The Anterior Cruciate Ligament, or ACL, is part of the knee and stabilises the joint to prevent too much movement. It is a strong band of tissue that connects the thighbone (femur) to the shinbone (tibia) and controls the front and back motion of the knee.
Injury generally occurs when the knee twists excessively when changing direction, or through hyper-extension if the knee straightens too far. This causes the ACL to become overstretched or torn – tears may be partial or complete.
A lot is mentioned about ACL injuries in the media and amongst sporting groups, as athletes are particularly susceptible to this type of injury. While most ACL injuries occur during non-contact incidents while playing sport, they can also happen when contact forces the knee into these extreme positions. ACL tears are frequent in popular sports including AFL, netball and soccer where sudden change of direction is a common movement.
Surgery is likely necessary for ACL tears to reconstruct the ligament and it involves a lengthy rehabilitation period before returning to sport is considered. However, more and more people are looking at management of this injury without surgery.
Making the decision on which option to choose must be considered carefully and must be an informed decision. There is definitely a lot of research behind physiotherapy and sports medicine about the treatment of ACL injuries. It has been found that regardless of the type of treatment, there is a higher chance of developing osteoarthritis in the knee, when compared to before the injury.
Surgery & Physio or Just Physio?
Sometimes circumstances will dictate which treatment option to choose – for example a young athlete who is playing competitive sport is likely to need surgery to ensure a safe return to sport. A less active person, or someone who has only a minor partial tear of the ligament would be a good candidate for not having surgery
There have been several studies conducted on patients with either a fully ruptured ACL or a high-grade ACL injury over the past few years. Some of the findings are:
1 year after ACL rupture:
Patients who did not undergo surgery performed better on some single leg hop tests and while they had less knee joint stability, their symmetry in hop tests was better.
5 years after ACL rupture:
Half the patients who decided on initial exercise-only management had the reconstruction at a later time.
10 years after ACL rupture:
Patients who selected to have ACL reconstructive surgery had better passive knee stability, but there wasn’t any difference regarding osteoarthritis or meniscus injuries, or activity levels between them and those patients who didn’t have surgery.
20 years after ACL rupture:
There wasn’t any difference in osteoarthritis in the patients who had surgery and those who didn’t. Functional outcomes were the same, but knee stability was still better in the patients who had surgery.
Pros & Cons of Surgery Plus Physiotherapy Rehab
There is a longer rehab time, as you are looking at a minimum of 10 months before being ready to return to sport.
Rehab is required on 2 areas of the knee – the new ACL that has been constructed, and the structure from which the new ACL was taken, which is usually the hamstring or patella tendon.
Greater muscle weakness is a downside following surgery.
There is a chance that the new ACL fails, and further reconstruction surgery will be required at a later date.
Surgery results in greater pain and there is also the risk of complications both during and after the surgery.
There is a greater financial cost when surgery is involved.
Pros & Cons of Physiotherapy Rehab Only
The time required for rehab is a lot shorter – returning to sport can happen in about 6 months with an optimal rehab program.
Support is growing around the studies that show the ACL can repair just with rehab alone.
Surgery is still a backup if required, such as if there are recurring incidents of instability regardless of having high quality rehab.
Studies are showing it is unlikely that there is a higher risk of osteoarthritis or meniscus issues following the injury.
There aren’t any of the potential risks that are associated with undergoing a surgical procedure.
The cost can be significantly less.
Deciding whether or not to have surgery for an ACL tear can be difficult as there are many factors to consider. Our advice is to definitely consider non-surgical management with a thorough exercise rehab program.
A rehab plan will involve your sports physiotherapist assisting you with specialist exercises that are designed to strengthen the muscles supporting the knee. There will be a focus on the upper leg – both the quadriceps at the front of the thigh and the hamstring muscles at the back.
Get in touch with the team at Melbourne Sports Physiotherapy to speak about tailoring a rehab plan specifically for your ACL injury. Call or book an appointment online and get moving pain free as soon as possible.