Conservative vs surgical management of ACL ruptures

When people hear of Anterior Cruciate Ligament (ACL) ruptures, it’s not uncommon to think of AFL players being rushed off for immediate surgery. But does an ACL rupture always require surgery? Can it heal? There is growing research to indicate that surgery is not always the answer.

The ACL is a ligament within the knee that attaches from the tibia (shin bone) to the femur (thigh bone). The role of the ACL is to control forward movement of the tibia and limit excessive tibial rotation. Like any other tissue of the body, when the ACL is loaded with more force than it can handle, rupture occurs. Common mechanisms of rupture often involve planting the affected leg to cut and change direction, landing from a jump, pivoting, twisting, or direct impact to the tibia (Delincé & Ghafil, 2012). 

While the immediate priority of an ACL rupture is to manage pain and swelling, at some point the patient will come to a crossroad in which they will need to decide whether to pursue surgery (reconstruction) or manage the injury without surgery. It is important to note that surgery is by no means a quick solution to the rupture, and still requires extensive rehabilitation similar to not having surgery.

While the decision is ultimately down to the patient, there are a few factors that can influence the pathway. The main factors that we see as physios are the following:

Knee trauma:

Unfortunately due to the anatomy of the knee and the mechanisms in which the ruptures take place, most ACL injuries occur along with damage to other structures in the knee, such as joint cartilage, meniscus, or other ligaments (Vaudreuil et al., 2019). In some instances, this secondary trauma can be significant enough to indicate surgical management as opposed to conservative.

ACL healing:

Like the rest of the body, the ACL to a degree has a capacity to heal. Unfortunately the degree of healing, and the functionality of the “healed” ACL is variable between people and there is currently no consistent way to predict if the ACL will not only fully heal but also then provide the required stability to the knee. 

Goals:

A significant factor of deciding whether to operate or not is what the patient is going to ask of their knee. If the patient is in their twilight years, mostly sedentary and has no ambitions of returning to moderately demanding physical activity then it’s likely that surgery will not be essential. However should the patient want to return to competitive sport such as netball or AFL then surgery is likely indicated.

Symptoms:

Rupturing an ACL is a traumatic experience not just from a physical perspective but also a psychological perspective. While the symptoms of the rupture will improve over time, sometimes patients will experience lingering symptoms. Residual pain and swelling or feelings of reduced stability and quality of life can often be indicators for surgery.

So to operate or not? Unfortunately the answer will differ from patient to patient and there is no “one size fits all” answer. While the above points can help to make an informed decision, regardless of the pathway you are leaning towards, a consultation with an orthopedic specialist is an essential step.

Fortunately, regardless of whether surgery is pursued or not the initial steps and priorities of injury management are the same: reduce swelling, increase movement, increase strength and increase function. It is also important to consider that aside from external pressure (such as returning to competition) a reconstruction usually does not need to be rushed, if a patient chooses to start non-operative rehabilitation, there is always the option to opt for reconstructive surgery further down the track. The benefit is, research has found lasting effects up to 6 years post operatively for patients who have undergone a thorough prehabilitation (Cunha & Solomon, 2022).

Want to know what steps it takes to return to sport following an ACL reconstruction? Check out the blog here to see the criteria we assess.

Blog by Luca Scomazzon-Rossi

Luca is physiotherapist here at Evolve Physio Group on St Kilda Road. Luca has experience treating ACL injuries to the Albert Park, South Yarra, Melbourne and Middle Park community.

References:

Cunha, J., & Solomon, D. (2022). ACL Prehabilitation Improves Postoperative Strength and Motion and Return to Sport in Athletes. Arthroscopy, Sports Medicine, And Rehabilitation, 4(1), e65-e69. https://doi.org/10.1016/j.asmr.2021.11.001

Delincé, P., & Ghafil, D. (2012). Anterior cruciate ligament tears: conservative or surgical treatment?. Knee Surgery, Sports Traumatology, Arthroscopy, 21(7), 1706-1707. https://doi.org/10.1007/s00167-012-2134-z

Vaudreuil, N., Rothrauff, B., de SA, D., & Musahl, V. (2019). The Pivot Shift: Current Experimental Methodology and Clinical Utility for Anterior Cruciate Ligament Rupture and Associated Injury. Current Reviews In Musculoskeletal Medicine, 12(1), 41-49. https://doi.org/10.1007/s12178-019-09529-7