When Do I Need a Lateral Extra-Articular Tenodesis?

Posted on: January 28th, 2026 by Our Team

Over the last decade, lateral extra-articular tenodesis, often shortened to LET, has become a much more common part of ACL surgery. Patients are also far more informed than they used to be, and many now come into the office specifically asking whether they need one or if it applies to them.

That’s not by accident.

The reason LET has become such a hot topic is simple: there is now very strong evidence showing that, in the right patients, adding a lateral extra-articular tenodesis can significantly lower the risk of ACL failure and improve overall outcomes. For certain high-risk knees, it can be a meaningful difference-maker.

So let’s walk through what it is, why it helps, and who typically benefits from this procedure.

What Is a Lateral Extra-Articular Tenodesis?

When you tear your ACL, you often tear more than just the ACL.

There is another structure on the outside of the knee called the anterolateral ligament (ALL). This ligament helps control rotational stability. Basically, it helps prevent the knee from twisting too much.

A lateral extra-articular tenodesis is a small additional procedure done at the same time as an ACL reconstruction. It uses a piece of tissue on the outside of the knee to reinforce that rotational control, essentially helping replace the function of the injured anterolateral ligament.

I often explain it this way: Your ACL is the main rope maintaining rotational stability. The LET is a supporting strap on the outside of the knee that helps keep everything from twisting when you cut, pivot, or change direction.

Why Has LET Become So Popular?

For many years, ACL reconstruction focused only on replacing the ACL itself. What we’ve learned over time is that some knees need more than just a new ACL.

Multiple high-quality studies now show that, in certain patients, adding a lateral extra-articular tenodesis can:

• Lower the risk of ACL re-tear
• Improve knee stability
• Improve patient satisfaction
• Protect the meniscus and cartilage over time

That’s why LET has moved from being rarely used to being selectively used in the right patients. It’s not for everyone — but when it’s indicated, it can make a real difference.

What Is a “Pivot Shift”?

One term you’ll hear a lot when discussing ACL injuries is the pivot shift.

In simple terms:

• A pivot shift is when the knee slips or shifts suddenly during certain rotational movements.
• Patients feel this as the knee giving way, buckling, or feeling unreliable.
• It usually happens during twisting, cutting, or quick direction changes.

The bigger the pivot shift, the more unstable the knee is.

When someone has a high-grade pivot, it often means that not only is the ACL torn, but the structures on the outside of the knee — including the anterolateral ligament — are also injured.

Why Pivoting Matters So Much

We know this very clearly from long-term data:

Patients who continue to pivot after an ACL injury or surgery tend to be the least satisfied with their outcome. They’re also at the highest risk for further damage, especially to the meniscus and cartilage.

Even a small amount of ongoing instability can:

• Make the knee feel untrustworthy
• Limit return to sport
• Increase the risk of future injury and arthritis

Our goal is not just to “fix the ACL,” but to give you a knee that feels solid, stable, and reliable.

Who Is a Good Candidate for a Lateral Extra-Articular Tenodesis?

Not every ACL tear needs an LET. But there are certain situations where it makes a lot of sense.

Patients With a High-Grade Pivot Shift

If your knee has a large pivot shift on exam, it often means you’ve lost important rotational control. In these cases, an ACL reconstruction alone may not fully address the instability.

Adding a lateral extra-articular tenodesis can help limit that twisting motion and better protect the new ACL.

Patients Who Hyperextend Their Knees

Some people naturally hyperextend their knees — meaning their knees bend backward more than average.

This puts the knee in positions that:

• Increase stress on the ACL
• Increase rotational instability

In these patients, adding lateral support can significantly improve overall knee stability.

High-Risk Athletes

Certain athletes are known to be at higher risk for ACL failure, including:

• Female athletes
• Athletes in higher risk sports such as soccer, basketball and lacrosse

In these high-risk groups, adding an LET has been shown to lower re-tear rates and improve outcomes.

Revision ACL Surgery

If you’ve already had an ACL reconstruction that was done well but still failed, the risk of another failure is higher.

In revision ACL surgery, a lateral extra-articular tenodesis is often a very strong addition to help reduce that risk and improve stability.

Patients With Increased Tibial Slope

The tibial slope refers to how steep the top of the shin bone is from front to back.

If that slope is higher than normal, the thigh bone can slide forward more easily, placing extra stress on the ACL. Patients with borderline or increased tibial slope may benefit from an LET to reduce that stress.

In Summary

You may be a good candidate for a lateral extra-articular tenodesis if you are:

• A high-risk athlete
• Someone with a high-grade pivot shift
• Undergoing a revision ACL reconstruction
• A knee hyperextender with instability
• A patient with borderline or increased tibial slope
• Someone with a clearly unstable knee

Final Thoughts

A lateral extra-articular tenodesis is not necessary for every ACL tear, and it’s not something I add automatically. But in the right patient, it can:

• Improve stability
• Reduce re-tear risk
• Protect the knee long-term
• Improve confidence and satisfaction

The key is choosing the right operation for the right person, based on anatomy, exam findings, sport, and goals — not a one-size-fits-all approach.

If you’re wondering whether a lateral extra-articular tenodesis is right for you, a thoughtful evaluation and an honest discussion are essential.