THE ACL SERIES:
PART 3 – SURGICAL OPTIONS &
REHABILITATION POST- ACL RUPTURE
So, you have ruptured your ACL… An injury that can be both daunting and debilitating. What often isn’t discussed are your options, both surgical and non-surgical.
We all know of someone who has had an ACL reconstruction, but is that the best choice for you? If you do have surgery, what does post-surgical rehabilitation look like? Are you likely to be worse off if you don’t have surgery straight away?
ACL RECONSTRUCTION SURGERY… WHAT DOES RESEARCH TELL US?
ACL surgeries are thought to cost in excess of US$625 million per year… and that’s in the US alone! While these surgeries place a significant burden on the health care system, it does mean there is a phenomenal volume of research on ACL rehabilitation options…
“In young, active adults with an acute ACL tear, a strategy of early ACL reconstruction plus rehab did not provide better outcomes when compared with a later reconstruction or no reconstruction at all.”
This means if a person ruptures their ACL, there are no statistically significant advantages of having their surgery done sooner rather than later (when interpreting the research). There are, of course, benefits of having the surgery done as soon as possible vs trialing a conservative approach… but these benefits vary person to person depending on their circumstances.
It is becoming more common for people to decide to see how they manage without surgery. Research is now showing many people can retrain their knees to function just as well without an ACL as they do with an ACL! The benefit of trialing a conservative approach is rehab can start as soon as pain allows. If conservative management fails, a reconstruction can be completed at a later date – with no long term negative effects.
SO, SURGICAL RECONSTRUCTION OR CONSERVATIVE REHABILITATION… WHICH IS BETTER?
We know research demonstrates surgical and non-surgical outcomes are similar at a five-year follow up. So essentially when you look at an overall picture, there is no difference in outcomes regardless if you choose to have reconstructive surgery or not.
While for some it can be an easy decision to opt for either a surgical or non-surgical approach, others find the decision a bit more difficult. This is something that should be discussed with a practitioner you trust will not give you a bias opinion. The following are important points to consider:
- Does your line of work place heavy demands on your knee stability (ie. Professional AFL player vs office worker)?
- Can you afford the time off work/school/general life for the surgical revision and recovery?
- Are you willing and prepared to invest the time, money and effort to a rehabilitation program post-operatively?
- Are you prepared to work hard to maintain your neuromuscular control once you return to your sport/activity?
- Do you want to return to a sport that has a high volume of pivoting?
- What condition is the rest of your knee in? Do you have chondral loss/degeneration? Is there associated meniscal damage?
Irrespective of treatment option, a proportion of individuals experience persistent knee difficulties and unsatisfactory outcomes following ACL rupture. The harsh truth is it takes a great deal of hard work and persistence to maintain knee control post-ACL rupture.
WHAT SHOULD YOUR REHAB INCLUDE?
We have talked a lot about rehabilitation following an ACL rupture. An appropriate and well-designed rehab program is necessary to ensure successful recovery… but what does this mean? At The Injury Clinic, we believe ACL rehabilitation programs should include:
- Recovery from surgery (if chosen) or injury (if non-surgical rehabilitation chosen): Time should be spent to allow pain and swelling from the initial injury (and surgery) and to obtain full range of movement through the knee.
- Strength: Unfortunately, there are often significant strength deficits that need to be addressed. These should be measured and monitored with a dynamometer and compared to the un-injured leg. The injured leg should have at least 85% the strength of the un-injured side before certain progressions can be made.
- Neuromuscular control: You may recall in an earlier blog we discussed mechanoreceptors. These are responsible for providing our brain with feedback on where our joints are and what they are doing. The ACL is full of mechanoreceptors, but unfortunately when the ACL is ruptured the ability for the mechanoreceptors to provide feedback is lost. This means neuromuscular control must be re-trained so other tendons, ligaments and muscles can provide appropriate feedback and control of the knee.
- Re-introduction of running, landings and agility: With 70% of injuries happening in non-contact landings, this is one of the most important phases of rehabilitation. Emphasis should be placed on neuromuscular control throughout running gait, landing mechanics and agility/direction changes.
- Maintenance of strength/control and prevention of re-injury: With extremely high re-injury rates (up to 25% of people will injure the same or opposite knee), maintaining strength and control is vital to maintain function. This is something that is often forgotten and overlooked.
There are several options available to people post-ACL rupture. The choice of surgical reconstruction vs conservative rehabilitation must be made to suit the individual and their specific needs. Regardless of this choice, an appropriate and well-designed rehab program is necessary.
Please contact us on (03) 5229 3911 or firstname.lastname@example.org if you have any questions or concerns regarding your ACL injury or rehabilitation.