Last month we talked about minor overuse injuries of the knee in young people, and how they can be managed. Today we are going to talk about the mother of all knee injuries, the ACL tear. ACL tears are unfortunately common amongst netballers and other sportspeople, especially young Australian ones. In fact, Australians undergo ACL repair more per capita than citizens of any other country in the world. This is probably to do with the fact that our main sports are all pivoting, twisting and 360 degree sports (netball, AFL football, soccer, basketball, etc).
We all have some pre-conceptions about ACL injuries; I’m going to list a few common ones right now:
- Needs surgery to repair the torn ligament, the sooner the better
- Probably needs 12 months out of sport
- Needs extensive ongoing rehabilitation
- Possibly never be able to return to pivoting sports (netball, football, basketball etc)
What if I told you that only one of those four listed ‘facts’ were true? Which one would you guess it was? If you guessed number three, you win a prize*!
I would imagine that every person reading this knows someone, either personally or via friends or family, that has injured their ACL and underwent surgery to fix it. I hate to break it to you, but that person may have put themselves through a painful, potentially costly, and likely unnecessary procedure for no reason other than “well that’s what you do for ACL tears”. As a physiotherapist, I (perhaps naively) like to believe that all modern medicine is based on solid science, and that medical procedures would be studied thoroughly for effectiveness and safety before being implemented on a broad scale. You would imagine my dismay, then, when I learned that there are no studies that show Anterior Cruciate Ligament Repair (ACLR) to be more effective than rehabilitation alone. In fact, the one Randomised Controlled Trial (RCT) study (one!?) comparing ACLR to rehabilitation alone showed similar outcomes with respect to pain, symptoms, function, return to sport levels, quality of life, subsequent meniscal tear and surgery rates, and radiographic knee osteoarthritis (OA) prevalence. I imagine the orthopaedic surgeon who published that paper may not have had many dinner invitations from his peers since!
Furthermore, there is no data to show that non-repaired ACL tears prevent return to type I (pivoting and cutting) sports. One case study described how an English Premier League soccer player returned to play 8 weeks after a full thickness ACL tear, and was able to play with no long-term issues. There are other elite sportspeople who have played at the highest level with ACL-deficient knees, including DeJuan Blair, who played basketball in the NBA with a grand total of zero ACLs in his body (i.e. he had fully ruptured his ACL in both knees, and played over 450 games of basketball at the highest level without repairing them). There are others; Tiger woods, and Aussie snowboarder Jess Rich, who competed in the winter olympics just one month after tearing her ACL. Mindblowing!
In short, it seems our Anterior Cruciate Ligaments are not so crucial after all. All of this is not to say that ACL repairs may be warranted in some circumstances, but prognostic factors for pain, function, quality of life and return to sport have been shown to be better in those who delay their reconstructive surgery, or elect not to have the surgery at all, versus those who have surgery within the first 10 weeks of injury. Re-rupture of the repaired ACL and rupture of the opposite knee ACL are also higher amongst people who undergo early repairs, when compared to those who have delayed repair, and the outcomes are even better in those who don’t have surgery at all.
If you, or someone you know, has damaged their ACL and is planning to undergo surgery to repair it, let them know that there is another way; a way that can have them back to sports without surgery, in potentially far less than 12 months.
Sometimes, it may feel like there is pressure from doctors and surgeons (and even physios) to have your ACL repaired as soon as possible, but it is definitely worth your time to chat to a physio at LifeForce to get their opinion, and take control of your own destiny! (Yes I am aware that that sounds corny, and I am perfectly OK with that!)
Call 8289 2800 to make a physiotherapy appointment at LifeForce health solutions at Golden Grove, to see what one of our experienced and friendly physiotherapists can do to help with your sport-related condition. You can also visit our website at www.lifeforcehealth.com.au to take advantage of our new online booking system!
* The prize is knowing that you are smarter than the average bear 🙂
REFERENCES
Filbay, S., Roos, E., Frobell, R., Roemer, F., Ranstam, J. and Lohmander, L., 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), pp.1622-1629.
Frobell, R.B., et al., Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ : British Medical Journal, 2013. 346.
Weiler, R., et al., Non-operative management of a complete anterior cruciate ligament injury in an English Premier League football player with return to play in less than 8 weeks: applying common sense in the absence of evidence. BMJ Case Reports, 2015. 2015: p. bcr2014208012.
