Anterior Cruciate Ligament: Decisions Decisions

If you’re a tiger’s fan, you’ve recently read the news of Alex Rance suffering an anterior cruciate ligament (ACL) tear, which will exclude him for the rest of the season. Sadly, this is becoming an increasingly problematic injury, particularly in the women’s AFL with approximately 9 times more ACL ruptures compared to the male competition (AFLW injury report, 2018).

While alarming for the AFLW, this is not surprising to anyone familiar with ACL research, as worldwide ACL injury rates in women are generally reported between 2-8 times higher than male counterparts (Arendt et al., 1995; Shea et al., 2004). More importantly, those that do suffer an ACL tear typically assume that surgical reconstruction is mandatory, which has been reported to cost Australian hospitals a massive $75 million dollars (Janssen et al. 2011).

What many people don’t realise is that surgery should not be recommended as the primary management. In fact, neither conservative (i.e., no surgery) or surgical management is superior (Frobell et al., 2013), leading to the obvious question, do you need surgery?

To reconstruct or not?

Like any injury, establishing your goals for sports/recreation in combination with a thorough physical and psychological assessment are paramount to directing the best course of action.

In the early stages following injury, it’s crucial to minimise swelling, establish full knee extension and regain quadriceps strength via a structured exercise program (van Melick et al. 2016). This is further supported by recent evidence including over 200 athletes that found exercise immediately following ACL injury can have a positive impact on knee function, that may ultimately change the need for reconstruction (Thoma et al., 2019). So, give exercise a go and don’t feel rushed making a decision on surgery!

After completing a 4-6 week exercise program, the decision regarding surgery should consider these questions:

  • Are you returning to high level twisting sports? (Football, soccer, basketball, netball etc)
  • Have you had several episodes of giving way or instability?
  • Do you require meniscal repair?
  • Have you tried conservative management?

If you’ve answered yes to one or more of these questions, it may be worth consulting a surgeon for their opinion. Following this consultation, you’ll be in a better place to make an informed decision about whether to ‘go under the knife’!

Dr. Tim Sayer
Physiotherapist

References

Arendt et al. (1995). Knee injury patterns among men and women in collegiate basketball and soccer: NCAA data and review of literature. Am J Sports Med. 23(6): 694-701.

Frobell et al. (2013). Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ. 24(10): 346:f232.

Janssen et al. (2011). High incidence and costs for anterior cruciate ligament reconstructions peformed in Australia from 2003-2004 to 2007-2008: time for an anterior cruciate ligament register by Scandinavian model? Scan J Med Sci Sports. 22(4): 495-501.

Thoma et al. (2019). Coper classification early after anterior cruciate ligament rupture changes with progressive neuromuscular and strength training and is associated with a 2-year success: The Delaware-Oslo ACL cohort study. Am J Sports Med. 47(4): 807-814.

Shea et al. (2004). Anterior cruciate ligament injury in pediatric and adolescent soccer players: an analysis of insurance data. J Pediatr Orthop. 24(6): 623-628.

Van Melick et al. (2016). Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on systematic review and multidisciplinary consensus. Br J Sports Med. 50: 1506-1515.