by John A. Baur, PT, DPT, OCS, CSCS, FAAOMPT

Frobell et al BMJ 2013 findings in a 5-year report shows that there was no difference in any outcome between those who were operated on straight away, those who were operated on later and those who did not have an operation at all. The message to the medical experts who are treating young, active patients with ACL injuries is that it may be better to start by considering physical therapy first rather than operating right away.

Does physical therapy first make a difference?

Eitzen et al JOSPT found in a 5-week progressive exercise therapy program (twice a week for 10 sessions) in the early stage after ACL injury, after a quiet knee, led to significant improved knee function before the decision making for reconstructive ACL surgery or further nonoperative management. The compliance to and tolerance for the program was high, with few adverse events.

A quiet knee is a knee that has full AROM (or almost full), has little swelling if any, has no quads lag and has little pain.

In a study conducted by the University of Delaware and Norway (Delaware-Oslo Cohort) which was funded by NIH and Norwegian National Institute of Health, 300 patients followed prospectively, 150 patients at each location (Delaware and Oslo, Norway). Patient were undergone orthopedic screening, 10 sessions of perturbation, functional testing, surgery or no surgery, 6 month / 1 year / 5 year follow up.
The differential response (those people who feel stable after the injury) to ACL injury can be affected by physical therapy. As physical therapy continues over a 3-month period, stability strategies change. A month-long stability program can substantially change the patients preoperatively to have their knees be stable. As physical therapy continues from the whole period from the injury/acute stage, to subacute (quiet knee) to surgery the patient progresses stability strategies change and the categories are fluid.

Noncopers can become more stable and potential copers can become unstable. Noncopers are patients who are unable to perform functional activities and have repetitive episodes of the knee “giving-way” or instability. These noncopers are less likely candidates for non-operative treatment.

While surgery introduces passive stability, successful outcomes is not inevitable. Patients intent to return to previous level of activity is not a predictor of actual return to play. So, for example, those who intent to undergo surgery because they intend to return to play or those who choose not to undergo surgery because they do not intend to return to play have been found to return to roughly the same outcome level after one year whether they intended to return to play or not.

In the Delaware-Oslo ACL Cohort, each group found that almost one-third of the patients with ACL ruptures did not need to undergo ACL reconstruction surgery and two-thirds did undergo ACL reconstruction surgery.

In Grindem et al BJSM 2014 study Delaware-Oslo ACL Cohort showed superior 2-year patient-reported outcomes compared with the usual care of Norwegian Knee Ligament Registry (NKLR). In 86-94% of the ACL reconstructive patients who underwent progressive preoperative and post-operative physical therapy at the sports medicine clinic had 2-year postoperative patient-reported outcomes (IKDC) comparable to the general population without knee injury.

Is a quiet knee enough to return to play? No

Does delaying surgery seem to help, hurt or make no difference? Delaying surgery seems to help outcomes after an ACL rupture.

In Grindem et al (BJSM 2016) found the risk of reinjury was reduced by 58% for each month return to sport (RTS) was delayed until 9-months after surgery. Only 5.6% of patients who pass the RTS criteria before returning to level I sports suffer reinjuries compared to 37.5% of those who didn’t pass. In addition, more symmetrical quadriceps strength prior to return to sport was an independent reducer of risk of knee reinjury. Those who returned to level I sports had a 4.68-times higher risk of knee reinjury than those who did not. Using simple decision rules could reduce reinjury by 84%.

Treatment Recommendations

– Treatment to decrease knee joint effusion early such as, cold, compression, elevation and active motion.
– Stretching, patellar mobilization and quadricep strengthening to restore and preserve passive and active knee extension.
– Increase / maintain quadriceps strength should include progressive exercise and neuromuscular reeducation electrical stimulation.
– Restore normal movement patterns/gait – Neuromuscular training with at least 4 session of perturbation training)
– Short-term progressive exercise therapy programs should be incorporated in the early stage after ACL injury, to optimize knee function as a first step in the preparation to return to previous activity (or not) with or without surgery.
– Physical therapy should incorporate exercise and postures for secondary prevention.

Secondary Injury prevention Exercise may include:

– Nordic Hamstring Curls
– Standing squats
– Drop jumps
– Triple single-leg hops
– Tuck jumps

Can individuals return to sports after ACL injury without ACL reconstruction surgery?

Why consider non-operative management?
– Some patients may wish to delay or avoid surgery
– Different practice patterns in different parts of the world
– Surgical reconstruction and return to sports activities are not an effective strategy for preventing early onset of knee OA.
– Not all patients need to have reconstructive surgery.

Management Algorithm Criteria

No physical impairments
– No Knee joint effusion
– Full knee active / passive range of motion
– ≥70% Quadriceps strength
– Able to hop on injured leg without pain
ACL Screening
– Hop Testing
o Single hop
o Triple cross-over hop
o Triple hop
o Timed hop (≥80%)
– KOS(≥80%)
– Global rating (≥60%)
– Number of giving way episodes (≤1)

Grindem et al (JBJS 2014) conducted a study on nonsurgical or surgical treatment of ACL injuries: knee function, sports participation and knee reinjury

Nonsurgical and surgical ACL outcomes were studied with different levels of sports. The study described categorized sport in the following levels:
Level 3 sports = Cross-country skiing, running, cycling, swimming, strength training Level 2 sports = Volleyball, martial arts, gymnastics, ice hockey, tennis/squash, alpine/telemark skiing, snowboarding, dancing/aerobics
Level 1 sports = Handball, soccer, basketball, floorball which involve running, pivoting, jumping, cutting

Almost 100% of nonsurgical patients return to level 3 sports/activities, about 60% return to level 2 sports and approximately 20% return to level 1 sports. In the operative patients almost 100% of patients return to level 1 sports.

More patients who participate in level 2 sports elected nonoperative management and more patients participating in level 1 sports elected operative management. Approximately all patients returned to the reinjury activity levels at about the same percentage.

Should individuals return to sports after ACL injury even if they have reconstruction surgery?
If our goal is long term knee health than maybe not.

At Physical Therapy First we believe that providing true sport physical therapy requires a physical therapist who is “evidence informed and clinically astute”. Physical Therapy First works hard to stay well-informed with the best and latest true sports physical therapy research and our residency / fellowship trained physical therapist are clinically skilled and astute. We believe this makes a true difference in our patient physical outcomes and successful return to sports.


Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med 2016; 50:804–808.

Grindem H, Eitzen I, Engebretsen L, Snyder-Mackler L, Risberg MA. Nonsurgical or Surgical Treatment of ACL Injuries: Knee Function, Sports Participation, and Knee Reinjury. The Delaware-Oslo ACL Cohort Study. J Bone Joint Surg Am. 2014 Aug 6; 96(15): 1233–1241.

Grindem H, Granan L P, Risberg M A, Engebretsen L, Snyder-Mackler L, Eitzen I. How does a combined preoperative and postoperative rehabilitation programme influence the outcome of ACL reconstruction 2 years after surgery? A comparison between patients in theDelaware-Oslo ACL Cohort and the Norwegian National Knee Ligament Registry. Br J Sports Med 2014; 0: 1–6.
NSMC (June 2016) Lynn Snyder-Mackler – Is there a place for non-operative treatment for ACL tears presentation.