What Is The Function Approach on ACL Tears?
To have an ACL reconstruction surgery, or take a conservative approach? That is the real question!
The incidence of ACL reconstructions in Australia is the highest in the world, and is increasing (Vertullo et al 2018). In Australia, we do play some of the most knee-twisting sports: AFL, netball, soccer, rugby and basketball. In my experience of patients with ACL tears, it’s surprising how little people are presented with the latest research and what best practice actually is. Whether you have had multiple surgeries, considering surgery or want to prevent it from happening, you should know what the literature says.
What is the ACL?
The anterior cruciate ligament is an important ligament that is deep in the knee. It is composed mainly of collagen fibres, with a small proportion of elastic fibres, thereby giving the ACL high tensile strength. Its function is to provide passive rotational stability for the knee and prevents your shin from sliding out forwards relative to your thigh during agility exercises, jumping, deceleration and pivoting with sudden changes of direction.
How is it torn?
It is usually non-contact with a sudden pivoting and twisting force is applied to the knee when the foot is fixed to the ground. It can also happen during incorrect landing position after a jump or from a direct blow to the knee from contact such as a tackle. Symptoms include an audible pop or crack at the time of the injury, a feeling of initial instability, swelling, lots of pain, decreased range of motion and tenderness.
What does the latest research inform us about treatment options?
In Australia, majority of patients who have ACL tears have surgical reconstructions. However, current research shows that this may not be the best course of treatment. The latest research that compared ACL reconstruction versus non-operative treatment concluded that people following ACL rupture should receive non-operative interventions before surgical intervention is considered (Monk et al 2016, Smith et al 2014). Early ACL reconstruction with rehabilitation did not provide better results at five year follow up than a strategy of initial rehabilitation with the option of having later ACL reconstruction (Frobell and Roos 2013). In layman’s terms, an ACL reconstruction is not superior to a structured, Physio-led, exercise focused rehabilitation. Physiotherapy needs to be presented as a sophisticated, optimum first treatment and management to patients who sustain an ACL injury; this is in fact current world best practice (Rooney 2018).
How will physiotherapy help?
Whether you have had surgery or not, physiotherapy is essential. Physiotherapy should focus on sport-specific exercise rehabilitation, range of motion deficits, lower limb strength, neuromuscular agility training, patient education, goal setting and a progressive return to pain-free function and sport. Here at Function PCP, we will also do a full movement screen and assessment to identify any other dysfunctions in the rest of your body that could also be affecting your knee joint as any other injury, aches or pains can make you have compensatory movements that could create greater stress on your knees.
How will physiotherapy help? How long will it take to get better? When can I return to sport?
Every patient is different. We tailor treatment and rehabilitation accordingly and therefore timeframes will differ. Typically if you have had an ACL reconstruction, it will take 9-12 months to return to sport with rehabilitation. However, without surgery, the timeframe could be a lot shorter anywhere between 3-6 months.
Studies show that ACL reconstruction is not a pre-requisite for returning to sport (Delincé & Ghafil 2013). Non-operated patients can return to high-level activities without symptom complaints or episodes of instability (Hurd et al 2009). At the elite level, athletes such as Tiger Woods (Golf), Dejuan Blair (NBA), Sean Elliott (NBA), Philip Rivers (NFL), Jess Rich (Winter Olympics) have returned to their sports with torn ACLs.
Prevention is the way
ACL tears are getting more common in Australia and millions of dollars each year are spent for surgical reconstructions. Regular neuromuscular agility programs, which help develop healthy movement patterns and muscle strengthening commonly injured joints, can shave off 50 to 80 percent of ACL injuries (Vertullo et al 2018). There are great resources such as the FIFA 11+, Australia’s Netball Knee Program just to name a few. https://knee.netball.com.au/