Is ACL Surgery Really Necessary?

We have all seen on the TV a teams marque player go down on the field and commentators go off on the TV that the player has just ended their season.

“They have done their ACL, that is the season done and we will see them back in 12 months.

It’s going to be a long road ahead”


A common scene from the football codes is a player painfully going down  and holding their knee.

They know what’s up and the time it is going to take to get back!

The Bias Toward Surgery!

There is so much emphasis into the surgical rehabilitation of an ACL with our elite athletes that we see a big cross over into the every day recreational athlete, weekend warrior or social sports enthusiast.

So now when anyone tears or Rupture their ACL, they NEED SURGERY!

It has almost become routine that if we see this ligament torn or ruptured on MRI that we head off to the orthopaedic surgeon and undertake an ACL reconstruction without any consideration to other options. 

But new an exciting evidence is beginning to appear that contradicts the need for this in many cases.

  • Recent studies have demonstrated healing capacity of the ACL with conservative management, scarily some of these even date back to 2011.
  • The risk of osteoarthritis may actually be greater in an ACL reconstructed knee then a non reconstructed knee
  • There are many athletes at the top level of their sport playing in the NBA, NRL, NFL, EPL all without ACL’s (well at least last time they checked it may have grown back)
  • You can still function at a very high level in sport without an ACL!

Above a case of rupture (left) and 3 month after (right) injury (Credit: Dr Louise Tulloh)

Why is this only just coming out?

Routinely, many ACL injured patients just whip off for surgery straight away, or at least within 6 or so weeks post injury, because it has long been thought this was the best practice for improved long term outcomes for return to sport. 

Moreover, the patients that don’t have surgery and just quit sport to live, are rarely, if ever are re-scanned to check. 

For the first time EVER!

This year in the clinic we have seen MORE NON OPERATIVE  management of and ACL tear or rupture than we have OPERATIVE management. 

How cool is that!

The Pro's & Con's LIST!

Some of the PRO’s we have seen from going conservative!
  • A quicker time to return to sport (as low as 6 weeks, up to 4 months if includes an MCL injury)
  • No painful surgery required
  • Quicker return of normal knee range of movement
  • Faster return of bulk and activation of the quadriceps and surrounding muscles
  • Equal hamstring strength (many post ACL never return normal hamstring function post surgery)
  • Less risk of complications from surgery eg excessive pain, swelling, DVT
  • Less pain and impact on normal life, quicker return to work and everyday tasks
  • A better ACL quality of life score following injury then following surgery
  • Better outcomes even if they end up going onto surgery later on

Some of the CON’s we have experienced!

  • Episodic knee instability with sport 
  • Re-injured and gone onto have surgery

When may ACL reconstruction be required?

There are some conditions that when seen really do require surgical intervention!

  • If meniscal injury occurs similtaneously with ACL rupture
  • A locked knee post injury when fragments of injured tissue get stuck in the joint
  • When the knee is inherently unstable and continues to give way
  • If a patient is functionally unable to return the affected knee and lower limb to pre injury status with conservative care
  • When conservative management fails in successfully returning the athlete or player to sport.

The above actually my MRI post ACL rupture. I also experienced a large lateral meniscal tear and locked knee requiring immediate surgery and ACL reconstruction. 

How do I know if surgery or not having surgery is the best outcome for ME following and ACL rupture or tear?

This really is an informed decision that you as a patient must make by:

  • Weighing up all the Pro’s and Con’s
  • Understanding (with a highly skilled clinician) the pathology present in the knee post injury 
  • Knowing the function of the knee post injury
  • Monitoring how well the knee improves with conservative management early on is a good predictor of long term positive outcomes
  • And ultimately the mindset and wiliest of the patient to over come the injury and put the work in needed to return strength, muscle size, proprioception and confidence in the knee again.

I hope you learned something from this blog.

As you can see I have personally had the pleasure of having an ACL reconstruction myself, but also rehabilitated many conservatively as well. 

Maybe you know of some people that have suffered an ACL injury this season and may benefit from some education on this hot topic.

Feel free to share it.