We all hear how ACL injuries are season-ending for professional athletes. But what if an athlete could return to sports without ACL surgery?

There have been many articles showing that patients can return to activity, including sports, without ACL reconstruction. A recent study by Hetsroni et al in the August 2013 journal of Knee Surgery, Sports Traumatology, Arthroscopy showed that a quarter of recreational skiers with ACL injuries can be treated non-operatively. However, most people go on to have continued episodes of instability causing additional injury if they return to sporting activities without surgery. So what are the risks of playing without an ACL and how do we know who can and can’t play without surgery?

The ACL is the main stabilizing ligament in the knee. It prevents excessive rotation of the knee joint that can occur with cutting and pivoting motions such as those in football, soccer, basketball and other similar sports. When the ACL doesn’t work, these rotational forces are transmitted to the other knee structures resulting in tearing of the meniscus and damage to the joint surface cartilage. Cartilage is the Holy Grail of orthopaedics and sports medicine. We do a very good job a reconstructing the ACL but our results with cartilage repair are adequate at best.

Joe Namath was the first famous athlete to return to sports without ACL surgery, which in his day was usually career-ending. What Broadway Joe proved is that a torn ACL, despite bracing, results in severe damage to the knee joint. Research shows that 90 percent of people with a torn ACL have significant problems or re-injury and only 10% of the patients did ok without surgery. These problems include persistent giving way, swelling, locking and pain.

What about braces? Braces simply do not work in preventing injury to other knee structures after ACL injury and this has been proven with a multitude of studies. The risk of playing with an ACL injured knee is severe and permanent damage to the remaining meniscus cartilage and the joint surface cartilage. We can fix the ACL but we don’t do a good job at fixing the joint surface cartilage. Injury to this cartilage means early and progressive arthritis.

There is now a testing battery that can identify players who can function without the ACL. Athletes that can return to activity without ACL surgery have been described as “copers” (being able to cope without an intact ACL). But it turns out that most people do not qualify as copers and the risk of returning to play without having corrective surgery is so great that most will not choose that route.

There are a few circumstances where an athlete might choose to rehab and play without surgery such as the national championship game for a college player or the state championship event for a high school player. For athletes, because the risk of permanent damage is so great, we advise against non-operative treatment.

In general, an ACL injury occurring in a young athlete or in a middle aged athlete unwilling to change his or her activity level requires surgery to safely return to sports. The risk is too great for permanent damage that would ultimately lead to the need for knee replacement at a later time. The good news is that with minimally invasive arthroscopic surgery and aggressive rehabilitation, we are very successful at returning athletes to their pre-injury level of activity.