Key Points

• Copers are people who can return to full activity after an ACL injury; 20–30 percent of people can cope without surgery. ACL surgery is effective at reducing joint laxity; however, there is no difference in joint laxity between copers and noncopers.

• Noncopers can become copers through training, with proprioception, strength, and expectations about recovery being the most significant factors that distinguish copers from noncopers. This suggests the mechanisms by which hands-on bodywork might play a beneficial role in ACL injury recovery and coping.

On a bright blue day of Colorado skiing, I rounded a turn poorly and seriously hurt my knee. I began journaling about that experience the next day and shared the first part of my story in the May/June 2023 issue of Massage & Bodywork (“Knee Journal: A Personal Log of an Injury’s Progress,” page 30). That article was published before I knew exactly what kind of knee injury I had; this second installment brings things up to date.

Day 51—The Results

An MRI confirmed what I suspected: I tore my medial collateral ligament (MCL) in my ski accident. But it also showed what I’d hoped it wouldn’t: My anterior cruciate ligament (ACL) was completely ruptured. Not only that, but I had a complex tear of the medial meniscus.

I was hoping I had just injured the MCL. Being highly vascular and outside the joint capsule, the MCL usually heals well on its own (and the MRI showed that by now, mine was doing just that). But complete ACL ruptures and meniscus tears (being less vascular and sealed deeply within the synovial joint), aren’t typically thought to repair themselves without surgery.¹ And the young orthopedic physician’s assistant who clumsily (but correctly) assessed my ACL was sure I was going to want surgery “to stay active.”

I do want to stay active, but who wants surgery? My combination of knee injuries is known as the “unhappy triad,” because, according to various sources on the internet, athletes who sustain it “can become really unhappy” in the long process (nine months or longer) of recovering from the surgical repairs. Wikipedia tells me that other names for this injury include the “horrible triangle,” “the terrible triad,” or crudely, a “blown knee.” Just writing those out makes my knee hurt.

But hold on a minute: What does it mean that, “blown” or not, my knee doesn’t hurt anymore? It hurt a lot right after my skiing injury, and for a couple of weeks after, certain movements would make me nauseous with pain. But the pain improved quickly, my repertoire of nonpainful movements increased, and the more I had the courage to use my knee, the better it felt. My first tentative hike was less than three weeks after the accident, and at five weeks, I was walking brace-free. By six weeks, I was back to cautious running. And my knee did not feel unstable; uncertain was a better word, and that feeling was improving fast too. None of these activities made my knee hurt.

Now that I’ve learned I have a “blown knee,” I have to say that I feel even more hesitant when moving. You can’t unsee your MRI, as they say. But I’ll work with that. This isn’t the first thought-virus I’ve caught in the process, and my mental immunity seems to be building.

All that aside, do I need surgery or not?

Day 52—Waiting

Now that an MRI shows I’m a candidate for surgery, I can schedule a consultation with a surgeon to discuss the options. The wheels of the medical machine turn slowly—the earliest available appointment is more than two months out. Meanwhile, I’m going to read up.

Day 79—Coping with ACL Injuries

I’ve been seeking out knee-injury stories. They range from inspiring to terrifying.

• My brother-in-law Gordon ruptured his ACL many years ago and gets by fine without it. He even skis, using a brace for protection.

• Nikki, one of the assistants at Advanced-Trainings.com, also ruptured her ACL, and even without surgery, still felt confident enough that she began training for a triathlon. But, on a long, uphill run, she tripped and tore her meniscus so badly that surgery was really her only option. She thinks the second injury probably would have been less severe if her ACL had been intact. Even a few years after the resulting surgery, she’s not back to running and is not sure she will be—she still has some pain as well as a “psychological setback,” she says. She misses running.

The research I’ve been reading portrays a similar range of stories. Some people cope just fine after an injury like mine; others don’t. The differences between these two groups have been studied extensively, looking for clues that might help more people recover.

Copers, as we’re called, have better balance, strength, and higher confidence in our ability to return to our desired levels of activity than noncopers.²

Somewhere between 20 and 30 percent of us are natural copers—thanks to the specifics of our injury, our genetics, preexisting conditioning, luck, etc., we recover well enough to get back to our previous activities, even without surgical ACL reconstruction. But even noncopers can become copers. In a large study, about half of the noncopers who completed a 10-session strength and balance training regimen soon after their injuries became copers. They were able to resume their previous levels of activity without surgery. They also had better function two years later than those who didn’t train.³

One of the goals of ACL surgery is to help a noncoper become a coper by targeting joint laxity: The surgeon’s aim is to make the joint tighter by replacing the torn ligament. And although surgery is very good at accomplishing this biomechanical goal, it only helps about two-thirds of people return to their previous level of activity.⁴

That might be because coping is not related to joint tightness or laxity—it’s long been known that there is, in fact, no difference in ACL laxity between copers and noncopers.⁵ The main differences are proprioception, strength, and expectations. And fortunately, those are all things I can keep doing something about, surgery or not.

Day 114—Rapture Despite the Rupture

Exhilarated. Not quite four months after my knee injury, I cautiously tried skiing today. Both my wife and my ski buddy Dan made sure to tell me, several times each, to take it easy. They didn’t need to remind me; I was terrified. But I was also determined to test my knee as part of my decision about having surgery.

The first turn felt fine—zero pain, though plenty of anxiety and fear. The second turn felt even better. Gradually, my protectiveness diminished with each run, until the terror turned into ecstasy. I did 11 rapturous runs, even finishing the day on some mild bumps, with a huge smile on my face.

Day 118—The Surgeon

The day of my surgical consultation arrived. I selected the surgeon in my network with the most years of experience, combined with a large number of positive patient reviews. I know—reviews aren’t indicators of competence, but they’re not nothing either. People like this guy.

When he comes into the consulting room, he looks amiable and athletic. The first thing he notices are my minimalist shoes. “I wear that brand too,” he says. “What kind of work do you do?” When I tell him I train bodyworkers in advanced myofascial techniques, his eyebrows go up. He nods and says, “That’s important work.” I like this guy too and am ready to give him five stars already.

He walks me through the MRI. “These look like chronic injuries, not acute,” he says. “They don’t look how we’d expect them to if they had occurred when you had your ski accident. We’ll never know for sure, but it’s likely that most of what we’re seeing was already there.”

OK, that’s a surprise. I had assumed I already had some ligament damage from a wallyball injury 15 years ago, but I’d thought it was my posterior cruciate ligament (PCL). Oh, and there was that yoga injury where the instructor (notorious for his forceful approach) stood and bounced on my knees to push them to the floor. That, and a bunch of other knee-things in my 62 active years, might explain what we were seeing. And if I’ve been doing OK with those this long, maybe I don’t need surgery now.

What about my torn meniscus? Won’t it need surgery? It’s likely it was also already torn when I had my ski accident. Acute injuries tend to produce simple meniscal tears, but complex tears like mine are usually due to age-related wear and tear (so to speak). And, given what I am able to do (I do brag a little about my recent ski day), he didn’t consider me a candidate for meniscal surgery.

No surprise, and he didn’t have to convince me. I already knew that:

• Twenty percent of people over 50 years old with knee pain have a meniscal tear. But even more (25 percent of people over 50) without knee pain have a meniscal tear.⁶

• In a well-known study, meniscal surgery turned out to be no more effective than sham surgery (an incision and arthroscopy with no repair).⁷

• Knee surgery does have the benefit of decreased odds of a later meniscal injury but the downside of increased odds of knee arthritis, perhaps because of the inflammatory reactions to surgery itself.⁸

My surgeon ends the appointment by saying, “Somehow or another, you’ve been able to cope with your knee injuries.” Inwardly, I smile—I was waiting for him to say that word. “So why have surgery?” he concludes.

I’m good with that. The surgery option will be there for me, if I decide I need
it later.

Day 171—The Present

Almost six months after my injury, I’m still learning about my knee. I still exercise it every day. Sagittal-plane activities like running are no problem. Dancing is great too. I’m tentative with cutting, landing, or twisting motions. I’m working up to a pickleball experiment.

My experience’s influence on my hands-on work is still taking shape too. More clients with knee injuries have magically found their way into my practice. I’m puzzling together an approach that they seem to love. My knee-work is more delicate, precise, and informed. I put a knee “master class” on my teaching schedule this fall as a kind of deadline for having something useful to share, and I’ll be ready. But for now, there’s still plenty to learn about how to help.

And my knee-journal entries are less and less frequent. This one was written at 11,000 feet as I backpacked in the Rockies, blissing out on wildflowers and blue skies. I’m aware I’d be telling a very different story if my recovery hadn’t gone so well, and I owe a lot of that to luck—and to having so many options, including the option to have surgery. I’m feeling grateful both for my body and for the learning it affords me, so that I can better help others less fortunate than I’ve been.

Author’s note: Everyone’s decision about having surgery (or not) is their own to make, and everyone’s injury, pain, function, circumstances, and options are different. This is a log of my personal decision-making about my knee injury. It is not a recommendation to make the same decision. And as practitioners, we can best serve our clients by supporting their decisions. 

Notes

1. a) Though completely ruptured ACLs are not conventionally thought to be able to repair themselves, these two papers discuss spontaneous ACL reformation. The conditions under which this might happen, including age factors, etc., aren’t well established. Hidetoshi Ihara and  Tsutomu Kawano, “Influence of Age on Healing Capacity of Acute Tears of the Anterior Cruciate Ligament Based on Magnetic Resonance Imaging Assessment,” Journal of Computer Assisted Tomography 41, no. 2 (March/April 2017): 206–11, https://doi.org/10.1097/RCT.0000000000000515; Matias Costa-Paz et al., “Spontaneous Healing in Complete ACL Ruptures: A Clinical and MRI Study,” Clinical Orthopaedics & Related Research 470, no. 4 (April 2012): 979–85, https://doi.org/10.1007/s11999-011-1933-8.

b) The outer parts of the meniscus are more highly vascularized than the inner parts, and tears here are known to heal on their own.

2. M. E. Eastlack, M. J. Axe, and L. Snyder-Mackler, “Laxity, Instability, and Functional Outcome After ACL Injury: Copers Versus Noncopers,” Medicine & Science in Sports & Exercise 31, no. 2 (February 1999): 210–5, https://pubmed.ncbi.nlm.nih.gov/10063808/. 

3. Louise M. Thoma 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,” The American Journal of Sports Medicine 47, no. 4 (March 2019): 807–14,  www.ncbi.nlm.nih.gov/pmc/articles/PMC6546284. 

4. Thoma 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.” 

5. Eastlack et al., “Laxity, Instability, and Functional Outcome After ACL Injury: Copers Versus Noncopers.”

6. Newcastle Sports Medicine, “The Knee Meniscus: Torn Between Rehab or Surgery?” (January 15, 2018), https://newcastlesportsmedicine.com.au/knee/meniscus-injuries/.

7. Raine Sihvonen et al., “Arthroscopic Partial Meniscectomy Versus Placebo Surgery for a Degenerative Meniscus Tear: A 2-Year Follow-Up of the Randomised Controlled Trial,” Annals of the Rheumatic Diseases 77, no. 2 (May 18, 2017): 188–95, https://doi.org/10.1136/annrheumdis-2017-211172.

8. Robert J. Ward et al., “Meniscal Degeneration Is Prognostic of Destabilzing Meniscal Tear and Accelerated Knee Osteoarthritis: Data from the Osteoarthritis Initiative,” Journal of Orthopaedic Research (April 2023), https://doi.org/10.1002/jor.25575; Edward C. Cheung et al., “Osteoarthritis and ACL Reconstruction—Myths and Risks,” Current Reviews in Musculoskeletal Medicine 13, no. 1 (January 2020): 115–22, https://doi.org/10.1007/s12178-019-09596-w.