{"id":7915,"date":"2026-07-02T07:44:41","date_gmt":"2026-07-02T06:44:41","guid":{"rendered":"https:\/\/isokineticmagazine.com\/?p=7915"},"modified":"2026-07-02T08:46:26","modified_gmt":"2026-07-02T07:46:26","slug":"anterior-cruciate-ligament-acl-injury-in-children-and-adolescents-diagnosis-treatment-and-return-to-sport","status":"publish","type":"post","link":"https:\/\/isokineticmagazine.com\/en\/2026\/07\/anterior-cruciate-ligament-acl-injury-in-children-and-adolescents-diagnosis-treatment-and-return-to-sport\/","title":{"rendered":"Anterior Cruciate Ligament (ACL) Injury in Children and Adolescents: Diagnosis, Treatment, and Return to Sport"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">Anterior Cruciate Ligament (ACL) Injury in Children and Adolescents: Diagnosis, Treatment, and Return to Sport<br\/>Anterior cruciate ligament (ACL) injury is one of the most common and significant traumatic knee injuries in young athletes. The ACL is a key ligament located at the center of the knee joint, providing essential stability during rotational movements, changes of direction, and high-intensity sports activities. <\/p>\n\n<p class=\"wp-block-paragraph\">In recent years, the increasing participation of children and adolescents in competitive sports at progressively younger ages has led to a significant rise in the incidence of anterior cruciate ligament (ACL) injuries in the pediatric and adolescent population.<\/p>\n\n<p class=\"wp-block-paragraph\">Unlike in adults, the management of ACL injuries in the pediatric population presents a unique challenge due to the presence of growth plates, also known as physes. These structures, located near the joints, are responsible for longitudinal bone growth during skeletal development. Any injury to the physes may impair normal growth and lead to developmental abnormalities of the lower limb.  <\/p>\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full\"><img decoding=\"async\" src=\"https:\/\/isokineticmagazine.com\/wp-content\/uploads\/2026\/07\/Immagine1.png\" alt=\"\" class=\"wp-image-7907\"\/><\/figure>\n<\/div>\n<h2 class=\"wp-block-heading\"><strong>The Therapeutic Dilemma<\/strong><\/h2>\n\n<p class=\"wp-block-paragraph\"><strong>Conservative Treatment<\/strong><\/p>\n\n<p class=\"wp-block-paragraph\">Nonoperative management of ACL tears in young patients may result in persistent knee instability. Each episode of giving way increases the risk of secondary meniscal injuries, which occur in up to 60\u201370% of cases, and contributes to the early development of joint degeneration and osteoarthritis. <\/p>\n\n<p class=\"wp-block-paragraph\"><strong>Surgical Treatment<\/strong><\/p>\n\n<p class=\"wp-block-paragraph\">Traditional ACL reconstruction techniques used in adults may pose a risk of injury to the still-open growth plates. Such injuries may result in growth disturbances, limb length discrepancy, or angular deformities of the knee, including genu valgum (knock-knees) and genu varum (bowlegs). <\/p>\n\n<h2 class=\"wp-block-heading\"><strong>How Is Remaining Growth Assessed? The STEP Method <\/strong><\/h2>\n\n<p class=\"wp-block-paragraph\">The choice of treatment depends on the amount of remaining skeletal growth. Therefore, chronological age alone is not sufficient, as in more than 25% of cases it does not accurately reflect the patient&#8217;s true skeletal maturity. <\/p>\n\n<p class=\"wp-block-paragraph\">A 14-year-old adolescent may have nearly complete skeletal maturity or still retain substantial growth potential. To accurately assess this condition, magnetic resonance imaging (MRI) of the knee is performed, and the Sagittal Tibial Epiphysis (STEP) method is used to evaluate the remaining growth potential. <\/p>\n\n<p class=\"wp-block-paragraph\">This method allows patients to be classified into three main categories:<\/p>\n\n<p class=\"wp-block-paragraph\"><strong>Prepubertal Children<\/strong><\/p>\n\n<p class=\"wp-block-paragraph\">This group generally includes boys younger than 12 years and girls younger than 10 years. They have widely open growth plates and an estimated remaining growth potential of more than 7.5 cm. <\/p>\n\n<p class=\"wp-block-paragraph\"><strong>Young Adolescents<\/strong><\/p>\n\n<p class=\"wp-block-paragraph\">This group generally includes boys between 12 and 15 years of age and girls between 10 and 13 years of age. They are in the midst of pubertal development and have an estimated remaining growth potential of 1 to 7.5 cm. <\/p>\n\n<p class=\"wp-block-paragraph\"><strong>Late Adolescents<\/strong><\/p>\n\n<p class=\"wp-block-paragraph\">This group generally includes boys between 16 and 18 years of age and girls between 14 and 16 years of age. The growth plates are nearing closure, and the estimated remaining growth potential is less than 1 cm. <\/p>\n\n<h2 class=\"wp-block-heading\"><strong>To Operate or Not to Operate? The BABY-Knee Decision-Making System <\/strong><\/h2>\n\n<p class=\"wp-block-paragraph\">Treatment decision-making is supported by the BABY-Knee clinical-radiological algorithm, a tool that integrates clinical data, physical examination findings, and magnetic resonance imaging (MRI) results.<\/p>\n\n<p class=\"wp-block-paragraph\"><strong>Score Below 3 Points<\/strong><\/p>\n\n<p class=\"wp-block-paragraph\">When the score is low, initial nonoperative treatment may be considered, based on:<\/p>\n\n<ul class=\"wp-block-list\">\n<li>Targeted physiotherapy focused on muscle strengthening;<\/li>\n\n\n\n<li>Control of joint instability;<\/li>\n\n\n\n<li>Regular clinical and radiological follow-up.<\/li>\n<\/ul>\n\n<p class=\"wp-block-paragraph\">The nonoperative treatment program typically lasts between 3 and 6 months. If the knee continues to experience recurrent episodes of giving way or if new injuries develop, the indication for surgical treatment should be reassessed. <\/p>\n\n<p class=\"wp-block-paragraph\"><strong>Score of 3 Points or Higher<\/strong><\/p>\n\n<p class=\"wp-block-paragraph\">In patients with a high score, surgical treatment is generally recommended, particularly when the following are present: <\/p>\n\n<ul class=\"wp-block-list\">\n<li>Significant meniscal injuries;<\/li>\n\n\n\n<li>Significant knee instability;<\/li>\n\n\n\n<li>Bucket-handle meniscal tears or ramp lesions;<\/li>\n\n\n\n<li>Participation in pivoting\/contact sports, such as soccer, basketball, or rugby.<\/li>\n<\/ul>\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full\"><img loading=\"lazy\" loading=\"lazy\" decoding=\"async\" width=\"595\" height=\"262\" src=\"https:\/\/isokineticmagazine.com\/wp-content\/uploads\/2026\/07\/Immagine2.webp\" alt=\"\" class=\"wp-image-7909\" srcset=\"https:\/\/isokineticmagazine.com\/wp-content\/uploads\/2026\/07\/Immagine2.webp 595w, https:\/\/isokineticmagazine.com\/wp-content\/uploads\/2026\/07\/Immagine2-300x132.webp 300w\" sizes=\"auto, (max-width: 595px) 100vw, 595px\" \/><\/figure>\n<\/div>\n<h2 class=\"wp-block-heading\"><strong>Growth-Sparing Surgical Techniques for ACL Reconstruction<\/strong><\/h2>\n\n<p class=\"wp-block-paragraph\">When surgical treatment is indicated, the orthopedic surgeon employs specialized techniques designed to preserve the integrity of the growth plates.<\/p>\n\n<p class=\"wp-block-paragraph\">The goal is to reconstruct the anterior cruciate ligament using an autologous tendon graft, positioned according to surgical techniques that minimize the risk of injury to the growth plates.<\/p>\n\n<p class=\"wp-block-paragraph\">The surgical technique is tailored to the patient&#8217;s degree of skeletal maturity and the amount of remaining growth.<\/p>\n\n<p class=\"wp-block-paragraph\"><strong>The Role of Lateral Extra-Articular Augmentation<\/strong><\/p>\n\n<p class=\"wp-block-paragraph\">In children and adolescents, a lateral extra-articular augmentation procedure (LEAP), also referred to as lateral extra-articular tenodesis (LET), is increasingly performed in conjunction with ACL reconstruction.<\/p>\n\n<p class=\"wp-block-paragraph\">This additional procedure acts as a protective reinforcement for the reconstructed ligament, significantly reducing the risk of graft failure and reinjury. Recent studies have reported a reduction in the failure rate from approximately 11% to around 4%. <\/p>\n\n<h2 class=\"wp-block-heading\"><strong>Potential Growth-Related Complications After Surgery<\/strong><\/h2>\n\n<p class=\"wp-block-paragraph\">Modern ACL reconstruction techniques in pediatric and adolescent patients are considered highly safe. Nevertheless, clinical follow-up throughout skeletal growth remains essential to ensure the early detection of any growth-related abnormalities. <\/p>\n\n<p class=\"wp-block-paragraph\"><strong>Type A: Growth Arrest<\/strong><\/p>\n\n<p class=\"wp-block-paragraph\">This occurs when a bone bridge forms across the growth plate. The resulting physeal tethering may lead to angular deformity of the limb or a mild limb length discrepancy. <\/p>\n\n<p class=\"wp-block-paragraph\"><strong>Type B: Growth Overgrowth<\/strong><\/p>\n\n<p class=\"wp-block-paragraph\">The increased vascularity associated with the healing process may overstimulate the growth plate. As a result, the operated limb may become temporarily longer by a few millimeters. <\/p>\n\n<p class=\"wp-block-paragraph\"><strong>Type C: Tension-Related Growth Retardation<\/strong><\/p>\n\n<p class=\"wp-block-paragraph\">Excessive tension in the reconstructed ligament may exert mechanical stress on the growth plate, thereby slowing its physiological activity.<\/p>\n\n<h2 class=\"wp-block-heading\"><strong>Rehabilitation After ACL Reconstruction and Return to Sport<\/strong><\/h2>\n\n<p class=\"wp-block-paragraph\">Rehabilitation following anterior cruciate ligament (ACL) reconstruction in children and adolescents requires a specialized, age-specific approach.<\/p>\n\n<p class=\"wp-block-paragraph\">Young patients are not simply \u201csmall adults.\u201d Their rehabilitation program should be dynamic, engaging, and based on functional exercises and movement-based activities that promote appropriate motor learning.<\/p>\n\n<p class=\"wp-block-paragraph\"><strong>When Is It Safe to Return to Sport?<\/strong><\/p>\n\n<p class=\"wp-block-paragraph\">Return to competitive sports should not be determined solely by the time elapsed since surgery. Likewise, the absence of pain alone is not a sufficient criterion for a safe return to sport. <\/p>\n\n<p class=\"wp-block-paragraph\">To be cleared for return to sport, the patient must successfully complete a series of standardized functional tests.<\/p>\n\n<p class=\"wp-block-paragraph\"><strong>Return-to-Sport (RTS) Criteria<\/strong><\/p>\n\n<p class=\"wp-block-paragraph\">The key criteria include:<\/p>\n\n<ul class=\"wp-block-list\">\n<li>Limb Symmetry Index (LSI) of at least 90\u201395%;<\/li>\n\n\n\n<li>Restoration of muscle strength comparable to that of the contralateral, uninjured limb;<\/li>\n\n\n\n<li>Successful completion of single-leg hop tests;<\/li>\n\n\n\n<li>Movement Analysis Test (MAT) score of at least 85\/100.<\/li>\n<\/ul>\n\n<p class=\"wp-block-paragraph\">The Movement Analysis Test (MAT) assesses movement quality during jumping, landing, and change-of-direction tasks, identifying abnormal movement patterns that may increase the risk of reinjury.<\/p>\n\n<h2 class=\"wp-block-heading\"><strong>Conclusions<\/strong><\/h2>\n\n<p class=\"wp-block-paragraph\">Anterior cruciate ligament (ACL) injury in children and adolescents requires highly specialized management. The presence of open growth plates necessitates a careful assessment of skeletal maturity and the use of dedicated growth-sparing surgical techniques. <\/p>\n\n<p class=\"wp-block-paragraph\">Thanks to modern diagnostic protocols, growth-sparing surgical techniques, and advanced rehabilitation programs, excellent functional outcomes can now be achieved, allowing young athletes to safely return to sports while minimizing the risk of complications and reinjury.<\/p>\n\n<div class=\"wp-block-buttons is-content-justification-center is-layout-flex wp-container-core-buttons-is-layout-fe48e5de wp-block-buttons-is-layout-flex\">\n<div class=\"wp-block-button\"><a class=\"wp-block-button__link wp-element-button\" href=\"https:\/\/esskajournals.onlinelibrary.wiley.com\/doi\/10.1002\/jeo2.70498\" target=\"_blank\" rel=\"noreferrer noopener\">REFERENCES<\/a><\/div>\n<\/div>\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Anterior Cruciate Ligament (ACL) Injury in Children and Adolescents: Diagnosis, Treatment, and Return to SportAnterior cruciate ligament (ACL) injury is one of the most common and significant traumatic knee injuries in young athletes. The ACL is a key ligament located at the center of the knee joint, providing essential stability during rotational movements, changes of [&hellip;]<\/p>\n","protected":false},"author":20,"featured_media":7905,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[592,246,247],"tags":[662,261,661,258],"class_list":["post-7915","post","type-post","status-publish","format-standard","has-post-thumbnail","category-news","category-news-from-the-centres","category-torino-en","tag-adolescents","tag-anterior-cruciate-ligament-en","tag-children","tag-lca-en"],"aioseo_notices":[],"aioseo_head":"\n\t\t<!-- All in One SEO 4.9.9 - aioseo.com -->\n\t<meta name=\"description\" content=\"Anterior Cruciate Ligament (ACL) Injury in Children and Adolescents: Diagnosis, Treatment, and Return to SportAnterior cruciate ligament (ACL) injury is one of the most common and significant traumatic knee injuries in young athletes. 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