Rehabbing Your Torn ACL Without Surgery

Photo: Cleveland Clinic Sports Medicine

Is it advisable to rehab your torn ACL without surgery?

If you’re willing to avoid high-impact activity and have no or minor other injuries in your knee, you can consider foregoing surgery. Some people live comfortably with the “no-op” choice.

Two things to know:

  • The research shows that a large number of people who initially attempt to rehab without surgery, especially those who want to continue active lifestyles, eventually decide on surgery.
  • There’s no way to accurately predict which are among the tiny minority of knees that can return to more aggressive sports and activities without ACL reconstruction surgery.

What Can You Do Without ACL Reconstruction Surgery?

Without surgery, after rehabilitation, you should be able to:

  • Go up and down stairs
  • Get in and out of a car
  • Ride a bike
  • Jog in a straight line
  • Have minimal discomfort

Some people decide against surgery and successfully return to activities or sports that normally do not involve twisting the knee. You may be able to resume alpine skiing, for instance, even if a fall on the slopes was how you tore your ACL.

While you might be able to enjoy these activities, performance might be below your preinjury experience. (Even with reconstruction surgery and complete rehabilitation, most people report achieving something less than their full preinjury sports capability.)

Two Other ACL Surgery Decision Factors

In addition to the five main ACL surgery decision factors, there are two others to consider when deciding whether to have ACLR surgery:

  • The operation and recovery will take time you might not have.
  • Surgery and recovery can be costly if you don’t have insurance or your plan has large deductibles.

Possible Downsides of No Surgery

Without surgery, your ACL will remain torn. The knee might heal—the swelling and pain will stop. But a torn anterior cruciate ligament does not reattach or heal itself.

You may still be able to live how you want by strengthening your leg and core (your hips contribute to leg strength and function) and adjusting your activities. If your desired activities require maintaining strength to avoid injury, you will need to continue training as long as you participate. 

Possible long-term downsides of not having ACL surgery:

  • Knee instability. You may feel your leg giving way. Regular exercises can reduce this.
  • Reduced activities. Without an ACL, the knee is unlikely to support aggressive landing, cutting and pivoting. Living with a torn ACL may mean limiting participation in sports, work and activities that cause the knee to swell, give way or feel unstable.
  • Risk of other injuries. The ACL restrains the thigh and shinbone in the knee. Without it, the bones may move in unintended ways. This can injure your knee.
  • Uncertainty. There is no way to accurately predict which are among the tiny minority of knees that can return to desired (more aggressive) sports and activities without surgery.

What to Do if You Don’t Want Surgery

The recommendations immediately following an ACL injury are similar whether or not you plan to have surgery:

  • Get your knee evaluated. You may have other injuries in addition to the ACL tear.
  • Follow the prehabilitation guidelines for rest and icing. The longer you wait to prehab, the weaker you get.
  • Do prehabilitation exercises to regain strength and function in your knee. If you change your mind and decide to have surgery later, you’ll be prepared. (Research shows better results even two years after surgery with good leg strength and function before.)
  • Discuss the pros and cons of your treatment options with your medical team and other advisors.
  • Work with a physical therapist on a program to return to your desired level of activities.
  • Get re-evaluated if you experience new swelling or instability.

Why Do I Need Rehab if I Don’t Have Surgery?

An ACL injury is traumatic. It causes acute weakness in your leg, swelling, bleeding into the joint (hemarthrosis), loss of motion and reflex inhibition in your quad muscle.

Following your injury, there will be immediate swelling. You may be unable to straighten your leg. Your knee may be unstable. A weak leg without an ACL can allow the knee to move in unintended ways. This can injure other parts of your knee.

With or without surgery, rehabilitation is critical to recovering leg strength and functional control. You’ll benefit from at least a basic rehabilitation program and then keeping your leg and core strong. The more active you want to be, the more you’ll want to restore strength and control in your leg.

Another rehabilitation benefit? Regular evaluation by a professional familiar with ACL injuries. Physical therapists and athletic trainers can identify and remedy weaknesses to keep your program on track. They can also advise and encourage you when you are ready to return to activities.

Everyone’s Injuries and Bodies Are Different

You might be able to return to activities others cannot. And what others can do—especially someone reporting a miraculous return to sport or work—might not be possible for you.

Read the studies about non-surgical outcomes carefully. Look for data on what activities those not having surgery can perform and at what level. Also note how long after injury someone is reporting on their return to activity and their level of performance. A report at six months is less informative than at two or six years.  

Younger patients especially will want to discuss with their doctor the impact of living without a functioning ACL.

The recommendation? Discuss your objectives with your surgeon and physical therapist or athletic trainer, then make the choice that you believe works best for you.

How to Decide? Look at Five Factors

There are five primary factors in the decision to have ACL reconstruction surgery. Discuss them with your surgeon and physical therapy and athletic training professionals, family and other advisors.

If you’ve also injured other ligaments (especially your medial collateral ligament), your meniscus or articular cartilage (the soft and slippery substance covering the ends of the thigh and shin bones in the knee), surgical reconstruction is recommended.

Without a functioning ACL, it will be difficult to return effectively to sports, work or other activities with aggressive jumping, cutting and pivoting. The more competitive the sport, the more it stresses the knee and the higher performance you want, the lower the probability you can return without ACL reconstruction. Most people who try to rehab without surgery do not return to sport.

Your sport, position and the level of competition—or the kind of work you do—create specific and different stresses on your knee. Skiing is different from soccer. Running back is different from defensive lineman. High school is different than college Division 1. This is why you want to discuss your situation with your medical professionals.

Not having surgery skips recovery from the operation. It usually lessens the rehabilitation time you need to return to normal activities. But if you want to return to play or aggressive jumping, cutting and pivoting, your “no-op” rehab program will be similar to the post-surgery regimen. And, as noted above, without surgery, the odds are against a successful return to any sport with aggressive movement.

It can take months of rehab to find out if you can achieve the strength and functionality you want without surgery. If not, you’ve added those months to the typical nine-month (or more) return-to-sport program after ACL reconstruction surgery. Rather than risk missing a second season, athletes frequently elect surgery as soon as recommended after their injury.

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