ACL tears – to repair or not to repair?

ACL TEARS – NON SURGICAL MANAGEMENT

DENISE GODFREY

Recently in the media, there have been many articles discussing the significant rates of unnecessary surgery being performed in Australia.

Trials to determine the effectiveness of surgery are generally of a poorer quality than other specialties as blinding is difficult, patients and/or surgeons are biased to one treatment and surgical interventions are difficult to standardise.

In Australia, 10,000 people have knee reconstructions each year.  We reconstruct 90% of ACL ruptures.  Current World Best Practice is in Scandinavia where only 50% are reconstructed.  Various studies have attempted to identify those people that are “copers” and more likely to do well with rehab and no surgery.

They demonstrate these signs:

  1. Less than one episode of giving way
  2. Over 50% of unaffected leg testing with 6 metre timed hop test (a test of dynamic knee stability). Even with a ruptured ACL, many people (after having 10 sessions of rehab) can hop quickly along a 6m line to 80% of capability of non-injured leg.
  3. Over 80% on a self-reported scale of function and global knee function (Kelly Fitzgerald, Hurd – University of Delaware)
  4. Tend to be people who are less fearful.

Non-copers tend to be people who exhibit profoundly altered movement patterns after ACL injury characterised by bracing and stiffening the knee (Hurd et al 2005).

It is believed however that “non copers” can become “copers” with rehab training in 70% in the “non-copers” group.  Hurd et al. report that “the reason behind patients decision to opt for surgery may in fact relate to strategy and pre-existing preferences rather than ability to cope.”

Some people fear that by not having the ACL repaired they may cause further damage to the knee but a 10 year follow up study comparing conservative versus operative treatment of ACL ruptures by Meuffels et al. (2009) in the British Medical Journal reported finding “no statistical difference between the patients treatment conservatively or operatively with respect to osteoarthritis, or meniscal tears of the knee, as well as activity level, objective and subjective functional outcome”.

There are many similar studies –

American Medical Journal of Sports Medicine by Hege Grindem et al. (2012) found that “operatively treated patients DID NOT have significantly different rates of returning to pivoting sports after 1 year in a pair matched cohort study.”

An English Premier League soccer player even returned to paying 8 weeks after tearing his ACL.  He had no surgery, just rehab.  That’s not to say everyone does manage to return to high intensity, contact sport (some studies suggest around 56%) but the percentage is similar for surgical or non-surgical management.

In conclusion, every individual needs to know the options available to them.  Having other ligament or meniscus damage, being in the older populations, or a history of previous trauma all need to be considered in your decision in going for surgery or staying non-operative but we would suggest a trial of about 3 months intensive rehab prior to making this decision.  Surgery can be undertaken at any time.  Our bodies have an amazing ability to heal even the ACL! MRIs taken after several months do show healing of some ACLs.

As Physiotherapists, we are experts in working you through your rehabilitation progress, allowing you to do most of it in your own gym at your pace.  We closely monitor and adjust your exercise program along the way to help you reach your maximum potential and return you to your goals!