ACL Reconstruction Surgery is an elective procedure and most of the time there is no rush to make a decision

In the event that you have ruptured your Anterior Cruciate Ligament, whether or not you will require ACL reconstruction surgery will really be dependent on a number of factors including:

• your unique individual circumstances,
• personal goals,
• knee stability, and
• the extent of damage and tearing incurred to your ACL and the surrounding knee structure.

Proceed with caution before electing to have ACL reconstruction surgery on your injured knee to repair a torn ACL.  There is no rush to make a decision, as long as your knee is not giving way.

In many cases, if you have completely torn your Anterior Cruciate Ligament an ACL operation to replace the severed graft may be required.  In other cases, patients may try to return to their normal activities without surgery.

In other words, there are some circumstances where you may want to consider strengthening and rehabilitation of your knee without surgery and without inserting a new ACL graft.

Rehabilitation before ACL reconstruction surgery is often recommended

Taking the opportunity to rehabilitate your knee before surgery may help provide you and your surgeon with more information to determine if surgery is appropriate.

ACL prehab before surgery also has other important benefits.  Studies suggest it can contribute to improving post-surgery outcomes in the event that the patient elects to have ACL reconstruction surgery.

In-depth and professional assessment of your injured ACL is important to make an informed decision about surgery

If you have torn your ACL it is really important to assess your next steps in consultation with your surgeon and therapist.

Consideration should be given to the severity of the injury plus your own personal goals moving forward such as your physical activity and competitive sports ambitions.

Overall it is advised that you discuss your options with your physician in order to make the most appropriate and informed decision.

Seeking the opinion of multiple knee specialists can also give you a broader spectrum of knowledge on your most suitable options going forward.

Therefore one of the first and most important steps in diagnosing your ACL tear symptoms is to determine and define the severity of the tear and the extent of damage to the knee where possible.

Immediately following an ACL knee injury, you need to be physically examined by a qualified medical professional (i.e. doctor, therapist or knee 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 as define the degree of damage to the ACL injury itself.

Is reconstruction surgery required for a partial ACL tear?

If you only have a partial ACL tear with a slight injury to the surrounding structures, then 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 a robust 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.

Your individual circumstances can impact whether or not ACL reconstruction surgery is right for you

The decision on whether or not ACL reconstruction surgery is right for you can depend on your unique individual circumstances.  The factors include:

• Your existing fitness levels,
• The types of activity that you wish to engage in in the future, and
• Your willingness to undergo an extensive and intensive ACL rehabilitation exercise program

Not to mention that there have been some cases of individuals successfully returning to sport without an ACL in tact.

It is also important to consider what actions were taken immediately after tearing your ACL.

The actions taken by you at this time will provide additional important information for you and your surgeon to consider when making an informed decision on the best treatment for your torn ACL.

An injured ACL can cause knee instability

A complete ACL tear can cause significant knee instability and in severe cases may even impact everyday activities like walking. Although typically it is pivoting and twisting movements where instability might become evident. 

Further, if you have torn your ACL than surrounding damage to the knee tissue and supporting structures is common and will need to be assessed. 

Performing activities that cause instability such as sudden changes in direction may cause additional damage to the cartilages and knee structure. 

If imaging reveals that you have a complete tear of the ACL including damage to your surrounding knee areas, the case for undergoing ACL surgery (i.e. an ACL reconstruction) is increased especially if a full knee recovery is your targeted result.

If the decision is made to have an ACL reconstruction you will need to discuss with your surgeon the various ACL graft options and procedures available and the most suitable timing to have surgery.

It is not uncommon for surgery to be delayed to:

• Provide time for an ACL prehab program to be undertaken to improve strength and mobility, and
• allow inflammation in the injured knee to decrease

Therefore increasing the likelihood of a successful ACL operation and return to normal activity following a full recovery.

ACL injury recovery without reconstruction surgery

As noted above, there are a number of circumstances where you may decide to undergo physical therapy and ACL rehabilitation without a knee reconstruction.

Situations that may be more suitable to non-surgical recovery include:

1. When you are older and are mostly sedentary
2. For people who engage in sports and activities that require minimal pivoting  (for example, cycling or jogging).
3. A person who has undergone initial pre-surgery rehabilitation and knee function is stable
4. You have a partial ACL tear and healing of the ligament is evident

The American Academy of Orthopedic Surgeons notes that the following patients are good candidates to forego ACL reconstruction surgery:

• Those who have an 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

How to recover from an ACL injury without surgery

In the event that you and your surgeon decide that the non-surgical option for a torn ACL is the right course of action for you, then you should begin the process of self-education. 

Understanding the path ahead in terms of what is required to return you injured ACL knee back to optimal strength and normal activity.

Your surgeon and therapist will lay out a rehabilitation program that will require a significant commitment from yourself to increase strength and mobility with specific exercises lasting a period of at least 3 months.

The rehabilitation period will include rigorous physical therapy will be combined with strategies to reduce knee swelling such as RICER and NO HARM. 

Whilst it is not always required a hinged knee brace might be provided 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, reducing swelling and improving your ability to maneuver – The goal is to minimize any knee instability.

Depending on the advice of your treating physician, 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 leg strength and mobility to similar levels of the noninjured leg, a brace probably will not be required in the long term if instability has been stopped. 

Research Studies comparing ACL injuries that avoided reconstruction surgery

If 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.

Further and perhaps surprisingly, 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 a surgical repair of their torn ACL’s.

In addition, the risk of developing osteoarthritis was not increased compared to the group who did have surgery. 

In fact, two years after the study ended, 60% of the patients who had chosen not to have surgery found that they didn’t need surgery.

It should be noted though that approximately half of the group that had treatment alone, without surgery, did require to have an operation within 5 years of the original injury due to experiencing symptoms of instability. 

Despite this positive outcome for study participants, you should be aware that not undergoing surgery has its implications.

What are the risks of not replacing your torn ACL through surgery

The main problem with not undergoing graft surgery and repairing your torn ACL is knee instability that can be not just annoying but can also be temporarily dangerous if you do not have complete functionality of your knee.

Stopping knee instability is important to reduce the risk of additional cartilage and structural knee damage resulting from collapsing and giving-way of the 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 form of meniscus damage.

Another study looked at a group of patients who had surgery within 12 months of injury compared to the other group who had surgery more than 12 months after injury.  The after 12 months group showed a higher level of meniscus tear rates.

In addition to instability, if you don’t have the tear surgically replaced you also risk experiencing a secondary injury because of the instability.

Summary

ACL reconstruction surgery is an elective procedure and most of the time there is no rush to make a decision.

The goal of ACL reconstruction surgery is mainly to stop or prevent knee instability. If you engage in activities that cause your knee to “give way” then you are at risk of causing damage to your knee.

It is not always clear if knee instability will be evident.  As a result, a person may wish to attempt to return to normal activities and sport without an operation.

Electing not to have surgery is an option.  

Understanding your future sporting and physical activity goals and aspirations going forward is an important consideration and a valid point of conversation with your surgeon.  

Your physical activity levels, existing mobility levels, instability, age, and the likelihood of having chronic knee instability all are important factors to consider. Plus your forward expectations on quality of life. 

The likely success of a non-surgical return to sports or normal activities for a person who has ruptured their ACL is difficult to predict and will be dependent on a number of factors.

A high quality and physically intensive rehabilitation program to strengthen the leg is important if a person wishes to try and return to sport without ACL surgery. However, it is not always clear if this will be successful.

In some instances, such as when a low-grade partial ACL tear has been incurred, it may be possible for the ACL to heal itself without undergoing an operation.   

If the decision to proceed with ACL reconstruction surgery is made then having the surgery performed by a highly experienced surgeon who performs many ACL operations each year is very important!

After ACL surgery, one of your first objectives will be to reduce swelling, restore balance, lock your knee and trying to walk normally in the first two weeks.

Good luck with your ACL injury and recovery!

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