In short: In children and teenagers with still-open growth plates, ACL surgery is performed with special, growth-sparing techniques, and the choice between surgery and conservative treatment is trickier than in adults. It belongs in the hands of a specialist experienced in paediatric orthopaedics. For parents, the hardest task is often not to transfer their own worry onto the child.
When your child stays down on the pitch clutching their knee, something flips inside you instantly. I know the feeling from the other direction – I've torn my ACL twice and know what that moment feels like when it becomes clear: something is damaged. But as a parent it's different again. You can't carry the injury for your child, and that's exactly what makes it so hard.
Maybe you're already at the doctor's, maybe you're still waiting for the MRI. Either way, you're in a state right now where your mind asks a thousand questions at once: surgery or not? Will the knee still grow properly? Will my child ever be able to do sport again? And – the question no one asks out loud – did I miss something?
I'm not going to make you any medical promises here. What I can give you is orientation: what is different in children and teenagers compared with adults, what to look for when choosing a doctor, and where your real role lies – which is less medical than you might think right now.
Important upfront: This article does not replace medical advice. Especially with a growing skeleton, every decision is individual and belongs in the hands of a specialist experienced in paediatric or sports orthopaedics. Use this as preparation for that conversation, not as a substitute.
At a glance
- With open growth plates, classic drill tunnels through the plate can be problematic – which is why there are special, growth-sparing surgical techniques.
- The decision surgery or conservative is trickier and more individual in children than in adults and absolutely belongs with a specialist experienced in paediatric orthopaedics.
- Young, athletically active people have an increased re-tear rate – a second tear (also in the other knee) is not uncommon.
- A paediatric-orthopaedic second opinion is almost always sensible for this decision.
- Your most important role as a parent is not medical but mental: radiate calm, motivate through months of rehab without pushing.
- For teenagers, sport often carries more than movement – identity and belonging to a group. Taking that seriously is part of the healing.
Why the growing skeleton changes everything
The central difference from adults lies in the growth plates (medically: epiphyseal plates). These are the cartilage zones near the joints from which the bone grows in length. As long as they are open – that is, until growth ends, somewhere in puberty depending on the child – the knee is a construction site that isn't finished yet.
In classic ACL surgery in adults, drill tunnels are placed through the bone to anchor the tendon graft. This is exactly where the concern lies in children: if such a tunnel runs through an open growth plate, it could theoretically disturb growth – for example as a leg-length difference or malalignment. That's why surgeons experienced in paediatric orthopaedics use growth-sparing techniques that spare or bypass the plates.
Which technique is right in a given case depends on the age, the maturity of the skeleton (often determined by an X-ray of the hand) and the specific findings. That's not a decision you have to or should make – it belongs in experienced hands. What you should know: these techniques exist, and you're allowed to ask about them specifically.
Surgery or conservative – why the question is harder here
In adults, weighing up surgery against conservative treatment is already tricky enough. In children and teenagers, two things are added that make it even more delicate.
First, the urge to move: keeping an unstable knee still is practically impossible for a movement-loving ten-year-old. Every giving-way can cause further damage to the meniscus or cartilage – and this secondary damage often weighs more heavily in the long term than the ACL tear itself. Second, the long perspective: a child has many decades of knee ahead of them.
At the same time, with a growing skeleton you don't want to operate prematurely. That is exactly the tension in which an experienced specialist is needed – someone who sees both regularly and can assess what specifically applies to your child. Blanket answers from the internet (including this article) won't help you here.
How this weighing-up works in principle, which factors come into play and what the research says, we've written up in detail for the adult situation – much of it will help you ask the right questions: ACL Surgery or Conservative Treatment?
The thing about the second tear
There's an honest figure you should know, even if it's uncomfortable: young, athletically active people have a clearly increased risk of another ACL tear – in the operated knee or in the other leg. Studies here show re-injury rates in teenagers and young adults that are clearly above those of older patients.
The reason isn't poorer healing but a mixture: the sport is more explosive, the comeback often happens too early, and neuromuscular control – clean landing, braking, turning – isn't back at the level that protects the knee.
For you as a parent, this is no reason to panic but a reason for patience. The most common mistake isn't too little training but too early a return to the pitch because the knee "feels good again". Feeling good and being load-bearing are two different things. Clearance for sport is a professional decision – not a gut feeling and not a calendar.
Your real role: calm, endurance, not pushing
Here comes the part no surgical report mentions and that nonetheless decides things over months. Children and teenagers read their parents' emotions like an open book. When your worry fills the room, it becomes their fear. That doesn't mean you should hide your feelings – but being the calm pole in the room is the most valuable thing you can contribute right now.
In my experience, three things carry:
- Radiate calm. Your child takes their cue from your reaction. A "We'll manage this, step by step" is more powerful than any research. Your own worry needs to be processed – but not on your child's back.
- Motivate over a long time without pushing. Rehab drags on for many months, and at some point comes the point where the exercises get boring and drive drops. Your job isn't to be a coach but to reliably stay involved – ask, come along, keep at it, but don't control.
- Endure setbacks. There will be days when nothing moves forward or the knee is swollen. If you stay calm then, your child learns: a bad day isn't the end of the world.
Pushing quickly tips into the opposite. When rehab becomes your project, the teenager withdraws – developmentally, that's almost programmed. In the end the motivation has to be their own. You are the frame, not the engine.
School, PE and the club
Alongside the knee, daily life carries on, and it needs organising. Clear early with the school which routes, stairs and seating situations are realistic and whether a note is needed for PE. A blanket "excused from sport" is often not ideal – in later phases, targeted, adapted movement can be more sensible than sitting out completely. Discuss this with the treating specialist.
With the club, an open conversation with the coach is worthwhile. Not only because of the load, but because contact with the team is enormously important (more on that in a moment). Many children benefit from staying involved – on the sidelines, at team talks, as part of the group – even if they can't play yet.
What's really going on inside the teenager
For an adult, an ACL tear is a hard interruption. For a teenager, it can feel as if a piece of their identity is breaking away. At that age, for many, sport isn't just a hobby but the answer to the question "Who am I?" – and the place where their friends are.
If your child suddenly can't go to training anymore, they may lose both at once: what they're good at, and the daily belonging to the group. This can show up as withdrawal, irritability or sadness that seems bigger to you than the knee injury "deserves". Take it seriously. It's not drama but a real grief over a real loss.
What helps is less a piece of good advice than the feeling of being seen. Keep the connection to the team alive. Let your child talk about the frustration without immediately talking it away. And if the mood tips over weeks and doesn't come back up, don't hesitate to bring in professional support – that's a sign of care, not of failure.
When to see a specialist
Warning signs – actively seek paediatric-orthopaedic expertise if: the growth plates are still open according to the findings; surgery is on the table and the treating doctor performs only a few paediatric ACL surgeries per year; the knee repeatedly gives way or locks (a sign of additional meniscus or cartilage damage); or you simply don't feel sure about the recommendation. A paediatric-orthopaedic second opinion is almost always sensible for this decision – that's not distrust of the first doctor but appropriate care for a growing knee.
Frequently asked questions
Does a child's ACL tear always need surgery? No, that can't be said across the board – the decision is especially individual in children and depends on age, skeletal maturity, accompanying injuries and activity. What matters is that an unstable knee can cause further damage, which is why doing nothing is rarely the solution. This weighing-up belongs with a specialist experienced in paediatric orthopaedics, ideally with a second opinion. The book Dranbleiben is written for adult patients, but the chapters on the surgery decision help you sort out the right questions for the doctor's appointment.
Can ACL surgery disturb my child's growth? With open growth plates, that's the central concern – which is why experienced surgeons use special, growth-sparing techniques that spare the plates. Which one fits in a given case is decided by the specialist based on age and skeletal maturity, not by you. Ask specifically at the appointment how growth is taken into account. For how to prepare such conversations and stay calm, you'll find templates in the Dranbleiben download area that can also be adapted to the parent role.
How do I motivate my child through the long rehab without pushing? Be the reliable frame, not the driver: stay involved, come along, endure setbacks – but don't make the rehab your project, or a teenager in particular will withdraw. In the end the motivation has to be your child's own. This mental endurance over months is exactly what Dranbleiben is about – written for adults, but the tools help you accompany your child through the tough phases.
Why is my athletic teenager so down even though the knee is healing? Because for teenagers, sport often carries more than just movement: identity and daily belonging to the group. If both fall away, that's real grief you should take seriously – keep the connection to the team alive and bring in support if the low mood persists. Dranbleiben covers this mental side in detail, and the community around the book shows that no one is alone with these feelings.
Read more
- ACL Surgery or Conservative Treatment? – the weighing-up in detail, to help you ask the right questions
- Fear of a Second ACL Tear – why young athletes in particular have an increased risk and how to deal with it
As a parent you can't carry the injury for your child – but you can be the calm, reliable pole they hold on to over the coming months. I wrote Dranbleiben for adult patients, out of two ACL tears of my own. And yet I keep hearing from parents that precisely the mental tools in it helped them accompany their child without unloading their own worry onto them. If you're looking for a companion who knows this path from the inside: you'll find exactly that in the book and the download area.