ACL Surgery - No more curves? - Physical Network (2023)

What evidence is there to support our decision on whether patients should undergo surgical or nonsurgical treatment after a cruciate ligament tear?

The best way for clinical readers to answer a specific question like this is through systematic reviews and meta-analyses that assess the highest standard of empirical evidence on the effects of interventions (Travers et al. 2019). Recent literature reviews have found similar results in nonsurgical and surgical groups in terms of pain, symptoms, function, return to athletic level, quality of life, subsequent meniscal tears and surgery rates, and radiographic prevalence of osteoarthritis (OA) of the knee (Smith et al. 2014, Delincé and Ghafil 2012, Monk et al 2016).

We know that randomized controlled trials (RCTs) are the ideal study design for musculoskeletal pain and injury when investigating the effectiveness of exercise therapy in non-essential surgical procedures. Ideally, a placebo surgical arm should also be used when testing procedures, with common elective surgeries for the knee, shoulder, and elbow now no better than placebo (Sihvonen et al. 2013, Beard et al. 2018, Kroslak and Murrell 2018). This has not yet been done in ACL injury, so physicians are urged to be skeptical, think critically, and consider the need for optional surgery, which has yet to be tested in a placebo-controlled study (Zadro et al. 2019).

It is almost inscrutable that a recent study by Kay et al. 2017 review found that only 1 of 412 randomized controlled ACL trials actually compared ACL reconstruction (ACL) to structured rehabilitation for acute ACL injury, with essentially every other study comparing different ACL surgeries and graft types against each other (Culvenor and Barton 2018). That single RCT, the famous KANON study (Knee Anterior Cruciate Ligament, Nonsurgical versus Surgical Treatment) by Frobell and colleagues (2013), recommended that their “results should encourage clinicians and active young adult patients to consider rehabilitation as a treatment option acute cruciate ligament rupture". Given the cultural trends in Western society up to this point in history - this is truly liberating, hopeful and revolutionary thinking!

Why do you think so many physiotherapists and athletes believe that surgery is necessary after a cruciate ligament tear?

This is a big, multi-faceted question, and it could almost be your own PhD! To me, three key drivers of this ideology are the beliefs surrounding the band itself, our current models of healthcare, and the mainstream media.

Our understanding of ACL tears has changed from "the anatomical job of the ACL is to do X, Y and Z, so let's try to replicate that surgically" to "what the best-designed studies show that the two Compare trial groups Reconstruct ACL and receive rehabilitation instead of just physical therapy and exercise? Better methodological rigor challenges what we used to believe.

We previously theorized that ACLR prevents OA and further meniscal damage compared to individualized, graded functional strengthening alone; We now recognize that this is a misconception unsupported by high quality science, with evidence that ACLR may actually increase the risk of OA

(Nordenvall et al. 2014, Culvenor et al. 2019, Filbay 2019). Studies also show that the ACL can heal if left alone (Ihara et al. 1994, Fujimoto et al. 2002, Costa-Paz et al. 2012), although it was previously thought impossible due to the lack of blood clot formation .

At least in Australia, where we have the highest reconstruction rates in the world (Zbrojkiewicz, Vertullo, and Grayson 2018), all of our public and private healthcare models are designed to expedite and fund early MRI, early surgical assessment, and early surgical assessment. Physical therapy and exercise as a "treatment and management" for ACL tears is not currently promoted, funded, or recommended by any government system or private insurance company; As such, both physicians and patients are simply unaware of the quality of research for the intervention they may be receiving.

There is widespread mass media alarmism and devastation when a player injures his knee on the pitch, with commentators often "fearing" the worst. Emotions arise as it is assumed that the athlete has injured the cruciate ligament and needs surgery and needs to refrain from sport for 9-12 months - this is a false narrative that we need to replace with a rational explanation of the more substantive data and encourage the players (and the general population) that many can function at an elite level without invasive surgery.

What does research suggest is the best treatment plan after a cruciate ligament tear?

Given the lack of high-quality studies showing additional benefits of reconstruction for physical therapy and exercise, the authors now highlight the "emerging notion that athletes with ACLR surgery may be overtreated but undertreated in terms of rehabilitation" (Grindem, Arundale, and Ardern 2018), therefore a culture shift away from early surgery to non-surgical treatment with surgery “as needed” is required (Zadro and Pappas 2018).

Another analysis by Filbay et al. (2017) of the KANON study showed that patients who received early ACLR had a poorer prognosis than non-surgical and late surgical arms in several areas because they suffered “second trauma” due to surgical piercing of the joint intrastructures, a period of prolonged joint inflammation and altered weight bearing (Bowes et al. 2019, Larsson et al. 2017).

We must devote our time to educating every patient after ACL injury through a shared decision-making process about this evidence and to underscore to them the concept of commitment and adherence to gradual, comprehensive and lasting rehabilitation with sustained preventive exercise after return to sport. We must challenge any belief that ACLR is a "quick fix" (Zadro and Pappas 2018) and emphasize the many benefits of immediate rehabilitation alone, ideally for at least 3 to 6 months, which has been called "world best practice". (Rooney 2018). The bottom line is that for many active patients, nonsurgical treatment remains a permanent, lifelong solution.

What should the rehabilitation process look like for someone undergoing non-surgical treatment? Similar to rehabilitation after ACL reconstruction?

The rehabilitation process is actually very similar, but the timeframes are expected to be significantly shorter since it does not require recovery from surgery or a transplant to be monitored. Non-weight bearing static stability tests such as Pivot Shift or Lachman are less relevant as they are now known to have poor correlation and functional stability between them (Snyder-Mackler et al. 1997, Hurd et al. 2009).

I like to use questionnaires such as the IKDC and KOOS (Collins et al. 2011, van Meer 2013) for baseline assessment of patients' knee function and the short form Örebro Musculoskeletal Pain Screening Questionnaire (Linton et al. 2011) for screening psychological risk or the Tampa Kinesiophobia Scale (Miller et al. 1991) to analyze the presence of fear avoidance.

It is important to outline to the patient the expected phases of the program and the criteria for progress, ideally in an oral and written treatment plan. Treatment initially involves reducing pain and bruising while improving ROM, muscle strength, function, and movement patterns.

End-stage physical therapy for return to sport includes athletic performance (eg, acceleration, agility, coordination, balance, endurance, and sport-specific skills) and assessment of psychological readiness (Filbay and Grindem 2019). After a successful resumption of play, “refresher sessions” can be scheduled at regular intervals to ensure continued adherence to preventative drills (Skou et al. 2018, Fleig et al. 2013, Nessler et al. 2017). I also encourage patients to share their success stories with friends, family, colleagues and social media connections so the general population can benefit from these positive messages!

Can You Return to Pivot Sports Without Surgery? Any good case studies on elite athletes?

Absolutely. It is important that readers are aware that this is a fallacy based on the biologically plausible theory that one cannot return to rotational/cut sports with an ACL-deficient knee - there are many peer-reviewed articles out there , showing that a return to these sports is achievable and safe for many patients (Meuffels et al. 2009, Grindem et al. 2012, Kovalak et al. 2018). In fact, there isn't a single group-level study that shows you can't return to extreme sports without an ACL. Through intense strengthening, neuromuscular control, balance, and sport-specific training, your musculoskeletal system can be more than adequate to compensate for ligament laxity, essentially making the ligament redundant.

Studies in professional athletes comparing physical therapy alone to surgery plus physical therapy have shown no benefit for the surgical group. A prospective study from Sweden in the 1990s showed no significant difference in the rates of sport return and OA in professional soccer players (Roos et al. 1995), as did a 2003 group comparative study of myklebust in professional soccer players. European handball. Van Yperen et al. (2018) compared 50 high-performance athletes and found no differences between groups in meniscus removal rates, radiographic OA, and functional outcomes at 20 years of follow-up.

The best-known case study without surgery involved an English Premier League player who, without surgery, was able to play again within 8 weeks after a complete tear and remained symptom-free in the long term (Weiler et al. 2015, Weiler 2016). There are many others who have been champions in multiple sports at the elite level, including the NBA, NFL, and Major League Baseball, although DeJuan Blair is one of my favorites: playing successfully in the NBA for the San Antonio Spurs for several seasons without an ACL in either Kneel!

What are some key variables that can help us predict whether someone will "cope" or "can't cope" with nonsurgical treatment?

The jury is out on how to predict whether someone “needs” elective reconstruction—we don't know if it's cultural trends, typical health pathways, beliefs/fears/likes/fears/preferences/parents/sports clubs of physicians, or Patients, lack of commitment to rehabilitation or true pathophysiological reasons why, despite quality, intensive, structured and graded rehabilitation, your knee will give way with persistent pain and consequent effusion.

Traditional algorithms have been heavily biased toward early ACLR, with elements such as progressive and intensive rehabilitation beyond a rigid period, movement patterns, and psychological avoidance of fear never previously considered ((Fitzgerald, Axe, Snyder-Mackler 2000, Hartigan et al. 2013) Many patients classified as copers still choose to have surgery (Hurd et al. 2008), and many non-copers, given sufficient time, become copers!(Thoma et al 2019, Moksnes et al 2008).

Based on the KANON study, psychological factors such as pre-existing preferences, beliefs and lack of motivation for rehabilitation and exercise were the main reasons patients chose to undergo reconstruction (Thorstensson et al. 2009) with physical quadriceps strength and jumping tests performed Key Success Factors ( Ericcson et al 2013) in all groups. Deciding not to have an ACLR and opting for exercise therapy alone is also a prognostic factor for fewer knee symptoms at 5 years of follow-up (Filbay et al. 2017).

How do you deal with the potential psychological damage after a cruciate ligament rupture for those who take a non-surgical route?

Again, this is an excellent question with a wide range of potential topics! In our subjective investigation, we need to question, at least superficially, the patient's beliefs about injury management options, expectations, short and long-term goals, social considerations, fears, and motivations (Burland et al. 2019, Sommerfeldt et al. al. 2018, Scott, Perry and Sole 2017). I have writings elsewhere that address specific screening questions about these elements (Richardson 2018).

On physical examination, I observe the manifestation of fear-avoidance movement patterns by the affected limb: protection, tightness, excessive co-contraction of the hamstrings and quadriceps, and disproportionate knee unloading (Hartigan et al. 2013). I then attempt to correct this with verbal or tactile cues and reassurance to alter these aberrant motor control strategies, which in turn will hopefully increase quality and range of motion (ROM) during functional task assessment and reduce pain.

Top Articles
Latest Posts
Article information

Author: Duane Harber

Last Updated: 03/17/2023

Views: 5864

Rating: 4 / 5 (71 voted)

Reviews: 86% of readers found this page helpful

Author information

Name: Duane Harber

Birthday: 1999-10-17

Address: Apt. 404 9899 Magnolia Roads, Port Royceville, ID 78186

Phone: +186911129794335

Job: Human Hospitality Planner

Hobby: Listening to music, Orienteering, Knapping, Dance, Mountain biking, Fishing, Pottery

Introduction: My name is Duane Harber, I am a modern, clever, handsome, fair, agreeable, inexpensive, beautiful person who loves writing and wants to share my knowledge and understanding with you.