Episode 294 | The Collateral Damage Consideration of Going Nonoperative in ACL Rehab

What is up team and welcome back to another episode on the ACL Athlete Podcast. I had an athlete a while back who went nonoperative, and they were crushing it—strong knee, strong quads, and overall, they were doing great. No giving way and doing everything right. Then one day, they were walking across a pool deck. The pool deck can be wet. They slipped, and the knee gave out. 

Now, here is the thing: if that same slip happens to someone with an intact ACL, in a lot of cases, the knee might be able to catch itself. Maybe there is an injury, and perhaps you get some meniscus or MCL involvement, but it is not necessarily as aggressive. There is a restraint there doing its job without you noticing that it is doing it. But this athlete did not have that. They did not have that seatbelt—the ACL was not there to help protect them. Instead of walking away from that moment with just a scare or what might have been a relatively minor ACL-related injury, they ended up with a significant meniscus tear, a complete MCL tear, and additional cartilage damage.

Today, I want to talk about something I do not think we discuss enough in ACL rehab, especially for people considering the nonoperative route. People choose nonoperative management for many different reasons, and I want to name a few before getting into the main point because it is not one path that leads someone there. Sometimes the decision is made on the day of the injury. It could be related to your age or the season of life you are in. You think about someone who is 15 years old versus someone who is 55, and then you consider what your sport actually demands from your knees. Your healthcare situation, insurance, and coverage also matter; whether you are in a universal healthcare system or a more insurance-based system, you might have to wait a long time for surgery. Or you might be able to get it scheduled the following week depending on availability and coverage.

Financial considerations can also influence the decision. Some people do not want to pay $10,000 for ACL surgery or take on that level of debt, so they decide to try managing without reconstruction. Your season of life, goals, age, country, healthcare system, and financial situation can all play a role. Sometimes the decision is influenced by information found online, such as people claiming they returned to sport without reconstruction or that the ACL healed on its own. I am using “heal” because the research and debate around that are still developing. You might read about it on a forum, see someone discussing it online, or hear it from a professional who is more inclined to recommend a nonoperative approach.

Sometimes the decision does not happen until later. Maybe you planned to have surgery, your prehab was going extremely well, your knee felt very stable, and you started thinking, “Maybe I will just see how this plays out.” I have had ACLers choose the nonoperative route from every one of those directions. Some had surgery scheduled but were not in a position to proceed because of their season of life, their resources, or the sport they wanted to return to. For example, someone may have torn their ACL skiing but only wants to hike or walk afterward, so their demands on the knee may be different from those of a competitive athlete. There are many considerations beyond simply saying, “Let us have surgery.” 

We have worked with people who did not have good coverage, had limited access to in-network surgeons, or were facing long surgical wait times. We have had people in other countries complete prehab with us while waiting for surgery, only to reach a point where their knee felt so good that they began questioning whether surgery was necessary. They then canceled the surgery and decided to continue nonoperatively. All of these factors can influence the decision. There is no single wrong way to arrive at this point because everyone is coming from a different context.

However, I want to be clear about what this episode is not. This is not me arguing that surgery is better than rehab or that rehab is better than surgery. I have had ACLers succeed nonoperatively, and I have people on our roster doing that right now. There are also people who choose surgery and do incredibly well. There is not a perfect, universal answer where everyone should automatically go operative, or everyone should automatically go nonoperative. The appropriate route can vary significantly depending on the person and how circumstances evolve over time.

What I want to discuss is the difference between making a bet on the nonoperative route and making that bet while fully understanding what it could involve. To some degree, choosing nonoperative care means accepting a level of uncertainty. Those are two very different experiences: making an informed decision about the risk versus getting blindsided by what happens later. Even if the final outcome looks similar on paper, the experience can be very different when you understand the potential trade-offs from the beginning.

Some ACLers adapt to life without an ACL. We often call these people copers. Others do not, regardless of what they do, and eventually need surgery. These are generally referred to as non-copers. There is research on this, including work by Fitzgerald, Axe, and Snyder-Mackler, that dates back to the early 2000s. Screening tools have been developed using strength testing, hop testing, and other criteria to help identify who may be able to function successfully without reconstruction and who may not.

I am not going to dive into all of the ACL-healing literature in this episode. The bigger question is how we can better understand the potential collateral damage that may occur when someone chooses the nonoperative route. One important point is that the classification is not necessarily fixed. Research has shown that someone who appears to be a good candidate early on may shift categories later depending on changes in training, strength, exposure, and what the knee can actually tolerate.

We have useful screening tools, but we do not have a crystal ball that can guarantee the exact path someone will take on day one. Instability episodes are a major part of this conversation. If you have more than one giving-way episode, that will typically move you toward the non-coper category. The exact situation still varies by person, but these screening tools can help people make more informed decisions rather than simply guessing.

Here is what I think often gets missed: people treat the decision as though it is only about whether the knee feels stable. Does it hold up or not? But the ACL is not only responsible for stability. It is also a mechanical restraint. It is the knee’s seatbelt. When the ACL is absent, that seatbelt is gone too. It helps structurally hold things in place and influences how stress is distributed across the other tissues in the joint.

The concern is not necessarily the passage of time itself. It is not that simply waiting longer without an ACL automatically builds damage in the background. Research has shown that delayed surgery, by itself, does not necessarily increase the risk of arthritis. The concern becomes more significant when someone repeatedly participates in activities that cause the knee to sublux or give way. Those episodes can damage other structures in the joint and potentially increase the risk of osteoarthritis later.

The risk shows up more in specific moments rather than simply in the weeks or months that pass without an ACL. The actual giving-way event is where the collateral damage can occur. That is exactly what happened in the pool-deck example. The athlete slipped, the ACL was not there to help absorb or control the load, and the meniscus, MCL, and cartilage took the hit instead.

We cannot always predict who will have one clean-giving-way episode and walk away relatively fine versus someone who experiences that same type of event and sustains substantial damage. But understanding that the risk is concentrated around instability moments—not simply the passage of time—is important. Some ACLers never experience another giving-way episode after the initial injury. Others have small episodes here and there, while some experience them repeatedly. Sometimes the knee flares up and settles down within a day or two, while other times the symptoms persist much longer.

There is no clean line that tells you in advance exactly what your nonoperative journey will look like. The injury itself, how your knee responds, the degree of instability, and the number of giving-way episodes all influence the potential path. More instability episodes generally make eventual surgery more likely. However, if surgery is difficult to access, must be delayed, is financially unrealistic, or you genuinely want to trial nonoperative care based on your goals and circumstances, it can be a reasonable option for the right person.

I am not saying everyone should choose nonoperative care. There are many people for whom I do not think it is the appropriate route, and the screening information can help determine whether it is viable. If you are navigating this decision now, or you are already several months into trying nonoperative care, there are three questions I would want you to consider. 

First, if I have a giving-way episode, am I going to treat it as meaningless noise, or am I going to treat it as new information that changes the conversation about my plan?

Second, am I genuinely at peace with the possibility that I may still need surgery later? Not simply hoping to avoid surgery entirely, but actually accepting that it remains a real possibility. 

Third, what is the one goal that is nonnegotiable for me, and does a significant giving-way episode put that goal at more risk than I am willing to accept?

Those questions will not necessarily prevent a slip on a wet pool deck from happening. Nothing can fully replace the ACL’s role in that moment. What these questions can do is help you determine your response before you are standing in the middle of the situation, rather than trying to make the decision for the first time while it is happening.

If you are a clinician or coach listening to this, this is not something you explain once at the beginning of care and then move on from. This is an ongoing informed-consent conversation, not a box to check during the first visit. You need to test for it, plan for it, and establish what a giving-way episode should trigger in the rehabilitation process. Guide the conversation before the event happens, rather than waiting until you are doing damage control afterward.

This is something we discuss with anyone who wants to navigate the nonoperative path. I am very honest with them about what this route can potentially lead to. There are people who have been highly successful with it, and there are also people who encounter challenges once they begin progressing into more dynamic activities. They may start experiencing more giving-way episodes, and eventually the intersection between their goals and their knee’s limitations leads them toward surgery. That is why it can be difficult to determine who will ultimately succeed without reconstruction. We have to collect data points throughout the prehab and rehab process to understand how the knee is responding. I am not going to sugarcoat the numbers in either direction. 

In the KANON trial, patients were randomized to either early surgery or rehabilitation first with the option of delayed surgery. In the rehabilitation-first group, 39% underwent surgery within two years, and by five years, that number had reached 51%. That does not necessarily represent a failure rate. It is simply part of the odds and reflects the fact that roughly half of the people who initially tried rehabilitation first eventually underwent surgery. More people are successfully managing nonoperatively than they were five years ago, but the important point is that people need to understand the range of possible outcomes before making the decision.

The ACLers I have seen who experience real regret about this path almost never regret trying it. What they regret is not understanding what they were actually risking when they made the decision. That is the main point I want to address today. If you do not have an ACL and choose the nonoperative route, there is a possibility that a giving-way episode could create additional damage in the knee. That could happen during an unexpected moment, such as slipping on a pool deck, or later when you begin exposing the knee to more demanding activities.

This is not me trying to scare people away from nonoperative care. There are also people who have undergone surgery who may have been better suited to trialing nonoperative management. However, many people are naturally pushed toward surgery, especially when they are consulting with an orthopedic surgeon. The typical formula is still: tear the ACL, have surgery, and follow the recovery timeline. Depending on the surgeon’s experience, location, and exposure to different approaches, some professionals may be having more nuanced conversations about this now.

Regardless of the route, the risks and trade-offs should not be hidden. If someone chooses nonoperative care, they should understand the possibility of collateral damage. If that information is clearly presented, the person can make a decision with the full picture in front of them. They can understand what they are accepting rather than being surprised several months later when something happens that nobody prepared them for.

If you are the person on the pool deck, for example, and you already understood that this was a possibility, then even if the outcome is unfortunate, you can recognize that you made the decision knowingly. That athlete eventually went on to have surgery because of the additional damage, but if they had never slipped on that pool deck, they might have gone years—or possibly the rest of their life—without needing reconstruction. That is part of the nature of life. Accidents happen, and not every risk can be controlled.

The important thing is to understand the risk-reward relationship and the trade-offs of nonoperative care. Anyone choosing not to have surgery should have a Plan A, Plan B, and Plan C. They should understand what each path looks like and how they will respond based on their specific context, goals, knee, and circumstances.

I hope this helps if you are currently on the fence and trying to weigh the pros and cons. I hear this question often, especially from athletes in their 40s, 50s, and 60s who are unsure whether they want to go through surgery. Their goals may not be as aggressive as those of a 15-year-old trying to return to high-level soccer or a 23-year-old who wants to ski at full speed. Different people have different goals, and those goals should influence the decision.

There is not just one way to approach ACL rehab. Even with ACL reconstruction, people need to understand the pros and cons of their choices, just as they would with graft selection. A quad tendon graft may involve a slower quadriceps recovery, donor-site discomfort, or extension challenges. A patellar tendon graft, hamstring graft, or allograft each come with their own considerations. Nonoperative care is no different. You deserve to understand the trade-offs before committing to the path.

The goal is to equip yourself with enough information that three or six months later, you are not saying, “No one told me about this, and I never thought about it.” You may decide that you do not want to deal with the possibility of additional damage, or you may decide that the risk is acceptable based on your goals. Either way, if the trade-offs were clearly explained, you can feel more at peace with the path you chose.

If the seatbelt is not there and your knee gives way, resulting in collateral damage, at least you can process that knowing you understood the possibility. You can say, “I knew this could happen, but it was worth trying. I exhausted that option, and now I am moving forward with surgery and recovery.”

I hope this is helpful. If you have any questions, you know I am here to help. I would love to hear your thoughts or opinions about what I shared today. Otherwise, I will catch you in the next episode. This is your host, Ravi Patel, signing off.