An ACL injury is common in competitive sports such as football, rugby, and basketball.While people may assume that ACL injuries happen more in contact or traumatic events during a game or training, research shows that noncontact injury mechanisms are more prevalent in competitive sports. In addition, women generally have a higher risk of an ACL tear than men due to different biomechanics, such as ligament laxity and a larger quadriceps angle.
When this unfortunate event happens, there are two treatment methods to consider: conservative and surgical.
Conservative management
- Involves non-invasive approaches to rebuild the ACL, such as strength and neuromuscular training
- If there are meniscus injuries involved, conservative treatment can be considered
- The recovery timeline is estimated at around 6 months only if no knee instability is observed
Pros and Cons of conservative management
- Pros
o Less expensive
o No risks of complications from the surgery
o Faster recovery
- Cons
o Risk of early onset of osteoarthritis in the affected knee
o Risk of secondary injuries to surrounding structures
o If this approach fails, the recovery timeline will take even longer than the surgical approach
Surgical approach
- Practitioners usually perform arthroscopic reconstruction, which is less invasive than open surgery and allows patients to recover more quickly
The two most used tendon graft sites:
- Hamstring grafts – one of the most popular site due to its favorable biomechanical profile and the ease of harvesting the tendon graft
o Pros: less quadriceps muscle weakness and atrophy, high load resistance following procedure, small harvest incision, less postoperative pain
o Cons: slower soft tissue-graft tunnel healing, the potential for tunnel widening, laxity
- Patellar tendon grafts o Pros: structural similarity to ACL, allows for early vigorous rehabilitation, less stretching, proper ultimate strength, and stiffness o Cons: high potential of anterior knee pain, patellar tendinopathy, increased joint stiffness, weakness, or atrophy of quadriceps
- Allograft – tendon, either synthetic or sourced from an organ donor, another option if the patient already had multiple knee injuries that required the usual graft sites to be used
There is very little to no difference between the first two options regarding their effectiveness. Both have been shown to provide good subjective outcomes and objective stability. Allografts have been observed with significantly higher failure rates.
Recovery timeline – after ACL reconstructive surgery
- Return to sport: around 9 months
- With an additional meniscus injury: will take longer, around 12-15 months
- The recommended hospital stay will be around 1-2 days. Before discharge, the surgeon will check the knee mobility and the knee wound, and whether the patient has sufficient maneuverability using elbow crutches.
- Typically, the patient will be able to walk on the same day, following the operation
o Allow for full weight-bearing walk with elbow crutches (commonly 1-2 weeks until the balance is returned and pain has dissipated) if only the ACL has been affected but not other weight-bearing structures
o However, for an additional meniscus repair, a non-weight-bearing walk with elbow crutches (4-8 weeks) is the common approach in order to protect the repaired meniscus. Following this period, there will be further test to determine next stage of recovery.
Eligibility for management options
If both options are available to people who suffer from an ACL tear, what is the indication to pursue a surgical or a conservative approach?There are 6 criteria that determine the best course of action for the individual suffering the injury. These criteria will be established during the initial consultation, upon which a suitable injury management plan will be created.
1. Complete or partial tear of ACL
The anterior cruciate ligament stops the anterior tibial translation and limits rotational knee movements. There are three grades of ligamentous injuries, from grade 1 to 3. Surgical treatment is recommended for those with a complete (grade 3) ACL tear. You may not need surgery for a partial tear (grade 2) of the ACL or a strained ligament (grade 1).
2. Instability
When patients experience repetitive knee buckling and instability, despite undergoing proper conservative rehabilitation, reconstructive surgery is recommended. Patients can assess their instability during twisting and pivoting movements and provide a subjective rating of knee instability, or schedule an appointment with one of our therapists to perform a ligament laxity test. The results of the test will help determine whether surgery is necessary or not.
3. Other structural damage
Usually, patients who experience an ACL injury along with either a high-grade meniscus tear or a medial collateral ligament (MCL) tear will need surgery to restore the stability of the knee. These structures are highly involved in knee stability, therefore reconstruction and repair of the damaged soft tissue will be necessary.
4. Return to low or high-demand activities
For those whose jobs do not involve heavy physical activity or live sedentary lifestyles, reconstructive surgery may not be necessary, provided that no or limited knee instability is observed. However, for those who engage in high-demand sports that involve jumping, cutting, and pivoting, it is essential to have stable knee joints to prevent any secondary injuries.
5. Age
The reconstructive surgery is usually not recommended for those whose growth plates are still open. Growth plates usually close near the end of puberty. For females, around 13-15 years of age; for males, it is usually when they are 15-17 years of age. However, recent research shows that the traditional transtibial technique and a newer technique, called transphyseal ACL reconstruction, can both protect the opened growth plate as much as possible. It is best to discuss this with the surgeon upon making the decision.
6. Patient preferences
Personal preference. Discussing the decision to undergo surgery can enhance patient satisfaction and outcomes. The desire to return to sports or activities, the potential risks and benefits of surgery, recovery time, and impact on daily life are perceived differently among individuals. Understanding personal preferences in the treatment approach can align with the goals and expectations of the patients.
