Silvia Sexton was enjoying spring ski conditions last March in Breckenridge when, on the last run of the day, she got stuck in slushy spring snow on Whale’s Tail, a double black diamond run, and fell. She heard a pop.

“It was painful. But not that painful. I slid down the steep part on my bottom and then skied until I got to a chairlift. By then, I was feeling dizzy and nauseous. I ended up getting a (first aid) sled the rest of the way down,” she said.

The Monday after her Saturday fall, she saw Dr. Martin Boublik, co-founder of UCHealth Steadman Hawkins Clinic – Denver, head team physician for the Denver Broncos, and associate team physician for the Colorado Rockies. Sexton completely tore her ACL (anterior cruciate ligament), and after reviewing her MRI, Boublik informed her that she also damaged her MCL (medial cruciate ligament).

The knee has four ligaments, which are tough bands of tissues that help keep the knee stable. The ACL, which connects the back of the thigh bone to the front of the shin bone, is vital in keeping the knee in place, especially when performing cutting and pivoting movements. When a person puts too much stress on the ACL while making those sudden twisting or pivoting movements or landing awkwardly after jumping, they can injure the ligament. ACL tears and injuries are common, and nationally, these injuries are on the rise, especially in younger athletes.

If Sexton were a professional athlete or someone who regularly plays sports that involve cutting, such as basketball, tennis, soccer, or high-level skiing, she would most likely receive a recommendation to have ACL repair surgery.

“Most of the time when we see someone who’s athletic, whether it’s a recreational athlete, a high school athlete, a high-level college or professional athlete, my recommendation is to reconstruct the ACL surgically so they can get back to their level of activity,” said Boublik.

When it’s a low-demand athlete, he says, it’s not so clear cut. It depends on their symptoms and activity level. In some cases, physical therapy, activity modification, and bracing can help the patient return to active, non-pivoting sports and lifestyle without surgery.

Whether to get ACL surgery or not is a common dilemma for many recreational athletes, especially in Colorado, where so many people are active. While the age of the patient can be a factor in deciding whether to get surgery, with older patients leaning toward non-surgical treatments and younger ones going with surgery, it’s not always a good indicator when it comes to ACL tears in Colorado, considering that people ski and play sports well into their 60s.

Surgery vs. PT for non-professional athletes

ACL injury treatment aims to restore knee function, eliminate knee pain and swelling, and reduce potential further damage to the knee, especially meniscus tears. Surgery is the best way to treat an ACL injury for competitive athletes who must return to their sport at a high level. On the other hand, physical therapy can help patients who don’t push themselves at such a high level by building up the surrounding muscles to provide knee stability. Wearing a brace during activity can provide additional support.

In addition to activity level, Boublik also considers whether there’s additional damage to the knee, such as a meniscus tear or cartilage damage, which may tip the scales in favor of surgery to help prevent further damage. According to the American Academy of Orthopedic Surgeons, about half of ACL injuries occur with meniscus or other cartilage or ligament damage. And, of course, it also depends on how your knee feels. Is there pain, instability, swelling, or stiffness?

The lengthy rehabilitation after ACL repair surgery, which can take anywhere from six to nine months, or longer, may deter people from choosing surgery. Yet, it can also take months of PT before patients feel strong and stable enough to return to hiking, biking, or yoga.

And, to complicate the decision even more, studies on ACL injuries don’t show one option leads to better outcomes than the other. A meta-analysis of 3,500 randomized controlled studies comparing surgical vs. non-surgical treatment for ACL injury found no significant difference between surgical and non-surgical treatment after 15 years in pain or returning to preinjury activity level. However, the analysis did report a higher rate of re-injury with rehabilitation than surgery.

Sexton liked walking, hiking, yoga, running, and biking – all activities that did not involve cutting or pivoting. She did ski but was happy to stay on the blues and some easy black diamond trails. By the second visit to Boublik, Sexton said she was feeling much better and could walk fine, although with a slight limp.

“I fully expected that we would reconstruct (Silvia’s knee). But then I saw her back after she had done a little rehab, and she said her knee felt quite good. I told her that her options are to go ahead with ACL reconstruction or continue rehab and get a functional brace.”

Silvia decided at the time to stick with PT and forgo surgery. After several months of PT and also diligently doing her exercises on her own at home, she was “feeling great.” She was jogging by the summer and skiing blue runs, and a few black runs off of Breckenridge’s Peak 10 by the end of the year. She said she was tentative initially, but both knees felt equally strong.

Before you decide whether you need ACL surgery

Boublik recommends that all patients undergo prehab and rehabilitation before surgery to help reduce swelling and stiffness and increase their range of motion. Physical Therapist Greg Ehmer at the UCHealth Sports Therapy Clinic does prehab with patients to improve their range of motion and strength. “Stiffness can be a risk of going through ACL surgery where you could permanently lose the ability to bend or fully straighten your knee,” Ehmer says.

After prehab, some people may feel well enough to put off the surgery or the decision. Sometimes, patients will adopt a “wait and see” strategy. However, there is the risk that waiting will result in further damage, especially if the knee is unstable and the patient experiences associated swelling and pain with activity.

“In general, we tend to fix ACL tears early. If you wait more than a few months, especially if the patient has ongoing symptoms, meaning instability in their knee, then you worry about doing more damage, and the structure most at risk is the medial meniscus,” says Boublik. “So, we try not to let the patient delay too much if there’s instability and especially if there are associated pain and swelling.”

One recent study found that waiting three months or more for ACL surgery was associated with an increased incidence of meniscal injury.

Physical therapy: before, after or instead of surgery

As mentioned above, doing PT before surgery is essential to help with strength and mobility and reduce stiffness. For most ACL surgeries, the surgeon harvests part of the patient’s own patella tendon, hamstring or quadriceps tendon for the ACL repair, which can cause muscle atrophy and weakness, says Ehmer. “The stronger we can get them going into the surgery, the less atrophy they’re going to have coming out,” he says. Ehmer sees patients about three times before surgery.

Then, after surgery, he sees patients anywhere from the same day as surgery to a couple of days after their first appointment, depending on the surgeon’s protocol. Following the initial visit, he keeps seeing them anywhere from nine months to a year, depending on when they pass their “return to sport” test. The test involves about 12 functional tests and a special machine called Biodex that measures quadriceps and hamstring strength on both their surgical and non-surgical knees.

“If they’re going back to any cutting or pivoting sport or skiing, they have to pass to get a clearance from the surgeon,” he says. “There’s a high rate of re-tears of the ACL, so we don’t want that to happen.”

In the beginning, Ehmer sees his patients about twice a week (three times a week for professional athletes) and then tapers down to once a week, with most of the work done by the patient at home. He says the more time you put into your physical therapy exercises at home, the quicker you’ll pass the test.

For patients who don’t choose surgery, he performs the same strengthening, mobility, balance, and dynamic stability exercises as his surgery patients. The time it takes to heal and get back to an active lifestyle with PT depends on the injury, the work the patient puts in, and the pain and swelling.

Boublik says that while some ACL injury patients do well with PT, bracing, and activity modification, it’s still important to monitor them to ensure their knee doesn’t give way. “If they develop symptoms of instability, especially if they come in with pain or swelling, then you worry that they’re doing more damage to their knee and that the conservative route might not be the best route for them,” he says.

What does the future hold for someone with an ACL injury? 

Some people may have heard that ACL repair surgery reduces the risk of arthritis in the future, while others think that non-surgical therapies are the better option for reducing arthritis risk. Unfortunately, studies show that whether you have surgery or not, an ACL injury can lead to an increased risk of arthritis. The goal of ACL treatment, whether surgery or PT, is to get the patient back to an active lifestyle.

“Just the act of tearing the ACL typically causes other changes in the knee. You get bone bruises. There’s a lot of inflammatory tissue in the knee. So, some of the risks of arthritis in the future may happen at the time of injury,” says Dr. Boublik.

As for returning to one’s pre-injury ability, Boublik says it’s variable. It depends on the initial injury and if there’s associated damage. With an isolated tear, for example, a patient undergoing surgery has an excellent prognosis of returning to high-level activities. A patient with much additional cartilage damage and bone bruising will have a more challenging time fully recovering. The more complex the injury, the less chance one has of returning to full pre-injury abilities.

Do you need an ACL? Most athletes, especially those who engage in cutting or pivoting activities, do not do well without an ACL. After an ACL injury, in most cases, the ACL does not heal or grow back.

A year and a half post-injury, Sexton is still doing fine, although she says that when she stopped doing PT regularly, she did start to feel a little weakness in her knee. She returned to seeing her PT in the spring and is back to doing her exercises at home.

“I think it was the right decision for the right time. But we’ll see if it gets worse,” she says.