Blog
ACL Rupture:
Do You Need Surgery?
An ACL injury can have a significant impact on an individual’s life, often affecting day-to-day activities and preventing participation in the sports and activities they enjoy most.
Author:
Andy McGree, Coach & Physiotherapist
|
Published 17 July, 2020
Share this Article:
Intro
Helping athletes recover from ACL injuries is one of the most rewarding parts of my role as a physiotherapist and strength and conditioning coach. Supporting someone through high-quality rehabilitation, helping them return to sport stronger than before, and assisting them in achieving goals they may have thought were no longer possible is incredibly fulfilling.
Naturally, the question of whether or not to have surgery is a topic I have developed strong opinions about throughout my career. It is also a question I have faced personally. I ruptured my ACL 12 years ago before beginning my current career path, and more recently experienced another ACL rupture after a fall from a ladder.
Why Is ACL Surgery So Common?
Australia has the highest rates of ACL reconstructive surgery in the world (Zbrojkiewicz, Vertullo & Grayson, 2018).
We regularly see professional athletes suffer ACL injuries and undergo reconstruction shortly afterwards, often facing a recovery period of 9–12 months. This familiar narrative has shaped public perception, leading many people to believe surgery is the only option.
When an ACL injury occurs, patients are often advised by physiotherapists, GPs, sports physicians, and orthopaedic specialists that surgery is the best path forward. As a result, many never stop to consider whether an alternative approach may be suitable for them.
However, treatment decisions vary significantly around the world, suggesting there may be more than one valid pathway.
My belief is that for many athletes, ACL reconstruction may not be necessary, and in some cases may not be the best option. Most importantly, patients should be given access to all available information before making such a significant decision
Elite Athlete Case Study: Returning Without Surgery
A Premier League Footballer's Recovery
A documented case involving an English Premier League footballer challenged many assumptions surrounding ACL injuries.
Following a complete ACL rupture, the athlete chose not to undergo surgery. Instead, he completed an intensive rehabilitation program and successfully returned to professional football just eight weeks after the injury. He experienced no significant complications during the following 18 months of competition (Weiler et al., 2015).
What Does This Tell Us?
This single case should not be viewed as proof that surgery is unnecessary for everyone. Many athletes succeed both with and without reconstruction, while others struggle regardless of the chosen path.
However, it highlights an important point: ACL reconstruction may not be essential for every athlete wishing to return to sport.
Research Evidence: Rehabilitation vs Surgery
The KANON Trial
One of the most important studies examining ACL treatment options is the KANON Trial (Frobell et al., 2013).
Researchers followed 121 active adults aged 18–35 who were randomly assigned to either:
- ACL reconstruction plus rehabilitation
- Rehabilitation alone
Participants in the rehabilitation group were allowed to undergo surgery later if they felt it was necessary.
After five years, researchers found:
- No significant differences in function or activity levels
- No significant differences in complications
- No significant differences in osteoarthritis development
Key Findings
Within the rehabilitation-only group, approximately 50% of participants eventually chose surgery.
Interestingly, outcomes remained similar across all groups:
- Immediate surgery
- Delayed surgery
- Rehabilitation alone
What This Means for Patients
Rehabilitation Alone Can Be Successful: If you choose rehabilitation first, there is approximately a 50% chance you may achieve your goals without surgery.
Delaying Surgery Does Not Appear Harmful: Outcomes were similar whether surgery was performed immediately or several months later.
You Can Trial Rehabilitation First: If you are unsure, a rehabilitation period of 3–6 months may help determine whether surgery is necessary for your individual circumstances.
Does ACL Surgery Prevent Osteoarthritis?
Many people believe ACL reconstruction provides greater long-term protection for the knee by restoring structural stability.
What research shows:
A systematic review by Oiestad et al. (2009) found that individuals who rupture their ACL are at increased risk of developing knee osteoarthritis regardless of treatment choice.
Importantly, rates of osteoarthritis were similar in patients who underwent ACL reconstruction and those who did not. While surgery restores the ligament itself, successful rehabilitation can often restore functional stability. Additionally, surgery introduces its own trauma to the knee, which may also contribute to long-term joint changes.
Choosing the Right Treatment Path
The current evidence suggests that outcomes can be very similar regardless of whether surgery is performed.
The most appropriate decision depends on:
- Sporting goals
- Activity demands
- Personal preferences
- Knee stability
- Lifestyle requirements
- Guidance from healthcare professionals
This decision should not be rushed. Open discussions with family members, medical professionals, and rehabilitation providers are essential.
“Having recently ruptured my ACL again, I have chosen not to pursue surgical reconstruction. Instead, I will use this experience to document the rehabilitation process and demonstrate what may be possible without surgery. Many athletes assume certain goals become impossible after an ACL rupture. Through this journey, I hope to challenge those assumptions and provide practical insight into non-surgical recovery.
My first rehabilitation goal is to complete a 5km run as part of PEAK’s Dream Big Virtual Running Festival within four weeks.”
— Andy McGree, Coach & Physiotherapist
Final Thoughts
An ACL rupture does not automatically mean surgery is required.
Current research suggests that many people can achieve excellent outcomes through structured rehabilitation alone, while others may ultimately benefit from reconstruction. The key is making a fully informed decision based on your unique circumstances.
Understanding the evidence, discussing your options with healthcare professionals, and taking the time to evaluate your goals can help you choose the path that is right for you.
Get Expert Guidance After an ACL Injury