Living Without an ACL: Challenges and Considerations

John Miller Physiotherapist

Article by John Miller

Living Without an ACL

Challenges and Considerations

An ACL (anterior cruciate ligament) injury significantly affects the stability of the knee joint, making specific movements difficult and increasing the risk of developing arthritis and cartilage tears. Living life without an intact ACL is possible. Still, it poses challenges, especially for athletes participating in high-demand sports that require quick and agile movements. These sports, called Level I sports, demand a functioning ACL at a higher level.

What are the High-Demand Level I Sports?

Based on the Cincinnati Sports Activity Scale (CSAS), a Level I sport was determined by the type of sport engaged in, with a minimum frequency of 1 to 3 days per week. Therefore, patients meeting the definition reported participating in sports involving jumping, hard pivoting, or cutting either 3 or 4 days per week (CSAS score of 100) or 1 or 2 days per week (CSAS score of 85). This definition aligns with the previously established Level I definitions reported by Hefti et al. and Daniel et al.

This article explores the implications of living without an ACL, the impact on daily activities, and the decision-making process for athletes considering surgery to return to their previous level of competition.

Knee Instability and Associated Risks

When the ACL is injured, the knee joint becomes less stable, leading to a sensation of the knee “giving out” or sliding too much during movement. This instability can be problematic as each episode may cause further damage to the knee cartilage, increasing the risk of developing knee arthritis and meniscus tears over time.

Limitations in High-Demand Level I Sports

High-demand sports such as AFL, football, soccer, netball, basketball, tennis, snow skiing, gymnastics, hockey, wrestling, and rugby rely on a functioning ACL for pivotal manoeuvres like cutting, pivoting, and sudden turns. Without a patent ACL, athletes encounter difficulties and challenges that may impede their performance and heighten the risk of additional injuries.

Daily Activities and Functionality

Individuals can generally perform non-pivoting, landing, or change of direction activities without experiencing episodes of knee instability or giving way.

Individuals can typically accomplish activities such as walking, running, cycling, swimming, and other low-impact exercises without significant issues. However, individuals should exercise caution during activities that involve sudden changes in direction or high impact to minimise the risk of instability and subsequent knee damage.

The Role of Surgery

Athletes aspiring to return to their previous level of competition often face a crucial decision regarding ACL reconstruction surgery. This surgical intervention aims to restore knee stability and improve functionality, enabling athletes to resume their sport with a reduced risk of instability and associated complications. Individuals should carefully consider the decision to undergo surgery, weighing the potential benefits against the risks, recovery process, and circumstances.


Daily activities without an ACL generally remain manageable, particularly activities that do not involve pivoting, landing, or abrupt changes in direction. However, the absence of an ACL can restrict an individual’s ability to fully participate in certain activities or sports, especially those demanding quick movements.

Athletes contemplating returning to their previous level of competition often choose ACL reconstruction surgery to restore knee stability and regain optimal functionality. They must make an informed decision about surgery, considering the potential benefits, risks, and circumstances.

Please consult your trusted knee sports physiotherapist or an orthopaedic surgeon for specific advice.

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