Ep 4: Non-Surgical ACL Rehabilitation

In this episode with Trent Cooksley, discover why not all ACL-deficient knees behave the same, and how modern evidence supports structured non-surgical rehabilitation as a valid, and sometimes optimal, pathway. 

Trent explains the principles of effective ACL rehab, from heavy quadriceps strengthening and posterior chain development to neuromuscular control, progressive running, and change-of-direction drills.

This episode emphasises that non-surgical ACL rehab is not about minimal effort or toughness; it’s about building a knee capable of supporting the life and activities you want to enjoy.

Tune in to understand when surgery may be necessary, when rehab alone is sufficient, and how evidence-based care can guide better outcomes for ACL injuries.

Disclaimer: Before making any health changes, consult with a healthcare professional.

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Transcript

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Welcome to the RX Physiotherapy Podcast, your go-to destination for all things physio, rehab, health and wellness. I'm April Patterson and tr, and each week we will dive deep into fascinating topics within the health world. From physiotherapy to nutrition and beyond, we cover it all. So sit back, relax, and enjoy the journey as we explore the exciting world of health and wellness. Let's get started. For decades, we were taught one simple rule. If the ACL is torn, it can't work. That belief shaped an entire generation of treatment decisions, but modern evidence has forced us to soften that stance. Not all ACL deficient knees behave the same, and function is not dictated by anatomy alone. Gday t Trent Cooksley here from RX Physiotherapy, and this episode isn't about avoiding surgery. It's about understanding when non-surgical rehab is not only reasonable, but optimal. Now, the shift towards rehab. First, ACL care didn't come from theory, it came from outcomes. The pivotal moment was the Bel at our study published in New England Journal of Medicine. I mentioned this paper and studied. I believe in the second podcast, uh, of this little series, and highly recommend giving a little look as well. So patients who began structured rehabilitation and delayed surgical decision making had identical outcomes at both two and five year compared to early reconstructions. And half of the half of this group actually never needed surgery at all, which forced clinicians to ask if some knees function well with the out ACL, what actually is happening now? Early work by Fitzgerald and MLA introduced the idea of copa, those who function without instability and non cos, those who don't. But later research showed that these particular labels are fluid and not fixed. Studies by Etson and Grendon demonstrate that many non COPA early after surgery become functional after targeted rehab. So the question isn't, is this person a copa? It's more leaning down. Has the knee been trained yet? So non ACL rehab is what? It's not minimal. It demands heavy quadricep loading, um, posterior chain development, deceleration and braking capacity, and also chuck in a bit of acceleration capacity. And there are two along with progressive running and change of direction, um, drills as well. Work by grinderman l uh, um, repeatedly show that quadricep strength is one of the strongest predictors of fraction regardless of surgical status. So we can kind of assume if strength is restored, ability often follows. One of the biggest fears around non-surgical care is instability. But instability isn't always structural. Research by Ki and Murray highlight that neuromuscular control plays a major role in dynamic stability. A knee can feel unstable because the muscles aren't strong enough. Timing is delayed and confidence is low. Rehab allows us to separate true mechanical instability from modifiable functional deficits. A common concern is long term damage within the knee, during non ACL, during non-surgical ACL rehab. Now longitudinal work by low manar and later work by. Shows that osteoarthritis risk remains elevated after an ACL injury with or without surgery. Uh, surgery doesn't protect the knee from degeneration. What seems to matter more is overall load management, uh, strength and maintenance and ongoing physical activity. Um, rehab doesn't increase risk. Poor preparation does. Now this matters, um, because some knees don't tolerate high demand sports, outer reconstruction. And our red flags this include reoccurring giving weight episodes, persistent swelling, so if the knees just really angry through the entire rehab, failure to regain overall strength. Um, so main things to look at there is that quad symmetry and quad strength symmetry. Um. Inability to trust the knee under fatigue in these cases. Sorry. Uh, rehab hasn't failed. It's, it's done its job by revealing the overall truth. Um, s becomes a be better informed, better timed, and often more successful due to the essentially prohibitation that has occurred. Over the, the three to six months that you will see, um, your ACL patients generally. So, non-surgical ACL rehab isn't about proving toughness. It's about building a need that can tolerate the life you want it to live. And some people need surgery and some people don't. The mistake is assuming that everybody does. And in the next episode, we're gonna have a little look into return to sport testing and why passing tests, uh, doesn't always mean being safe when it comes to return to sport. Cheers for listening once again, and I'll catch you in the next one.