Do All ACL Tears Need Surgery? Not So Fast.

Nope. And this is a question worth thinking about because the answer is more nuanced than most people think. Are we doing too many ACL surgeries? Possibly. Are some people going without surgery who actually need it? Also possibly.

I have had athletes come in with a confirmed ACL tear and zero instability. These patients may be "copers"... people who actually function really well without an ACL. On the other hand, I have had athletes tell me their knee keeps giving out, but they refuse surgery because they cannot stomach time off the mats. Those people often end up getting surgery, and some wait years before finally pulling the trigger. Both situations are worth understanding.

Copers… Who Are They?

The coper classification was developed by the Delaware-Oslo group to identify athletes with an ACL tear who go back to sport without surgery and do just fine. Their screening test puts athletes into two buckets… potential copers or noncopers. This is based on four things: a timed 6-meter hop test, the Knee Outcome Survey, a global rating score, and the number of giving-way episodes. You have to pass all four to be considered a potential coper.

What is interesting is that research found 55% of athletes qualified as potential copers at first screening, and that number jumped to 68% after completing a structured rehab program. Meaning some people who looked like they needed surgery initially did not… after doing the work in PT first.

Who Should Think About Surgery?

I rarely tell an athlete they must have surgery. I lay out the options, give them the best information I can, and let them decide.

What I watch for in grapplers specifically is limping or swelling after training, avoiding standing/wrestling exchanges, and a slow decline in how well they can train and compete. When those things start showing up, it usually means the knee is unstable and the athlete has started losing confidence in it. That fear of the next give-way is real and it changes everything about how someone moves and competes.

The other concern with waiting too long on an unstable knee is that every hard training session puts the meniscus, cartilage, and other ligaments at risk. The damage that piles up while waiting sometimes makes the eventual surgery and recovery harder than it needed to be.

When Can You Get Back To Training?

There is no set timeline for returning to sport after choosing to go the nonoperative route. It depends on the athlete, the sport, and how locked in they are with rehab.

The approach I use is criteria-based… meaning you get back when you pass functional, strength, and mental readiness testing, not just when a certain number of months have passed. In my experience that process takes somewhere between three and nine months for nonoperative cases. And finding a physical therapist who actually understands grappling is not a bonus… it’s everything.

Final Thoughts

ACL tears are not a one size fits all injury and surgery is not always the answer. Some athletes do great without it. Some genuinely need it and are only making things worse by waiting. The goal is to figure out which one you are, get the right information, and make a decision you feel good about.

Whatever path you choose… It all begins and ends with physical therapy. 

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Dr. Megan Lisset Jimenez 

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References

Filbay SR, Bullock G, Russell S, Brown F, Hui W, Egerton T. No Difference in Return-to-Sport Rate or Activity Level in People with Anterior Cruciate Ligament (ACL) Injury Managed with ACL Reconstruction or Rehabilitation Alone: A Systematic Review and Meta-Analysis. Sports Med. 2025;55(9):2191-2205.

Thoma LM, Grindem H, Logerstedt D, et al. Coper Classification Early After Anterior Cruciate Ligament Rupture Changes With Progressive Neuromuscular and Strength Training and Is Associated With 2-Year Success: The Delaware-Oslo ACL Cohort Study. Am J Sports Med. 2019;47(4):807-814. Pubmed ID: 30790527.

Paterno MV. Non-operative Care of the ACL-Deficient Knee. Curr Rev Musculoskelet Med. 2017;10(3):322-327. Pubmed ID: 28756525.