Introduction
At the Injury Clinic, we commonly see many knee injuries across a wide variety of sports. ACL injuries can be a devastating injury which we see in pivoting sports, such as football, soccer and netball. Recovery from these injuries typically takes a minimum of 12 months, with a high percentage of athletes (up to 35%) not returning to their previous sporting level. In Australia, we see many elite level athletes who sustain these kinds of injuries immediately undergo a surgical reconstruction, but this is not the only course of treatment. While surgical management is a common treatment pathway, we now know that a conservative (non-operative) approach may be the best option for some people.
At The Injury Clinic, we recognise the rehabilitation following an ACL rupture can be daunting, and there is a significant amount of information to consider when deciding the management plan that is most appropriate for each individual. The information below covers the most recent research and evidence into best management of ACL ruptures, and is designed to help those who have sustained an ACL injury decide what is the most appropriate management option.
Key Considerations
Once a person has sustained an ACL injury they are faced with the option to either have it surgically reconstructed, or rehabilitate their knee conservatively. Historically, it has been thought that to return to a higher level of sport and activity an ACL reconstruction is essential. Research has since indicated that the long term outcomes following an ACL injury are the same regardless of whether a person has a surgical reconstruction or not. It is then up to the individual and their sport/life demands to decide if they feel having a surgical reconstruction is the most appropriate treatment option. At The Injury Clinic, we encourage our clients to consider the following points after an ACL injury:
- Many people with ACL injuries are able to continue to participate in sporting activities without a reconstruction.
- Australians are over-treated with surgery, and under-treated with rehabilitation.
- Regardless of which management option (surgical or conservative) a person chooses, the structure of the rehabilitation and time to return to sport are often nearly the same.
- Research has found similar long term outcomes following ACL reconstruction and conservative management of ACL ruptures in terms of:
- Physical activity levels,
- Symptoms (including pain),
- Knee osteoarthritis (joint degeneration), and
- Quality of life.
- People who have an ACL reconstruction initially without first assessing their response after 3 month’s of conservative management had a higher level of osteoarthritis in the future.
- There was no difference in an athlete’s ability to return to sport after early surgery or having waited for 3-6 months.
- People who do not have surgery may actually have higher rates of returning to sport at their pre-injury level.
- Very few people (only 5%) are actually undergoing the recommended rehabilitation after surgery.
From the research, we know that it is essential for a person to adhere to a structured rehabilitation program. This should consist of both ongoing physiotherapy and a gym-based strengthening program, that progresses to include activities that replicate sporting demands. Regardless of the initial course of treatment, ACL re-injuries are common, and to minimise this risk, consistent and ongoing rehabilitation is imperative to ensure the best possible outcomes.
Surgical vs Conservative ACL Management
Did you know…
Recent research has shown definite results of both ACL and meniscal tears healing with time and appropriate rehab. Additionally, higher grades of ACL injury have a higher level of vascularity (blood flow) which indicates these have a greater chance of healing. They can also heal over a longer period of time, meaning even if they have not fully healed within 3 months, they still have the possibility of healing.
In saying this, not all ACLs can heal without surgical intervention. Some people may be able to return to their normal movement and activities, and even high level of sport without surgery or a healed ACL; others will require surgery to allow them to return to normal function and sport.
Who should consider surgery:
While conservative management is becoming a more prevalent option, a surgical reconstruction should still be the first option for some people. As all ACL injuries are different, there are a few variables that we consider indications that a person will need surgery. These are:
- Persistent episodes of knee instability or “giving way”
- Loss of confidence in their knee
- True locking of knee
- Persistent joint line pain
- Other significant injuries to the knee (ie. significant meniscus tears or MCL injuries)
When we look at the research for children who have had a significant ACL injury, the considerations for surgery are similar. In appropriate cases, it is suggested a child gives the ACL an opportunity to heal and spends 3-6 months following a conservative rehabilitation program before opting for surgery.
ACL Rehabilitation – What does this look like?
At The Injury Clinic, we have had success with our physiotherapists and strength and conditioning coaches working together to provide the best possible rehabilitation for our patients. All stages of rehabilitation should be completed under the management and guidance of physiotherapists and S&C coaches to optimise recovery and reduce the risk of re-injury.
Key rehabilitation points:
- Following the initial injury, there are some people who may benefit from wearing a hinge knee brace for a short period of time. This varies person to person and if implemented, needs to be as soon as possible following the incident where the injury occurred.
- Initial management will be focused on:
- Symptom relief,
- Range of movement exercises, and,
- Restoring normal gait (walking) patterns.
- As symptoms start to improve, rehabilitation will progress to include functional exercises, gym based strength and conditioning and the reintroduction of plyometric loading.
- These exercises will progressively become more challenging and will work on restoring function and ensuring there are no deficits or weaknesses in the knee that was injured.
- Gradually, rehabilitation will look to progress to the level where we can start to introduce some sport-specific exercises. Eventually, a person will have the confidence to return to their sport or activity.
The time frame from the initial injury until the return to sport does vary. We often see and hear of elite sports people following an accelerated return to sport protocol. While this can be implemented in the community, we also need to consider that those in the elite sporting environment often have significantly more time to complete their rehabilitation when compared to someone in the community who may have different work/life/family demands.
It is also important to remember, that even once rehabilitation has been ‘completed’ and a person has returned to their activity, ongoing strength and conditioning will be essential to minimise the risk of re-injury. This is regardless of whether a person has had a surgical reconstruction, their ACL has healed, or they have returned to function without an ACL.
In Conclusion
At The Injury Clinic, we know an ACL injury can be devastating and overwhelming for many people. Where previously all ACL ruptures were reconstructed surgically, research has indicated that conservative management can also be an appropriate option for many people. Regardless of the pathway a person may choose, an appropriate rehabilitation program is essential to ensure both the return to sport and reduce the risk of further injuries. If you would like to book an appointment with one of our physiotherapists to discuss what management plan may be best for you, please click here and book an appointment online.
