Do I need surgery after an ACL rupture ?
This is a bit of a hot potato topic at the moment with some very vocal social media posts regarding this topic.
It’s an interesting debate as to whether you go for surgery or not and whether your ACL can heal. The main issue is you need to look at what your final goal happens to be.
Can the torn ACL heal ?
Complete ACL tears are thought to be difficult to heal due to the following issues:
- they do not seem to posses the same repair qualities as other ligaments in the knee such as the MCL.
- Inability of blood clots to form during the initial phase of healing that results in a lack of scaffolding between the 2 ruptured end-points
- Layer of synovial tissue forming over the ruptured ACL end points effectively capping the torn ends which prevents tissue healing.
- It was thought that the ones that heal probably were incomplete ruptures with a few intact fibres that weren’t seen or had some intact synovial tissue on MRI to act as a scaffolding or a framework to repair and build around.
Evidence the ACL can heal
There is now an increasing body of evidence showing that under the right conditions the Anterior cruciate ligament (ACL) repair without surgery and this could be key to better patient outcomes, according to new findings challenging the common notion that an ACL injury cannot heal.
The ability of the ACL depends on:
- The type of tear the ACL has sustained, the less complex the better.
- Undergoing a strict bracing regime to allow optimal healing
- starting this process early, there may be a 3 week window of opportunity following injury to get self healing
Cross brace protocol for ACL tears.
The cross bracing protocol is the method that is receiving the most attention and its goal is to create an environment in the knee that encourages the healing of the ACL .
It involves the following bracing regime:
- week 0-4 post injury : non weight bearing , range of motion brace fixed at 90 degrees
- week 5-8 post injury: non weight bearing , range of motion brace is fixed from 90 degrees to 60-45degrees
- Week 9-12 post injury : range of motion is allowed full flexion and progressing to full extension.
With this protocol there still needs to be an intensive and effective exercise based rehabilitation program in place to get back to full function.
After management with the Cross Bracing Protocol (CBP), 72 out of 80 (90%) participants with complete rupture of the ACL at injury had signs of ACL healing on 3-month MRI.
Despite the encouraging findings from the study on the cross bracing protocol it is difficult to predict with any accuracy who has the potential to heal and the success rate of the new tissue and how it will play out in the long term.
Surgery for the ACL.
The following are considerations for the surgical option;
1.Does your knee gives way or feel unstable when supporting your weight?
If it does and continues to do so after a period of rehabilitation, you may be more likely to benefit from surgery.
2. Consider the type of sports and activities you want to do.
Surgery is more commonly recommended if you want to return to sports that involve cutting and twisting motions such as AFL, rugby league, netball, skiing and touch football, etc.
3. Have you also injured your meniscus or other structures ?
The more structures that are injured along with an ACL injury may indicate that surgery is a preferred option for you.
Here’s a good video demonstrating a hamstring graft for ACL reconstruction.
The hamstring graft is the most common technique we see but other sites can be used such as;
- Patellar tendon
- Peroneal tendon.
- Artificial grafts such as the LARS.
Non surgical approach for ACL ruptures.
There is mounting evidence that we can do really well with a focused and intensive rehab approach and not require surgical intervention even if the ACL doesn’t heal . However the success behind this approach may depend on a the following factors:
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Are you a good deficient ACL “coper” ?
Some individuals seem to cope with an ACL deficient knee better than others.
There has been research done that has tried to identify those people that may cope with an ACL deficient knee.
According to a this study the following criteria indicate that a person may be a good coper without ACL surgery:
- Timed 6m hop > 80% of uninjured side
- Number of episodes of knee giving way < 1
- Knee outcome survey >80%
- Global rating score >60%
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Have you “ACED” your ACL rehab ?
Evidence is showing that a period of 5 -6 weeks intensive rehabilitation should be done prior to the decision of what path you decide to take.
In both non surgical and surgical intervention the people who did the best excelled at there quads strength and hopping functional tests. So in a nutshell rehabilitation plays a huge role in the success of both methods of treatment.
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What are you looking to achieve following ACL injury ?
Your long term goals and previous injury history will play a role in your decision.
Evidence suggests that if you want to return to high level , “high risk ” sports then reconstruction is probably a better solution. There is limited evidence demonstrating the outcomes of a non surgical approach and return to high level pivoting sports, this was done with elite level handball players undergoing rehabilitation only by Myklebust et al 2003. The results demonstrated no difference between the two groups in terms of return to sport, rates, function and osteoarthritis (OA) rates long-term.
However this is only one study and we still probably need a greater amount of data to definitively say which approach is best .
In summary best option for ACL tear
For complete tears of the ACL, conservative treatment, meaning no surgery, is showing great promise can potentially be successful in patients, including those intend to return to high level activities that involve cutting, pivoting, jumping or contact sports.
However long term satisfaction with non operated knees compared to operated knees is still relatively unknown. but expect this knowledge to expand in the coming years.
Regardless of the path you take the key to success is that your rehabilitation is criteria driven and the end result is a knee that has the following ;
- asymptomatic, mobile, strong knee
- Has good proprioceptive control
- Good plyometric and dynamic strength
- Sufficient training volume and sports-specific skills needed to return to desired activity level
- Patients also need to be psychologically robust and confident with the knee
I would always advise that you seek surgical opinion regarding ACL reconstruction as everybody’s situation is unique.
No matter what path you take you should always be looking after the strength and neuromuscular control of the knee for the best result.
Cheers Dave
References:
- Healing of acute anterior cruciate ligament rupture on MRI and outcomes following non-surgical management with the Cross Bracing Protocol: BJSM, November 16, 2023
- Spontaneous Healing in Complete ACL Ruptures: A Clinical and MRI Study: Clin Orthop Relat Res. 2012 Apr; 470(4): 979–985.
- Influence of Age on Healing Capacity of Acute Tears of the Anterior Cruciate Ligament Based on Magnetic Resonance Imaging Assessment: J Comput Assisted tomography Mar/Apr 2017;41(2):206-211.
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Coper classification early after ACL rupture changes with progressive neuromuscular and strength training and is associated with two-year success:The Delaware-Oslo ACL Cohort study –Am J Sports Med. 2019 Mar; 47(4): 807–814.
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Does ACL reconstruction alter natural history?: A systematic literature review of long-term outcomes. J Bone Joint surg am 2014 Feb 19;96(4):292-300.
- Can All ACL’s be Managed Non-Operatively? Mick Hughes : Learn .physio blog 2021