Unmasking the Truth About ACL Injuries: Surgery vs. Rehabilitation
It can be so confusing!
Trying to decide whether you need surgery for your ACL rupture can be tricky!
Introduction
Anterior cruciate ligament (ACL) injuries are among the most common knee injuries, and the path to recovery is often shrouded in myths and misconceptions. As physiotherapists committed to providing the best care for our patients, it's vital to provide a clear understanding of ACL injury management, grounded in evidence-based research. In this blog post, we'll delve into some common misconceptions surrounding ACL injuries based on the recent work of Dr. Stephanie Filbay, a Senior Research Fellow at the University of Melbourne.
Myth 1: A Torn ACL Cannot Heal Without Surgery
For years, it's been widely believed that a torn ACL has minimal healing potential, leading many to believe that surgery is the only option. However, Dr. Filbay's research challenges this notion. Her analysis of the KANON trial revealed that a remarkable 53% of participants who opted for initial exercise-based rehabilitation displayed signs of ACL healing on MRI scans two years after the injury. These individuals reported superior knee-related quality of life and sports function compared to their counterparts who chose early surgery. Moreover, a novel non-surgical bracing protocol yielded promising results, with 90% of patients demonstrating signs of ACL healing after three months of rehabilitation and bracing.
These findings strongly suggest that ACL ruptures can indeed heal without surgery, offering hope for improved patient outcomes.
Myth 2: ACL Reconstruction Is the Sole Path to Returning to Sports
It's a common belief that only ACL reconstruction can pave the way for athletes to return to cutting and pivoting sports. However, research challenges this conventional wisdom. Several studies have compared return-to-sport rates between individuals who underwent ACL reconstruction and those who pursued exercise-based rehabilitation. Surprisingly, these studies found no significant difference in return-to-sport rates.
This reiterates that individuals with ACL injuries can often make a triumphant return to their favourite sports without the need for surgery, dispelling the myth that reconstruction is the only route to recovery.
Myth 3: ACL Reconstruction Prevents Future Knee Injuries
Another widespread assumption is that ACL reconstruction reduces the risk of subsequent knee injuries. However, many studies supporting this belief have limitations, and there's insufficient evidence to definitively establish the necessity of surgery for knee protection.
Research indicates that subsequent knee injuries can occur regardless of whether a person opts for ACL reconstruction or exercise-based rehabilitation. Intriguingly, up to one in three individuals experience graft rupture after ACL surgery, often leading to additional meniscal or cartilage damage.
It's vital to prioritise the prevention of further damage, irrespective of the chosen management approach.
Myth 4: ACL Reconstruction Lowers the Risk of Osteoarthritis
Although it's commonly believed that ACL reconstruction decreases the risk of knee osteoarthritis, recent research challenges this assumption. Most studies have either found no significant difference in osteoarthritis rates between the surgical and non-surgical groups or even higher rates among those who underwent reconstruction.
What's crucial to consider is that most research examines radiographic (x-ray) osteoarthritis, which doesn't necessarily correlate with knee symptoms. Fewer studies have delved into symptomatic osteoarthritis and its comparison between management strategies.
Myth 5: ACL Reconstruction Guarantees Superior Outcomes
Despite the prevalent belief that ACL reconstruction leads to better outcomes, multiple systematic reviews suggest otherwise. Patient-reported outcomes, including sport and recreational function, knee pain, symptoms, and quality of life, often show no substantial differences between individuals who undergo ACL reconstruction and those who don't.
Two randomised controlled trials have even concluded that early ACL reconstruction doesn't yield superior knee function, pain relief, symptom reduction, or quality of life compared to exercise-based rehabilitation. A recent systematic review and meta-analysis advocate for a rehabilitation-focused approach as the primary treatment for ACL patients without significant concomitant injuries.
Conclusion: Informed Decision-Making Is Key
So, when it comes to ACL injuries, should you opt for surgery or exercise-based rehabilitation? The answer isn't one-size-fits-all. Patients deserve the opportunity to make informed decisions that align with their values and preferences.
In most cases, initiating treatment with exercise-based rehabilitation is a sensible choice. Patients can still opt for surgery later if necessary. This approach doesn't result in worse long-term outcomes, although it may extend the recovery timeline if surgery becomes the chosen path. Conversely, early ACL reconstruction carries potential surgical risks, higher costs, and the risk of graft rupture, with no guarantee of superior long-term outcomes. It's essential to recognize that once ACL reconstruction is performed, the native ACL cannot heal.
Physiotherapists play a pivotal role in educating patients about their options. Dr. Stephanie Filbay and her team are actively developing resources, including a patient decision aid for ACL injury, to enhance their knowledge about ACL injury management options.
By dispelling these ACL injury myths and advocating for evidence-based practices, we can enhance patient outcomes and ensure they receive the care that best suits their individual needs and goals.
Myth busting misconceptions about anterior cruciate ligament injury management
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