In the event that you have ruptured your Anterior Cruciate Ligament, whether or not you will require ACL reconstruction surgery for your ACL injury (otherwise known as a ‘knee reconstruction’) will really be dependent on your unique individual circumstances and the extent of the damage incurred to your ACL and also the surrounding knee structure.
While in most cases if you have completely torn your Anterior Cruciate Ligament a complete ACL operation to replace the graft will be required, there are also some instances where you may want to consider strengthening and rehabilitating your knee without surgery and without inserting a new ACL graft.
Either way if you have a torn ACL it is really important to assess your next steps in consideration of the severity of the ACL injury plus your own personal goals and targets. Overall it is advised that you discuss your options with your physician in order to make the best and most informed decision. Seeking the opinion of multiple specialists can also give you more comfort and diverse knowledge on your best options going forward.
Therefore one of the first and most important steps in addressing your ACL tear symptoms is to determine and define the severity of the tear and the extent of damage to the knee. Immediately following an ACL knee injury, you need to be physically examined by a qualified medical professional (i.e. doctor, physiotherapist or orthopaedic surgeon) who may suggest having imaging tests including an x-ray or MRI. Imaging is important as it will help the physician determine the extent of damage to your knee structure as well define the degree of damage to the ACL injury itself. If you only have a partial ACL tear with a slight injury to the surrounding structures, it is possible that you may be in a position to elect to undergo ACL rehabilitation without surgery. This is particularly the case if your injured ACL has a good blood supply which enables your ACL to heal itself back to full recovery with the right rehabilitation program. That is you may not require ACL reconstruction surgery as a high quality strength and ACL rehabilitation program could be enough to return you to normal activity including competitive sport.
The decision on whether or not to have ACL reconstruction surgery following an ACL rupture depends on several factors, including your activity levels, the type of activity that you normally engage in, and your ability and willingness to undergo extensive and specific ACL rehabilitation exercises and protocols. It is also important to consider what actions were taken immediately after tearing your ACL. The steps taken by you at this time will provide the critical information for you and your surgeon to making an informed decision on the best treatment for a torn ACL.
If imaging reveals that you have a complete tear of the ACL including damage to your surrounding knee areas, you will in most cases have to undergo ACL surgery (i.e. an ACL reconstruction) if a complete and full recovery is your targeted result. A complete ACL tear can also lead to significantly more knee instability than a partial tear and can cause your everyday activities like walking to be impacted. In fact, if you have torn your ACL than surrounding damage to the knee tissue and supporting structures is common and will need to be assessed. Once it is determined that you require a knee reconstruction you will need to discuss with your physician the various ACL graft options and procedures available and the most suitable timing to undergo an ACL reconstruction. It is not uncommon for surgery to be delayed to allow inflammation in the injured knee to decrease and therefore improving the likelihood of a successful ACL operation and recovery.
Ideal situations for rehabilitation without ACL Reconstruction Surgery
As noted above, there are some circumstances where you may decide to undergo physical therapy and ACL rehabilitation without a knee reconstruction. Generally speaking this option is more suitable when you are older and are mostly sedentary or for people who engage in sports and activities that require minimal pivoting which is one of the key functions and roles of the ACL to enable this movement successfully (for example, cycling). The American Academy of Orthopedic Surgeons notes that the following patients are good candidates to forego ACL reconstruction surgery:
- Those who have a ACL partial tear and no instability of the knee structure
- People with complete tears, but no instability whilst participating in low impact sports
- Sedentary people who require a limited range of movements and due to older age making a full ACL recovery post-surgery is not as likely as a younger and more active person
- Children who are still growing
What the Non-ACL surgical Option Looks Like
In the event that you and your physician determine that the non-surgical option for a torn ACL is the right course of action, you should begin the process of self-education to understand the path ahead in terms of what is required to return you injured ACL knee back to maximum strength and working order. Your physician should explain that ACL rehabilitation without an operation will still require a lot of commitment from you to increase strength and mobility through specific exercises lasting a period of at least 3 months.
The rehabilitation period will include rigorous physical therapy and may include using a hinged knee brace for added support (depending on your preferences and personal circumstances). The design and frequency of the physical therapy sessions should be determined in conjunction with your physiotherapist. But in most cases, your ACL recovery exercises will focus on regaining knee strength and practising manoeuvres that minimize knee instability. Following rehabilitation, you may require to continue wearing a hinged knee brace to maintain knee stability during movement. However, by committing to a full recovery program that returns your ACL injured knee to full strength, the use of a supporting brace is not likely to be required.
Should you choose not to have ACL reconstruction surgery to replace your torn ACL, in many cases you will still be able to meet your physical activity objectives and targets in the long term. A 2010 Swedish study of 121 young, active adults who had ACL tears included a group of patients who chose to delay surgery and try physical therapy first. Another group of patients had the torn ACL surgically repaired within 10 weeks of the injury. The first group wound up having the same outcomes as the patients who had surgery. The patients who chose not to have surgery had no significant difference in their pain level or level of function compared to the patients who had surgical repair of their torn ACL’s. In fact, two years after the study ended, 60% of the patients who had chosen not to have surgery found that they never needed it. Despite this positive outcome for study participants, you should be aware that not undergoing surgery has its implications.
The Impact of not repairing your torn ACL through surgery
The main problem with not undergoing graft surgery and repairing your torn ACL is knee instability which can be not just annoying but also temporarily dangerous if you do not have complete functionality of your knee. Also, chronic instability can lead you to experience long-term damage to the knee. One study found that 10 years after the ACL tear, 90% of people who did not have an ACL reconstruction had experienced some formed of meniscus damage and 70% of people had damage to their cartilage due to long-term knee instability. In addition to instability, if you don’t have the tear surgically replaced you also risk experiencing a secondary injury because of the instability.
Therefore whilst ACL reconstruction surgery to replace a torn ACL is not always required, your decision to forego the operation has to be well thought out. Taking into consideration the severity of the ACL injury incurred as well as your individual mobility and activity requirements. Your activity levels, age, and the likelihood of having chronic knee instability all are important factors to consider. Engaging in ACL rehabilitation first as a means to assessing whether surgery is in fact required is also another possibility for you and your physician to consider.