Non-operative Anterior Cruciate Ligament management – to do or not to do?
Have you just ruptured your Anterior Cruciate Ligament and are unsure of what the best management is? Are you hesitant about having surgery? The good news is, there may be another option for you.
What is the ACL, and what does it do?
The knee is a hinge joint and the anterior cruciate ligament (ACL) with other ligaments connect the thigh and shin bone. The ACL is a dense bundle of connective tissue, and its primary role is to provide stability to the knee. It does this by limiting the amount the shin bone can move forward on the thigh bone.
Traditionally, surgery via an ACL reconstruction is the primary treatment to manage a rupture. This is done by using the patella, quadriceps, or hamstring tendon to create a new ACL. Australia has the high rates of reconstruction in the world (Zbrojkiewicz, Vertullo and Grayson 2018).
This article aims to highlight the benefits of a non-operative approach to ACL ruptures. It should be noted that there is limited high-quality evidence in the form of systematic reviews and randomised control trials when comparing ACL reconstruction to non-operative management.
What are common misconceptions about surgery?
The progressive nature of Australia’s healthcare system has meant it is easy to access early surgery. However, this has meant that we have become dependent on early surgery as a quick fix for many musculoskeletal conditions and the benefits of physiotherapy and exercise is not always explored.
Many are unaware that the recurrence of a subsequent ACL rupture is still high, particularly in the first 2 years post op (Paterno et al. 2012). It is common to think that you can’t return to cutting and pivoting sports with an ACL deficient knee however a comprehensive rehabilitation protocol enables the musculoskeletal system to compensate for ligament laxity.
It is becoming more common for a non-operative approach to be used as recent systematic review has shown similar outcomes pain, symptoms, quality of life and function measured by the KOOS. This review also showed a higher prevalence of radiographic knee OA in the surgical group. (Monk et al. 2016). Another systematic review showed there was no difference in knee stability and return to sport participation (Smith et al. 2010)
This is not to say that surgery is useless, in certain circumstances, ACL reconstruction is necessary, but it is essential to know what those circumstances are.
So, what makes you the right candidate for non-op?
At bounceREHAB we can assess your knee using specific outcome measures. These include strength testing, hop tests, the incidence of knee instability, and self-reported knee function questionnaires. We will then refer you to a surgeon with the results of the assessments to decide on the best management for you.
Below are the assessments results for someone who would be suitable to conservative trial management of the ACL.
So how can the team at bounceREHAB help?
The process using conservative management is like rehab post-reconstruction. However, you may progress through faster as you aren’t recovering from surgery and rehabbing a graft site in conjunction.
A typical protocol looks something like this:
What are the risks?
There is a possibility that non-operative management won’t work for you but the benefits of having a long prehab period before surgery has enormous benefits compared to going straight into early surgery. Literature compared early surgery vs structured rehabilitation plus delayed ACL reconstruction if needed on the outcomes of pain, symptoms, function in sports and quality of life (Frobell et al. 2010). This trial (KANON) showed patients who received early ACL reconstruction were prognostically worse across those domains compared to the non-surgical and delayed surgical arms at 12 months. At 2 years post there was no difference in scores.
It should be noted that the knee suffers secondary trauma due to the surgical drilling through intra-articular structures, a period of prolonged joint inflammation and altered weight bearing.
In Summary, at bounceREHAB we believe that a multidisciplinary team approach is key for your health care. In working with your GP and Surgeon we can help guide the best decision for rehabilitation after an anterior cruciate ligament injury.
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Frobell, R., Roos, E., Roos, H., Ranstam, J., & Lohmander, L. (2010). A Randomized Trial of Treatment for Acute Anterior Cruciate Ligament Tears. New England Journal Of Medicine, 363(4), 331-342. doi: 10.1056/nejmoa0907797
Monk, A., Davies, L., Hopewell, S., Harris, K., Beard, D., & Price, A. (2016). Surgical versus conservative interventions for treating anterior cruciate ligament injuries. Cochrane Database Of Systematic Reviews. doi: 10.1002/14651858.cd011166.pub2
Paterno, M., Rauh, M., Schmitt, L., Ford, K., & Hewett, T. (2012). Incidence of Contralateral and Ipsilateral Anterior Cruciate Ligament (ACL) Injury After Primary ACL Reconstruction and Return to Sport. Clinical Journal Of Sport Medicine, 22(2), 116-121. doi: 10.1097/jsm.0b013e318246ef9e
Smith, T., Davies, L., & Hing, C. (2009). Early versus delayed surgery for anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Knee Surgery, Sports Traumatology, Arthroscopy, 18(3), 304-311. doi: 10.1007/s00167-009-0965-z