Do You Really Need Surgery After An ACL Rupture?

We often treat people who have sustained an ACL rupture. This injury is most commonly
seen in change of direction sports such as football, netball and rugby. Most commonly,
people are advised to have ACL reconstruction surgery using a graft most commonly taken
from the hamstring tendon. Time to return to sport after this operation is recommended
anywhere from 1 year post surgery and is individualised to the person.

There is new research and multiple case studies showing that ACL reconstructive surgery is
not always necessary to return to sport. It has been proven that some people can return to
the same level of sport, often with faster timelines when choosing non-operative

This research looks to categorise those with a diagnosed ACL rupture as a ‘COPER’ or a
‘NON-COPER’. If you are classified as a ‘coper’ it means you are potentially able to function
and return to sport with rehabilitation rather than ACL surgical reconstruction.

How do we know if you are a coper?

Once your knee has started to settle and you have less pain, minimal swelling and full knee
movement your physiotherapist can perform a series of simple outcome measures or tests.
This will help guide us on whether we recommend that you have your ruptured ACL
surgically reconstructed or to try non-operative management first.
These tests include four one legged hop tests, incidence of the knee giving way since injury
and two self-reported questionnaires. The outcomes of these tests will be used to classify
the person into coper vs non-coper and aid our recommendation on which treatment
options are suitable. Throughout the research those with additional injuries to the meniscus,
chondral surfaces or other ligaments, were not recommended to try non-operative

Why try non-operative management?

Research has shown that 72% of “copers” returned to pre-injury level of sport without
surgery. No further meniscal injuries, chondral injuries or increased risk of osteoarthritis
were found. Research also shows there is no difference in function, symptoms or activity
level for patients that choose ACL reconstruction vs non-operative management both
short-term and long-term.

What if you try non-operative and change your mind?

Many people decide to have delayed ACL reconstruction surgery. There is no difference in
outcomes between immediate ACL reconstruction and delayed ACL reconstruction.

The most important part of your recovery whether you choose surgical reconstruction vs
non-operative management is your adherence to your rehabilitation programme. We use a
guide with stages to determine readiness for return to sport. Key targets to move through
the stages are full active range of motion of the knee, no swelling, similar strength of the left
and right leg and a high level of agility and balance. To pass the last stage to give the all clear
to return to sport training you must pass a battery of tests which include single leg hop,
strength and balance testing.