Does ACL Injury Require Surgery

Athletes who want to get back into action after an anterior cruciate ligament (ACL) tear are often advised to have surgery as soon as possible. But is this advice really warranted? Do players with deficient ACLs who have surgery have better results than those who don't? These are the questions explored by the author of this article.

A literature review was done to answer the question. The author (a Physical Therapist and director of the Jerusalem Sports Medicine Institute) searched for information to answer two other questions. First, is it possible to identify patients with an ACL tear who need surgery in order to be able to return-to-play? And second, what are the differences between those who can go back to play without surgery (called copers) and those who require surgical reconstruction of the knee (the noncopers)?

There is actually a third group of ACL injured and those are the adapters -- athletes who manage without surgery by reducing or modifying their activity level. This group is unable to resume high-level sports activities but must lower their sports participation in order to avoid surgery.

Current evidence does not support the need for immediate surgery for all ACL tears. It is possible that even with ACL repair or reconstruction, the high-level of sports play will not protect the knee from future injuries. And there is some question whether this type of surgery really restores full stability and biomechanical function of the knee.

With all that in mind, let's take a look at what was found in the literature to clear up some of these questions. Of the 65 published articles that were included in the study, only five were specifically looking at copers versus noncopers.

To better understand the specifics of copers versus noncopers, copers were defined as athletes who could go back to their preinjury level of sports without knee problems. They did not have episodes of the knee giving out from underneath them. And they were even able to perform activities requiring jumping, pivoting, cutting, and quick stop-start moves. Noncopers were unable to return to their previous level of activity and/or they reported episodes of knee instability described as "giving-way."

As it turns out, noncopers really do have significant objective findings to explain why they can't perform normal knee activities. Their quadriceps muscles are weak and the noncopers have decreased quadriceps control. They have more cocontraction of the quadriceps and hamstrings muscles (both contract at the same time), and significant changes in the way the knee moves.

Cocontraction is just one way the body has of automatically protecting an injured joint by increasing stiffness around the joint. This is an effective way to help the joint compensate for loss of ligamentous support. Some studies also showed that the way the quadriceps and hamstrings muscles contract during movement changes in noncopers.

Now that we know there are true (measurable) differences between copers and noncopers, the next natural question is: can a noncoper rehab successfully to become a coper without surgery? Right now, that question isn't really asked and noncopers are routinely referred for surgery. There hasn't been a tool or test that can sort out one group from the other.

We do know that specific training programs that include strength training combined with perturbation (balance) training helps retrain the muscles (reducing cocontraction) and restores more normal knee motion. But does this training eliminate the need for surgery? The answer to this question remains unclear and points to the need for further study of this problem.

Several groups around the world have started studying ACL injuries with this intent and focus. Their preliminary results show that as many as two-thirds of athletes with ACL injuries can obtain good knee function and return to sports with the rehab program just described. But the recovery period takes time and some athletes may still opt for surgery in hopes of a faster return-to-play.

There are still many other factors and variables that must be examined when studying the results of treatment (conservative versus surgical) for ACL injuries. The risk of future injury or development of osteoarthritis has been raised as an issue. It's possible that these problems are just as likely for copers as noncopers (i.e., those who don't have surgery versus those who do). If that's the case, then the idea of preventing these problems by having surgery comes under fire.

Complications of surgery must be considered as well as changes in the way patients move and function when they fear another injury. It may seem like this literature raised more questions than it answered. This highlights the fact that decisions about treatment for ACL injuries are complex. The bottom-line is that there's enough evidence to support a nonsurgical approach to ACL tears -- even for athletes who intend to return to full sports participation. Finding a way to sort out who will do well without surgery and who won't is the next step.

Reference: Yonatan Kaplan, PT, MSc (Med). Identifying Individuals with an Anterior Cruciate Ligament-Deficient Knee as Copers and Noncopers: A Narrative Literature Review. In Journal of Orthopaedics & Sports Physical Therapy. October 2011. Vol. 41. No. 10. Pp. 758-766.

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