Australia has the world’s highest rate of ACL reconstruction surgery. Rehab may be just as good

If you’ve ever watched a game of Australian rules football, rugby league or basketball, you’ve probably seen it happen: a player lands awkwardly, grabs their knee, and doesn’t get back up.

An anterior cruciate ligament (ACL) injury is one of the most common and feared knee injuries in sport.

Every year, thousands of Australians rupture their ACL.

The ACL is a strong band of tissue that helps keep the knee stable, especially during quick turns, sudden stops and awkward landings.

At the time of injury, people often report feeling a “pop” in their knee with rapid swelling, acute pain and sometimes, the feeling the knee might buckle when trying to stand or walk.

So, what next? For most, it’s surgery.

But our recent research shows for most people, rehabilitation delivers similar results to surgery.

Read more: Injured your ACL? It’s more than just a knee injury

Are Australians too reliant on surgery?

Our team of physiotherapists and an orthopaedic surgeon recently researched the latest evidence from around the world on how best to treat ACL injuries, and particularly what happens when you do or don’t have surgery.

An estimated 90% of young active Australian adults with an ACL rupture choose to have surgery – an ACL reconstruction. We have the highest and also fastest growing rates of ACL reconstruction surgery in the world. This may be why most people assume surgery is the only treatment option.

But in Australia, no studies have compared surgery versus other treatments, such as physiotherapy rehabilitation.

However, other countries, such as Sweden, Norway and Denmark, more routinely offer a period of rehabilitation first before deciding on the need for surgery. Importantly, patients can still be deemed appropriate candidates for surgery after first trialling rehabilitation.

What we found

When our team reviewed all the evidence from robust studies (mostly from these countries), there was no difference in most short- and long-term outcomes between surgery first, rehabilitation without surgery, or rehabilitation first plus later surgery.

In simple terms, patients’ knee strength, ability to do daily activities and ability to return to sport was similar, regardless of treatment choice.

Importantly, at least half the patients who started with rehabilitation chose not to have surgery within the first two years after their injury, without compromising their outcomes.

This also matters because surgery comes with risks, including:

• infection: about 1%
• deep vein thrombosis (a blood clot): up to 8%
• graft failure (where the new ligament ruptures): up to 20%

These risks may not always be presented to patients or may sometimes be downplayed, which can lead to a lack of awareness when making treatment decisions.

Despite these risks, ACL reconstruction surgery may be the best option for some patients, especially those with concurrent injuries to the meniscus, cartilage and/or other knee ligaments.

Patients aiming to return to sports with lots of cutting and turning, like football or netball, and patients with a knee that still feels unstable even after extensive rehabilitation, may also be good candidates for surgery. For these reasons, surgery is the norm for treatment in professional sport, though with some exceptions.

Re-injury remains a big concern – re-rupture of the new ACL graft affects up to 20% of patients. About half of all patients with an ACL rupture will also develop knee osteoarthritis within 10 years of injury. This risk is mainly driven by the injury itself.

While surgery may make the knee feel more stable, it does not remove the long-term risk of osteoarthritis.

Rehab is crucial, with or without surgery

Regardless of the treatment pathway, rehabilitation is an important component of recovery.

A physiotherapist will guide patients in restoring knee stability by improving knee range of motion, muscle strength, balance and coordination.

Nine to 12 months of rehabilitation is recommended after surgery before returning to sport, with checkpoints along the way used to measure progress.

Exercising prior to surgery may also speed up recovery.

Nine to 12 months can feel like a long time, especially if you’re used to being active or playing sport.

Research tells us not meeting rehabilitation goals is related to a lower likelihood of returning to sport and increased risk of re-injury, highlighting the importance of seeing it through.

Talk to the experts

The bottom line is, not every ACL rupture needs immediate surgery – some people do just as well with a structured exercise-based rehabilitation program.

The right advice at the time of injury is crucial.

ACL injuries require a proper assessment by experts, such as physiotherapists and orthopaedic surgeons, who will help guide decisions about imaging, available treatment options and whether surgery is necessary or not.