ACLR + LET: Overkill or the New Gold Standard? - #AMR381

Surgeons are adding more lateral extra-articular procedures to ACL reconstructions, especially in young cutting and pivoting athletes. On paper, it sounds great—tighten up the anterolateral side, improve stability, protect the graft. But what does that actually mean for clinical outcomes and for how we manage rehab?

A new Level 1 systematic review and meta-analysis just pulled together the randomized trials comparing isolated ACL reconstruction to ACL reconstruction plus a lateral extra-articular procedure. The results raise important questions: Are these athletes truly more stable? Do we see fewer graft ruptures? And are we quietly trading those benefits for more pain, stiffness, or long-term joint issues?

In this week’s podcast, we break down what the data really show, how it should influence your decision-making as a sports physical therapist, and what to watch for when an athlete walks in with a LET on their op note. Check out the full episode to hear how (and when) this should change your rehab approach.

To see full show notes and more, head to: https://mikereinold.com/aclr-let-overkill-or-the-new-gold-standard/

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Transcript

Welcome And Course Announcement

SPEAKER_02 0:49

On this episode of the Ask My Crystal, we talked about a recent research study that looked at whether or not adding lateral extra-articular procedures to A-cell reconstruction is proved outcomes. The Ask My Cry. Helping people feel better. Before we get to the podcast, I wanted to make sure you knew about my free online course on the introduction to performance therapy and training. If you want to learn how to get started optimizing and enhancing performance, this is the course for you. Head to micrenault.com/slash performance to sign up today. Welcome back, everybody. The latest episode of the Ask Mike Reynolds Show. We are here with another journal article review for you. Let's see, we have the crew from Champion PT and Performance here, Brendan Gates, Anthony Videtto, DeWesh Podell, Dave Tilley, Mike Scadillo, and Dan Pope. And we're going to be talking about a study from AJSM in 2025 out of Australia that Lenny is going to review. He's going to grace us with his wisdom. But basically they talk about do they does adding a lateral extraarticular procedure to an ACL reconstruction enhance outcomes? Lenny, what did they find?

Key Findings On Re-Tear And Stability

Population Limits And Graft Types

Who Should Consider LET

SPEAKER_00 2:11

That was they found an interesting finding. It was out of Australia, and ironically, it was four physical therapists and a PhD. And I had to look up what the other author was. He was a I think it was a he. Yes, he's a the Bachelor of Surgery, which is apparently a degree you get in like English, like Australia or Great Britain type countries. So it's a Bachelor of Surgery. So four PTs. It was interesting that four PTs uh in one Bachelor of Surgery and a PhD put the study together on you know adding LET or uh ALL. So what they're talking about is in a traditional ACL reconstruction, um, you know, you add uh you do patellotendograph, hamstring graph. Now the surgeons are trying to be better, they're trying to control for um you know retail. So they wanted to look at this study, they looked at 10, uh, it's a systematic review and meta-analysis to see if the addition of these extra articular procedures um helps to decrease retail rates uh in during ACL surgery. So you had groups of people that had just a standard ACL reconstruction, which again, this study's not of Australia, so primarily uh one of the weaknesses, in my opinion, because I am a fatal attendant guy, this was mainly done on hamstring autographs. So, you know, noted, a lot of hamstring autographs. Um, and they wanted to see the outcomes over a period of time, and they followed these patients over a period of time. So it was a Cochrane uh, you know, database review. They used certain uh um criteria to find these studies, uh randomized control studies, all level one studies, so very powerful, strong studies that we uh highly uh respect and and and and are the most powerful to influence our practice. Um low heterogeneity heterogeneity, so they all kind of give similar type. Um there's not a lot of uh randomness in the study, uh in the studies that were in the 10 studies that were included. Um, and they showed a significant difference in retail rates using the leap, so the lateral extraarticular procedures that included LET, so lateral extraarticular tenidesis, or ALL, anterior longitudinal ligament. So two different procedures. So that's you know, you gotta be cautious there because you get two different types of procedures being done uh on uh during these ACL reconstructions of hamstring autographs. Um there was a low representation of females, only about 33% of the people in the study were female, and the average age was 26 years old. So you get an older group of people versus the younger crowd that's more likely to retain their ligament or benefit from the addition of this of this uh procedure. So you want to see that female younger than 20 years old more included in these studies, and it wasn't. The studies that were included did not have that age group uh as strongly included. And so I think some of the takeaways are gonna be that adding it in in certain population may help. On the short term, um, there's more pain, uh, the strength is compromised early on, but it all kind of goes uh equal about a year out of surgery. And so for me personally, if I'm if I'm seeing patients, I just had a kid who had a left ACL reconstruction, he tore the right side, and the surgeon and I were going back and forth because the surgeon included me whether or not to include an LET or not. Primarily, I'm seeing LETs, not ALLs, as that extra procedure being done, so that extra articulatinides of the IT band being done, and he chose to do the surgery because I think he was the surgeon was freaking out that this kid has already had a history of a tear. Let's let's uh let's let's really lock him down and and prevent that extra rotatory instability that this procedure does do, and let's do the LET. So I don't know, but curious to hear everybody's thoughts on this on these papers. Um again, it was biased towards men older, 26 years old. Um they didn't control the PT. I think that was another important finding was it was just physical therapy was done based off of you, the person. There was no uh protocol to kind of progress these patients appropriately. So I think that's a little disappointing as well, but that's what we commonly see in the research. So I'm just gonna open it up to you guys. That's kind of the the 35 35,000 foot view of these pay of this paper. Um, curious what you guys think. Would you recommend an LET to your patients based off of this data?

Early Rehab Pain, Swelling, And Quads

SPEAKER_01 6:49

Yeah, I can jump in and Lenny just definitely stole the thunder. Unfortunately, those are my notes as well. I think I read the whole paper and I was like, oh, this is great. And then I'm like, wait a minute, this is they're seeing mostly males who are older and they're doing hamstring grafts. That is literally the opposite of what I see in the clinic. And I could be biased because I see a lot of gymnasts, dancers, you know, I've like a lot of soccer players. My primary HTL, I was looking through my patient list, is like a 16 to seven-year-old female with a bone patellar bone graft. And they're like super not super lax, but most of them are really laxed. And the LET in my mind, from what I've learned from Lenny and other papers, is like we're trying to control some of that excessive genetic laxity that they have. So if we're thinking about doing something that's gonna maybe be more painful and short term and make it harder to get back, maybe some some longer-term quad type stuff with the swelling, um, when you recommend that, it's like you want to make sure that the person is gonna go through something that gives them a lot of extra stability and is good. So I read the whole paper and I was like, oh, this is cool, this is good to see, but like, man, this this couldn't be farther away from the person that I'm seeing 10 years older, opposite better, hamstring grafts. And I was a little nervous to, you know, maybe automatically say everyone gets an LAT words. I think where my clinical brain goes is for someone who is younger, lax, type one. They had a lot of type one pivoting sports, which I guess would say is is definitely a plus. But you know, a jumping and landing sport, I think volleyball, I think basketball, I think gymnastics, and someone who's young and lax, that's when I'm thinking about like, okay, maybe this person is more appropriate for this. And the other piece of it too is that like, you know, surgeons are the ones who I think are suggesting this or dictating this. It's not really a choice that we make, but it's good to know up front that if someone is getting an LAT, I had a kid with a L E T meniscus, lateral and medial and a BTB. That kid's quad was like mushy, right? It took so hard to get his leg so swollen, so cranky, so angry that it took a long time. And I had to educate him a lot on like, listen, this is gonna go a lot slower than maybe you want because you had so much work done. Your leg is very, very, you know, the joint is angry right now, as they say. So those are kind of my takeaways.

SPEAKER_02 8:42

Dave, can I just ask, like to your point though, um do you I'm you you we're never gonna have a perfect study, right? You guys have great limitations, right? You bring up good limitations, right? We can't have a perfect study. It's so impossible to do a study like that. Dave, do you what do you you think your people in your your avatar that you just you just described right there, wouldn't this be helpful for them?

SPEAKER_01 9:04

Yes. And that is kind of where I think it's uh we had this discussion around like bracing, right? Like bracing when is that appropriate, when to not. And I think it's something that if a surgeon is already thinking about the fact that this person's young and lax and they're going back to a really high-risk sport, they have long-term college goals, they're 16, they want to play at least six more years and get a scholarship. In my mind, I'm trying to be like, yeah, this is like the perfect person who might do well with that extra stability if we forfeit, you know, some quad activation or swallowing comfort in the beginning. But the thing that's really hard is you get somebody who has a quad tenant repair in LET. Holy moly, those things are hard to get going. Like they're really cranky and angry, and the quad is really rough. So that's the hard thing is that the more you do on top of a meniscus and an ACL, I think that middle two, you know, six weeks to ten weeks is really hard to get somebody, you know, stronger, less swollen, less painful, whatever.

SPEAKER_02 9:53

So are LET, the LET. Educating them on that. So I was just gonna ask, are you are you educating people on that? Like it's when you say, like, look, hey, pre-op, like you're you're getting this procedure, like get ready. We're gonna have a little bit more work to do at the beginning. Okay. Yeah.

Protocol Gaps And Education

SPEAKER_00 10:06

Yeah, I think a general rule of thumb is lateral structures tend to get more swollen. I think we've talked about this before in the podcast. So when you do, and they're painful, right? Versus a medial, uh, medial structure, like an MCL sprain, the knee gets stiff, or grade two, grade three, or like a recon a repair or reconstruction of the MCL. They get stiff with a LET or a lateral sided injury, they get more swollen and painful, but they don't necessarily get as stiff. So the protocols don't change much, and they said that in the paper too. Like range of motions don't change much uh with the addition of the LET, but there's just more swelling and pain, which is probably why the quads didn't come back as quickly in that group. But everybody kind of normalized at a year plus side of surgery. So you're gonna you'll get there. It's just a tougher road to get there. But you have a more maybe relatively stable knee with a decreased risk of a tear. There was one paper that did talk about OA in the knee, and that was uh quickly squashed that the paper wasn't strong, strongly powered, and there was some bias in the paper. But there has been discussion in the orthopedic world that the addition of these leak procedures or LET or ALL can lead to some uh wearing in the knee because of the extra stress on the knee and the stability in the knee that is um afforded from the surgery, that it may wear the knee down quicker in the patal femoral joint. So I would kind of be cautious interpreting that, but keep an eye on that because that may that may pull itself out in the future as we see more of these done and we study this the these procedures more.

PT Visit Shortfalls And Outcomes

SPEAKER_02 11:32

I I wish somebody would tell the Tommy John surgeons that concept, right? Right, right. Maybe maybe tighter is not better, but anyway. Yeah. Uh uh, you know what scares me? Here's what scared me about this, because I think you could summarize this article in a sentence that said adding this makes you more stable with better outcomes, right? With just some short-term increases in, you know, some stuff that subsides. Uh but here's what scares me. So, you know, I just recently recorded a presentation for Dan Pope, Kevin and Coughlin, and I's upcoming return to sport course, you know, little little little uh uh little plug, a little teaser in there. And um some of these articles blew my mind. Two studies published in the last couple years. Yeah, why don't you guys guess? What is the average amount of PT visits? Dan, if you know the answer, if you saw my presentation, what is the average amount of PT visits for ACLs in the United States? Guess 12. I was gonna say 12. I was gonna say I threw up with this number. So you you you are I I kind of led you to go low, right? So um, so 12. Anyone else? 24. So the the part that blew my mind, two studies, one published in 2021 in OJSS, OJSM, uh 17. Uh recently in arthroscopy this year, 21. And by the vast majority of these are at the beginning, right? Right. So let's so what eight, let's say 18. 18 PC visits after ACL. I mean, no, no wonder why the outcomes suck.

SPEAKER_00 13:17

And you're probably doing twice a week for six weeks. So, like the majority of them are the first six weeks, and then you kind of you know, you cherry pick the business for the next six weeks.

SPEAKER_02 13:25

I did the math trying to break it down because they broke it down. 52% of those visits are in the first six weeks. So essentially nine visits are 1.5 times a week. And then for the next month, it was just once a week, and then after that, you just saw somebody three other times after that. 90% of people are done within the first 16 weeks.

Surgical Choices And Overuse Concerns

SPEAKER_00 13:42

So you wonder why retail rates are so high, right? They're not strong enough, they're not the PT they need. And they just declare it because of a time base. Six months out. Oh, your knee looks good enough. You get a stable Achman's, you know, let's let's start doing some uh you know soccer stuff or something like that. And then but this is where we come in. This is where education comes in, this is where our business comes in. We have uh people like Duesh and his in our coaching staff that can handle this. I think that's what's critical um in these surgeries and surgeries that involve what we talked about, is you need to have a good relationship with a strength coach or PT gym that has the facilities to provide what they need. Um and it it's it's it's it's hugely beneficial. And I think our retail rates are significantly lower in our population than what the research is saying for that reason. So, you know, I think that's a strong point, not of this paper, but I think that comes out of this stuff in our discussions.

SPEAKER_02 14:35

That's the only thing that makes me more nervous about a procedure like this that might be better in the long run, but to me, I I think you almost argue requires more PT, and you could argue that's a huge problem with our profession right now.

SPEAKER_00 14:48

And and talking to the surgeons, um, people that I trust locally in Boston and and and in Birmingham, where I used to work, um, they say the LET is good, but it's I think it's overused and a good patella tendon, a PTG, and most of the athletes is suspicious and good. It's a stable knee. You get the quads back, it's a very uh reproducible surgery and rehab. You understand what's going on. You don't have the hiccups that you get from a quad tendon. We haven't even don't even get me going with quad tendon graphs. Um remember when they do an LET, when they do these surgeries, there's more, there's more time uh in the surgery ward, there's more uh uh anesthesia going on, there's more pain, there's more time that there it's just it's it's more stress for the body. So it it should be done in a patient that really would benefit it, like the ones that Dave sees, um, the that gymnast who's very lax trying to get back to a high-level level one pivoting cutting sport, I think is is would be the take home, in my opinion.

SPEAKER_02 15:49

Yeah, so like if you're more statistically likely to re-injure it. Right. So like you're less than whatever, 21, 23 years old. I know there's like a cutoff in there. You're less than that, you're going back to high-level sport, you're female.

SPEAKER_00 16:02

You're very, very laxed. Like your baiting score is off the track, like you you're positive for everything, you know. You're right. But whatever the, however, you say biting, baiting, whatever that uh scale is, you know.

Risk Profiles And Laxity Criteria

SPEAKER_02 16:12

It's I mean, I'm Reinhold, it's an I EI is I. I'm just right, right. So anybody that says otherwise is wrong, but yeah, just saying, but it's just science. Uh but so all right, so let's put this and a couple weeks ago, this episode together. Um, I I don't know about you guys. You tear your ACL. I'm getting an NMES unit to use at home, right? Based on a couple weeks ago, right? Right. I'm getting a game ready, right? Why wouldn't you get a game ready? Are you bananas not to get a game? What does that cost? A hundred bucks to rent? Like just rent a game ready. Um, uh, getting a game ready. I'm probably gonna get a CPM, you know, after ACL for me, right? I got a thumbs up from Brennan, right? Like, like I that's what I would do if it was my knee. What do you what are you taking by chance? You have you have you spent more money in in golf training aids, Len, than people spend in in stuff to help them with their ACL rehab at home. Right.

SPEAKER_00 17:05

Our doctors use all that stuff, and it's very, I think we're very it's very beneficial to them, and I think we're kind of biased because we see that side. Um, and I've seen the other side too, where you don't, um they just a little easier. Those first few weeks are a little easier for the person physically, mentally, and it just helps so much in the long run, in my opinion. So yeah.

Must-Have Rehab Tools At Home

SPEAKER_02 17:25

Awesome. Great article. Thanks, Line. Good review. Yeah, another good article. This is fun. I'm enjoying these. I think we're all, I know, I see everybody here. I think everybody's enjoying it here, too. So if you like it, please let us know. Send send me an email like on the website or comment on our social medias. Uh DM me, it'd be great to hear from you. And you know, please keep subscribing, rating, reviewing these on Apple Podcasts and Spotify. And we'll see you on the next episode. Thank you so much.