Ruptured ACL, what are my options?
This is a difficult question to answer and one that has been raised increasingly often by patients in our clinics over recent years. There is a growing body of evidence comparing both surgical and non-surgical options, highlighted by high profile athletes such as Tiger Woods who won 5 out of 6 tournaments before having surgical repair and some case studies on Premier League players who are currently playing without an ACL after an 8 intensive week rehab protocol (Weiler et al, 2015).
An important aspect in all of this is whether you have an unstable knee, meaning does it give way. If it does give way, and you decide to ‘wait and see’ or for complete non-surgical well then you increase your risk of meniscus tear. This is thought to be associated with the early onset of arthritis, especially in the young adult (Roos, 2005). However, the evidence is mixed. Moksnes et al (2013) would suggest there is no difference between surgical and non-surgical in a 5-year follow up. We probably need a longer follow up times here before we can reach a conclusive decision.
For those who opt for surgery, there are a few things to keep in mind. There are risks such as deep vein thrombosis (DVT), infection, graft failure. It is also important to remember and this is something that isn’t as well known; only 63% of surgical patients return to pre-injury level and 44% return to competitive sport (Arden et al, 2011). Fear of re-injury is seen as one of the most common reason for this low number (Flanigan et al, 2013).
So what should you do?
Answering this is difficult and is individual to each case, however we would recommend following the advice provided by the BOA Blue Book for ACL injuries which states:
“Reconstruction is indicated in ACL Deficient patients with symptomatic instability or a desire to compete in high risk activities”
In simple terms, if you encounter regular giving way or instability and you wish to return to sport that involves pivoting at speed, surgery is recommended. If you don’t have an unstable knee, comprehensive rehabilitation, guided by a Sports Physiotherapist is a good option.
We hope this helps with your understanding. If you have any queries, please do not hesitate to get in contact.
ARDERN, C. L., WEBSTER, K. E., TAYLOR, N. F. & FELLER, J. A. 2011. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med, 45, 596-606.
BOA Blue Book http://www.boa.ac.uk/publications/documents/boa_cruciate_blue_book_2009.pdf
FLANIGAN, D. C., EVERHART, J. S., PEDROZA, A., SMITH, T. & KAEDING, C. C. 2013. Fear of reinjury (kinesiophobia) and persistent knee symptoms are common factors for lack of return to sport after anterior cruciate ligament reconstruction. Arthroscopy, 29, 1322-9.
MOKSNES, H., ENGEBRETSEN, L. & RISBERG, M. A. 2013. Prevalence and Incidence of New Meniscus and Cartilage Injuries After a Nonoperative Treatment Algorithm for ACL Tears in Skeletally Immature Children: A Prospective MRI Study. Am J Sports Med, 41, 1771-9.
ROOS, E. M. 2005. Joint injury causes knee osteoarthritis in young adults. Curr Opin Rheumatol, 17, 195-200.
Weiler, W. Monte-Colombo, M. Mitchell, A. Haddad, F.. (2015). 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 . BMJ. 11 (2), p1-6