ACL injuries happen 100,000 to 200,000 times a year in the United States, and for decades the standard advice has been simple: if you want to return to sport, get surgery. Newer research suggests the decision isn't that simple. Here's what a 5-year study found and what it means for you.
ACL injuries and the case for surgery
Athletes have historically feared ACL injuries because many believed it meant they would never return to their prior level of sport. Advances in surgical techniques, rehabilitation, and clinical understanding have significantly improved outcomes, and today most athletes are able to return to, or close to, their pre-injury level.
The traditional orthopedic recommendation has been clear: if you want to return to sports, you should have ACL surgery. The reasoning is that without the ACL, other knee structures may take more stress during high-demand activities, potentially increasing the risk of additional injury or future osteoarthritis.
What the research shows: ACL surgery vs. non-operative rehab
A study published in the American Journal of Sports Medicine, "Does Anterior Cruciate Ligament Reconstruction Improve Functional and Radiographic Outcomes Over Nonoperative Management 5 Years After Injury?", examined 144 athletes over a 5-year period. It found no clinically significant differences between the surgery and non-surgery groups in:
- Pain scores
- Performance-based testing
- Presence of arthritis
- Activities of daily living
- Knee-related function
That doesn't mean surgery is unnecessary for everyone, but it does challenge long-held assumptions about what counts as "best practice."
Is ACL surgery right for you?
All research should be interpreted carefully and not generalized to every individual. This study doesn't claim that surgery is never beneficial or that non-operative management is universally superior. It suggests something important: even surgeries historically considered "essential" may not always be the right choice.
Every ACL injury is unique. Factors to consider before deciding include:
- Activity level
- Knee stability
- Sport demands
- Age
- Goals
- Associated injuries
If you're facing an ACL injury, speak with a qualified physical therapist or orthopedic specialist who can help you weigh the risks, benefits, and evidence for your situation. If you do choose surgery, read our guide to ACL graft options.
A research-driven approach at Kauno
At Kauno, we pride ourselves on being research-driven. We believe our community deserves information grounded in quality data, not fear, outdated beliefs, or subjective opinions. Whether you choose surgery or non-operative rehab, we believe in empowering you with evidence, education, and a plan that aligns with your goals.
Weighing surgery after an ACL tear? Our physical therapists can help you understand your options and build a plan either way.
book a sessionthe takeaway
A 5-year study found no clinically significant differences between ACL surgery and non-operative rehab in pain, function, or arthritis. The right choice depends on your knee, your sport, and your goals.
Frequently asked questions
Do you always need surgery for a torn ACL?
Not always. A 5-year study of 144 athletes found no clinically significant differences in pain, performance, arthritis, daily activities, or knee function between those who had surgery and those who didn't. The right choice depends on your individual situation.
Why has ACL surgery been the standard recommendation?
The reasoning is that without the ACL, other knee structures may take more stress during high-demand activities, potentially increasing the risk of additional injury or future osteoarthritis.
Does skipping ACL surgery lead to arthritis?
In the 5-year study, there was no clinically significant difference in the presence of arthritis between the surgery and non-surgery groups.
What factors affect the decision to have ACL surgery?
Activity level, knee stability, sport demands, age, goals, and associated injuries should all be considered with a qualified physical therapist or orthopedic specialist.
How common are ACL injuries?
ACL injuries occur at a rate of 100,000 to 200,000 cases per year in the United States.
References
Wellsandt, E., Failla, M. J., Axe, M. J., & Snyder-Mackler, L. (2018). Does Anterior Cruciate Ligament Reconstruction Improve Functional and Radiographic Outcomes Over Nonoperative Management 5 Years After Injury? The American Journal of Sports Medicine, 46(9), 2103–2112. https://doi.org/10.1177/0363546518782698
