When faced with an ACL (Anterior Cruciate Ligament) injury, one of the most significant decisions is whether to pursue surgical or non-surgical (conservative) management. While surgery is often considered the standard treatment, current research suggests that some individuals can successfully return to their pre-injury level of sport without surgical intervention. Understanding your options and the factors involved in this decision is crucial to achieving the best outcome for your knee and lifestyle.
Copers vs. Non-Copers: Can Conservative Management Work for You?
In the literature, individuals who can successfully return to their previous level of activity without surgery are referred to as “Copers.” Conversely, those who are unlikely to succeed with non-operative management or fail to regain sufficient knee function are termed “Non-Copers.” Determining which category you fall into is key to deciding on the right treatment path.
How Do You Know If You’re a Coper or Non-Coper?
A 6-8 week period of focused rehabilitation, often referred to as prehab (see our Prehab article), can help make this determination. During this time, the focus is on:
- Reducing inflammation and swelling
- Restoring range of motion
- Rebuilding strength and function in the injured knee
Physiotherapists use specific assessment protocols during this period to evaluate your progress. Based on these assessments, they can provide a recommendation on whether conservative management is a viable option or if surgery might be necessary.
Assessment protocols typically include:
- Strength tests for key muscle groups, such as the quadriceps and hamstrings.
- Functional tests, including single-leg balance, hopping, and agility drills.
- Range-of-motion assessments to ensure full extension and flexion.
- Evaluation of pain and swelling levels during and after activity, and
- Questionnaires relating to daily function post ACL injury.
These measures help physiotherapists determine whether the knee can handle the demands of your sport or daily activities without surgical intervention.
Timeframes: How Does Non-Operative Management Compare to Surgery?
One of the most common questions about non-operative management is how long it takes compared to surgical recovery. Interestingly, the timelines are often similar. Whether you choose surgery or not, the typical rehabilitation period is approximately 12 months before returning to sport. However, these timelines can vary depending on individual progress and the achievement of return-to-sport criteria (see our Returning to Sport After ACL Injury article).
Non-operative rehabilitation includes regular check-ins with your physiotherapist to monitor progress and adjust your program as needed. This personalized approach ensures you’re progressing safely and effectively through each stage.
Risks of Further Injury: Is Surgery Safer?
Another critical consideration is the risk of re-injury. Research shows that individuals who suffer an ACL injury are at a higher risk of:
- Re-injuring the same knee
- Injuring the ACL in the opposite knee
- Developing osteoarthritis in the affected knee
Interestingly, these risks appear to be similar for both operative and non-operative groups. What’s most important in reducing these risks is a commitment to a comprehensive rehabilitation program, allowing adequate timeframes for recovery, meeting specific functional criteria before returning to sport, and maintaining ongoing strengthening protocols.
For example, studies suggest that ongoing neuromuscular training—including balance, strength, and proprioception exercises—can help reduce the likelihood of future injuries. Your physiotherapist will incorporate these exercises into your program to address potential weaknesses and imbalances.
Will My ACL Heal on Its Own?
In a small number of cases, the ACL can heal or partially heal with non-operative management. However, predicting whether this will happen is challenging. Research shows that even if the ACL doesn’t fully “re-grow,” many individuals can still achieve successful outcomes through conservative management.
One promising approach is the Cross Bracing Protocol, a specific bracing strategy aimed at facilitating ACL healing. This protocol involves extended periods of immobilization to allow the ligament to repair itself. While early results are encouraging, this method is not suitable for everyone and requires strict adherence to the protocol. Further research is needed to confirm whether it leads to outcomes equal to or better than other management strategies.
What Does Non-Operative Management Involve?
Non-operative rehabilitation closely mirrors post-surgical rehabilitation. Here’s an overview of what to expect:
Initial Phase
- Goals: Reduce swelling and inflammation, restore range of motion, and regain normal function (e.g., walking).
- Strategies: Include icing, compression, gentle range-of-motion exercises, and supervised physiotherapy sessions. Regaining full extension and flexion is a priority during this phase.
Strength and Proprioception Phase
- Focus: Graduated strengthening exercises targeting key muscle groups like the quadriceps, hamstrings, and glutes.
- Proprioception Training: Balance and control exercises to improve your knee’s ability to react to movement and stabilize itself. Tools like wobble boards and resistance bands are often used.
Dynamic Exercise Phase
- Activities: Introduction of plyometrics, return-to-running exercises, and agility drills.
- Timing: Usually begins around the 16-week mark, with progressive increases in intensity and complexity.
Return to Sport Phase
- Goal: Safely return to sports or high-level activities.
- Criteria: Specific benchmarks for strength, agility, and confidence must be met, typically taking around 12 months.
Each individual’s pathway is unique, with progress assessed continuously to ensure readiness for each subsequent phase. Progressions are based on achieving specific strength outcomes (e.g., percentage of normative strength value), functional test results, and patient-reported confidence levels.
How to Decide: Surgery or Conservative Management?
Making the decision between surgery or conservative management can be daunting, the good news is you don’t have to make it straight away. Starting a prehab program will help prepare your knee for surgery (if you choose to do so), provide stronger indication of suitability for conservative management, and give you time to work through the decision making process. Ultimately it is a personal decision to make but consideration should be made to your personal goals, willingness to commit to a rigorous rehabilitation program, and the level of activity that you’re aiming to return to.
Conclusion
At Adaptive Strength, our experienced physiotherapists are here to assist you through the decision-making process and provide evidence-based care tailored to your needs. If you’re facing an ACL injury, reach out to us for a comprehensive assessment and personalized plan to get you back to your best.
