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ACL Injury: Should You Choose Surgery or Rehabilitation First?

  • Writer: Joseph Smith
    Joseph Smith
  • Apr 5
  • 3 min read

Professional insights from senior Physiotherapist at MOVE Sports Physiotherapy Geelong



Joseph Smith

Senior Physio at Move Sports Physiotherapy & Pilates Geelong


Anterior cruciate ligament (ACL) injuries are one of the most common and challenging knee injuries, especially among active individuals. In Australia, surgery is often the default approach—around 90% of people with an ACL tear undergo reconstruction.

However, growing evidence suggests that non-surgical rehabilitation can be just as effective for many people, with up to 50% avoiding surgery altogether after an initial rehab-based approach (Frobell et al., 2013). Even more importantly, outcomes from delayed surgery appear to be similar to early surgery, meaning you don’t necessarily lose long-term results by trying rehabilitation first (Filbay et al., 2024).


So how do you decide what’s right for you?


Male physiotherapist examining client knee in clinic at Move Sports physiotherapy Geelong

Understanding the 3 Types of ACL Patients

When deciding between surgery and non-operative management, most people fall into one of three broad categories.


1. High-Demand Athletes (Change-of-Direction Sports)

This group includes individuals who participate in sports involving cutting, pivoting, and rapid direction changes, such as:

  • AFL

  • Soccer

  • Basketball

  • Netball

Traditionally, surgery is recommended for these athletes because returning to pre-injury performance without an intact ACL can be difficult.

Another key consideration is time. High-level athletes may not want to spend months rehabilitating only to discover they still need surgery later.


That said, research challenges this assumption. A randomized controlled trial found similar return-to-sport rates between surgical and non-surgical groups, including:

  • Level 1 sports (e.g. soccer, basketball):

    • 54% (non-operative) vs 62% (operative)

  • Level 2 sports (e.g. skiing, athletics):

    • 88% (non-operative) vs 77% (operative)


This suggests that some athletes can successfully return to high-level sport without reconstruction (Frobell et al., 2010).

However, we currently can’t reliably predict who will cope well without surgery, as more long-term research is needed.


2. Low-Demand Individuals

This group includes people who:

  • Were injured during a one-off or unusual activity

  • Primarily engage in low-impact exercise such as:

    • Walking

    • Gym training

    • Swimming

    • Running

For these individuals, non-surgical management is often highly effective, and many can return to their normal lifestyle without needing an operation.

A structured rehabilitation program should almost always be the first line of treatment in this group.


3. The “In-Between” Group

This group sits between the two extremes and includes people who:

  • Participate in moderate- to high-demand sports (e.g. surfing, snowboarding, martial arts, athletics), or

  • Play high-demand sports but are open to trying rehabilitation first


For these individuals, the decision is more nuanced.

A common approach is to:

  1. Begin with structured rehabilitation

  2. Monitor knee function, stability, and confidence

  3. Decide later whether surgery is necessary


This approach allows you to avoid surgery if possible, while still keeping it as an option if your knee doesn’t cope.



Image of rehabilitation exercise at Move Sports Physiotherapy Geelong

Can You Try Rehab First?

Yes—and for many people, this is a very reasonable approach.

If you’re willing to:

  • Commit to rehabilitation

  • Accept the possibility of delayed surgery

  • Potentially spend more time out of sport

…you may find that you can return to high-level activity without reconstruction.



If You Choose Surgery: When Is the Right Time?

Timing matters.

Before undergoing ACL reconstruction, it’s important to achieve what clinicians call a “quiet knee.”


A quiet knee typically has:

  • Minimal swelling (only a soft effusion)

  • Full or near-full knee extension

  • Good strength and control

  • Ability to ride a stationary bike comfortably

Just as importantly, you should feel psychologically ready for surgery.


Interestingly, many people reach a point during rehabilitation where their knee feels so good that they question whether surgery is even necessary. This is one reason why prehabilitation (rehab before surgery) leads to better outcomes.



How Long Should You Try Rehabilitation Before Surgery?

Current recommendations suggest:

  • At least 3 months, and

  • Up to 6 months of structured rehabilitation

After this period, your physiotherapist can assess:

  • Strength

  • Stability

  • Functional performance

This helps determine whether your knee can cope without an ACL—or whether surgery is the better option.

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Key Takeaways

Surgery is common, but not always necessary. Many people can achieve excellent outcomes with rehabilitation alone. Delaying surgery does not effect long-term outcomes.

A trial of rehabilitation is often a safe and effective first step.


Book a Physiotherapy Assessment at MOVE Sports Physiotherapy & Pilates Geelong, and let us help support you along your ACL recovery.





References

 
 
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