[ literature review ]

YONATAN KAPLAN, PT, MSc (Med)1

Identifying Individuals With an

Anterior Cruciate Ligament-Deficient
Knee as Copers and Noncopers:
A Narrative Literature Review
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D
espite the thousands of published articles on anterior cruciate agement.3,5,29,39 Nearly 25 years ago, the
ligament (ACL) injury, how to determine which individuals well-known “rule of thirds” was proposed
for ACL injuries treated with rehabilita-
may or may not be candidates for surgical intervention remains
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

tion.53 It stated that one third of indi-

to be established. Two treatment options, nonoperative viduals can resume previous recreational
management or reconstructive surgery, are available for an individual activities without reconstruction (“cop-
with ACL deficiency (ACLD).13,42 Con- Previous studies have reported poor in- ers”), one third can manage without re-
troversy exists as to which intervention dividual outcomes after nonoperative construction by modifying/lowering their
results in a more successful functional management of ACL injury, further re- activity level (“adapters”), and one third
outcome for individuals with ACLD.43 inforcing a preference for surgical man- require reconstruction because of recur-
rent giving-way episodes in activities of
daily living (“noncopers”).
TTSTUDY DESIGN: Narrative literature review. was based on the terms “anterior cruciate ligament
Journal of Orthopaedic & Sports Physical Therapy®

Very few randomized or quasi-ran-

TTOBJECTIVES: First, to explore the differences
and outcomes between individuals who have had
anterior cruciate ligament (ACL) reconstruction
and those who did not undergo surgical interven-
tion, following a tear of the ACL. Second, to review
the evidence related to the ability to identify
individuals who may or may not need surgery after
an ACL rupture. Finally, to describe the differences
between copers and noncopers.
TTBACKGROUND: ACL rupture may result in
increased tibiofemoral laxity and impaired neuro-
muscular function, which ultimately may lead to
knee instability and dysfunction. Individuals who
opt to choose surgery due to these changes may
be defined as “noncopers.” Conversely, those in-
dividuals who have an ACL-deficient knee without
functional impairment and instability and suc-
cessfully resume preinjury activity levels without
surgical intervention may be defined as “copers.”
TTMETHODS: An electronic search was conducted
up to April 2011, using medical subject headings
and free-text words. The subject-specific search
reconstruction versus conservative treatment,”
“copers,” “noncopers.”
TTRESULTS: A similar percentage of copers and
noncopers return to sporting activity. Three papers
used an algorithm and screening examination
involving individuals with ACL injuries. Evidence
suggests that, as opposed to copers, noncop-
ers have deficits in quadriceps strength, vastus
lateralis atrophy, quadriceps activation deficits,
altered knee movement patterns, reduced knee
flexion moment, and greater quadriceps/ham-
string cocontraction.
TTCONCLUSION: ACL screening examina-
tion showed preliminary evidence for detecting
potential copers. Objective differences exist
between copers and noncopers. Individuals with
ACL injury should be informed of the possibility
of good knee function following a nonoperative
rehabilitation program. J Orthop Sports Phys Ther
2011;41(10):758-766. doi:10.2519/jospt.2011.3384
TTKEY WORDS: ACL, clinical decision-making
algorithm, instability
domized clinical trials address the basic
question as to whether an ACL rupture
necessarily requires surgical reconstruc-
tion. Despite this, the vast majority of or-
thopaedic surgeons in the United States,
where more than 200 000 ACL recon-
structions are performed annually at a
cost of $3 billion,65 advocate early surgi-
cal intervention when managing patients
with ACL rupture who wish to resume
high-level sports activities.29 The figures
in Europe are probably somewhat less,
with no overall data reported. In Sweden
for example, 3000 ACL reconstructions
are performed annually.63
This standard of practice of perform-
ing ACL reconstruction is influenced by
both a high return-to-sport rate after
surgery and the assumption that resum-
ing jumping, cutting, and pivoting sports

Director, Jerusalem Sports Medicine Institute, Lerner Sports Center, Hebrew University of Jerusalem, Jerusalem, Israel. Address correspondence to Yonatan Kaplan, Jerusalem
1

Sports Medicine Institute, Lerner Sports Center, Hebrew University of Jerusalem, Churchill Str 1, Mount Scopus, Jerusalem, Israel. E-mail: sportmed@zahav.net.il

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41-10 Kaplan.indd 758 9/21/2011 4:41:45 PM

 without ACL reconstruction will inevita-
bly result in knee instability. There is also Articles identified through database Additional articles identified
searching, n = 84 through other sources, n = 16
easy access to surgical facilities and wide-
spread private health insurance coverage
of the procedures.37 Nevertheless, there is
no evidence to date that clearly establish-
es that noncopers, as determined soon af-
ter an ACL injury, should be excluded as
Articles after duplicates removed,
rehabilitation candidates.49 n = 96
There is no consensus, based on objec-
tive criteria, on when, if at all, an indi-
vidual should return to high-level sports Articles excluded, n = 12
after ACL reconstruction or nonoperative
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treatment.49 The benefit of early ACL re-

construction to regain the desired activity
Articles screened, n = 84
level and contribute to subjective well-
being is, therefore, not obvious. Contin-
ued high athletic demands after an ACL
Articles excluded, n = 19
rupture have been reported to eventually
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

lead to meniscal damage, articular car-

tilage damage, and degenerative arthri-
Full-text articles accessed for
tis,54,61 although this has not been clearly eligibility, n = 65
demonstrated.46,47,55,60 It seems, from the
literature, that the primary indication for
FIGURE 1. Flow diagram showing study selection.
individuals with an ACL injury to have
had ACL reconstruction is to restore knee
stability and enable return to the desired 2011: Cochrane Central Register of Con- Sports Medicine and European Society
activity level. However, few studies have trolled Trials (CENTRAL), MEDLINE, of Sports Traumatology, Knee Surgery,
Journal of Orthopaedic & Sports Physical Therapy®

shown that ACL reconstruction actually
restores dynamic knee stability (more
simply understood as not giving-way) or
enables full return to preinjury activity
level in most individuals.20,62
The primary objectives of this nar-
rative literature review are as follows:
to explore the differences and the out-
comes between individuals who have
ACL reconstruction and those who have
not undergone surgical intervention; to
review the evidence related to the ability
to identify individuals who may or may
not need surgery after an ACL rupture;
and to describe the differences between
EMBase, CINAHL, and the Musculosk-
eletal Injuries Group’s specialized regis-
ter. The subject-specific search was based
on the terms “anterior cruciate ligament
surgery versus conservative treatment,”
“copers,” and “noncopers.” The search was
restricted to studies that included human
participants and were published in Eng-
lish. The reference list of relevant articles
was also reviewed to identify additional
publications not identified in the formal
search strategy.
RESULTS
and Arthroscopy. Removal of duplicates
left a total of 96 potential articles, from
which 12 articles were excluded for not
meeting the inclusion criteria, as set forth
in the Methods section, and a further 19
articles were excluded for their poor re-
search quality. The balance of 65 full-text
articles were thus reviewed, of which 5
were randomized controlled trials (RCTs)
dealing specifically with the topic of oper-
ated versus nonoperated individuals and
copers versus noncopers.
Definitions: Copers, Noncopers, and
Adapters

T
copers and noncopers. he results of the literature
search are summarized in FIGURE
METHODS 1. The literature search identified
84 articles, and 16 additional articles
ACL injury potentially has deleterious
effects on knee muscle function, knee ki-
nematics, knee stability, and propriocep-
tion.40 While the majority of individuals

T
he author undertook a comput-
erized bibliographic database search
within the medical and allied health
literature. The following databases were
searched from their inception to April
were identified through other sources,
such as communication with content ex-
perts in the field of ACL screening and
rehabilitation and the 2010 conference
proceedings of the American College of
with an ACL-deficient knee lack dy-
namic knee stability, some seem to have
the ability to dynamically stabilize their
knee, even during pivoting sports activi-
ties.10,21,32,37 These individuals may be de-

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41-10 Kaplan.indd 759 9/21/2011 4:41:46 PM

 [ literature review
fined as copers, in that they are able to
resume all preinjury activities, including
sports, without episodes of knee giving-
way, and do not require surgery.56,64 Nu-
merous researchers have included their
own variations to this basic definition.
The Delaware group stipulated that this
ability to participate must continue for
at least 1 year after ACL injury,35 while a
Swedish group further specified that the
copers must be able to return to function
at a high level (level 1 sports: jumping,
cutting, pivoting)14,19 at least weekly after
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injury, without complaint of instabil-
ity.24,25,40 Noncopers, on the other hand,
have been defined as individuals who
either did not return to their previous
activity level or experienced giving-way
episodes on resumption of preinjury
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
activities.16,49,57,58,64 A third category of
those described as “adapters” consists
of individuals who have been defined as
demonstrating more than 3 mm of side-
to-side difference in ACL laxity at initial
examination.15 This definition is, howev-
er, problematic, as laxity measurements
have been reported to have little predic-
tive value in differentiating between cop-
Journal of Orthopaedic & Sports Physical Therapy®
ers and noncopers.16,56,64 These so-called
adapters represent the vast majority of
individuals with ACLD who are man-
aged nonoperatively and are able to avoid
evoking episodes of instability by modify-
ing their activity levels.
Differences Between Copers and
Noncopers
Researchers have investigated whether
differences exist between copers and
noncopers and whether clinicians can
identify those patients who may be able
to cope with ACLD.31 Evidence suggests
that potential copers, identified by a
screening examination, have movement
patterns consistent with those of indi-
viduals who have good functional knee
stability (ie, not giving way), as opposed
to noncopers.12 It has been reported that
true copers had significantly less ante-
rior tibiofemoral knee joint laxity, fewer
giving-way episodes, significantly higher
activity level, and greater improvement in
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41-10 Kaplan.indd 760
Knee Outcome Survey activities of daily
living scale and International Knee Doc-
umentation Committee2 scores compared
to true noncopers at a 1-year follow-up.49
No statistically significant differences
between true copers and true noncopers
were observed for any of the single-leg
hop tests. A small sample of noncopers
who performed hop tests displayed re-
duced knee range of motion and exter-
nal knee flexion moments as opposed
to copers.58 Noncopers walked with sig-
nificantly reduced knee compression and
shear forces versus controls.1 Copers per-
formed better (P<.05) than noncopers on
all 4 hop tests.16 Diminished quadriceps
control was observed when people with
ACLD performed static and dynamic
tasks.58 The most striking feature of this
impaired control was failure to turn the
quadriceps off when performing flexion
tasks in which the knee extensors are
usually silent. The findings suggest that
poor control of quadriceps activation
after ACL injury is relatively consistent.
Noncopers exhibit a stiffening strategy,
consisting of lower sagittal plane knee
motion and knee moments and higher
muscle cocontraction, in comparison
with their contralateral limb and indi-
viduals without injuries, to maintain
knee stability in the absence of ligamen-
tous support. Conversely, potential cop-
ers have movement patterns somewhere
between those of individuals without
injuries and those of noncopers.56 In a
recent publication,9 it was reported that,
at 4 months postinjury, noncopers had
poorer gait performance compared to
copers for kinematics and time-distance
variables. Noncopers seem to utilize a
common abnormal movement pattern of
lower knee extensor loading even during
unanticipated tasks. 33 Functional out-
comes further suggest that a subgroup of
noncopers require additional supervised
rehabilitation to pass stringent criteria to
return to sports.28
Studies have revealed significant dif-
ferences in angle-specific knee torque
values between potential copers and
noncopers (P<.05).6,17 Moderate to strong
]
associations were noted between angle-
specific torque values and single-leg hop
performance, but only for noncopers (r =
0.32-0.58). It was concluded that angle-
specific quadriceps muscle torque values
measured at less than 40° of knee flexion
provide more information on the quad-
riceps strength deficits after ACL injury
than the commonly used peak torque val-
ues. Two studies have analyzed electro-
myographic patterns of individuals with
ACLD during an unanticipated cutting
task during walking. Individuals in the
coper group preferentially used a par-
ticular vastus lateralis and medial ham-
strings activation pattern at a frequency
more than twice that observed in the
control group.33,34 The noncoper group,
compared to the control group, also pref-
erentially used a medial hamstrings acti-
vation pattern more than twice as often
and utilized a distinct medial hamstrings
and lateral hamstrings activation pattern.
Can Noncopers Become Copers?
Currently, most noncopers are referred
for surgery35,49 without testing whether
it might be possible for them to become
true copers and to avoid a surgical proce-
dure and the ensuing lengthy rehabilita-
tion process. The first published RCT on
the topic indicated that noncopers who
received perturbation training combined
with a standard nonoperative ACL reha-
bilitation program had a greater increase
in Lysholm Knee Rating Scale scores af-
ter training than subjects who received
only the standard program.7 A more
recent RCT trial studied 26 individuals
with acute ACL injury or rupture of an
ACL graft, who were randomly assigned
to either a standard rehabilitation pro-
gram (standard group) or the standard
program augmented with a perturbation
training program (perturbation group).22
Results of this study led to the conclusion
that augmenting nonoperative ACL re-
habilitation programs with perturbation
training techniques may enhance the
probability of a successful return to high-
level physical activity by reducing the risk
of continued episodes of giving-way of
9/21/2011 4:41:47 PM

All diagnosed ACL tears 1985-
1989, n = 200
Year 0 100 ACL tears included
Year 3 Unilateral nonreconstructed
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ACL tear at 3 y, n = 87
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Year 15 Unilateral nonreconstructed
ACL tear at 15 y, n = 67
FIGURE 2. Flow chart showing patient’s movement through the study. Reprinted with permission from Kostogiannis
et al.40 Abbreviation: ACL, anterior cruciate ligament.
the knee during athletic participation.
Journal of Orthopaedic & Sports Physical Therapy®
This allows individuals to maintain their
functional status for longer periods. More
recently, following a preoperative pertur-
bation training program, it was shown
that noncopers who received perturba-
tion training and progressive quadriceps
strength training had more symmetrical
strength and knee movements 6 months
postoperatively compared to noncopers
who received strength training alone.27 A
similar study was conducted using per-
turbation training on potential copers.11
It was found that perturbation training
reduced quadriceps femoris hamstring
muscle and quadriceps femoris gastroc-
nemius muscle cocontractions and nor-
malized knee kinematics.
Surgery Versus Conservative Treatment
In 2005, a Cochrane review published by
a Finnish group44 concluded that there
was insufficient evidence from random-
ized trials to determine whether surgery
or conservative management was best for
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41-10 Kaplan.indd 761
Not included:
• Tegner 10, n = 5
approximately
• Explicit wish for
reconstruction, n = 3
• Etc (for details see text)
Excluded, n = 11:
• Reconstructed, n = 8
• Bilateral tears, n = 3
Excluded, n = 16:
• Reconstructed, n = 13
• Bilateral tears, n = 3
Lost to follow-up, n = 6
ACL injury in the 1980s and that there
was no existing high-level evidence to
advise current practice management. A
more recent systematic review explored
the prognosis of conservatively managed
ACL injury.51 The authors concluded
that, on average, individuals with an iso-
lated ACL tear or an ACL tear with an
associated injury (eg, torn meniscus)
reported good knee function (87/100
on the Lysholm Knee Scale) at a 12- to
66-month follow-up. On average, func-
tional performance assessed with the
hop-for-distance test was in the normal
range. From preinjury to follow-up, there
was a reduction in Tegner activity level
of 21.3%. According to the methods used
in the assessed studies, individuals with
a conservatively managed ACL tear have
a good short- to medium-term prognosis
in terms of self-reported knee function
and functional performance. However,
individuals reduced their activity levels
by 21%, on average, following injury.
A closer look at the literature involv-
ing the sports population reveals an in-
teresting picture. In 1 study, at a 6- to
11-year follow-up, 18 of 22 (82%) com-
petitive handball players treated with-
out reconstruction returned to their
preinjury activity level, compared to 33
of 57 (58%) in those who had ACL re-
construction.32 The conclusion of this
paper was not that conservative man-
agement is better but that the return to
preinjury level of play following an ACL
injury is limited, irrespective of manage-
ment. This study predominantly included
women as compared to men (50 to 29),
which is not typical of most studies. In
a group of 38 former college or high
school athletes with chronic ACL injury,
a low rate of functional limitations was
reported.54 In a review of follow-up stud-
ies on the treatment of ACL injuries, the
rate of return to preinjury activity level
ranged from 8% to 82% in patients who
had undergone reconstruction, and from
19% to 82% in patients who did not have
reconstruction.52
Randomized Controlled Trials
Although many reviews related to ACLD,
copers, and noncopers were retrieved,
only 3 RCTs compared surgical and non-
surgical treatment. The first 2 RCTs as-
sessed surgical reconstruction of the torn
ACL,4,59 and the most recently published
RCT26 compared 2 strategies for manag-
ing an ACL tear in a population of non-
elite athletes. The authors of the latter
concluded that in young, active adults
with acute ACL tears rehabilitation plus
early ACL reconstruction was not superi-
or to rehabilitation plus optional delayed
ACL reconstruction. The latter strategy
substantially reduced the frequency of
surgical reconstructions. Two observa-
tional studies have shown similar out-
comes for patients who underwent ACL
reconstruction.48,49
Algorithms and Screening Examination
As some individuals have the potential to
manage well without an ACL reconstruc-
tion following an ACL injury, the chal-
lenge in the management of patients with
9/21/2011 4:41:48 PM
 [ literature review ]
Concomitant injuries:
• Bilateral injury, n = 57
All patients, n = 832 No participation, n = 85
• Multiple ligament, n = 66
• Other, n = 25

All others, n = 599

Chondral defect/repairable
MRI
meniscus, n = 167

Unresolved
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Prescreen rehabilitation, n = 432 impairments, ACLR, n = 87

n = 87

ACLR , n = 198
Screening examination, n = 345 NC, n = 199
No ACLR, n = 1
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

ACLR, n = 53

PC, n = 146
Lost to follow-
up, n = 5

Failed
Rehabilitation, n = 88 rehabilitation, ACLR , n = 5
n=5
Unknown RTS,
Journal of Orthopaedic & Sports Physical Therapy®

ACLR, n = 2
n=2
Pass rehabilitation, n = 83
Failed RTS,
ACLR, n = 13
n = 13

Adapters, n = 5 Pass full RTS, n = 63

No ACLR, ACLR, n = 1 No ACLR, n = ACLR, n = 36 Lost to follow-

n=4 25 up, n = 2

FIGURE 3. Treatment and screening examination algorithm outcomes. Abbreviations: ACLR, anterior cruciate ligament reconstruction; MRI, magnetic resonance imaging; NC,
noncoper; PC, potential coper; RTS, return to sports. Reprinted with permission from Hurd et al.35

ACL injury is to develop an algorithm or
screening examination that effectively,
soon after injury, identifies copers and
noncopers.35 The intention would be to
create a tool that could potentially identify
those individuals who, early after an ACL
tear, may have the potential to return to
preinjury activity level for a limited time.23
Three published papers have reported on
the use of an algorithm and screening ex-
amination with that goal in mind,35,40,50
and are specifically discussed below.
The Swedish Group Study
A team of Swedish investigators fol-
lowed 200 individuals with ACL inju-
ries over a 15-year period and reported
on the individuals who had unilateral
nonreconstructed ACL tears (FIGURE 2).40
Their main hypothesis was that good
knee function and a satisfactory activity
level could be achieved by early activity
modification and neuromuscular reha-
bilitation, thereby limiting the need for
reconstruction surgery.
Their primary findings were that good
subjective results and a satisfactory activ-

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41-10 Kaplan.indd 762 9/21/2011 4:41:49 PM

 ity level can be achieved in the majority
of patients, limiting the need for ACL
reconstruction in these patients to only
23%. Early activity modification, neuro-
muscular rehabilitation, and a gradual
return to activities resulted in good knee
function and an acceptable activity level.
Approximately 60% of the patients re-
sumed their preinjury activity level with-
in 3 years of injury and an additional 12%
decreased their activities by just 1 level.
The results achieved with the Swedish
group’s specific treatment algorithm are
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similar to those presented in studies of
surgically treated individuals, both at me-
dium- and long-term follow-up.45,65 The
authors concluded that because a high
proportion of patients can cope with-
out reconstructive surgery, it is better to
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
adopt a restrictive attitude towards early
surgical reconstruction.40
The Delaware Group Study
A team of investigators from Delaware
published a 10-year prospective study35
involving the largest group (832) of high-
ly active individuals with subacute ACL
tears.35 Their main objective was to uti-
Journal of Orthopaedic & Sports Physical Therapy®
lize a treatment algorithm and screening
examination to guide individual manage-
ment and determine potential for highly
active individuals to succeed with non-
operative care. Concomitant injury, un-
resolved impairments, and a screening
examination were used as criteria to guide
management and to classify individuals
as noncopers or potential copers for non-
operative care (FIGURE 3). The individuals
who met all inclusion criteria completed
the screening examination a mean of 6
weeks after injury. Potential copers were
classified as individuals who met all of
the following criteria at the screening ex-
amination: (1) hop test index of 80% or
more for the timed 6-meter hop test, (2)
Knee Outcome Survey activities of daily
living scale score of 80% or greater, (3)
global rating of knee function of 60 or
greater, and (4) no more than 1 episode
of giving-way since the injury.21 Potential
noncopers were classified as those who
did not fulfill the above criteria.
journal of orthopaedic & sports physical therapy  |  volume 41  |  number 10  |  october 2011  |  763
41-10 Kaplan.indd 763
Baseline, n = 125
Follow-up, n = 102
Nonoperated, n = 52
Return to Did not return
preinjury to preinjury
activity activity
level, n = 36 level, n = 16
FIGURE 4. Flow chart of the subjects throughout the study. Reprinted from Moksnes et al.49 Abbreviation: ACL,
anterior cruciate ligament.
There were 199 (58%) individuals
who were classified as noncopers and 146
(42%) as potential copers. On completion
of the study, only 25 (39%) of those who
returned to sports did not undergo surgi-
cal reconstruction. The final figures show
that 89% (308/345) of the initial group
were known to have gone on to surgery,
whereas, only 7% (25/345) did not. The
other 4% were lost to follow-up. They
concluded that their classification algo-
rithm was an effective tool for prospec-
tively identifying those individuals who,
early after ACL injury, wanted to pursue
nonoperative care or had to delay surgical
intervention and had good potential to do
so. Seventy-two percent of the potential
copers who elected nonoperative man-
agement were able to successfully return
to preinjury sports activities without fur-
ther episodes of instability or a reduction
in functional status. Thirty-six (57%) of
these potential copers ultimately had re-
Contralateral ACL injury, n = 1
Moved abroad, n = 4
Lost to follow-up, n = 8
ACL reconstruction within 1 y
prior to follow-up, n = 10
ACL reconstructed, n = 50
Return to Did not return
preinjury to preinjury
activity activity
level, n = 35 level, n = 15
construction surgery.
Despite this, the authors strongly
encouraged all patients identified as po-
tential copers who elect nonoperative
management to do so only after par-
ticipating in rehabilitation that includes
perturbation activities. These may be
understood as activities that challenge
balance, such as standing on an unsta-
ble surface or responding to externally
applied forces. Their stated intention,
with development of the screening ex-
amination, was to identify individuals
who might be successful with short-term
(ie, 6 months or less) nonoperative
management.
The Norwegian Group Study
The third and final group50 carried out a
2-year prospective cohort study (FIGURE
4) consisting of 125 patients with ACL
injuries who were participating in level 1
(jumping, cutting, pivoting) and 2 (heavy
9/21/2011 4:41:50 PM
 [ literature review
physical work, skiing, or tennis) sports at
the time of injury.30
Their screening examination con-
sisted of (1) the timed 6-meter hop test,21
(2) the Knee Outcome Survey activities
of daily living scale,36 (3) the global rat-
ing of knee function assessed by a visual
analogue scale,21 and (4) determining the
number of episodes of giving-way since
the injury.21 Screening was performed
within 6 months of injury. On analysis,
the positive predictive value of classifica-
tion as a potential coper at the screening
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examination was 60% (95% CI: 41%,
78%), while the negative predictive value
of the classification was 30% (95% CI:
16%, 49%). This showed that, for all ele-
ments of the prognostic accuracy profile,
the results were not statistically signifi-
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
cant, as the 95% CIs included the null
values for the statistics. The null values
for sensitivity, specificity, and positive
and negative predictive values were all
50%, indicating that the level of prognos-
C
tic accuracy was no different than ran-
dom occurrence. Therefore, the screening
examination had a poor predictive value
for correctly classifying copers and non-
Journal of Orthopaedic & Sports Physical Therapy®
copers at the 1-year follow-up, bringing
into question the use of this screening ex-
amination and criteria to determine who
should have surgery after ACL injury.
Their investigation provides prelimi-
nary support for the possibility that a
significant proportion of individuals who
are initially considered as potential non-
copers may be able to regain dynamic
knee stability similar to potential copers.
One year after the screening examina-
tion, 60% of those originally classified as
potential copers were true copers, while
70% of the individuals initially classi-
fied as potential noncopers were also
true copers. Individuals who underwent
ACL reconstruction, as well as those who
followed a conservative rehabilitation
program, showed excellent results on
functional questionnaires at the 1-year
follow-up exam. Thus the Norwegian
group’s study has provided a scientific
rationale for not excluding potential non-
copers from nonoperative treatment soon
764  |  october 2011  |  volume 41  |  number 10  |  journal of orthopaedic & sports physical therapy
41-10 Kaplan.indd 764
after the injury.
The most recent of the papers18 con-
cerning the value of the screening exami-
nation investigated whether functional
tests incorporated in the original screen-
ing examination could contribute to ex-
plaining those who later go through ACL
reconstruction. It also examined wheth-
er changes to the content or the time of
conducting the screening examination
(before or after 10 sessions of exercise
therapy), could improve its explana-
tory value. The authors concluded that
conducting the screening examination
after 10 sessions of progressive exercise
therapy gave the overall highest explana-
tory values, suggesting that the screening
examination should be conducted sub-
sequent to a short period of rehabilita-
tion to inform decision making for ACL
reconstruction.
DISCUSSION
ontroversy still exists over
whether good functional perfor-
mance can be achieved in the short
and long term in individuals with ACLD
who choose a conservative (nonsurgical)
management approach following injury.
The primary issue is whether these indi-
viduals can return to preinjury level of
play.
There is reasonable evidence to rec-
ommend that all individuals who sus-
tain ACL injury undergo preoperative
intervention, which includes the timely
application of the algorithm for an evi-
dence-based determination of the indi-
cation for surgical reconstruction. The
results presented above indicate that a
large percentage of individuals identified
as rehabilitation candidates, using the
treatment algorithm and screening ex-
amination, who elect nonoperative care
were able to delay surgery without expe-
riencing further knee instability. Reha-
bilitation of the injured knee takes time,
and there is a concern that excluding po-
tential copers from nonoperative treat-
ment may lead to unnecessary surgery
in a number of individuals and exclude
]
potential noncopers from significant pre-
operative rehabilitation.
The different knee joint loading pat-
terns observed between noncopers and
copers reflect the different walking strat-
egies adopted by these groups, which may
have implications for knee joint stability.
The strategy adopted by the copers may
reflect an effective way to stabilize the
knee joint during walking after an ACL
rupture and the key role that knee kine-
matics might play in this strategy. It is
clinically relevant to investigate if gait re-
training would enable noncopers to walk
in a manner similar to copers and thereby
improve their knee joint stability.
We still do not have the optimal set
of criteria to correctly assign individuals
with an ACL tear to the correct treatment
early after injury. No single outcome
measure is sufficient to determine the
functional status of individuals with
ACLD. Consequently, the KOS-Sport,
Global Knee Function Rating, hop tests,
and Quadriceps Index should all be in-
cluded when assessing these patients.31
Although perturbation training positively
influenced the negative effects following
ACL injury, it remains uncertain how
long these changes may last and what the
long-term outcomes are.
A few comments are warranted on
outcomes for young active adults with
an acute ACL tear who underwent reha-
bilitation followed by early ACL recon-
struction. Outcomes in this group were
not superior to those who underwent
rehabilitation followed by optional de-
layed ACL reconstruction. In fact, in that
study, the latter strategy substantially
reduced the frequency of surgical recon-
structions. However, long-term obser-
vational studies of early versus delayed
ACL reconstruction have shown that
delayed surgery may be associated with
a significantly greater rate of damage to
the meniscus, the articular cartilage, or
both.3,5,29,38,39,54,61
Given the growing evidence that ear-
ly-onset knee osteoarthritis is a risk after
ACL rupture, whether the injury is man-
aged operatively or nonoperatively,38,45,65
9/21/2011 4:41:51 PM
 we must question if surgical intervention
in an individual without symptoms has
become more a matter of usual practice
rather than evidence based. It seems that
the resumption of the previous activity
level following ACL tear may increase
the risk of future osteoarthritis, regard-
less of whether the ACL is reconstructed
or not.19,32,45,57 Individuals with the high-
est preinjury activity level seem to have
a higher probability of not returning to
their preinjury activity level. This may
possibly be due the fact that as many as
Downloaded from www.jospt.org at on November 23, 2015. For personal use only. No other uses without permission.
20% of them have fear of reinjury.41
It may be beneficial to compare or
weigh the benefits of operative versus
nonoperative management in this quest
to identify copers and noncopers. Not
specifically reviewed in this manuscript
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
are the potential complications related
to operative management, such as time,
costs, quality of life, and complications
such as arthrofibrosis, graft failure/re-
jection, and revisions. These are very im-
portant considerations when considering
surgery versus the potential consequenc-
es of nonsurgical management. Studies
with larger outcomes are necessary to
Journal of Orthopaedic & Sports Physical Therapy®
confirm the consequences of long-term
nonoperative management.
CONCLUSION
F
or individuals who injure their
ACL, choosing between surgical
or nonsurgical conservative man-
agement can be a complex decision. It
depends on lower extremity function/dy-
namic stability, the type and level of sport
activities, and the individual’s own inter-
est in modifying his/her activity level. For
those who choose to return to pivoting
sports, especially at a high level, surgery
still seems to be the preferred treatment.
Despite this generally accepted approach,
there are some individuals who may do
well without surgery, even at a high level
of function and sports participation. The
goal of determining who can do well with-
out surgical reconstruction has had sparse
attention in the literature and remains the
ultimate challenge of future research. t
journal of orthopaedic & sports physical therapy  |  volume 41  |  number 10  |  october 2011  |  765
41-10 Kaplan.indd 765
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