To Cut, Or Not To Cut? That Is The Question
The decision around choosing elective surgery and having ACL reconstruction surgery is not always a straightforward one. Following a complete ACL rupture, many individuals will find that they are unable to freely participate in any cutting, or pivoting-type sports due to feelings of instability. While others may find they have even more limitation and experience instability of the knee during normal activities of daily living, such as simply doing housework, or walking downstairs… Yet, there are however some individuals who following a complete ACL tear find they can still participate in sports without experiencing any such instability symptoms. Henceforth, making any decisions regarding having an ACL reconstruction verses taking a more conservative approach and opting for specific activity avoidance, or undertaking a purely physiotherapy strengthening, rehabilitative approach is a decision that is made on a “case by case” basis. And despite ACL reconstruction surgery generally being considered a “successful” surgery where most patients opting to have the procedure find that any symptomatic instability of their knee is eliminated post surgically and the surgery itself has very low complication rates. Still not everyone who ruptures their ACL goes on to ultimately make the decision to have reconstructive surgery.
ACL Surgery Has A Long Post-Surgical Rehabilitation Process
One of the biggest barriers I find when talking to patients about pros and cons about undergoing any ACL reconstruction surgery is the significant time frame involved post surgically to returning to sport, or pre-injury functional levels. The rehabilitation program itself is very involved, typically demanding around 8-12 post-surgical visits with your physiotherapist, spaced out over a period of 9-12 months as well as a commitment to a progressive home exercise program and sport specific training progressions throughout the course of recovery. Simply waiting the 8-12 months post-surgery and then returning to play when the “time is up” is not a responsible way to approach any ACL reconstruction surgery rehabilitation and is setting yourself up for potential re-injury and disappointment on returning to play. Recovery requires equal measures of time and commitment to a progressive rehabilitative physio program.
Key Factors In The ACL Reconstruction Surgery Decision Process
A younger, active adult, or the more serious and competitive athlete in my experience will almost always elect to have knee reconstruction surgery over taking the conservative pathway. Especially those individuals who are involved in playing competitive sports that involve rapid changing of direction and regular pivoting movements such as the football, netball, and basketball codes demand. Having knee reconstruction surgery will ideally give the athlete a clinically and subjectively more stable knee. Therefore, better allowing them to perform those cutting and pivoting actions with confidence. Generally, it is a patient’s goals around returning to types of activity and both their necessary recreational and vocational activity levels, not age, that ultimately determine if the surgical intervention pathway is chosen.
Nonsurgical Management Of ACL Tears
Typically, patients choosing against having an ACL reconstruction surgery are most likely less active individuals. If the patient is not currently involved in, and feel they are unlikely to be involved in regular sport, or activities that involve a lot of rotational changes of direction and pivoting in the future, then they may well decide not to undergo reconstruction surgery.
Collateral Damage May Be The Deciding Factor
It is important to consider that when someone tears their ACL that frequently an ACL rupture is not the only injury sustained, approximately 50 percent of all ACL injuries will occur in combination with some other damage to structure in the knee such as the meniscus, articular cartilage, bone bruises, or other ligaments like the MCL. As a result of any collateral damage, surgery may come more strongly recommended. Also, a patient with a ruptured ACL experiencing significant functional instability has a high risk of developing secondary knee damage either acutely on return to activity, or chronically over time and should therefore should more strongly consider having an ACL reconstruction. It is possible secondary damage may occur in patients who have repeated episodes of instability due to their ACL injury and in patients with chronic instability risk of meniscal and articular cartilage damage years down the track is significantly increased.
Candidates For Nonsurgical Management
It is worth noting, that of late there has been a rise in the number of patients opting for taking the non-surgical path following an ACL tear. Even with the more active athletes, who traditionally would have undergone a knee reconstruction there are some interesting case studies comparing the outcomes between surgical and non-surgical management of these individuals. As always, more research is required, but Australia as a nation has an extremely high ACL reconstruction rate and it is always a good idea to investigation the cost verses benefit of any intervention (surgical or otherwise). It will be interesting to see in 10-20 years, if the number of ACL reconstruction surgeries increase, or decrease as we learn more around the long-term consequences of either pathway.
As it currently stands conservative, non-surgical management of ACL injuries for individuals with partial tears and no instability symptoms is an acceptable approach. As it is for any, individuals with isolated complete tears without symptoms of knee instability during low-demand activities and the patient has no need, or desire to be involved in high-demand sports or activities in the future. Generally this relates to individuals living relatively sedentary lifestyles or participating in only very light manual work, or activity.
Disclaimer: This information is provided as an educational service, and is not intended to serve as a substitute for personalized medical advice. Sydney Physio Clinic does not endorse any treatments, procedures, products mentioned in this post. Anyone seeking specific advice, or assistance around making a decision regarding having “ACL reconstruction surgery” should consult his, or her physiotherapist, orthopaedic surgeon, general practitioner, sports medicine specialist, or otherwise appropriately skilled medical practitioner.