Anterior Cruciate Ligament Treatment Without Surgery: Tips & Rehab Protocol

You have experienced a partial or complete tear of the anterior cruciate ligament (ACL) and have not undergone surgery? You are probably wondering about the most appropriate rehabilitation to achieve optimal recovery.

In such cases, when there is no surgery, we often refer to it as “conservative treatment” or “functional treatment.”

While there is a wealth of information available about the rehabilitation process after ACL reconstruction surgery, there is much less information available about rehabilitation during conservative treatment.

Hence, this blog post.

As a physiotherapist, I will address the most frequently asked questions from patients and internet users regarding rehabilitation for a non-surgical ACL injury. As always, my answers are based on:

👩🏽‍⚕️ My experience as a physiotherapist since 2009, working with individuals who have undergone ACL tears, both with and without surgery.

📚 In-depth research conducted in the international scientific literature dedicated to this subject (all references are provided at the end of the article).

Do you still have unanswered questions? I am more than happy to address them in the comments section! 💬

Should I wear a brace or use crutches for a non-operative ACL tear?

There are no specific studies comparing the outcomes of individuals who used a brace or crutches versus those who did not.

Therefore, we need to reason theoretically to determine whether or not it is better to use a brace or walk with crutches in the case of a non-surgical anterior cruciate ligament (ACL) injury.

Let’s start by discussing the benefits of crutches. They can:

• Enable you to walk for longer periods or more easily.
• Reduce pain while walking.
• Minimize the feeling of knee instability while walking.

If you can walk without crutches with minimal limping, pain, and a stable knee, then you can do without them. However, if you experience difficulty walking without crutches, you can use them for a few days or, at most, a few weeks.

Regarding the brace (also known as an orthosis or knee support), here’s why it is commonly prescribed by physiotherapists or doctors:

• To enhance knee stability while walking and prevent it from giving way.
• To maintain proper knee extension (knee fully straightened).

Based on my experience, I believe that a brace is not necessary. To improve stability while walking, you can simply walk more slowly or, if needed, use crutches.

To maintain proper knee extension, proper posture and specific exercises can be sufficient.

Wearing a brace can often be cumbersome. Some individuals may rely on the brace excessively, leading to knee stiffness in flexion.

In most cases, a knee brace is not necessary after a non-surgical ACL tear.

For those who still prefer to use a brace, the following type of model is suitable (see on Amazon). There is no need to seek out sophisticated models that provide no additional benefits.

You can obtain this model at a pharmacy with a prescription from a physiotherapist or doctor to ensure reimbursement.

When should rehabilitation/physical therapy start after a non-operative ACL tear?

As soon as you are available and feel ready!

Some people believe they should wait until the knee pain subsides or until the knee swelling reduces before starting rehabilitation. However, seeing a physiotherapist early on allows you to address these pain and swelling concerns and determine what you can do to mitigate them.

Of course, this is assuming that you have received sufficient information from your doctor and conducted your own research.

Therefore, I recommend scheduling an appointment with a physiotherapist in the early days following your injury, even if you haven’t had an MRI or the diagnosis of a partial or complete ACL tear is not yet confirmed.

⚠️ However, there is no absolute urgency.

This initial physiotherapy appointment will primarily involve assessing the condition of your knee and addressing your concerns.

You can ask any questions you may have, and you will leave the appointment with practical information on what to do (or not do) in the coming days.

Furthermore, this appointment does not necessarily mean diving headfirst into intense rehabilitation. Your physiotherapist may suggest a follow-up appointment only after 1 or 2 weeks of the initial contact.

💡 If you have difficulty traveling, it’s good to know that a physiotherapist can provide home visits.

Lastly, there are no published data in the international medical literature to definitively state that individuals who start rehabilitation early recover faster or better than others.

Moreover, we also lack evidence demonstrating that individuals who undergo rehabilitation likely have better recovery compared to those who do not. However, there is a strong consensus on this matter among international and multidisciplinary experts in knee ligament injuries:

After an ACL injury, patients may be offered a period of progressive rehabilitation to improve impairments and overall function.

Diermeier et al. 2020

Is there a rehabilitation protocol for a non-operative ACL tear?

There are numerous protocols for the rehabilitation of a non-surgical ACL tear.

These protocols can be found in rehabilitation centers, hospitals, physiotherapy schools, clinics, sports medical and paramedical teams, as well as private physiotherapy practices.

Many protocols can also be found online. They are typically very detailed, not very concise, and challenging to implement. For example:

• A 10-page PDF protocol from a hospital in the United States (English, link provided at the end of the blog post).
• A 4-page PDF protocol from an orthopedic surgeon in the United States who is a member of the American Academy of Orthopaedic Surgeons (English, link provided at the end of the blog post).

However, following a protocol intended for post-ligament reconstruction rehabilitation is perfectly satisfactory because the rehabilitation follows the same general principles (except for the precautions related to the type of surgery, such as patellar tendon graft or hamstring graft).

The principles and progression are similar.

Here are also some French PDF protocols that can be applied to non-surgical ACL rehabilitation (conservative treatment):

• Swiss University Hospital (CHU),
• French medical consensus from the 2000s,
• and French National Authority for Health (HAS) 2008.

Tip: Search “acl non operative protocol .pdf ” or “non operative acl rehab” in your search engine for more options!

Often, the doctor or surgeon you consulted will provide a standard protocol to follow. However, it is not personalized to your case and will not offer anything beyond the protocols mentioned above.

However, there are no studies comparing the effectiveness of one protocol over another, nor any protocol that has been designated as a consensus among those who frequently handle this type of rehabilitation.

ℹ️ So, don’t be surprised if your physiotherapist approaches it in their own way, based on their habits and your feedback! That’s perfectly fine, as long as they adhere to some key principles:

• Aim to regain full extension and flexion of the knee 🦵 (no movement is strictly prohibited after an ACL tear!).
• Provide advice on managing pain (adapting activities and postures, building confidence and patience) and swelling (compression, elevation, walking, and… patience!).
• Respond optimistically to your inquiries 😎.
• Gradually increase the difficulty, volume, or intensity of exercises aimed at improving muscle strength, flexibility, cardiovascular capacity, balance, and proprioception 📈.

You can find many rehabilitation protocols and exercises for non-surgical ACL tears, particularly online. However, none of them have been tested or designated as more effective than others.

How long does rehabilitation take for a non-operative ACL tear?

Several factors will influence the duration of rehabilitation for an non-surgical ACL tear, as well as the length of physiotherapy sessions:

• Your physiotherapist’s practice habits.
• Your goals (return to sports or not; if yes, which sports).
• Your desire to take a relatively autonomous approach or not.
• Your recovery progress over time, considering your overall condition, the severity of your injury, and your medical history.
• Whether your rehabilitation sessions are covered by insurance or not.

⏱️ Generally, rehabilitation for a non-surgical ACL tear lasts several months, ranging from 3 months to 1 year, with an average duration of 4 to 6 months.

The end of rehabilitation is determined not by a specific timeframe but by the improvement of symptoms and the resumption or non-resumption of targeted activities.

Additionally, rehabilitation doesn’t necessarily mean physiotherapy sessions exclusively.

Do I need to go to a rehabilitation center for a non-operative ACL tear?

An ACL tear often is not sufficient reason to warrant a full inpatient stay at a rehabilitation center (in any case in France).

Some centers may occasionally offer day hospitalization options, but I believe it would be more appropriate to reserve those spots for individuals who require more extensive rehabilitative care from a third party (e.g., in the case of spastic cerebral palsy or physical therapy for Parkinson’s disease).

However, there is one exception: high-level athletes may sometimes receive an advantage (not morally or scientifically justified, in my opinion) and be granted a place at a rehabilitation center, even in the case of a non-surgical ACL tear.

Rehabilitation for an ACL tear does not require daily supervised care and assistance with nursing tasks (e.g., dressing, meals) to maximize the chances of recovery. Therefore, an inpatient stay at a rehabilitation center is not necessary.

Can I walk with a torn ACL?

Absolutely! There are no contraindications to resuming walking on the same day as an anterior cruciate ligament (ACL) tear. In fact, it is beneficial because it:

• Limits the risk of knee stiffness and swelling (edema).
• Maintains your muscle strength and cardiovascular fitness to some extent.
• Provides less constraint in your daily life.

⚠️ You can take some precautions to minimize pain and avoid worsening knee instability:

• Walk a bit slower than usual.
• Wear proper footwear.
• Avoid unstable terrain.
• Optionally, use crutches to relieve weight-bearing, reduce pain, and assist in stabilizing your knee.

You can walk as much as you want. Just make sure that it does not significantly increase your pain during or after the walking session.

Walking is possible immediately after an ACL tear, with or without crutches. However, it is often easier and safer to use crutches for a few days or even weeks.

When can I return to sports after a non-operative ACL tear?

We have a lot of data from national and international studies on return to sport after ACL surgery. However, we don’t have specific data on return to sport without ACL surgery.

It is reasonable to assume that the timelines are approximately the same for individuals who recover without the need for surgery because:

• Two to five years after the injury, the recovery is similar for both operative and non-operative cases (BMJ 2021; Cochrane 2016).
• There are some cases reported in the literature of non-operative high-level athletes returning to sport quickly, sometimes as early as two months after ACL rupture (Weiler 2015).

However, it’s important to note that some individuals may return to sport quickly but experience a re-rupture of the ACL.

That’s why it is recommended to wait an average of nine months before returning to sport after ACL reconstruction (and also for non-operative cases) (Kaplan 2019).

Specifically, the risk of re-rupture is reduced by 51% for each month of waiting to return to sport up to nine months. After that, the risk is not significantly reduced by waiting longer (Kaplan 2019).

⏱️ It is suggested to wait a minimum of 4 to 6 months before resuming sports after ACL tear, ideally nine months (Kaplan 2019).

Rather than focusing on a specific minimum time, it is more important to fulfill certain criteria. Five criteria are defined for return to sport after ACL reconstruction.

In the absence of specific documentation on non-operative cases, these criteria can be relied upon (Kaplan 2019).

These five criteria are:

1. Psychological state (confidence in your ability to return, perception of knee stability).
2. Muscle strength (of the muscles controlling the knee).
3. Functional abilities (activities involving the legs that you can perform).
4. Modifiable and non-modifiable risk factors.
5. Time elapsed since the ACL rupture/surgery.

These criteria should be discussed directly with the physiotherapists who are familiar with your history and medical records. Some criteria can be assessed using specific tests, although it is not certain if these tests truly provide additional value in making better decisions regarding return to sport (Kaplan 2019).

Some examples of these tests are:

• Hop tests: Single Leg Hop test and Single leg crossover hop test.
• Lachman test.

In practice, some individuals start running on stable ground very gradually, around 2 to 3 months after the ligament injury (at the earliest).

The progression of sports resumption typically follows this order:

1. Stationary biking (as early as the first few days).
2. Gradual jogging or other sports without pivoting.
3. Pivot sports without contact (skiing, tennis, swimming all strokes).
4. Pivot sports with contact (handball, football, rugby, judo, etc.).

What results can I expect from rehabilitation for a non-operative ACL tear?

Long-term (2 to 5 years after the rupture), you can expect the same results as after ACL reconstruction!

Most people are able to resume sports, including pivot sports, and even compete. And, of course, they can engage in all their daily activities without any particular pain.

A research team examined the progress of 50 athletes, both recreational and high-level, who had undergone ACL surgery or opted for non-operative treatment after a rupture, 20 years after their injury. Here are their conclusions:

In this retrospective pair-matched follow-up study, we found that after 20-year follow-up, there was no difference in knee osteoarthritis between operative versus nonoperative treatment when treatment was allocated on the basis of a patient’s response to 3 months of nonoperative treatment.
Although knee stability was better in the operative group, it did not result in better subjective and objective functional outcomes.

Yperen 2018

Can I undergo ACL surgery if rehabilitation is not sufficient?

Yes, it is a possible option that some individuals consider.

For example, a Dutch study followed two groups of approximately 80 individuals aged 18 to 65 who had experienced an ACL rupture:

• One group underwent surgery (early ACL reconstruction).
• The other group initially attempted rehabilitation before potentially opting for surgery.

In this second group, 50% of the individuals eventually chose to undergo surgery within the 5 years following the ACL rupture.

This figure is similar to a previous study where, within 2 years of the rupture, 39% opted for surgery after attempting rehabilitation alone. (Cochrane 2016)

However, another study mentions a 0% surgery rate within 10 years following the rupture! (Tsoukas 2016)

This is why a research team estimates the risk percentage of undergoing ACL reconstruction after attempting functional treatment to be 17.5%. (Krause 2018)

Can I take time off work for a non-operative ACL tear?

Yes, sick leave can be granted for any reason, including a non-operative partial or complete ACL rupture. The issuance of sick leave is primarily determined by:

• Your type of occupation
• The impact of your health condition on the tasks you are required to perform personally and professionally
• Your personal preferences
• The prescribing practices of your primary care physician (in France, physiotherapists cannot prescribe sick leave)

If you have a physically demanding job, a few days or weeks of sick leave are often necessary. For a more sedentary job, it is evaluated on a case-by-case basis.