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Is Surgery Necessary after an ACL Tear?

If you tear your ACL, do you need to get surgery? This question used to be a no-brainer. As new evidence has been gathered over the past decade, the answer is no longer clear. Studies have begun showing spontaneous healing of the ACL without surgery. Given enough time, even the ACL can heal…sometimes. The location and severity of the tear influence the healing potential. Even if the ACL doesn’t heal, some evidence suggests outcomes are equivalent for surgical and non-surgical routes. We don’t have enough data to suggest that non-surgical routes are the preferred option. Furthermore, regardless of the initial treatment, rehabilitation and return to sport treatment remain inadequate, given the high retear rates and failure to return to pre-injury athletic levels.

The rehabilitation approach will differ if someone elects a surgical or non-surgical route. How does an athlete determine which route to take? This recent study aimed to evaluate the natural course of acute ACL healing over 5 years. Sixty-two patients were randomized to early ACLR and 59 went to rehabilitation with an option of delayed ACLR. Thirty of the latter group elected surgery within the 5-year follow-up timeline. At both 2- and 5-year follow-ups, the best outcomes belonged to the healed ACL group (16), despite having worse ACL laxity scores than the surgical groups. It appears ACL healing is more likely if the tear is less severe. What does this mean for your patients? ACL-R remains a strong option, but it is not a guarantee and is not devoid of risk. Surgery carries risk and retear rates remain high. On the flip side, some ACLs don’t heal, and return to sport is not guaranteed if you forgo surgery. It is an individual decision.

Personally, I would not get surgery if I tore my ACL today. If, however, I was a collegiate or professional athlete, I most likely would. That opinion may change over the next 5-10 years as new research is developed. That is how we should approach everything in our field.


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