability, meniscal or cartilage damage, and early degenerative changes. Modern surgical techniques offer different risk profiles based on skeletal maturity. Reconstructive procedures can disrupt open growth plates, so performing surgery on patients who have not yet reached skeletal maturity is challenging. Therefore, accurately assessing skeletal maturity is crucial when deciding on the most suitable surgical approach.
Conclusions ACL injuries in patients who are not fully grown require management that is tailored to skeletal maturity rather than chronological age. Non-operative treatment may only be acceptable in low-activity children who have been carefully selected. When chosen appropriately, surgical reconstruction can restore knee stability while minimizing growth-plate complications.
References
1.Morales-Avalos R, Torres-González EM, Padilla-Medina JR, Monllau JC. ACL anatomy: Is there still something to learn?. Rev Esp Cir Ortop Traumatol. 2024;68(4):422-427. doi:10.1016/j.recot.2023.02.005
2.Kohn L, Rembeck E, Rauch A. Verletzung des vorderen Kreuzbandes beim Erwachsenen : Diagnostik und Therapie [Anterior cruciate ligament injury in adults : Diagnostics and treatment]. Orthopade. 2020;49(11):1013-1028. doi:10.1007/s00132-020-03997-3
3.Duthon VB, Barea C, Abrassart S, Fasel JH, Fritschy D, Ménétrey J. Anatomy of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc. 2006;14(3):204-213. doi:10.1007/s00167-005-0679-9
4.Hassebrock JD, Gulbrandsen MT, Asprey WL, Makovicka JL, Chhabra A. Knee Ligament Anatomy and Biomechanics. Sports Med Arthrosc Rev. 2020;28(3):80-86. doi:10.1097/JSA.0000000000000279
5.Siegel L, Vandenakker-Albanese C, Siegel D. Anterior cruciate ligament injuries: anatomy, physiology, biomechanics, and management. Clin J Sport Med. 2012;22(4):349-355. doi:10.1097/JSM.0b013e3182580cd0
6.LaBella CR, Hennrikus W, Hewett TE; Council on Sports Medicine and Fitness, and Section on Orthopaedics. Anterior cruciate ligament injuries: diagnosis, treatment, and prevention. Pediatrics. 2014;133(5):e1437-e1450. doi:10.1542/peds.2014-0623
7.Wiggins AJ, Grandhi RK, Schneider DK, Stanfield D, Webster KE, Myer GD. Risk of Secondary Injury in Younger Athletes After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med. 2016;44(7):1861-1876. doi:10.1177/0363546515621554
8.Dingel A, Aoyama J, Ganley T, Shea K. Pediatric ACL Tears: Natural History. J Pediatr Orthop. 2019;39(Issue 6, Supplement 1 Suppl 1):S47-S49. doi:10.1097/BPO.0000000000001367
9.Bloom DA, Wolfert AJ, Michalowitz A, Jazrawi LM, Carter CW. ACL Injuries Aren't Just for Girls: The Role of Age in Predicting Pediatric ACL Injury. Sports Health. 2020;12(6):559-563. doi:10.1177/1941738120935429
10.Caine D, Caine C, Maffulli N. Incidence and distribution of pediatric sport-related injuries. Clin J Sport Med. 2006;16(6):500-513. doi:10.1097/01.jsm.0000251181.36582.a0
11.Jones SJ, Lyons RA, Sibert J, Evans R, Palmer SR. Changes in sports injuries to children between 1983 and 1998: comparison of case series. J Public Health Med. 2001 Dec;23(4):268-71. doi: 10.1093/pubmed/23.4.268. PMID: 11873887.
12.Majewski M, Susanne H, Klaus S. Epidemiology of athletic knee injuries: A 10-year study. Knee. 2006;13(3):184-188. doi:10.1016/j.knee.2006.01.005
13.Shea KG, Grimm NL, Ewing CK, Aoki SK. Youth sports anterior cruciate ligament and knee injury epidemiology: who is getting injured? In what sports? When?. Clin Sports Med. 2011;30(4):691-706. doi:10.1016/j.csm.2011.07.004
14.Lohmander LS, Ostenberg A, Englund M, Roos H. High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players twelve years after anterior cruciate ligament injury. Arthritis Rheum. 2004;50(10):3145-3152. doi:10.1002/art.20589
15.Lohmander LS, Englund PM, Dahl LL, Roos EM. The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis. Am J Sports Med. 2007;35(10):1756-1769. doi:10.1177/0363546507307396
16.Stanitski CL. Anterior Cruciate Ligament Injury in the Skeletally Immature Patient: Diagnosis and Treatment. J Am Acad Orthop Surg. 1995;3(3):146-158. doi:10.5435/00124635-199505000-00004
17.Kaeding CC, Léger-St-Jean B, Magnussen RA. Epidemiology and Diagnosis of Anterior Cruciate Ligament Injuries. Clin Sports Med. 2017;36(1):1-8. doi:10.1016/j.csm.2016.08.001
18.Ahldén M, Samuelsson K, Sernert N, Forssblad M, Karlsson J, Kartus J. The Swedish National Anterior Cruciate Ligament Register: a report on baseline variables and outcomes of surgery for almost 18,000 patients. Am J Sports Med. 2012;40(10):2230-2235. doi:10.1177/0363546512457348
19.Granan LP, Forssblad M, Lind M, Engebretsen L. The Scandinavian ACL registries 2004-2007: baseline epidemiology. Acta Orthop. 2009;80(5):563-567. doi:10.3109/17453670903350107
20.Shea KG, Pfeiffer R, Wang JH, Curtin M, Apel PJ. Anterior cruciate ligament injury in pediatric and adolescent soccer players: an analysis of insurance data. J Pediatr Orthop. 2004;24(6):623-628. doi:10.1097/00004694-200411000-00005
21.DeLee JC, Curtis R. Anterior cruciate ligament insufficiency in children. Clin Orthop Relat Res. 1983;(172):112-118.
22.McCarroll JR, Rettig AC, Shelbourne KD. Anterior cruciate ligament injuries in the young athlete with open physes. Am J Sports Med. 1988;16(1):44-47. doi:10.1177/036354658801600107
23.Koch PP, Fucentese SF, Blatter SC. Complications after epiphyseal reconstruction of the anterior cruciate ligament in prepubescent children. Knee Surg Sports Traumatol Arthrosc. 2016;24(9):2736-2740. doi:10.1007/s00167-014-3396-4
24.Kaeding CC, Flanigan D, Donaldson C. Surgical techniques and outcomes after anterior cruciate ligament reconstruction in preadolescent patients. Arthroscopy. 2010;26(11):1530-1538. doi:10.1016/j.arthro.2010.04.065
25.Stracciolini A, Stein CJ, Zurakowski D, Meehan WP 3rd, Myer GD, Micheli LJ. Anterior cruciate ligament injuries in pediatric athletes presenting to sports medicine clinic: a comparison of males and females through growth and development. Sports Health. 2015;7(2):130-136. doi:10.1177/1941738114554768
26.Lin CY, Casey E, Herman DC, Katz N, Tenforde AS. Sex Differences in Common Sports Injuries. PM R. 2018;10(10):1073-1082. doi:10.1016/j.pmrj.2018.03.008
27.Kocher MS, Saxon HS, Hovis WD, Hawkins RJ. Management and complications of anterior cruciate ligament injuries in skeletally immature patients: survey of the Herodicus Society and The ACL Study Group. J Pediatr Orthop. 2002;22(4):452-457.
28.Mizuta H, Kubota K, Shiraishi M, Otsuka Y, Nagamoto N, Takagi K. The conservative treatment of complete tears of the anterior cruciate ligament in skeletally immature patients. J Bone Joint Surg Br. 1995;77(6):890-894.
29.Vavken P, Murray MM. Treating anterior cruciate ligament tears in skeletally immature patients. Arthroscopy. 2011;27(5):704-716. doi:10.1016/j.arthro.2010.11.062
30.Moksnes H, Engebretsen L, Risberg MA. Performance-based functional outcome for children 12 years or younger following anterior cruciate ligament injury: a two to nine-year follow-up study. Knee Surg Sports Traumatol Arthrosc. 2008;16(3):214-223. doi:10.1007/s00167-007-0469-7
31.Woods GW, O'Connor DP. Delayed anterior cruciate ligament reconstruction in adolescents with open physes. Am J Sports Med. 2004;32(1):201-210. doi:10.1177/0363546503258868
32.Wall EJ, Myer GD, May MM. Anterior cruciate ligament reconstruction timing in children with open growth plates: new surgical techniques including all-epiphyseal. Clin Sports Med. 2011;30(4):789-800. doi:10.1016/j.csm.2011.07.002
33.Malina RM, Cumming SP, Morano PJ, Barron M, Miller SJ. Maturity status of youth football players: a noninvasive estimate. Med Sci Sports Exerc. 2005;37(6):1044-1052.
34.Sanders JO. Maturity indicators in spinal deformity. J Bone Joint Surg Am. 2007;89 Suppl 1:14-20. doi:10.2106/JBJS.F.00318
35.Simonian PT, Metcalf MH, Larson RV. Anterior cruciate ligament injuries in the skeletally immature patient. Am J Orthop (Belle Mead NJ). 1999;28(11):624-628.
36.Kaeding CC, Flanigan D, Donaldson C. Surgical techniques and outcomes after anterior cruciate ligament reconstruction in preadolescent patients. Arthroscopy. 2010;26(11):1530-1538. doi:10.1016/j.arthro.2010.04.065
37.Beasley LS, Chudik SC. Anterior cruciate ligament injury in children: update of current treatment options. Curr Opin Pediatr. 2003;15(1):45-52. doi:10.1097/00008480-200302000-00008
38.Anderson AF. Transepiphyseal replacement of the anterior cruciate ligament using quadruple hamstring grafts in skeletally immature patients. J Bone Joint Surg Am. 2004;86-A Suppl 1(Pt 2):201-209. doi:10.2106/00004623-200409001-00010
39.Angel KR, Hall DJ. Anterior cruciate ligament injury in children and adolescents. Arthroscopy. 1989;5(3):197-200. doi:10.1016/0749-8063(89)90171-0
40.Graf BK, Lange RH, Fujisaki CK, Landry GL, Saluja RK. Anterior cruciate ligament tears in skeletally immature patients: meniscal pathology at presentation and after attempted conservative treatment. Arthroscopy. 1992;8(2):229-233. doi:10.1016/0749-8063(92)90041-9
41.Millett PJ, Willis AA, Warren RF. Associated injuries in pediatric and adolescent anterior cruciate ligament tears: does a delay in treatment increase the risk of meniscal tear?. Arthroscopy. 2002;18(9):955-959. doi:10.1053/jars.2002.36114
42.Mohtadi N, Grant J. Managing anterior cruciate ligament deficiency in the skeletally immature individual: a systematic review of the literature. Clin J Sport Med. 2006;16(6):457-464. doi:10.1097/01.jsm.0000248844.39498.1f
43.DeLee JC, Curtis R. Anterior cruciate ligament insufficiency in children. Clin Orthop Relat Res. 1983;(172):112-118.
44.Kocher MS, Garg S, Micheli LJ. Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents. J Bone Joint Surg Am. 2005;87(11):2371-2379. doi:10.2106/JBJS.D.02802
45.Guzzanti V, Falciglia F, Stanitski CL. Physeal-sparing intraarticular anterior cruciate ligament reconstruction in preadolescents. Am J Sports Med. 2003;31(6):949-953. doi:10.1177/03635465030310063401
46.Micheli LJ, Rask B, Gerberg L. Anterior cruciate ligament reconstruction in patients who are prepubescent. Clin Orthop Relat Res. 1999;(364):40-47. doi:10.1097/00003086-199907000-00006
47.Grassi A, Borque KA, Laughlin MS, Tao MA, Zaffagnini S. Age-specific over-the-top techniques for physeal sparing anterior cruciate ligament (ACL) reconstruction in skeletally immature patients: Current concepts for prepubescents to older adolescents. Knee Surg Sports Traumatol Arthrosc. 2025;33(10):3510-3522. doi:10.1002/ksa.12607
48.Kennedy A, Coughlin DG, Metzger MF, et al. Biomechanical evaluation of pediatric anterior cruciate ligament reconstruction techniques. Am J Sports Med. 2011;39(5):964-971. doi:10.1177/0363546510390189
49.Kocher MS, Heyworth BE, Fabricant PD, Tepolt FA, Micheli LJ. Outcomes of Physeal-Sparing ACL Reconstruction with Iliotibial Band Autograft in Skeletally Immature Prepubescent Children. J Bone Joint Surg Am. 2018;100(13):1087-1094. doi:10.2106/JBJS.17.01327
50.Perkins CA, Willimon SC. Pediatric Anterior Cruciate Ligament Reconstruction. Orthop Clin North Am. 2020;51(1):55-63. doi:10.1016/j.ocl.2019.08.009
51.Chipman DE, Pascual-Leone N, Cordasco FA, Green DW. Anterior Cruciate Ligament Reconstruction in Skeletally Immature Athletes Using All-Epiphyseal Techniques. Clin Sports Med. 2022;41(4):569-577. doi:10.1016/j.csm.2022.05.002
52.McCarthy MM, Graziano J, Green DW, Cordasco FA. All-epiphyseal, all-inside anterior cruciate ligament reconstruction technique for skeletally immature patients. Arthrosc Tech. 2012;1(2):e231-e239. Published 2012 Nov 22. doi:10.1016/j.eats.2012.08.005
53.Cruz AI Jr, Fabricant PD, McGraw M, Rozell JC, Ganley TJ, Wells L. All-Epiphyseal ACL Reconstruction in Children: Review of Safety and Early Complications. J Pediatr Orthop. 2017;37(3):204-209. doi:10.1097/BPO.0000000000000606
54.Chambers CC, Monroe EJ, Allen CR, Pandya NK. Partial Transphyseal Anterior Cruciate Ligament Reconstruction: Clinical, Functional, and Radiographic Outcomes. Am J Sports Med. 2019;47(6):1353-1360. doi:10.1177/0363546519836423
55.Lo IK, Kirkley A, Fowler PJ, Miniaci A. The outcome of operatively treated anterior cruciate ligament disruptions in the skeletally immature child. Arthroscopy. 1997;13(5):627-634. doi:10.1016/s0749-8063(97)90191-2
56.Shifflett GD, Green DW, Widmann RF, Marx RG. Growth Arrest Following ACL Reconstruction With Hamstring Autograft in Skeletally Immature Patients: A Review of 4 Cases. J Pediatr Orthop. 2016;36(4):355-361. doi:10.1097/BPO.0000000000000466
57.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;41(8):1771-1779. doi:10.1177/0363546513491092
58.Frosch KH, Stengel D, Brodhun T, et al. Outcomes and risks of operative treatment of rupture of the anterior cruciate ligament in children and adolescents. Arthroscopy. 2010;26(11):1539-1550. doi:10.1016/j.arthro.2010.04.077
59.Wong SE, Feeley BT, Pandya NK. Complications After Pediatric ACL Reconstruction: A Meta-analysis. J Pediatr Orthop. 2019;39(8):e566-e571. doi:10.1097/BPO.0000000000001075
60.Collins MJ, Arns TA, Leroux T, et al. Growth Abnormalities Following Anterior Cruciate Ligament Reconstruction in the Skeletally Immature Patient: A Systematic Review. Arthroscopy. 2016;32(8):1714-1723. doi:10.1016/j.arthro.2016.02.025
61.Dekker TJ, Godin JA, Dale KM, Garrett WE, Taylor DC, Riboh JC. Return to Sport After Pediatric Anterior Cruciate Ligament Reconstruction and Its Effect on Subsequent Anterior Cruciate Ligament Injury. J Bone Joint Surg Am. 2017;99(11):897-904. doi:10.2106/JBJS.16.00758
62.Kelly PM, Diméglio A. Lower-limb growth: how predictable are predictions?. J Child Orthop. 2008;2(6):407-415. doi:10.1007/s11832-008-0119-8
63.Frank JS, Gambacorta PL. Anterior cruciate ligament injuries in the skeletally immature athlete: diagnosis and management. J Am Acad Orthop Surg. 2013;21(2):78-87. doi:10.5435/JAAOS-21-02-78
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2025 Dominika Miazga, Julia Matuszewska, Alicja Maziarczyk, Jakub Lambach, Julia Dabrowska, Michał Białogłowski, Maja Wojcieszak, Kacper Kutnik, Weronika Woźnica, Joanna Kania
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Stats
Number of views and downloads: 4
Number of citations: 0
