Do I need to repair my ruptured ACL?

Posted May 30, 2018

ACL reconstructive surgery and whether or not to have it is a hot topic in sports medicine right now. Historically, the absence of an ACL following traumatic injury would result in 1) increased episodes of instability, 2) increased risk of developing secondary osteoarthritis, and 3) reduced knee-related quality of life (Monk AP, 2016). In recent years, there has been an influx of research that has suggested that some individuals who have ruptured their ACL and chosen not to repair it may actually be able to carry-on without any knee issues.

The discussion of whether or not you need to repair your ACL is not a simple one by any means. It comes with a host of other questions, one of which being – what do you actually need your ACL for? Are you a high level athlete that relies heavily on cutting and pivoting to perform back at an elite level in their given sport? Perhaps you’ve also sustained a small meniscal tear during the injury. If you relate to this population, then you will most likely need an ACL reconstruction. On the other hand, perhaps you’re a desk-worker who ruptured their ACL playing social netball over the weekend and don’t have any real desire to return to netball. If you relate to this group, then this blog will provide you with evidence based information that may give you confidence in trialling a non-operative approach to your knee rehab.

The discussion of whether or not you need to repair your ACL is not a simple one by any means. #performbetter @pogophysio Click To Tweet

Whatever your situation may be – physiotherapists are likely the best equipped to help you with your decision as they take into account your symptoms, sport, activity levels, previous injuries, available time, financial freedom, self-confidence, occupation, motivation, and arguably most importantly, your future goals for physical activity/sport.

First of all, let’s discuss what the ACL is and what its role is in sport and day to day life. The Anterior Cruciate Ligament is a thick ligament that sits in the middle of your knee joint and connects the thigh bone (femur) to the shin bone (tibia). Its primary function is to prevent the tibia from sliding forward relative to the femur and thus without the ACL, your knee would inherently feel more unstable.

The ACL is at risk of rupture when the angle on the inside of the knee increases (this is called ‘valgus’ and is depicted to the right). This image also helps us understand why most ACL ruptures occur during cutting or stepping movements. While walking, other ligaments, tendons and muscles are responsible for knee stability, and little is provided by the ACL.

Now that we’ve got a clear understanding of the anatomy and function of the ACL, let’s delve a little deeper into some evidence surrounding whether or not individuals without ACL reconstruction reported any issues after their decision to avoid going under the knife.

In 2016, a Cochrane review compared the outcomes of two groups: surgery versus conservative management (no surgery) of ACL knee ruptures. The review concluded that between the two groups, there was no significant difference in self-reported outcomes of knee function at 2 and 5 years (Monk AP, 2016).

A 2013 high-quality randomised control trial with 121 young, active patients also compared the difference in self-reported knee outcomes at 5 years. These knee outcomes included pain, symptoms, function in sports and recreation, return to pre-injury activity level, radiographic OA and meniscus surgery. The authors concluded that there was no significant difference between the two groups and that “These results should encourage young, active patients to consider rehabilitation as a primary treatment option after an acute ACL tear” (Frobell, 2013).

At face value, the conclusion from these studies is that anyone that opts to not repair their ACL will have a happy knee with no issues. If you look a little closer, you’ll see that this isn’t entirely true. In these studies, as many as 50% of the people in the no surgery group ended up requiring surgery down the track. This was due to episodes of recurring pain and instability. So what can you draw from this evidence? This evidence suggests that there are a large number of individuals that for many reasons, opt to avoid surgery. In half of these people, surgery turns out to be a necessary option to restore healthy knee function. If you opt to go conservatively, there is a chance that you’ll need to have the surgery later on if your knee is feeling painful and unstable.

So you have two options here: 1) Repair your ACL and spend the money (~$12,000), time (9-12 months) and effort (intensive rehab) coming back from surgery. 2) Avoid the knife and undergo strict rehab to improve the strength, stability and balance of your injured leg. This is achieved by activating new neuromuscular patterns to the muscles surrounding the ACL deficient knee and ultimately achieving ‘dynamic stability’. If you choose the latter, you must keep in mind that there is a chance that conservative rehab won’t work as planned and that you’ll need a knee reconstruction in the future.

All in all, a case has been made in recent years that a large number of individuals that have opted for a conservative approach to their ACL rupture have been able to live out a normal life with no knee issues. The decision of whether or not to go through with conservative rehabilitation is complicated and multi-factorial. It must take into account every factor of your life and most importantly, your future goals for sport and physical activity. Other factors like age and whether or not you have sustained any other injuries to your knee also play a large role in your decision. Physiotherapists and specialists should be consulted to help your decision making, given their clinical expertise and ability to take into account every person’s many individual factors.

George Dooley (APAM)
Master Physiotherapist

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References

Frobell, R. B., Roos, H. P., Roos, E. M., Roemer, F. W., Ranstam, J., & Lohmander, L. S. (2013). Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. Bmj, 346, f232.

Moksnes, H., Snyder-Mackler, L., & Risberg, M. A. (2008). Individuals with an anterior cruciate ligament-deficient knee classified as noncopers may be candidates for nonsurgical rehabilitation. journal of orthopaedic & sports physical therapy, 38(10), 586-595.

Monk, A. P., Hopewell, S., Harris, K., Davies, L. J., Beard, D., & Price, A. (2014). Surgical versus conservative interventions for treating anterior cruciate ligament injuries. Cochrane Database Syst Rev, 6.

Paterno, M. V. (2017). Non-operative Care of the Patient with an ACL-Deficient Knee. Current reviews in musculoskeletal medicine, 10(3), 322-327.

Snyder-Mackler, L., & Risberg, M. A. (2011). Who needs ACL surgery? An open question.