ACL injuries seem to be becoming more and more common, and not just among sportspeople. When someone suffers an ACL injury they are usually prescribed immediate surgery followed by a programme of physical rehabilitation. But, is this really the best approach to provide patients with the outcome they are looking for?
Within this blog post we’ll take a closer look at the most up to date evidence on a non surgical approach to managing ACL tears, the concept of ACL healing and the significance of shared decision making. If you are interested, you should take time to read Kieran Richardsons masterclass about Non- Surgical management of ACL tears.
A high Success rate when it comes to ACL reconstructions can be found in the majority of western countries. However, one area in particular is prominent when it comes to delivering high rates of non surgical management. In Scandinavia, their healthcare model means that a patients first appointment will be with a non- surgical orthopaedic specialist. At this appointment they undergo an in depth examination. Wherever possible patients will undergo a physio first route leading a reduction in the number of surgeries.
What is the Physio First Approach
Physio first is not a completely new concept, as long ago as 1994 it was proven that there were a lot of patients who could make a full recovery without undergoing surgery. While prospective studies during the 1980’s highlighted that while surgery is essential for some patients, many others are able to manage without going under the knife. So, how do we identify people who can cope and those who can’t?
As it happens, most people can cope but only if given the correct amount of time. By giving patients around 6-12 months most will have the ability to cope. Unfortunately it is virtually impossible to predict at the outset who will do well. However, there are some markers that can be used to identify patients who can cope.
For example, patients who have less than one episode of giving way, who can score 80% on a timed hop test, 80% on the KOS ADL subscale or those who have a 60% global rating of knee function will usually have the ability to cope well in the long term.
Surgery v Conservative Care
One of the most comprehensive and high-quality studies on ACL management, the KANON trial, looked at the different outcomes for individuals who underwent early surgery followed by physical therapy and those who followed a programme of supervised exercise therapy, with the option for delayed reconstruction if necessary. The study came to the conclusion that early surgery was not superior in any way to the initial non-surgical approach, with the early surgery group in lots of cases experiencing poorer outcomes. However, many participants changed over from rehabilitation to surgery due to their pre conceived beliefs.
Even today there is a strong leaning towards early surgery, mainly because people believe it is essential if you want to get back to normal exercise routines and as a result achieve a better outcome. This clearly demonstrates the important part that a patients mindset and psychology plays in ensuring you get the outcome you want, and why education during rehab is invaluable.
There is one certainty where ACL injuries are concerned and that is, that both the surgical and non surgical pathways both have risks and neither give you a guaranteed route back into your chosen sports. But seeing that there is no compelling evidence that surgery is definitely the best option, it is surely worth trying physio to see if it works for you.
If you are concerned about the risk of developing osteoarthritis there is no difference between either method, so should never be used as an excuse to take the surgical approach.
Is It Possible for ACLs to Heal?
One very good reason to take the conservative management approach is the possibility that the ACL will heal on its own. It was not that long ago that once you had torn an ACL it was torn forever. The belief was that it would not be able to heal as it had no blood supply. However, evidence recently has refuted this by proving that the ACL does indeed have a blood supply, albeit a very small one.
There are a number of stories that contain details of professional athletes who have suffered ACL ruptures that have healed without surgery. A systematic review in 2021 that showed ACLs can heal supports these stories. One of the main problems though, is that the quality of such studies are in many cases really poor. However, there are not actually any studies that offer definite proof that ACLs are unable to heal. With research in its infancy it is necessary to undertake better quality studies to demonstrate how you can increase the odds of a tear healing successfully.
What We Don’t Know and The Collaborative Approach
Does the knee need to be braced, how about weight bearing? While there may be some to debate about those points one thing is absolutely certain, an ACL is unlikely to heal with no early intervention. This in turn highlights how important it is to begin rehab as soon as possible, preferably in week one but certainly no later than the third week.
While there are a number of very good reasons why physiotherapy Leeds should be your first option, it is important not to pressurise anyone into it. At the end of the day patients should be given the chance to have input into what is best for them. One way to do this is through a process where decision making is shared, and during which the pros and cons of both surgical and non surgical approaches. To ensure the patient is properly informed answers to all questions should be readily available and explained to them in layman’s terms. Ideally consultations should involve lengthy and in depth discussion, unfortunately in reality these days doctors often only have time to cover the basics.
The treatment and management of ACL tears still has a lot of grey areas and there is no doubt improvements could be made. But as we feel confident enough to say that taking a conservative approach should be the first course of action. This is because outcomes are as good if not better than immediate surgery. Here at Physio Action, we offer a range of solutions when it comes to Physiotherapy in Leeds and surrounding areas such as Harrogate, Ilkley and Guiseley. Get in touch with us today for more information!