The crowd was roaring as Jenna sprinted down the sideline. Her team was up by one, just two minutes left on the clock. She planted her right foot hard, ready to cut inside—then it happened. A sharp, unmistakable pop.
In an instant pain shot through her knee, and she collapsed. The cheers turned to gasps. Jenna tried to stand, but her leg wouldn’t hold. Somewhere deep down, she knew this wasn’t just a bruise or a sprain.
Later, in the sterile glow of the MRI room, the words hit harder than the pain itself: “You’ve torn your ACL.” Devastated but determined to recover, Jenna needed to decide what to do next to get herself back on the field.
Wait, what do you mean – “decide”? If you tear your ACL, you have to go get surgery and then rehab for a year right?
Not necessarily. We now know some ACL tears can heal. Buckle up as we go through the pros and cons of different treatment options.
First, there is the surgery option.
Rehab after an ACL surgery is serious business. The amount of time and effort it takes to return to sport can be cumbersome. There aren’t many injuries that take a full 12 months to recover from.
Due to this time commitment that some people don’t have, or the amount of trauma that was induced during the earlier ACL reconstruction surgeries, they have opted to go without surgery. Some of these people went on to return to sport, and perform at a very high level. These are the John Elways of the bunch (he tore his ACL in high-school, did not want or get surgery, went on to be the number one draft pick out of college, won MVP, and 2 super bowls.
So how many people can get by without an ACL?
We have found some people are “Copers” and others are “Noncopers”
In an effort to find how many people actually needed an ACL reconstruction, Yonatan Kaplan, PT MSc (Med) wrote a review on the research on identifying how many people returned to activity at their pre-injury level.
What he found:
- Roughly a third of people cope with an ACL deficient knee tear and return to the previous activities so activity at their previous level.
- Roughly a third can cope, but have to change their activities. These “copers” are also okay with the outcome of activity modification.
- And the other third end up having instability issues , limited activity, and require surgery. These are the “non-copers”
Other folks have gone on to try to identify and predict who is a coper and who is not, but even 70% of those that were identified as non-copers, turned out to be copers. https://pmc.ncbi.nlm.nih.gov/articles/PMC2801138/pdf/nihms127487.pdf
Evidence of Spontaneous ACL Healing
What was once thought of as impossible (and still is according to google’s AI) started to appear now appears more common. The first case studies of an ACL that healed itself were back in the ‘90s, but these were assumed to be on rare occasions. When the researchers started investigating what the copers’ anatomies look like (looking for degenerative changes in the joint), they found one third of those that had previously torn ACLs that had healed. When controlling for those who went back for surgery later on (removing the non-copers), a half of the copers had healed their ACLs. https://bjsm.bmj.com/content/bjsports/57/2/91.full.pdf
That is pretty amazing for a ligament that was once thought to not have the ability to heal itself.
So one in three ACLs has the potential to heal, but can we improve the likelihood that it does?
Believe it or not, there have been advances in this realm thanks to a physio in Australia, a retired orthopedic surgeon, and a young woman who didn’t want surgery on her torn ACL.
They decided to brace her knee at a 90 degree angle for four weeks then slowly release the brace a week at a time to straighten her knee again. The idea was to bring the two ends of her torn ACL closer together to help it heal, and it worked!
The whole story is worth a listen: https://podcasts.apple.com/us/podcast/bjsm-podcast/id330966919?i=1000725160352
It took five more years for them to get four more people to try this bracing protocol, but they all healed. As did the next eleven. Over time, they have identified whose ACLs are likely to heal based on the person’s goals and what their ACL looks like on an MRI. The first article written on the matter can be read here: https://pubmed.ncbi.nlm.nih.gov/37316199/
Those who are more likely to heal on their own:
- Are taller – longer ligaments are more likely to unite.
- Had a less traumatic injury – people with multiple ligaments torn or large bone bruises are less likely to heal
- Are highly motivated and work really hard in rehab – think an infinite number of bridges, leg lifts, and long wall sits, etc.
Why would you want to opt for this option?
- The normal anatomy of the Native ACL is retained
- The ACL’s original femoral origin and tibial insertion, native blood and nerve supply is maintained
- It’s cheaper: Bracing + rehabilitation is much less expensive than ACL surgery.
- Less pain compared to ACL surgery, especially during the first 2-3 weeks post-treatment.
- Avoids Graft/Donor Site dysfunction
- Safer for Pediatric Patients:
- Avoids potential growth plate injuries associated with ACL surgery in skeletally immature individuals.
- Reduces Risks Associated with ACL Surgery:
- Avoids post-surgical pain, infection, bleeding, DVT, anesthetic complications, and surgical scarring.
- You can do more exercise, sooner, to limit muscle loss
Other things to consider if this non-surgical treatment appeals to you:
- You should brace within a week – the ACL ends can die within 8-21 days
- Use anticoagulants to prevent blood clots
- Another MRI is indicated at 12 weeks to ensure ACL healing
- You need a team made up of an orthopedist, a radiologist, and a PT
- The rehab still takes a year until you can return to contact sport
- You can always go back and get surgery if the ACL doesn’t heal
- There is limited research, but rates of re-tear appear to be similar and may even be lower
- For more information from Tom visit his: https://www.stadiumclinic.com.au/pdf/cross-bracing-protocol-patient-information-booklet.pdf
This is still a very new treatment for ACL tears but now over 1000 people that have undergone this treatment. More and more data should continue to be released as we know more about this course of treatment. As we know now, those that underwent the cross bracing protocol do not have a statistically higher rate of retear compared to surgery. (Surgeries retear rate is 9%)
Ski Season is coming up and with it come the unfortunate but common ACL tears. We wish you all happy skiing and healthy knees, but if the worst comes to worst we at Alta would love to help guide you through your recovery – whether you decide to get surgery or not.