If you watch sport on a regular basis you will at some point come across an unfortunate participant who suffers an injury to their ‘anterior cruciate ligament’ (ACL). You may even know of someone who’s torn their ACL. Most athletes are fearful of such an injury as they understand it means a long lay off from their sport. In-fact up to 9 to 12 months. As the normal medical management is surgical reconstruction. Followed by a period of intensive rehab. However is this really the ‘Gold Standard’ of treatment? Well the literature seems to suggest otherwise.
The Evidence for ACL Injury Management
The evidence for preferring a non-operative approach appears to be building. Frobell et al in 2013 found that half of the patients that underwent physio rehabilitation alone appeared to fully recover. In other words there was no difference between non-surgical and their operated counterparts at 5 years follow up. In terms of function, meniscal surgery rates and arthritic changes. In fact, ACL surgery appears to increase the risk of OA in the long term. A number of clinicians (Richardson K. 2019) and researchers are now promoting intensive physio rehabilitation as the gold-standard of management.
So do we need our ACL’s?
Well it appears that 2 things could be happening for those who recover without surgery. Firstly that the improvements in neuromuscular control through intensive rehabilitation compensate for any ligament deficiency. Effectively making the ligament ineffectual. Secondly, the ligament can also spontaneously heal. A study by Costa-Paz et al (2012) found fully healed ligaments at 2 years follow up in a group of 14 patients. Something thought impossible up until a few years ago!
There are increasingly more reported cases of athletes returning to sport without surgery. Including premier league footballers, to NBA basketball and rugby players. Who have returned following ACL rupture and had no surgery. The good news is that recovery will generally be quicker. Making it a much better proposition for those athletes.
Most patients should undergo a period of intense rehab for around 3-6 months. Patients need to understand that conservative management is not inferior to surgery or more likely to lead to early arthritis. Also patients must be aware if they opt for surgery then good outcomes cannot be guaranteed.