Can athletes still perform at an elite level without an ACL? The answer may surprise you. While surgical reconstruction is often the go-to solution for athletes aiming to return to high-demand sports, a deep dive through the newest research suggests that conservative (non-surgical) management can be just as effective. In fact, many elite athletes have proven that a successful career is possible without undergoing ACL reconstruction. In this article, we’ll explore the ACL’s function, common injury causes, and the range of recovery options, including stories of athletes who reached the top of their game without an ACL.
Understanding the ACL: Function and Role
The ACL (anterior cruciate ligament) is one of the four main ligaments in the knee and plays a key role in stability. It connects the thigh bone (femur) to the shin bone (tibia) and restricts forward movement and excess rotation, making it crucial in sports with frequent cutting, pivoting, or quick directional changes.
Key Functions of the ACL:
Controls forward movement of the tibia.
Stabilizes the knee during rapid directional changes or deceleration.
Prevents excessive rotation in pivoting activities.
Who Tears Their ACL and How?
ACL tears often happen in high-demand sports, such as soccer, basketball, skiing, and football. Female athletes are at higher risk due to anatomical and biomechanical differences, as well as hormonal influences.
Common Injury Mechanisms:
Quick Changes in Direction: Pivoting with the foot planted can strain the ACL.
Sudden Stops: Abrupt decelerations, common in basketball or soccer, increase ACL stress.
Improper Landings: Awkward knee angles during jumps can cause the knee to collapse inward.
Direct Impact: Forceful hits, such as a tackle, can tear the ACL.
Rehabilitation Options: Conservative Management vs. ACL Surgery
While ACL reconstruction is common for athletes wanting to fully restore knee stability, conservative management is a valid alternative. Emerging research now compares outcomes like knee pain, function, range of motion, joint stability, return-to-sport time, and osteoarthritis (OA) rates between surgical and non-surgical ACL patients.
What Did the Research Find?
The studies show no significant difference between surgical and non-surgical groups in terms of knee pain, function, range of motion, jumping ability, or ability to return to sport. The non-surgical group did experience increased joint laxity (movement), but this did not impair knee function. Surprisingly, studies found that non-surgical patients did not have higher rates of osteoarthritis or additional knee damage. In fact, one study found that surgical patients had a higher risk of OA long term.
For some athletes, conservative treatment led to faster recovery times, fewer complications, and less re-tears (obviously) than the surgical route. However, knee laxity can be a barrier, as many participants in these studies scored lower on confidence questionnaires pertaining to their knee abilities comparatively to their surgical counterparts.
Conservative Management: A Realistic Option for Some Athletes
Non-surgical rehab programs emphasize strengthening the muscles around the knee, including the quadriceps, glutes, and hamstrings, to compensate for the ACL’s role in stability. With the right approach, history has shown us that some athletes can continue performing at high levels, even without an intact ACL.
Athletes Who Excelled Without an ACL:
Mickey Mantle: Baseball legend Mickey Mantle tore his ACL during a World Series game in his rookie season in 1951. Due to the time frame, ACL surgery was not commonplace, so he was forced to rehabilitate the knee conservatively. The man nicknamed: “The fastest player to first base” managed to carve out a legendary Hall of Fame career spanning 18 seasons, all without his right ACL.
John Elway: Legendary NFL quarterback John Elway tore his ACL back in high school. He went the non-surgical route and carved out a Hall of Fame career winning two Super Bowls. Equally impressive, he missed a total of 9 games due to injury during his 15 year career
Jimmy Hitchcock: NFL cornerback Jimmy Hitchcock played his entire career without an ACL in either leg. He opted out of surgery after tearing both ACLs in high school. The respected defender went on to play 8 NFL seasons, leading the league in interceptions in 1998.
DeJuan Blair: The 6ft 7in power forward tore both of his ACL's during his high school basketball days. He had surgery to try and repair the ligaments however they didn't take and later investigation confirmed he was without either ACL. The former Spur went on to play a 450 game NBA career without an ACL in either leg.
Hines Ward: Two-time Super Bowl champion Hines Ward played 217 NFL games as a wide receiver without an ACL in his left knee. Fun fact, Hines found out he had a torn ACL during his NFL combine when they tested his knee laxity. Despite advice to get it repaired, the future Superbowl MVP decided to continue his career status quo. Evenly impressive, he completed an Ironman triathlon post-retirement.
Joe Namath:“Broadway Joe” Namath tore his ACL during his college years at the University of Alabama. Despite opting for a non-surgical, conservative approach, Namath led his team to a national championship and secured his spot as a promising NFL prospect. During his NFL career Namath opted for surgery but his college accolades were achieved sans ACL.
Tyjae Spears
If you’re looking for a current example, look no further than current Tennessee Titans running back Tyjae Spears. In high school Tyjae tore his right ACL, opted for surgery and tore it again in college. He opted not to repair it which ultimately hurt his draft stock during the combine. The 23 year old entered the league in 2023 and played his entire rookie season injury free. He is currently competing in his sophomore season as an integral part of the Titans run game this season.
Peter Wallace: Rugby player Peter Wallace tore his ACL during the 2014 season. The Scotsman opted for surgery however the reconstruction was ultimately unsuccessful. He decided to rehab his knee instead and played his final two seasons of his 13 year career without an ACL before retiring in 2018
Connor McDavid
No Connor did not tear his ACL, however he tore the closest ligament to it. In 2019 the NHL superstar managed to tear his PCL, meniscus, and fracture his fibula in the final game of the season. While surgery was advised, he opted for an extensive rehab plan instead. Not only did he return to lead the NHL in scoring 6 short months later, repeat imaging revealed that his PCL had spontaneously reattached its fibres.
Although the ACL and PCL differ in specific function, both ligaments connect the tibia and femur, play key roles in knee stability, and are made of collagen fibres. This highlights the importance of exploring non-surgical options as viable treatments for elite athletes with knee ligamental injuries.
What Does Surgical Reconstruction Entail?
For athletes seeking full structural stability, ACL reconstruction is currently the most common choice. This keyhole surgery typically uses a graft from the hamstring, patellar tendon or cadaver to replace the torn ligament. Recovery takes 9-12 months, with a focus on restoring range of motion, quad activation, muscular strength and return-to-sport functionality.
Will I Need to Wear a Brace to Play Sports or Run Again?
The short answer is no. Whether you choose surgery or conservative rehab, completing a targeted rehabilitation program focused on progressive loading and tissue adaptation can allow you to return to the activities you enjoy without needing a brace. While some may prefer wearing a brace for added confidence, it’s optional rather than essential.
Should I Get ACL Surgery?
In some cases surgery may be the best course of action. This article doesn't aim to discredit surgical intervention but rather to highlight the growing evidence supporting conservative rehab as a viable—and sometimes preferable—choice for ACL injuries. Surgery is often recommended by professionals, yet it’s important to consider that conservative management can offer impressive outcomes for both elite athletes and everyday individuals, allowing for full activity without compromising knee stability.
Making an informed choice is essential, and the right option depends on your personal goals, activity level, and injury specifics. Work closely with your physiotherapist and medical team to assess all factors and determine the best path for you.
Our Sources
Papaleontiou, A., Poupard, A. M., Mahajan, U. D., & Tsantanis, P. (2024). Conservative vs Surgical Treatment of Anterior Cruciate Ligament Rupture: A Systematic Review. Cureus, 16(3), e56532. https://doi.org/10.7759/cureus.56532
Tsoukas, D., Fotopoulos, V., Basdekis, G., & Makridis, K. G. (2016). No difference in osteoarthritis after surgical and non-surgical treatment of ACL-injured knees after 10 years. Knee Surgery, Sports Traumatology, Arthroscopy, 24(9), 2953–2959.
Monk, A. P., Davies, L. J., Hopewell, S., Harris, K., Beard, D. J., & Price, A. J. (2016). Surgical versus conservative interventions for treating anterior cruciate ligament injuries. Cochrane Database of Systematic Reviews, 4(4), CD011166. https://doi.org/10.1002/14651858.CD011166.pub2
Dunn, K. L., Lam, K. C., & Valovich McLeod, T. C. (2016). Early operative versus delayed or nonoperative treatment of anterior cruciate ligament injuries in pediatric patients. Journal of Athletic Training, 51(5), 425–427. https://doi.org/10.4085/1062-6050.51.5.11
Fink, C., Hoser, C., Hackl, W., Navarro, R. A., & Benedetto, K. P. (2001). Long-term outcome of operative or nonoperative treatment of anterior cruciate ligament rupture—Is sports activity a determining variable? International Journal of Sports Medicine, 22(5), 304–309.
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