ACL Tears
“POP” Now what?
This is an injury usually caused by a quick stop, pivot, cutting movement or just landing awkwardly – The ACL tear. As you lie on the ground clutching your knee, what goes through your head?
This is a common scenario for soccer players and often leads to a lost season, months of physiotherapy, and an uncertain future.
Once you get a diagnosis you may be faced with two options: 1. Surgical management (repair followed by physiotherapy) or 2. Conservative management (physiotherapy only)
As physiotherapists we are evidence based practitioners, which means we must stay current in terms of the research supporting the latest treatment interventions for different pathologies. We are always asking the questions : “why?”, “has this been proven?”, “in what populations does this work?”.
A 2016 Cochrane review concluded that there was no difference in patient reported knee outcome scores for function at 2 years and 5 years post-injury between people that had surgery and people who didn’t. 1 What we know is that 20% of people who undergo surgical repair experience another rupture within 2 years, and over 50% of people that try a conservative approach go on to have surgical repair within 5 years anyway because of instability. With any surgery to the knee and with instability we have increased risk of osteoarthritis. So, what are you supposed to do?
To help us answer that question there was a study done in 2018 that helped provide some guidance and give us insight into the long term sequelae of an ACL injury. 2 This study compared 50 individuals over 20 years. In this pair matched follow-up study, after 20 years there was no difference in knee osteoarthritis between those people that had a surgical repair and those that opted for nonsurgical treatment. Treatment was allocated based on the patient’s response to a trial of 3 months of physiotherapy. Knee stability was better in the group that had surgery but that did non translate into better subjective or objective outcomes.
- Monk, A. P., Davies, L. J., Hopewell, S., Harris, K., Beard, D. J., & Price, A. J. (2016). Surgical versus conservative interventions for treating anterior cruciate ligament injuries. Cochrane Database of Systematic Reviews, (4).
- van Yperen, D. T., Reijman, M., van Es, E. M., Bierma-Zeinstra, S. M., & Meuffels, D. E. (2018). Twenty-year follow-up study comparing operative versus nonoperative treatment of anterior cruciate ligament ruptures in high-level athletes. The American journal of sports medicine, 46(5), 1129-1136.
M Chui | Apr 6, 2019 at 12:23 am
So why they still are doing surgery?
Janice | Apr 7, 2019 at 11:11 am
Taking an evidence based approach we can not ignore the patient’s values and preferences. While surgical and nonsurgical treatments have similar outcomes, we need to examine the individual needs of our patients. A sedentary individual who isn’t involved in high impact sports would be a good candidate for conservative management (physiotherapy only). Someone more athletic who is loading their knee more would probably benefit more from a surgical approach (reconstruction and physiotherapy)
Marcus | Apr 6, 2019 at 6:18 pm
Thanks for this information
Janice | Apr 7, 2019 at 11:09 am
We still need more research to refine the clinical algorithms needed to identify who may be the best candidate for a surgical approach as opposed to a nonsurgical approach after an anterior cruciate injury.
Uri | Apr 7, 2019 at 10:35 am
Aren’t surgical techniques better now than they were 20 years ago?
Janice | Apr 7, 2019 at 11:09 am
Not a lot has changed since 2000. Rehab protocols are similar and failure rates the same:
Arthroscopy. 2016 Nov;32(11):2357-2363. doi: 10.1016/j.arthro.2016.04.016. Epub 2016 Jun 8
The prevalence of OA 10 years post injury is reported as the same in 2019 as it was in 2009:
Lie, M. M., Risberg, M. A., Storheim, K., Engebretsen, L., & Øiestad, B. E. (2019). What’s the rate of knee osteoarthritis 10 years after anterior cruciate ligament injury? An updated systematic review. Br J Sports Med, bjsports-2018.
Frank PT | Apr 16, 2019 at 6:55 am
I tore my ACL last Spring playing rugby and decided to have a recosntruction which was done in August. I had an ACL rupture without any other damage and prior to surgery had pretty good function – full range of motion. However, when I would attempt any higher level dynamic movements like cutting, my knee buckled. With physical therapy, the incidence of buckling decreased, but most of the studies out there noted return to moderate level activities, whereas I wanted to return to playing rugby and football. So after taking everything into consideration, I went for the surgery.
So, from my experience I don’t think that everyone who tears their ACL requires surgery. If the patient is returning to higher level activities, it may benefit them. But if they just want to go back to regular exercise, they may not need it. It’s always difficult to generalize study findings to the general population, as we all know. I’ve had physical therapist colleagues question my decision to have surgery because of what the research says. Based on my personal goals, and impairments, I think the surgery was the right decision.
Janice | Apr 16, 2019 at 6:58 am
Thanks for sharing your experience Frank. It’s important to examine the patient’s goals when weighing treatment options.