When you see an orthopaedic surgeon, you may assume you’re headed for the operating theatre. So it can be quite a surprise when they recommend the gym!
Although some musculoskeletal conditions definitely require surgery, many can be managed conservatively, either initially or completely. That’s why, in most cases, I begin by considering what can be done right now, without surgery, to help reduce pain, restore function and offer long-term joint protection.
Understanding conservative care
Conservative management of orthopaedic conditions does not mean passively resting, taking pain relief and hoping for the best. Rather, it refers to a comprehensive, evidence-based program designed to address specific clinical goals, which may include improving strength, range of motion, load tolerance, movement control and proprioception.
Exercise therapy is the cornerstone. Across a broad range of musculoskeletal conditions, from hip and knee osteoarthritis to shoulder pathology, structured exercise programs are recognised for their ability to reduce pain and improve function. In some cases, non-surgical management may delay or reduce the need for operative intervention.
At my clinic, conservative care is coordinated across a multidisciplinary team of medical specialists, physiotherapists and exercise physiologists. Weight management, activity modification, bracing, manual therapy, and targeted strengthening all have a role.
Can the ACL heal without surgery?
In short, there are occasions when the ACL can heal without surgery. The KANON trial was one of the earliest, widely published papers that showed some patients can do very well without surgery. That being said, patient selection is key, and there are times when practitioners are missing the signs that surgical reconstruction is the patient’s most reliable pathway forward. Put simply – it should never be all or nothing. An individualised approach to ACL treatment is necessary for every patient.
ACL reconstruction (or, in some cases, ACL repair) remains the appropriate path for many patients, particularly those with persistent instability or high athletic demands. But the KANON trial does reinforce a principle central to my approach: the decision to operate should never be automatic.
Prehabilitation
Prehabilitation refers to structured exercise, education and conditioning undertaken before an operation to optimise your physical and psychological readiness. It’s usually done when surgery is planned, but conservative care can naturally transition into prehabilitation if it becomes clear that surgery is needed.
A 2023 systematic review and meta-analysis encompassing 48 trials and 3,570 patients across a range of orthopaedic procedures found that prehabilitation significantly improved:
- Preoperative function, health-related quality of life, and muscle strength
- Postoperative function in the short to medium term.
Prehab also addresses the psychological dimension of surgery. A study of prehabilitation in patients planning a total knee replacement found that the exercise program significantly improved their mental health before surgery.
Joint preservation
Maintaining a native joint may be preferable to replacing it, particularly in patients who are still highly active. Joint preservation encompasses a range of surgical and non-surgical techniques used to protect the native joint, improve mechanics and delay progression where possible.
In the knee, osteotomy, or surgical realignment, is one of the most established joint-preserving procedures for patients with osteoarthritis affecting one side of the joint. Rather than replacing the joint, the procedure realigns the leg to shift load away from the damaged compartment. A recent systematic review reported long-lasting improvements in patient-reported function.
Careful planning, modern imaging and refinements in surgical technique are helping make joint preservation more accurate, personalised and relevant for active patients seeking to maintain function.
A care pathway that works with you
What I have described is not a rigid algorithm but rather a philosophy of care that places the patient and their goals at the centre.
A sustained conservative program keeps some patients out of the operating theatre. For others, a joint-preserving procedure is the right next step. And for those who have reached the point where surgery is appropriate, prehabilitation helps improve conditioning before surgery.
Musculoskeletal pain and joint degeneration do not have to be things you simply endure. With the right team and the right plan, one that takes your injury, your age, your activity level and your goals seriously, there is almost always something meaningful that can be done.
If you’re unsure where to start, an orthopaedic consultation is a sensible first step: not because surgery is necessarily on the table, but because a thorough assessment gives you the information you need to make good decisions about your care.
Disclaimer
All information is general and not intended as a substitute for professional advice. Any surgical or invasive procedure carries risks.
References [Accessed 29 May 2026]
- Holden, M. A., Metcalf, B., Lawford, B. J., Hinman, R. S., Boyd, M., Button, K., Collins, N. J., Cottrell, E., Henrotin, Y., Larsen, J. B., Master, H., Skou, S. T., Thoma, L. M., Rydz, R., Wellsandt, E., White, D. K., & Bennell, K. (2022). Recommendations for the delivery of therapeutic exercise for people with knee and/or hip osteoarthritis. An international consensus study from the OARSI Rehabilitation Discussion Group. Osteoarthritis and Cartilage, 31(3). https://doi.org/10.1016/j.joca.2022.10.009
- Lewis, J. (2016). Rotator Cuff Related Shoulder pain: Assessment, Management and Uncertainties. Manual Therapy, 23(23), 57–68. https://doi.org/10.1016/j.math.2016.03.009
- Filbay, S. R., Roemer, F. W., Lohmander, L. S., Turkiewicz, A., Roos, E. M., Frobell, R., & Englund, M. (2022). Evidence of ACL healing on MRI following ACL rupture treated with rehabilitation alone may be associated with better patient-reported outcomes: a secondary analysis from the KANON trial. British Journal of Sports Medicine, 57(2). https://doi.org/10.1136/bjsports-2022-105473
- Filbay, S. R., Roemer, F., Roos, E. M., Turkiewicz, A., Frobell, R., Lohmander, L. S., & Englund, M. (2025). Association Between ACL Continuity on Magnetic Resonance Imaging at 5 Years After an Acute ACL Rupture and 11-Year Outcomes: A Secondary Analysis From the KANON Trial. The American journal of sports medicine, 53(8), 1893–1900. https://doi.org/10.1177/03635465251339061
- Punnoose A, Claydon-Mueller LS, Weiss O, Zhang J, Rushton A, Khanduja V. Prehabilitation for Patients Undergoing Orthopedic Surgery: A Systematic Review and Meta-analysis. JAMA Netw Open. 2023;6(4):e238050. doi:10.1001/jamanetworkopen.2023.8050
- Ndjonko, L. C. M., Jose, J. M., Nair, N. S., Paska, J., Tagoe, J. A., Hoang, R., & Novicoff, W. (2025). Prehabilitation for Total Knee Arthroplasty: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Journal of Orthopaedic Reports, 100580. https://doi.org/10.1016/j.jorep.2025.100580
- Dal Fabbro, G., Grassi, A., Agostinone, P., Lucidi, G. A., Fajury, R., Ravindra, A., & Zaffagnini, S. (2024). High survivorship rate and good clinical outcomes after high tibial osteotomy in patients with radiological advanced medial knee osteoarthritis: a systematic review. Archives of orthopaedic and trauma surgery, 144(9), 3977–3988. https://doi.org/10.1007/s00402-024-05254-0
