Ep 6: Can the ACL heal on its own?

For decades, we’ve believed the ACL cannot heal. But modern research is changing the narrative. 

In this episode, Trent Cooksley from RX Physiotherapy explores the healing potential of ACL injuries, why some knees recover without surgery, and how rehab-first approaches can guide smarter decisions. 

Learn why MRI appearance doesn’t tell the whole story, and how function, not perfection, determines long-term outcomes. 

If you or someone you know is navigating an ACL injury, this episode will help you make evidence-informed choices. 

🎧 Tune in to learn how better testing and smarter rehab strategies can help athletes return to sport with greater confidence and lower risk of re-injury.

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've said one sentence with absolute confidence the ACL does not heal. And for a long time that statement made sense. Early surgical observations showed retracted ligament ends, poor clot formation, and minimal visible healing. So the conclusion became doctrine. But modern imaging, improved rehab protocols and long term outcome data have forced us to update. In that statement, the more accurate version is most likely this and should be this. Some acls don't heal, some partially heal, some heal enough to function, and the imaging proves it. Good day. Trent Cooksley here from RX Physiotherapy here for the final episode for your ACL series. And this episode we're gonna be diving into the healing capacities of the ACL and trying to yet again, kind of slow the surgical route decision. So what do we mean by healing? Um, this me matters because healing doesn't mean normal. In muscu musculoskeletal medicine, healing means structural continuity, functional low tolerance, acceptable symptom control. RI based studies have shown that anatomical perfection is not required for function. Work by Phil Bay and Croley has consistently shown that patient report. A function often doesn't correlate directly with imaging appearances. So when we talk about ACL healing, we're really asking can the knee function safely and repeatedly underload? Now, the first evidence that changed the dogma of ACLS came from. Costa Paz Etal in 2012. They followed patients with ACL tears managed non-surgically, and found that from MRI evidence of ligament continuity, uh, restoration of fiber alignment and functional knee stability. These weren't isolated cases. They were repeatable findings, uh, import. Importantly, these patients weren't just resting, they were undergoing structured rehabilitation. Now, this suggests that, um, that the a CO had some level of biological healing capacity, uh, under the right conditions. Now, tear location matters, proximal versus distal. As not all ACL tears are equal. Uh, a major contribution came from Al List and the Felice, uh, who studied their location using MRI and Arth arthroscopic. Uh, they found that proximal ACL tears had significantly higher healing potential distal and mid substance tears healed less reliably. This makes sense. Biologically, uh, proximal tears retain better blood supply. The ligament remains closer to the femoral, um, footprint. Imaging didn't just show healing. Definitely helped to predict which, uh, ACL injury had better chances of healing and which ones that had a little lesser chance of success. More recently structured rehab first approaches have produced consistent imaging findings, studies examining patients managed using principles similar to the Melbourne ACL rehabilitation guideline have shown reduced retraction of the ligament ends, uh, improved fiber continuity on MRI, functional stability without reconstruction. Now this aligns with work by Murray Fleming, uh, who demonstrated that ACL does possess, uh, intrinsic healing potentials, but requires controlled loading, early swelling management, and avoidance of prolonged immobilization. Uh, healing is not passive. It's load dependent. Now, function versus appearance. Which matters more? Here's where clinicians must be careful. MRI Healing doesn't guarantee success and a lack of perfect healing doesn't guarantee failure. Long term outcome studies by Bel and Fill Phil Bay show that function and quality of life can be excellent without an anatomical perfection. Surgical knees can still have poor outcomes. Imaging is a piece of the puzzle, and it's not a decision maker. Uh, the real question is, does the knee tolerate the demands of the person's life when healing is unlikely? And. Surgery is smarter. Uh, the evidence is just important. Healing is less likely when there are recurrent giving away episodes. Persistent effusions, uh, remaining. Despite rehab, high demand pivoting, sports is non-negotiable and the strength fails to recover in these cases. Non-surgical rehab hasn't, hasn't failed. It's essentially identified, uh, the limits of, um, adaptation surgery becomes targeted and not reactive. So let's update the sentence. Uh, the ACL doesn't heal becomes some acls can heal well enough to function if managed correctly. Rehab first care isn't about optimism. It's about evidence informed patients. The goal is isn't to avoid surgery, it's to choose it for the right reasons, at the right time, and for the right knee. And this that's where modern a CO care finally becomes personalized. Now, I hope you've enjoyed this series on ACLS and gained a little bit more knowledge, hopefully being able to slow down the, the processes and decision making, uh, when it comes to ACLS and ACL injuries. Hopefully you've enjoyed listening and you've learned a little bit about it. Cheers, bye.