By Jessica Bank

Evidence based options for non-surgical management of ACL tears

• You cannot return to twisting sports before getting an ACL reconstruction –FALSE

• There is no high quality evidence to support non-surgical management of ACL tears over surgical management –FALSE

• Having an ACL reconstruction will reduce the risk of developing osteoarthritis –FALSE

• An ACL can’t heal – FALSE

 

Australia has the highest rates of ACL reconstructions in the world. Is there enough evidence to support non-surgical management and how can we reduce the rate of ACL reconstructions?

In 2015 an English Premier league soccer player ruptured his ACL, did not have surgery and return to play in 8 weeks. In the long term his knee remained symptom free, allowing him to renegotiate another contract in 2016. How is this possible?

Why is the incidence of ACL reconstructions so high in Australia?

ACL injuries in Australia are on the rise as a result of a number of factors such as the lack of implementing prevention programs at the general population level, the type of sports that Aussies like love to play and better access to better imaging techniques like MRIs.

ACL reconstructions (ACLR) have concurrently rapidly increased, due to other reasons such as:

• Increased awareness of the availability of ACLR in the general population
• ACLRs being funded privately and federally
• Media coverage of borderline hysteric reactions of an athletic with a suspected ACL tear
• Difficulty in efficiently education clinicians of best practice
• Lack of up to date patient friendly resources and education material about best practice for ACL tears and non-surgical options

 

Is there enough evidence to support non-surgical management of ACL tears?

Contrary to popular belief there is no high-quality evidence for ACLR being superior to structured, supervised physiotherapy and exercise. The evidence-based practice rules that govern scientific culture are not the same as they were 40-50 years ago which is when many of the systems to roll out procedures where created.

Hundreds of high-quality randomised controlled trails have been conducted comparing different ACL surgical techniques, but the trials comparing rehabilitation alone to surgery and rehabilitation have not shown any significant benefit to the surgical group.

Physiotherapy and exercise alone can be a permanent solution for many people aiming to return to cutting and pivoting sports.

What about professional Athletes?

Like the player in the English Premier League mentioned before, there are many case studies in the media that show it is safe and achievable to return to top level twisting and landing sports with a non-surgically managed ACL tear.

There needs to be a shift in ideology and behavior based on current clinical guidelines and systematic reviews so that a high level athlete does not suffer from a “devastating”, “heart breaking” or “shocking” ACL injury, based on 9-12 months off post surgery. Instead it must become more commonplace for athletes to return to high-level sport with a non-surgical regime within 3-6 months. These time frames may be shorter or longer based on an individual’s injury and goals.

What about co-existing high-grade knee injuries?

Clinicians have known since the mid 90s that acute meniscal tears can heal, along with other structures of the knee such as the ACL or MCL. So there is no reason as to why someone with a coexisting high-grade knee injury should not undergo non-surgical management.

What to do after an ACL injury

• Don’t panic!
• Consider all options including non-surgical management
• Seek out a physiotherapist that has an understanding of non-surgical ACL tear management such as us at Innovations Physiotherapy & Pilates