Andrew Lay, Physiotherapist
do you need surgery for an ACL tear? - PHYSIOTHERAPY COMPARED TO SURGERY FOR ACL TEARS AND RETURNING TO SPORT.
The ACL is a strong band of tissue in the middle of the knee that helps keep the knee stable.
It’s especially important for activities that require quick turns, sudden stops, or jumping—things athletes do all the time.
So, when it gets hurt, people often feel unsteady on their feet and may experience swelling, pain, or even feel a “pop” in their knee.
After an ACL tear, many athletes and active people worry if they’ll ever get back to their favorite activities.
This worry is totally normal, and it's why some people think surgery, like ACL reconstruction, is the only way forward. But surgery isn’t always necessary.
Physiotherapy has helped many people regain strength, stability, and confidence without needing an operation.
In Melbourne, most people have heard of ACL injuries given the popularity of sports like AFL, basketball, soccer and netball where sharp changes of direction are very common and there are many famous cases in elite sport.
We typically associate ACL ruptures with the need for surgical reconstruction and a lengthy period of rehabilitation before potentially returning to sport.
Recently, people have started inquiring about non-surgical management of this injury.
An informed decision is important in determining whether to go with surgery and rehab combined or rehab on its own without surgery.
There is no right or wrong, and research in physiotherapy and sports medicine has evolved and the case for non-surgical management can now be made.
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IS SURGERY NECESSARY FOR ACL TEARS?
When we talk about ACL reconstruction without surgery, it’s helpful to understand what that means.
ACL reconstruction surgery involves taking a piece of tendon from another part of your body (like your hamstring or kneecap) to replace the torn ligament. It’s a long process that often requires a lot of healing time afterward.
Physiotherapy, on the other hand, uses exercises and treatments to make the muscles around the knee stronger and more stable.
This method can be very effective, especially for people who aren’t professional athletes or don’t put as much strain on their knees regularly.
In a recent study, out of 45 patients with either a fully ruptured or high grade ACL injury, 17 demonstrated clear improvement in ACL structure on MRI scan after 6-12 months of knee strengthening (Ihara, 2017).
WHICH IS BETTER LONG TERM - SURGERY + PHYSIOTHERAPY REHAB OR PHYSIOTHERAPY REHAB ONLY WITHOUT SURGERY?
Regardless of which management, there is an increased chance of osteoarthritis in the knee compared with before the injury.
To assist with decision making, the following is a summary of some of the research in support of non-surgical management of ACL ruptures when compared with surgical management:
1 year after ACL rupture:
Exercise-only athletes compared with ACL reconstruction athletes performed better on 2 out of 4 different single-leg hop tests. There was no difference between the groups in the other 2 tests (Moksnes, 2009).
Exercise-only athletes compared with ACL reconstruction + exercise athletes had less knee joint stability on testing, but better left vs right symmetry with hop tests. Both exercise-only and reconstruction + exercise athletes had the same rate of return to pivoting sports (Grindem, 2014)
5 years after ACL rupture:
There was no difference in multiple knee questionnaire scores between early reconstruction and exercise-only management. 50% of patients who went with initial exercise-only management went on to have the reconstruction later.
Authors concluded that “young active adult patients should consider rehabilitation as a primary treatment option” after an ACL tear (Frobell, 2015).
10 years after ACL rupture:
Patients who had surgical ACL reconstruction had better passive knee stability on examination, but there was no difference between patients treated operatively and non-operatively with respect to osteoarthritis or meniscal injuries and activity level (Meuffels, 2009).
20 years after ACL rupture:
There was no difference in osteoarthritis between surgical and non-surgical groups, and no difference in functional outcomes, although knee stability was still better in the surgical group.
In other words, the findings seen at 10-year follow-up were still maintained at 20 years post-injury (van Yperen, 2018).
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The Pros and Cons of ACL Reconstruction Surgery
Pros of ACL Surgery:
- Stability: Surgery aims to replace the torn ligament, which can restore the knee's stability.
- Confidence: Some athletes feel more confident knowing they’ve "repaired" the ligament.
- Return to High-Impact Sports: For those in high-demand sports, surgery might offer a better chance of returning to the same level of performance.
Cons of ACL Surgery:
- Long Recovery: Recovering from ACL surgery can take several months, often six to twelve, and it requires intense rehab.
- Risks: As with any surgery, there are risks, like infection or complications from anesthesia.
- Not Always Necessary: Many people, especially those who aren't in high-impact sports, can fully recover with physiotherapy alone.
SUMMARY OF ACL SuRGERY PROS AND CONS:
Surgery + Physiotherapy rehab |
Physiotherapy rehab only |
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Why Choose ACL Tear Treatment Without Surgery?
Physiotherapy has become a popular option for ACL tears. This approach doesn’t replace the ligament but strengthens other parts of the knee to help it work well without a new ACL. Here’s what you can expect:
1. Strength Training: Exercises focus on strengthening the muscles around the knee, like the quadriceps and hamstrings. Strong muscles help support the knee and make it feel more stable.
2. Balance Exercises: Since the ACL helps with balance, physiotherapy includes balance work to help retrain your body and prevent falls or missteps.
3. Flexibility: Keeping the knee flexible helps prevent stiffness and allows for a better range of motion, which is crucial for sports or active lifestyles.
4. Return-to-Sport Programs: Physiotherapists often create gradual plans to help you safely return to your favorite activities. For example, you might start with simple exercises and slowly add more challenging movements.
ACL Repair: Building Strength and Stability Without Surgery
If you choose ACL repair through physiotherapy, your journey will include different stages:
Initial Rest: Right after the injury, it’s essential to rest, ice, and elevate the knee to reduce swelling and pain.
Early Rehab: Gentle movements and exercises start to build strength. This stage may focus on exercises like leg raises or stationary cycling to keep the knee moving without stressing it too much.
Advanced Rehab: As strength returns, more intense exercises are added, like squats, lunges, or step-ups. The goal is to build muscle and ensure your knee can handle everyday movements.
Return-to-Sport Training: When you're ready, the physiotherapist will guide you through specific exercises that mimic the movements you’d do in your sport or activity. This can include jumping drills, quick turns, and other high-intensity moves to test the knee’s stability.
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Realistic Expectations: How Long Does Recovery Take?
Physiotherapy recovery timelines can vary. For some, noticeable improvements happen within a few weeks.
For others, it may take a few months to feel fully stable and ready to get back to high-impact activities.
The key is patience and consistency. Working with a physiotherapist regularly and sticking to the exercise plan can make all the difference.
If you’re wondering, “How long to recover from an ACL tear with physiotherapy?” a good estimate is three to six months, depending on the severity of the injury and how dedicated you are to the exercises.
Can You Return to Sport Without ACL Surgery?
The big question is often, “Can I play sports again without ACL surgery?”.
The answer is yes, for many people!
Studies have shown that people who do physiotherapy after an ACL tear often regain enough strength and stability to return to their favorite activities.
However, it’s essential to follow your physiotherapist’s advice closely and not rush back too soon.
Each knee and person is different, and what works for one person might not work for another. This is why a personalized treatment plan is crucial.
Your physiotherapist will know when you’re ready to start running, jumping, or playing sports again, and an elite way to determine this is via ACL return to sport testing protocols, which the Melbourne Sports Physiotherapy team can assist you with.
ELITE SPORT CASES:
Daniel Menzel (AFL): Total 4 reconstructions: Left x3, Right x1 – 2 failed left knee reconstructions
Alex Johnson (AFL): Total 6 reconstructions: Left x5, Right x1 – 4 failed left knee reconstructions
DeJuan Blair (NBA): ACL rupture in both knees during high school. Surgeries failed and he went on to play NCAA1 college basketball and NBA without an ACL in either knee.
Jessica Rich (Snowboarding): Ruptured ACL 1 month before 2018 Winter Olympics, medically cleared for Big Air event without reconstruction but not for Slopestyle
Phillippe Marquis (Skiing): Ruptured ACL 1 month before 2018 Winter Olympics, was scheduled for surgery but competed in Mogul skiing. Would have had no chance to compete if he had immediate surgery. Ended up having surgery after the Olympics as scheduled.
Yuvraj Singh (Cricket): Continued playing at international level without reconstruction. ACL healed with rehabilitation.
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Making the Right Choice for Your ACL Recovery
Choosing between surgery and physiotherapy for an ACL tear is a big decision. There are many factors to consider, such as your age, lifestyle, and sports goals. Here are some key points to keep in mind:
Physiotherapy is Effective: For many people, ACL tear treatment without surgery offers a safe, effective way to heal. Physiotherapy strengthens muscles around the knee, which can give you the stability needed for daily life and even some sports.
Surgery Has Pros and Cons: Surgery is sometimes necessary for people who want to return to high-impact sports. But remember, it comes with risks and a long recovery process.
Listen to Your Body: If your knee feels stable and strong, you might be ready to return to sports. If it doesn’t, it’s okay to take more time. Recovery isn’t a race.
Consult a Physiotherapist: A physiotherapist can guide you on the best exercises and recovery plan tailored to your needs, helping you achieve the best possible outcome.
How can we help you?
At Melbourne Sports Physiotherapy our goal is to get you moving pain free as soon as possible.
But, we also want you to actually move better and live a healthier, more active and fulfilling life!
If your sports, fitness training or work has been wearing your body down, book in with one of our expert massage therapists so we can help you reduce your pain or stiffness.
If you are showing some signs of this condition or simply want help prevent this from happening in the future then book in with one of our highly experienced Remedial Massage Therapists today!
You can make an appointment by calling or booking online.
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