Understanding the ACL: Is Surgery Always Necessary?
Have you injured your ACL and feared the worst? Perhaps you’ve heard media speculations about the recovery time of athletes after ACL reconstruction surgery. But did you know surgery isn’t the only option for treating and rehabilitating an ACL injury, whether it’s a partial or full rupture?
In fact, ACL injuries can be treated and rehabilitated both operatively and non-operatively across various levels of sport, from grassroots to elite.
The Australian Context: High Rates of ACL Surgery
For decades, surgical repair, known as ACL reconstruction, has been the primary treatment in Australia. Australia has one of the highest rates of ACL surgery worldwide, with reports indicating that 90% of people who suffer an ACL rupture undergo surgery.
This blog explores the other side of ACL injury management: non-operative treatment.
To Operate or Not to Operate?
The choice between operative and non-operative management is complex and should be informed by a thorough understanding of both options. Every patient needs to be educated on the pros and cons of both surgical and non-surgical approaches. Understanding the nature of their injury and the rehabilitation process involved in both paths is crucial for making an informed decision aligned with their goals and activities.
What is Non-Operative Management?
Non-operative management involves rehabilitating the ACL injury without surgery. Research, including the well-known KANON (Knee Anterior Cruciate Ligament, Nonsurgical versus Surgical Treatment) trial by Frobell et al. (2013), suggests that rehabilitation can be a viable primary treatment option after an acute ACL tear.
A 2023 follow-up study on the KANON trial found that one in three patients who received rehabilitation without surgery showed evidence of ACL healing on MRI after two years. Additionally, those with signs of healing experienced improved knee-related quality of life compared to those whose ACLs did not show signs of healing.
Regardless of the treatment choice, the rehabilitation process following an ACL rupture is lengthy, typically involving a minimum of nine months of progressive exercises performed a few days per week. Although the rehabilitation period may be slightly shorter for those not undergoing surgery, further research is needed.
Rehabilitation begins with simple exercises supervised by a physiotherapist and progresses to resistance exercises and dynamic movements such as jumping, hopping, and agility drills.
What is the ACL Cross Bracing Protocol?
The ACL Cross Bracing Protocol is a novel non-operative technique developed by orthopedic surgeons Drs. Merv and Tom Cross. This method aims to heal a ruptured ACL by bracing the knee at a fixed 90° flexion, a position that closely approximates the ends of the torn ACL. Ideally, this approach allows the ACL to heal without the need for reconstructive surgery.
To be a candidate for the Cross Bracing Protocol, patients must meet several criteria:
Recent Injury: The ACL must have been injured within the last 2-3 weeks, with the optimal timeframe for starting the protocol being 4-7 days post-injury.
MRI Assessment: An MRI is required to determine the severity and location of the ACL tear and identify any other knee injuries that may need surgical repair.
Health Screening: A history of deep vein thrombosis (DVT) or pulmonary embolism.
Functional Independence: Patients must be able to manage their home, work, or study life during the immobilisation period of the first four weeks required by the protocol.
Ultimately, studies have shown promising results with this approach. As of October 2023 a follow up study showed, 90% of participants (72 out of the initial 80) exhibited signs of ACL healing on a 3-month MRI. Of the first 301 participants, 284 (94%) achieved ACL healing, with over 100 participants being more than two years post-injury. Only 11% of patients following the ACL Cross Bracing Protocol have experienced a re-rupture.
Final Thoughts:
There is ongoing research into the comparative effectiveness of operative versus non-operative management of ACL injuries. However, it is crucial to educate every patient on their options. Being informed about the pros and cons of surgical and non-surgical management, and understanding the rehabilitation process, empowers patients to make decisions that best suit them, their goals and lifestyle.
Interested in the operative vs non-operative management of ACL injuries? Do you want to know the week by process of the cross bracing protocol? Let us know. We have Sport & Exercise Physiotherapists here to help.
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