Is ACL surgery the only way? Why knee exercise may trump for ACL injury!

ACL tear shown in detail - click physiotherapy
Close up animated photo of ACL tear in the knee.

ACL injury – the basics

For years we have assumed that if something is broken, we need to fix it. It makes sense to think this way, but this may not always be the case with an ACL injury.

An ACL injury occurs mostly with cutting sports, as the shin bone rotates outwards and the thigh rotates inwards. For more information on the exacts head over to our ACL injury page. For now, lets get to talking about operating.

Traditionally we have operated as soon as possible, to avoid any further giving way of the knee. Recent research highlights that with rehabilitation, some knees won’t give-way even without an ACL! But why would you want to avoid surgery?

ACL repairs are good, but they aren’t perfect. Our expectations of what we will be like after surgery are much higher than what reality leaves us with. Research demonstrates that only 42% of people receiving reconstructions will return to competitive sport. Also around half the people that have reconstructions will develop osteoarthritic changes within 10 years.

You also need to way up other complications like numbness post surgery. Or infection and other risks that come with having invasive surgery.

So, what’s the alternative?

Very simply, the alternative to ACL reconstruction, is not having ACL surgery and opting for knee rehabilitation. I understand this is a scary concept, but there is good evidence to say you are much better to at least give this option a go.

Why not have surgery?

We know from research, that there are people out there who cope without an ACL. We call these people ‘copers’. (yes, researchers aren’t the most creative bunch) The evidence in support of this is growing due to some good quality trials. The leading trial in this field is called the ‘CANON’ trial, by Frobell and his colleagues.

From this research it’s clear that around one quarter of total ACL injuries could cope without an ACL. This group of people were equally happy with the outcome of their knee. They had similar levels of discomfort, their return to sport rates were similar and most other measurable outcomes was the same.

Based on this research we can conclude that one quarter of people may not need an ACL reconstruction! These copers will respond well to knee rehabilitation and avoid the recovery after surgery as well as other possible complications like infection, joint stiffness and more.

What about further injury to my knee if it’s not repaired?

There is always a risk of further damage to knees regardless of surgery of not. The good news, is that there is no higher risk of injury if you choose to delay your ACL surgery. The risk of further meniscus damage is equal whether or not you get your ACL repaired. You don’t have to spend sleepless nights worrying about further damage to the knee any longer.

How can you tell if you’re a coper or not?

Time is the best answer to this question. When you sustain an ACL injury like this, it’s normal to want it fixed as quickly as possible. The evidence is now suggesting that you wait for a period and see how it goes.

Trial three months of rehabilitation and if the knee doesn’t give way, then you may succeed in avoiding surgery. Remember, even a year down the track there is always the option to continue with surgery – there’s no benefit for getting surgery early. You are not at risk of further injury!

What other things come into the equation?

It really matters what type of sport (if any) you want to get back to. People engaged in high intensity cutting sports like soccer or hockey would be encouraged to get the ACL surgery, even if they trialled three months knee rehabilitation with no giving way. This is because the demands placed on the knee during these sports are much higher.

If you aren’t interested in performing high-level, cutting sports, it’s totally fine to trial rehabilitation first and see how the knee responds.

Your opinion matters in this decision too. If you really want to have the surgery, it will probably be offered to you. Just remember to sum up the pros and cons, as many people have an unrealistic view of what their knee will be like after surgery.

What rehabilitation for ACL injury looks like

Whether you think you need surgery or not, all ACL deficient knees will need a period of knee rehabilitation. The purpose of this rehabilitation is to restore normal movement and restore strength and balance to the knee. Early on the rehabilitation will involve simple bending and straightening exercises to help the knee movement.

As the rehabilitation progresses your therapist will add more strength-based and balance exercises to help the knee recover. The balance exercises help the knee to identify where it is in space, without having the ACL ligament to relay some of that information. To find out more about progressing load effectively – check out our blog titled ‘what your rehabilitation is missing

The last aspect of rehabilitation is getting the knee ready for more high demand such as cutting, jumping and hopping. At any stage during this rehabilitation if the knee gives way or feels really unsteady, then surgery may be the option you need. Click Physiotherapy can help with your knee rehabilitation from start to finish, click here if you would like to book a free initial appointment.

Online rehabilitation is idea for ACL injuries as we can walk with you daily, making sure your exercises are a perfect fit for where you’re at. Find out more about online physiotherapy treatment with this blog – ‘In pain? 3 reasons why you should choose online physiotherapy‘.

Final comments on ACL injury:

Not everyone will need an ACL reconstruction. Although it still is a great choice for those intending on returning to high-level, cutting sports or if your knee continues to give-way. If you delay surgery, there is NO increased risk of damage to the knee, and outcomes of a delayed surgery will be similar. So, get started with your knee rehabilitation early and that may be all you need!

To book your free initial consultation with a physiotherapist – click here!

References

Richard B. Frobell, Ewa M. Roos, Harald P. Roos, Jonas Ranstam, L. Stefan Lohmander (2010) A Randomized Trial of Treatment for Acute Anterior Cruciate Ligament Tears. The New England Journal of Medicine. 363:331-42

Stephanie R. Filbay, Hege Grindem. (2019) Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture, Best Practice & Research Clinical Rheumatology, https://doi.org/10.1016/j.berh.2019.01.018.

Wellsandt, E., Failla, M. J., Axe, M. J., & Snyder-Mackler, L. (2018). Does Anterior Cruciate Ligament Reconstruction Improve Functional and Radiographic Outcomes Over Nonoperative Management 5 Years After Injury? The American Journal of Sports Medicine, 46(9), 2103–2112. https://doi.org/10.1177/0363546518782698

ACL injury

What causes ACL injury?

An ACL injury occurs when it’s put under stress, outside the ligaments ability to cope. This often happens when landing from a jump where the body was twisting in the air, or a sharp cutting movement during sprinting. For this reason, ACL tears are very common in cutting and jumping sports like netball and soccer.

 

ACL_Tear
Source: Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436

What is the ACL?

Your ACL (anterior cruciate ligament) is a major supporting ligament in the knee. The ACL ligament is made up of tough fibres called collagen. These small fibres are grouped together like the strands of a rope to form a cord. It is found deep inside the knee, between two moving condyles. Together with the PCL ligament they are called cruciates because they form the shape of an ‘X’ or cross inside the knee.

The ACL ligament helps prevent giving way of the knee during rotation. It is usually put under tension with cutting movements like side-stepping or when landing from a jump.

How do I know if I’ve ruptured my ACL?

ACL tears (or ruptures) are usually felt immediately and patients may describe hearing a distinct ‘popping’ sound. Often this sound can be heard from meters away. The knee usually swells within thirty minutes, indicating bleeding inside the joint.

Most commonly, ACL injuries can be a clinical diagnosis by a GP or physiotherapist. The questioning during interview will give the clinician an accurate idea, and there are tests with good reliability to detect any ruptures. If in doubt, MRI scans are the gold standard for diagnostic imaging. These are free in Australia for acute knee injuries when referred by a GP.

When will I need surgery?

ACL injuries have seen a huge change in management over the last ten years. Historically, surgery was recommended to reduce the chances of osteoarthritic change and improve knee stability. However, research has shown you have equal chances of degenerative changes with or without ACL surgery. There is also no increased risk of further injury if you opt to manage your knee without surgery.

Even though we understand that a good portion of people will manage well without surgery, there are not any reliable tests at this stage to identify who will cope well. The best advice is to trial a period of three months of ACL rehabilitation first to see how the knee responds. If there aren’t any episodes of giving way, then surgery and the prolonged recovery may be able to be avoided.

Some exceptions to the above rule do exist. If you plan on returning to high-level cutting sports like soccer, rugby or netball, then an ACL reconstruction would be recommended, regardless of how stable the knee feels. If you want surgery over trialling conservative management, then this is taken into consideration and a decision can be made between you and your surgeon.

Source: https://doi.org/10.1016/j.otsr.2011.03.016

 

What does surgery involve?

Surgery options can change depending on where you are in the world and which surgeon performs your operation. The standard procedure in Australia is a hamstring graft with a tape-locking screw to secure the graft.

The procedure involves the surgeon drilling two holes where the ACL attached into the bone. A tendon is harvested near the hamstrings and folded four or five times to make it thick and strong.

From here the tendon is passed through the two holes and secured with some screws that lock into the holes. The outside marks are then stitched and slowly bone will grow around the screws to hold them in place.

ACL Rehabilitation:

ACL rehabilitation involves a period of progressive exercises that focus firstly on knee range, then on knee strength and balance with higher level tasks. The idea is to get your knee functioning as closely to pre-injury level as possible.

Whether you are having surgery or not, all ACL deficient knees will need a period of knee rehabilitation. Early on the rehabilitation will involve simple bending and straightening exercises to help with knee movement and mobility.

As the rehabilitation progresses your therapist will add more strength-based and balance exercises to help the knee recover. The balance exercises help the knee to identify where it is in space, without having the ACL ligament to relay some of that information. 

The last aspect of rehabilitation is getting the knee ready for more high demand such as cutting, jumping and hopping. At any stage during this rehabilitation if the knee gives way or feels really unsteady, then surgery may be the option you need.

Online Treatment

Click Physiotherapy is perfectly positioned to help you through online physiotherapy as we can offer tailored exercise programs that track your progress daily. Our qualified physiotherapist can assess you over video conference, asking you to perform tasks that will give us an idea of your strength.

From here we can craft and adjust an exercise program through regular video conference’s. We send this exercise program to you and you always have access via a convenient, easy to use, phone app. Communication with your therapist is always open through this app which allows text-based contact whenever you need it.

As your rehabilitation progresses, you can take us with you to your training environment – either on the field or at your local gym. Our video consultations can be performed wherever, so that we can adjust your exercise program to your own environment.

We will track your adherence to exercise and follow your progress through questionnaires that can be sent through the same app. This information can then be relayed to your doctor or specialist so all the key players remain in the loop with regards to your knee injury.

For more information, please read our blog titled, ‘In Pain? 3 Reasons why you should choose online physiotherapy‘.

Can I prevent ACL injuries?

There have been exercise programs created and made available to the public which focus on neuromuscular and strength training. These are evidence-based and aimed at reducing the number of acute knee injuries.

One program called the FIFA 11+ has a variety of training exercises that you can perform on a regular basis – like before training sessions. To access that program please click on this link.