What are your options?

The standard approach has been to get an early ACL reconstruction. This approach has been based on the belief that ACLs don’t heal and a reconstruction is required to stabilise the knee and therefore prevent further knee damage and ultimately reduce the chances of osteoarthritis (OA). 

 

You only have to switch on the sports news in Australia to hear about the latest sports star to do their ACL and the story will usually conclude with when they are scheduled in their surgery. If the top sports stars get it, it must be the best thing for your knee, right? The answer is a little more nuanced than that.

 

High quality research has called these assumptions and ultimately the early surgery approach into question. To judge whether any intervention, including surgery, works, we need high quality randimised controlled trials to reduce the chances of bias and other factors influencing the results. 

 

Out of the entire body of research into ACL reconstructions, Blom et al (2021) found only two randomised controlled trials looking at the clinical effectiveness of ACL reconstructions compared to exercise alone with an option for delayed surgery. Both of these studies showed that on average, early surgery was no more effective than exercise based rehabilitation with an option for delayed surgery. The advice based upon these studies is for most people to undergo a comprehensive, supervised exercise-based rehabilitation program for 3-6 months before deciding whether they need surgery or not. 

 

In addition to this research, we also have emerging research showing that ACLs can heal. The preliminary results are very promising but we do need more research in this area. As it stands now, early bracing to hold the knee in a bent position seems to increase the chances of the ACL healing. 

 

So currently your primary options are:

1. Early bracing of the knee followed by exercise based rehabilitation and an option for delayed surgery

2. Early exercise based rehabilitation with an option for delayed surgery 

3. Early reconstruction surgery followed by exercise based rehabilitation 

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But don’t you have to have a reconstruction to return to sport?

No, people have made a successful return to different sports with exercise based rehabilitation alone including the cutting and pivoting sports. Out of those that receive an ACL reconstruction, 65% return to their preinjury level and 55% return to competitive sports (Adern et al 2014). Re-injury rates are quite high with 20% who return to sport experience a second ACL injury (Wiggins et al 2016). 

 

As it stands, we have a paucity of high quality evidence comparing exercise based rehabilitation to ACL reconstruction for return to sport. Monk et al (2016) concluded that there is currently low quality evidence that there is no difference between ACL reconstruction and exercise rehabilitation and exercise based rehabilitation alone. 

 

So we don’t currently have evidence to say that ACL reconstruction provides superior results for return to sport. The current recommendations based upon the best available evidence for return to sport is to trial exercise based rehabilitation for 3-6 months. If your knee is performing well you may not require surgery and can return to sport once you pass all the criterion for return.  If you are still experiencing instability episodes then consider surgery. 

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Will a reconstruction help reduce the chances of meniscus (cartilage) damage?

There is a link between meniscus injuries (which is a layer of cartilage in your knees) and developing osteoarthritis (OA). So it is important to try and reduce the chances of further meniscus damage. ACL reconstruction is often theorised to stabilise the knee and reduce further meniscus damage. However, Ekas et al (2020) found there was no good evidence that ACL reconstruction reduces the chances of meniscus damage.

 

Does a reconstruction reduce your chances of osteoarthritis (OA)?

 

ACL reconstructions have long been promoted as reducing the chances of OA because of the belief that they prevent further knee injuries. However, when we look at the evidence, it is clear that ACL reconstructions do not reduce the chances of OA could be slightly higher post reconstruction compared to exercise rehabilitation alone (Frobell et al 2013; Lie et al 2019). 
 

Based on all this information, what is the best option for you?

 

The best option for you will depend on many factors including the nature of your injury and other associated injuries, your goals, preferences, timeframes, desire to return to sports, value you place on long term knee health etc. 

 

As it stands, the recommendations based on the best available evidence are as follows.

 

The only high quality RCTs on the topic do NOT support early reconstruction as superior. As such it is prudent to recommend a period of exercise therapy before considering surgery. In addition, pre operative rehabilitation improves post surgical outcomes in those that go on to have a reconstruction. For those that still experience functional instability after exercise therapy, a reconstruction may be of benefit. 

 

However, if you would like to explore the new bracing protocols that have shown very promising early results in helping to increase the likelihood of healing, Geoff can discuss these with you and see if you are a good candidate for healing. Please note that it is essential that if you go into a brace it is done early, ideally within 1 week of injury. Overall the decision about which is the best option for you is best made by you with all of the information. 

 

At Be Strong Physio we are passionate about informing you with all of the latest, high quality information to aid you in making the best decision for you and your long term health and happiness. 
 

Evidence based ways to reduce the chance and impacts of OA 

If you are concerned about the long term impacts and want to reduce your chances of osteoarthritis, the good news is there are several risk factors that are modifiable. 

 

The three main modifiable risk factors are:

1. Increased body weight

2. Reduced lifetime physical activity levels

3. Weak quadricep muscles

 

At Be Strong Physio we can work with you to help you find ways to stay active and participate in physical activity. We will help you accurately measure you quadriceps strength using dynamometers and help you work on sustainable exercise programs that you can perform to keep your quads strong and body healthy. 

 

Supervised, high level exercise based rehabilitation must form the cornerstone of either option 

There is high quality evidence that shows that no matter which option you end up choosing, high quality, supervised exercise rehabilitation will result in far better results both in terms of return to sport but also your satisfaction levels with your knee and long term health. 

 

The research shows that rehabilitation must be intense, comprehensive and return to sport must be based upon meeting criteria such as relative symmetry showing that your affected knee and leg are as strong and can perform as well on functional tests. 

 

Your rehabilitation program will be individualised based upon your own impairments and the goals you are working towards. 

 

Some of the common exercises that will be included are:

• Resistance training for your whole body with a particular focus on single leg work to work on symmetry of your leg strength and performance.  

• Resistance training will typically start with lower weight higher repetition work and will progress to heavy strength work with lower repetitions.

• It will include balance and proprioception work.

• Graduated return to jumping, hopping, running, cutting, pivoting, decelerating and sport specific training etc. 

 

The exercise based rehabilitation needs to be incredibly thorough, detailed and intense to ensure that you achieve relative limb symmetry and to set you up for either a return to sport or for whichever physical activities you choose to continue to participate in as well as reduce long term knee health issues.  

 

If you have an old ACL injury, what can you do to improve your knee and overall health?

If you have an old ACL injured knee, whether you had a reconstruction or not, you will benefit from keeping your leg and whole body strong and active. At Be Strong Physio we specialise in helping people of all fitness standards build up their fitness in a sustainable way.

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References

 

Ardern CL, Taylor NF, Feller JA, et al. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematicreview and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med 2014;48:1543–52.

 

Culvenor AG, Eckstein F, Wirth W, Lohmander LS, Frobell R. Loss of patellofemoral cartilage thickness over 5 years following ACL injury depends on the initial treatment strategy: results from the KANON trial. Br J Sports Med. 2019 Sep;53(18):1168-1173. doi: 10.1136/bjsports-2018-100167. Epub 2019 Feb 8. PMID: 30737199.

 

Filbay SR, Grindem H. Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture. Best Pract Res Clin Rheumatol. 2019 Feb;33(1):33-47. doi: 10.1016/j.berh.2019.01.018. Epub 2019 Feb 21. PMID: 31431274; PMCID: PMC6723618.

 

Filbay SR, Roemer FW, Lohmander LS, Turkiewicz A, Roos EM, Frobell R, Englund M. 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. Br J Sports Med. 2022 Nov 3:bjsports-2022-105473. 

 

Filbay SR, Ackerman IN, Russell TG, Macri EM, Crossley KM. Health-related quality of life after anterior cruciate ligament reconstruction: a systematic review. Am J Sports Med. 2014 May;42(5):1247-55. doi: 10.1177/0363546513512774. Epub 2013 Dec 6. PMID: 24318609.

 

Frobell RB, Roos EM, Roos HP, Ranstam J, Lohmander LS. A randomized trial of treatment for acute anterior cruciate ligament tears. N Engl J Med. 2010 Jul 22;363(4):331-42. doi: 10.1056/NEJMoa0907797. Erratum in: N Engl J Med. 2010 Aug 26;363(9):893. PMID: 20660401.

 

Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ. 2013 Jan 24;346:f232. doi: 10.1136/bmj.f232. PMID: 23349407; PMCID: PMC3553934.

 

Lie MM, Risberg MA, Storheim K, Engebretsen L, Øiestad BE. What’s the rate of knee osteoarthritis 10 years after anterior cruciate ligament injury? An updated systematic review. Br J Sports Med. 2019 Sep;53(18):1162-1167. doi: 10.1136/bjsports-2018-099751. Epub 2019 Apr 1. PMID: 30936063.

 

Monk AP, Davies LJ, Hopewell S, Harris K, Beard DJ, Price AJ. Surgical versus conservative interventions for treating anterior cruciate ligament injuries. Cochrane Database Syst Rev. 2016 Apr 3;4(4):CD011166. doi: 10.1002/14651858.CD011166.pub2. PMID: 27039329; PMCID: PMC6464826.

 

Saueressig T, Braun T, Steglich N, Diemer F, Zebisch J, Herbst M, Zinser W, Owen PJ, Belavy DL. Primary surgery versus primary rehabilitation for treating anterior cruciate ligament injuries: a living systematic review and meta-analysis. Br J Sports Med. 2022 Aug 29:bjsports-2021-105359. doi: 10.1136/bjsports-2021-105359. Epub ahead of print. PMID: 36038357.

 

Wiggins AJ, Grandhi RK, Schneider DK, et al. Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Am J Sports Med 2016;44:1861–76.