do you need surgery for an ACL tear? - PHYSIOTHERAPY COMPARED TO SURGERY FOR ACL TEARS AND RETURNING TO SPORT.
The ACL (Anterior Cruciate Ligament) is one of the stabilisers of the knee joint to prevent excessive movement.
It is typically injured if the knee excessively twists when turning to change direction or hyper-extension of the knee if it straightens too far.
Usually, this injury happens during non-contact incidents during sport but can also happen due to contact when other forces push the knee into these positions.
In Melbourne, most people have heard of ACL injuries given the popularity of sports like AFL, basketball, soccer and netball where sharp changes of direction are very common and there are many famous cases in elite sport.
We typically associate ACL ruptures with the need for surgical reconstruction and a lengthy period of rehabilitation before potentially returning to sport. Recently, people have started inquiring about non-surgical management of this injury.
An informed decision is important in determining whether to go with surgery and rehab combined or rehab on its own without surgery. There is no right or wrong, and research in physiotherapy and sports medicine has evolved and the case for non-surgical management can now be made.
IS SURGERY NECESSARY FOR ACL TEARS?
“ACLs can heal themselves”...Impossible, you may say!
Research suggests it is definitely possible.
In a recent study, out of 45 patients with either a fully ruptured or high grade ACL injury, 17 demonstrated clear improvement in ACL structure on MRI scan after 6-12 months of knee strengthening (Ihara, 2017).
WHICH IS BETTER LONG TERM - SURGERY + PHYSIOTHERAPY REHAB OR PHYSIOTHERAPY REHAB ONLY WITHOUT SURGERY?
Regardless of which management, there is an increased chance of osteoarthritis in the knee compared with before the injury.
To assist with decision making, the following is a summary of some of the research in support of non-surgical management of ACL ruptures when compared with surgical management:
1 year after ACL rupture:
Exercise-only athletes compared with ACL reconstruction athletes performed better on 2 out of 4 different single-leg hop tests. There was no difference between the groups in the other 2 tests (Moksnes, 2009).
Exercise-only athletes compared with ACL reconstruction + exercise athletes had less knee joint stability on testing, but better left vs right symmetry with hop tests. Both exercise-only and reconstruction + exercise athletes had the same rate of return to pivoting sports (Grindem, 2014)
5 years after ACL rupture:
There was no difference in multiple knee questionnaire scores between early reconstruction and exercise-only management. 50% of patients who went with initial exercise-only management went on to have the reconstruction later.
Authors concluded that “young active adult patients should consider rehabilitation as a primary treatment option” after an ACL tear (Frobell, 2015).
10 years after ACL rupture:
Patients who had surgical ACL reconstruction had better passive knee stability on examination, but there was no difference between patients treated operatively and non-operatively with respect to osteoarthritis or meniscal injuries and activity level (Meuffels, 2009)
20 years after ACL rupture:
There was no difference in osteoarthritis between surgical and non-surgical groups, and no difference in functional outcomes, although knee stability was still better in the surgical group.
In other words, the findings seen at 10-year follow-up were still maintained at 20 years post-injury (van Yperen, 2018).
SUMMARY OF PROS AND CONS:
Surgery + Physiotherapy rehab
Physiotherapy rehab only
Longer rehab time – minimum 10 monthsbefore back to sport
Need to rehab 2 sites - the new ACL and the structure from which the new ACL was taken (usually hamstring or patella tendon)
Greater financial cost
Greater muscle weakness
Chance of failure and re-reconstruction
Pain post-surgery and other uncommonpotential post-surgery complications
Reduced rehab time – can return in 6 monthsdepending on rehab
No surgical trauma
ACL can repair with rehab alone without surgery
Research is growing in support
Surgery is still an option should you do high quality rehab but have recurring incidents of instability/giving way in the future (“delayed surgery”)
No increased risk of futureosteoarthritis and meniscal issues according to current research, but it is theoretically possible
ELITE SPORT CASES:
Daniel Menzel (AFL): Total 4 reconstructions: Left x3, Right x1 – 2 failed left knee reconstructions
Alex Johnson (AFL): Total 6 reconstructions: Left x5, Right x1 – 4 failed left knee reconstructions
DeJuan Blair (NBA): ACL rupture in both knees during high school. Surgeries failed and he went on to play NCAA1 college basketball and NBA without an ACL in either knee.
Jessica Rich (Snowboarding): Ruptured ACL 1 month before 2018 Winter Olympics, medically cleared for Big Air event without reconstruction but not for Slopestyle
Phillippe Marquis (Skiing): Ruptured ACL 1 month before 2018 Winter Olympics, was scheduled for surgery but competed in Mogul skiing. Would have had no chance to compete if he had immediate surgery. Ended up having surgery after the Olympics as scheduled.
Yuvraj Singh (Cricket): Continued playing at international level without reconstruction. ACL healed with rehabilitation.
Whether to have surgery is a difficult decision to make, fortunately there is compelling support for non-surgical management. The choice is yours but regardless, a successful return to sport is possible with a thorough exercise rehab program.
How can we help you?
At Melbourne Sports Physiotherapy our goal is to get you moving pain free as soon as possible.
But, we also want you to actually move better and live a healthier, more active and fulfilling life!
If your sports, fitness training or work has been wearing your body down, book in with one of our expert massage therapists so we can help you reduce your pain or stiffness.
If you are showing some signs of this condition or simply want help prevent this from happening in the future then book in with one of our highly experienced Remedial Massage Therapists today!