Episode 22 | Should You Have ACL Surgery Immediately or Wait?

What’s up guys, and welcome back to another episode on the ACL Athlete Podcast. Today is episode number 22, and we are diving into this question: Should you have ACL surgery immediately, or wait? Let’s say that you’ve had your knee injury, you’ve had an ACL injury, and you know that it is torn. Should you have that surgery as quickly as possible, or should you wait? And this is a question that I get very often, and you see these in different threads in different groups. People tear their ACLs, trying to figure out what are the next steps. It’s a whole new world to them. But then they ensue this terrifying feeling of, if I don’t get this ACL surgery, then what if something bad happens? Maybe it’s too late. All these different feelings start to flood as soon as this happens. 

To start this off, we’re going to lead with the typical answer of “It depends,” which is very difficult with these types of questions. Because it’s going to really depend on your situation, where you’re at, what the goals are, and maybe like other injuries that have happened at that same time. But we’re just going to go ahead and assume that ACL surgery is needed and is happening for sure. It’s an ACL reconstruction and nothing else crazy is going on. We’re not thinking three or four different ligament tears, meniscus, all these different things. Let’s just say ACL, and if we want to throw in there a meniscus, but it’s not really impeding your day-to-day.

The first thing to consider is, what are your goals and if it is time sensitive. Let’s take this example of an athlete who tears it in their junior year or their third year of high school, and they want to come back to play for their senior year of, let’s say soccer or football, whatever it is. The nine-month timeline is still going to apply. If there is any physical therapist, the surgeon who says you can do it in five to six months, from what we know at this point right now, they are wrong because of the evidence. It is incredibly clear at this point nine months gives you enough time. But it’s not time alone, it’s what you do in that nine months that’s going to be important. Let’s say this person needs to be back exactly in nine months. So that is something where you might have to consider, depending on when that tear happens and you need to come back for this specific season. You might need to have surgery sooner rather than later.

Now, if you do not have to have surgery immediately which goes in most cases that I see, probably 80 to 90% of cases don’t need to have surgery immediately. And this is typically an athlete who doesn’t necessarily have this big competition coming up that may determine something about their career or their trajectory for where they’re trying to go. My role here is a bare minimum of four weeks but ideally 8 to 12 weeks. And I’m going to tell you exactly why. 

Number one, the evidence and the research that supports prehab (pre-operative rehabilitation) which essentially just means having some rehab done before you have the surgery shows better outcomes in the long run. If you look at [Fayle] 2016, Eitzen in 2010, van Melick in 2016. These are all research studies that look at prehab and waiting a little bit before you have surgery. They compared two different groups and they saw that the prehab group did better. And that makes sense, right? You can get into physical therapy, you can start working on your range of motion, you can start working on your quads, you can work on getting the swelling down, your gait, all these things that you’re going to need to relearn, and do once you have your surgery. You get exposed to it and you’re able to get used to the process that you’re going to have right after surgery. This leads me to my next point, which is just looking at the function of the knee and looking at how the physiology and the recovery and the healing of everything.

When we’re looking at this knee and had a trauma of an ACL injury and maybe a meniscus. Usually, there’s pain, there’s swelling, there is some quad atrophy, or your quads don’t want to activate as well because it’s painful. Swelling is limiting your joint range of motion. It might be impacting your gait in the way that you’re walking.

All of these things are impacting daily life in the sense of utilizing your knee. Being able to get this knee back to what we call the quiet knee of the normal range of motion, especially that extension, and then getting the quads to make sure they’re activating on their own where you contract it. And then decreasing the swelling and decreasing the pain. All of these things are going to be important because you’re going to have to address them, as I said earlier, right after you get out of surgery. Getting that normalized is going to help so much. And then you could start strengthening the knee, you could start building it up. That way whenever you hit surgery and you get out, you’re stronger. You’re able to jump onto things and learn things quicker. 

There is a slew of benefits to having prehab and making sure that you take a little bit of time before you jump into surgery. And the whole premise here is allowing the need to get back to ” normal” to where it was before. And it’s essentially okay, it feels almost the exact same as it was before minus the ACL, which is going to be needed, especially the cutting and the pivoting and things of that nature. And oftentimes the surgeons will not even operate with a ton of knee swelling because of the pressure and the fluid. And it can throw the joint off in terms of the way that it’s moving. So that’s something that they will also wait and ask people to do that so it can calm down. 

The only exception might be if there’s some sort of urgency, like a broken bone that they need to screw back in, or other trauma that could create some sort of risk. Here, we’re thinking of more so those freak accidents or maybe a car accident, where the knee is in a much more compromised position as compared to, let’s say, just on the field and you’re cutting and you tear your ACL. 

Now, one of the things that are important here that as I’ve worked with people and started to see is, if you have a bone bruise, or other injuries that happen with the ACL injury. The time actually gives you some buffer room to allow things to heal and potentially minimize post-surgery complications, like increased swelling and pain. I’ve seen some athletes where the surgeon tells them they need surgery sooner rather than later. And they have a bone bruise or something that is in there that has created some trauma. We know with bone, there just needs to be more time for healing. Because it goes through a process just like any part of our other body that has had some trauma. It ends up causing a lot of swelling and pain and discomfort. But what could have been done instead, was to allow that bone bruise to heal and allow that to normalize and then have the surgery, and then these athletes have a better post-op process because they’re not dealing with that bone bruise or the other injuries that are still in that process. 

My next point is, if you are older it may also let you know if you could be a coper, aka getting away with not having ACL surgery. We usually have two categories when people do tear their ACLs. Because sometimes people don’t want to have surgery. We’re seeing more research that shows that some people can get away with not having surgery, and that doesn’t necessarily make things worse down the road. This will be a podcast episode in and of itself. But you could usually categorize people as copers and non-copers. And coppers are people who have an ACL tear, but maybe their joint isn’t as unstable and the musculature around it is stronger. It’s also related to their sport and the activities they do. 

The same thing to non-copers, those are people who have the ACL tear, but typically have more instability cases where their knee gives out. Then that might create more of a risk. With that said, if you wait a little bit of time, let’s say 8 weeks, 12 weeks, you do your prehab and you start to notice that the knee is fine, it’s normal, and maybe your goals aren’t necessary to get back to competitive or cutting and pivoting sports, then this might be something that could be a blessing in disguise. This all comes back to the goals and how your knee is responding during this time. But this time allows you to be able to see, maybe I don’t necessarily need ACL surgery. And you could even delay the surgery if it’s not necessary, unless something down the road may seem to warrant it. 

And speaking of blessing in disguise, I remember from my first ACL injury and surgery. This goes back to my sophomore year of high school. And I tore my ACL in April, and I had to wait for my first one due to my insurance coverage. There was some sort of issue, so I had to change surgeons and all these different things. I ended up having surgery in July, which was about three months later. I knew I needed it. I was in high school and wanted to continue playing competitive sports. Also at that point, I really didn’t necessarily have a choice. They were just like, this is what you do. I had the surgery, but it was three months later. In the meantime, I actually ended up doing some prehab and working on getting my range back, working on the pain and especially the swelling. I was working on getting my quads going and really just strengthening. It wasn’t like, I was just not doing anything. I was focused on still strengthening, which was awesome. I came out of the surgery. I was used to the exercises. I knew the stuff that I needed to do. My rehab took off pretty quickly, and I recovered very well. I attribute a lot of that to being able to do the prehab and waiting, allowing my knee to calm down. Being able to check that box on the quiet knee. And progressively build on my knee as I waited for the insurance to figure itself out and then have the surgery. So that was truly a blessing in disguise and I really attribute that to my recovery from my first ACL reconstruction. 

To review, if you are trying to consider having ACL surgery immediately, or if you’re trying to wait, this really depends. If it is time-sensitive, then might need to do it sooner. If it is not time-sensitive, I advise my athletes to wait 8 to 12 weeks at the bare minimum of 4 weeks. The research supports this approach of doing prehab, aiming for a quiet knee. Surgeons shouldn’t and typically will not operate on a swollen knee unless there is something urgent that needs to be repaired; allowing the initial trauma to normalize and heal, and that allows for better post-op success. It might allow you to evaluate whether a non-operative approach is something in the cart for you based on your goals and how your knee is responding. You might not need to spend all the money, you might not need to spend all that time and going through a surgery when you might have a chance not to have an operation. All of these things are big important points for whether you should have surgery immediately or wait. 

So that is it for today, my friends. A reminder to all of you each month, I am picking one person to have a free strategy call. All you have to do is sign up for our newsletter, which you can find in the show notes below, and then leave us a review. Do me a favor and go and do that. It doesn’t take too long. And just help us out. So that’s it guys. Thank you all so much again for listening. The feedback has been incredible. I am so thankful that you guys take the time to spend however long it is to listen to these episodes. And I hope that you’re getting value from it. Thanks again for listening. This is your host, Ravi Patel, signing off.