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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Mana NankivellMana Nankivell
00:38 18 Apr 23
I highly recommend Trent and the Physio Fit team.I sustained a knee injury (fat pad impingement) in a half-marathon around 18 months ago, and after 12 months of seeing a (different) physio and sports doctors without any improvement, I was told by the doctor that I would "probably just have to put up with the pain".I booked in with the team at Physio Fit for another opinion, and it was the best decision I ever made. Trent put together a very manageable rehab plan for me and was quick to respond and adapt when something didn't work out. In the past 6 months, I've gone from not being able to walk without pain or even think about hiking, running or cycling without my knee flaring up, to running my first post-injury 5.5km trail run and hiking 10km with a 10kg pack!
Laura O'ConnorLaura O'Connor
08:47 05 Feb 23
This clinic is the pinnacle of physiotherapy in Adelaide. Ive seen a couple of different physios at physiofit over the years for different injuries and the experience has been absolutely amazing each time! Highly recommend seeing the team here for all your physio needs!
Ryen ArcherRyen Archer
02:50 03 Feb 23
Corey is absolutely fantastic, worked out my issues and we have been working to improve them for a few months now and all I can say is I am feeling a million times better! thanks physio fit! Keep up the great work!
Amy SzyndlerAmy Szyndler
02:44 03 Feb 23
I attended Physio Fit to get my tennis elbow treated. Always a friendly greeting from the lovely reception staff, and my physio, Corey, was fantastic; very friendly, knowledgeable and provided treatment that was personalised and holistic. Following Corey's advice and exercise regime helped me get back to the activities I enjoy, pain-free. Highly recommended.
Debbie MossDebbie Moss
07:21 02 Feb 23
Have been taking my daughter here for quite a few months now for ongoing back issues. The care that she has been given through her Physiotherapist Corey, has been fantastic. Everything has been explained and if exercises have needed to be modified he has. Would thoroughly recommend this place for any Physio needs. All staff that we have dealt with have been friendly and professional. A great team and environment.
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