ACL Injuries: Surgery or Rehab?

Not all ACL tears require surgery and rehab can be a great choice - here is a physiotherapist’s guide to making the best decision for YOU.

ACL injury during football

ACL Injury and Physio Rehab

As a physiotherapist, I’ve helped countless patients navigate this challenging decision. The truth ? Not every ACL tear requires surgery. But the right choice depends on a variety of factors such as your lifestyle, activity levels and goals, occupation, and the specifics of your injury. In this guide, we’ll break down:

• How ACL injuries happen

• When surgery is (and isn’t) necessary

• The latest research on rehab—with or without surgery

• What recovery actually looks like

Understanding the ACL: Why It Matters

Your anterior cruciate ligament (ACL) is a key stabilizer in your knee, preventing excessive twisting and forward movement of your shin bone on your thigh bone. Think England vs Sweden 2006 World Cup... watching Michael Owen collapse like the proverbial sack of potatoes in the first few minutes whilst no-one was near him. Classic ACL mechanism of injury. When it tears, even partially—often due to sudden stops, jumps, or direction changes—you might:

• Hear or feel a pop

• Experience rapid swelling - usally within an hour or so as the ACL bleeds a lot

• Feel instability when walking or pivoting - the knee may feel wobbly or give way.

But here’s the big question: Does a torn ACL always mean surgery is required?

The ACL usually tears with twisting over a fixed foot - NOT necessarily as a contact injury.

Surgery vs. Non-Surgical Treatment for ACL tears: Who Needs What?

1. When Surgery Is Usually Recommended

Research and clinical guidelines suggest that ACL reconstruction (ACLR) surgery is often the best choice IF:

✅ You’re young and active – Athletes in cutting/pivoting sports (soccer, basketball, rugby) usually need surgery to restore stability and prevent further damage.

✅ You have a complete tear with instability – If your knee frequently “gives way,” surgery may be necessary to avoid secondary injuries (e.g., meniscus tears).

✅ You want to return to high-level sports – Studies show that 80-90% of athletes return to sport after surgery, though only ~65% reach their pre-injury level.

Did You Know?

• About 50% of ACL-injured patients develop knee osteoarthritis within 10-20 years, whether they have surgery or not. However, surgery may help delay this by improving joint stability.

  
  

2. When Non-Surgical Rehab Might Work for ACL tears

Surgery isn’t the only path. Conservative (non-surgical) treatment can be effective if:

✅ You’re less active generally – If you don’t play sports to a high-level then rehab alone may restore enough function to allow a lower level of participation..

✅ You have a partial tear – Some partial ACL tears can heal with structured physiotherapy.

✅ You’re willing to modify activities – Switching from football to cycling or swimming or gym work may allow you to avoid surgery as these activites place lower demands on the knee.

Key Stat:

• A 2023 study in the British Journal of Sports Medicine found that 50-60% of patients with isolated ACL tears avoided surgery with dedicated rehab. However, return-to-sport rates were lower than surgical patients.

The Latest Research on ACL Rehab (With or Without Surgery)

Whether you choose surgery or not, rehabilitation is the cornerstone of recovery. Here’s what modern evidence says:

1. Pre-Surgery Rehab ("Prehab") Matters

• Strengthening your knee before surgery leads to better post-op outcomes.

• A 2022 meta-analysis found that prehab reduces muscle loss and improves early mobility after ACLR.

2. Post-Op Rehab: What Works Best?

• Early motion & weight-bearing (no more immobilization thankfully !)

• Progressive strength training (focus on quads, hamstrings, glutes)

• Neuromuscular retraining (balance, agility, plyometrics / bouncing / springing )

• Psychological readiness – Fear of re-injury is a major barrier; graded exposure helps.

3. Non-Surgical Rehab Essentials

• Bracing (short-term) for stability

• Targeted strength work to compensate for ligament laxity

• Sport-specific drills (if returning to activity)

Did You Know?

• Only ~55% of non-surgical patients return to their previous sport, compared to ~80% of surgical patients. But if you’re okay with activity modification, rehab alone can work well.

The Recovery Timeline: What to Expect

Non-Surgical Rehab

• Weeks 0-6: Reduce swelling, restore range of motion, gentle strengthening.

• Months 2-4: Progressive strength & stability work.

• Months 4-9: Sport-specific drills (if applicable).

• 9+ months: Gradual return to activity (if stable).

Post-Surgical Rehab

• Weeks 0-6: Regain motion, reduce swelling, activate muscles.

• Months 2-3: Strength building, single-leg balance.

• Months 4-6: Running, agility drills.

• Months 7-9: Sport-specific training.

• 9-12+ months: Return-to-sport testing (hop tests, strength symmetry checks).

Important Note:

• Full recovery takes 6-12 months, even if you “feel fine” earlier. This time varies depending on the type and level of sport that you want to return back to. Rushing back increases re-tear risk (which is 15-25% in high level athletes).

This is the aspect that every patient has to be honest with themselves - post op physio rehab is lengthy and takes commitment and as a clinician my question is always " Can you commit to the rehab afterwards ? No judgement either way but it's really important that these qestions are considered beforehand and a patient is honest with themselves and the surgical team so the right choice can be made.

Making the Right Choice for Your ACL tear

Still unsure? Here’s a quick checklist:

✔ Consult a sports medicine doctor or orthopaedic surgeon – Imaging (MRI) and a physical examination will determine tear severity.

✔ Discuss your goals – Are you a competitive athlete? Or happy with low-impact activities?

✔ Start rehab ASAP – Even if you’re considering surgery, prehab improves outcomes

My final Thoughts

An ACL injury can feel overwhelming, but with the right approach, most people return to an active life even if it may look a little different. The key is:

• Making an informed decision (surgery vs. rehab)

• Committing to a structured rehab program

• Being patient ( no pun intended ! ) ......recovery takes time !

If you’re dealing with knee pain and suspect an ACL injury, don’t wait—get assessed early. The sooner you start treatment, the better your outcome.