Acl Knee Operate Image

The ACL Debate – To Operate Or Not?

Not everyone needs surgery after an ACL tear!

There’s a huge hype at the moment about trying to push people away from surgery and into conservative management, however, I don’t think we can place everyone into the same category. ​

This is where a screening system comes into play to classify those that may be potential ‘copers’ and be able to manage without a new ACL and the ‘non-copers’ who should follow the surgical pathway sooner.


So what does a potential ‘coper’ look like?

A coper is someone who is:

  • Able to return to jumping/cutting/pivoting sports without any instability or ‘giving way’ of the knee
  • Significantly less laxity in the joint upon clinical testing (i.e. less anterior tibiofemoral translation).
  • Fewer reported episodes of ‘giving way’
  • Return to significantly higher activity levels


So what differences are noted in those who are classified as non-copers?

  • Athletes who experienced giving-way episodes on resumption of pre-injury activities
  • Demonstrate a ‘stiffening’ strategy and higher muscle co-contraction
  • Poorer gait performance in terms of kinematics and time-distance variables after 4 months 
  • Increased quad loading even during anticipated tasks


So how can we determine who is a coper and non-coper?

There are a few tests that we can perform in the clinic once the knee has settled that can help up classify each person.

A coper should be able to demonstrate:

  • >80% limb symmetry on a 6m timed hop test
  • >80% on a KOOS questionnaire 
  • >60% on a global rating of knee scale
  • Have no reported episodes of instability


The current world BEST practice after ACL injury is to do 3 months of intense ‘pre-hab’ before deciding whether to have surgery or not.

Interestingly, Thoma et al (2019) recently found that 45% of those initially classified as a “non-copers”, were able to turn themselves into a “potential coper” after 5 weeks of rehab (as per exercise protocol by Eitzen et al, 2010).

From this information, I think we should be discussing options with clients and at least try a period of rehab before rushing into surgery. 

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