ACL Injuries: Does everyone need surgery?

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Physiotherapy Brisbane - Activate Health & Fitness

“Not all ACL injuries need surgery because surgery doesn't always give the best results!”

What do we know about ACL injuries?

Your "ACL" is your Anterior Cruciate Injury in your knee.  If you do an ACL injury it's considered a serious injury that usually means 6-12 months off sport and an intensive rehabilitation plan.  In Australia there is a strong belief that the best management for an ACL tear is surgery, and that you can only return to sport if you get it fixed. This belief is being shown to be inaccurate with new research coming out of Australia, and Scandinavia, as a result of analysing injuries across different court and field sports (netball, soccer, football, basketball, ect).


Research Results - The shocking truth!

1

Australia relies on surgery to fix the problem

In Australia 90% of ACL injuries undergo surgical repair.

This is compared to 50% in scandanivian countries, where avoiding surgery often gives patients faster rehabilitation and better outcomes.

2

5 years post surgery - surgical and non-surgical patients had the same results

When we look at people "returning to sport" after an ACL injury they are either successful at returning to their pre-injury level or sport, or unsuccessful if they don't get back to the same level.  The research showed there was no difference in "return to sport" at 3 or 5 years post-injury for people who had surgery compared to people who didn't.  As a result we started are starting to question the need for surgery in all ACL injuries.

3

The risk of secondary arthritic changes was the same for surgery and non-surgery groups

The research showed that surgical and non-surgical groups had the same chance of developing arthritic changes in the long term.  As a result we believe it is the trauma of the injury that causes the risk of arthritis and not the choice of management.

How do I know if I need surgery?

There are a portion of ACL injuries that need surgery, these people are referred to as "non-copers". They have episodes where their knee gives way, or have other injuries in combination with their ACL (i.e meniscal tear, medial ligament tear).  These people are unable to stabilise their knee and require surgery.  The remaining injuries are considered to be "copers" which means they can stabilise their knee by training their muscles, therefore they have the potential to have a successful rehabilitation without surgery.

SO WHAT ARE THE PRO'S AND CON'S OF SURGERY?

Pros

  • Reconstruction of the ACL ligament means more passive stability in the joint (when muscles are not active) 
  • Best management for "non-copers"
  • Can be done at any stage post injury (it is safe to trial rehabilitation first and if it isn't working then have surgery)

Cons

  • Every surgery has a risk of complications i.e infection
  • Surgery done too early (when knee is still swollen) has shown to have poor results long term
  • Post surgery you need a minimum of 9 months off sport (to let the graft mature) compared to 3-6 months for some non-surgical patients
  • Long waiting lists for public hospitals, it could be years before you get the surgery
  • Expensive procedures for private patients, and the overall cost of injury management is much higher for surgical patients compared to non-surgical. 

Conclusion:

Don't make the mistake of having surgery before you try rehabilitation - you may not need it.

The current recommendations for ACL injury are:

 - Have an examination as soon as possible post-injury, you will need a scan to confirm the amount of damage.

 - See a physiotherapist for initial recommentations:  The most common recommendation is to give the knee time to settle using crutches or a brace, then trial early rehabilitation to see if you are a "coper" or a "non-coper".  If it is clear you will be a "non-coper" then your physiotherapist will refer you back to your doctor for a surgical consult.

 - After an initial period of rehabilitation (6-8 weeks) discuss with your therapist how your are progressing, this is a good time to consider surgery vs no-surgery.


Research References:

  • Filbay, S.R., et al. (2017) “Delaying ACL reconstruction and treating with exercise therapy alone may alter prognostic factors for 5-year outcome: an exploratory analysis of the KANON trial.” British Journal of Sports Medicine 51(22): 1622-1629
  • Ardern, C.L., et al. (2018). “2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries.” British Journal of Sports Medicine 52(7): 422-438
  • Frobell, RB, R.E., Roos HP, Ranstam J, Lohmander LS. (2010). “A randomized trial of treatmentfor anterior cruciate ligament tears.” N Engl J Med. 363(4): 331-342


    • Physiotherapy Brisbane - Activate Health & Fitness

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