Should You Have Surgery for that Anterior Cruciate Ligament Tear...Or Not?

Highly active people who injure their anterior cruciate ligament (ACL) in the knee are often faced with an important treatment decision: surgery or no surgery? Wouldn't it be great if there was a test that people could take to help them answer this question?

What we need is a way to tell who is a good candidate for nonoperative care and who should just go ahead and have the surgery. In fact, such a tool may be here. Researchers at the University of Delaware have put together clinical guidelines using a screening exam that might just do the trick.

At least their results (72 per cent success rate) was much higher than in other studies where patients decided for themselves not to have surgery. Their work will have to be repeated by others to validate their findings. But for now, they report an increased ability to return highly active adults to their preinjury level of activity safely and effectively without surgery.

The results of this study are important because there's been an increasing trend to perform surgery early for people who want to get back to their high-demand activities. There's a belief that the risk of further injury and/or damage to the joint is too great to wait.

But other studies of long-term results following ACL repair or reconstruction aren't always so good either. And there are people who do, in fact, get back to high-level activity without surgery and without a recurrence of the problem -- no symptoms, no instability, no recurrence or reinjury.

So, what does this screening exam and treatment decision tree look like? First, it's based on more than 10 years' worth of study, clinical trials, and careful evaluation. Second, the athletes included were those who put in more than 50 hours each year of high-demand activities such as jumping, cutting, pivoting, or lateral movements.

Third, each athlete was examined for other injuries that might keep them from trying a conservative approach. For example, a ruptured ACL along with damage to other knee ligaments or injury to the other knee, the meniscus, or joint cartilage makes the person a poor candidate for nonoperative care. Likewise, fractures, dislocations, back injuries, or nerve injuries also put the patient at increased risk for a poor result with conservative care.

If the patient had the time and inclination to do so, he or she could try conservative care for any of these other injuries first. If successful, then they could come back and go through the screening process to decide what to do about the ACL injury. Before qualifying for the screening exam, the injured athlete had to meet the following criteria:

  • Have no (or minimal) joint swelling
  • Have full knee range-of-motion (equal to the uninjured side)
  • Have at least 70 per cent (or more) quadriceps strength (compared to the uninjured side)
  • Be able to hop on the injured knee without pain while wearing a brace

    Once again, if they could not meet all four of these criteria, they could try a rehab program and come back for screening. But they had to complete all four before the end of a month (30-day trial) or be sent to the surgeon instead.

    It's not that they couldn't go to rehab for more than four weeks and still have a successful result. It's more the fact that these were high-activity athletes who wanted to get back to their preinjury level of play as soon as possible. Waiting more than four weeks would mean missing important competitive events -- and that would defeat the purpose of using this screening tool to ensure a rapid return to high-demand sports activities.

    In the experience of these authors, by the time everyone went through this rigorous scrutiny, less than half of the patients (42 per cent) were still eligible for conservative care. But for those patients, taking the nonsurgical approach and getting back to sports quickly was worth it.

    The exam is made up of a series of hopping tests (with a brace on) and patient self-report. The patient's self-assessment includes questions about knee symptoms, function (e.g., kneeling, squatting, climbing stairs), and report of any episodes of the knee giving way (buckling underneath the patient).

    Patients considered good candidates for conservative care could perform 80 per cent or more of the hopping tests, 60 per cent or better on overall tests, and have only up to one episode of the knee giving way. If they passed all these tests, they were considered a coper and were referred to Physical Therapy for rehab.

    Rehab included a focus on perturbation exercises (putting the patient off balance), muscle strengthening, and cardiovascular exercise (aerobic training). Agility and coordination training along with sport-specific skills were also included. Before returning to sports participation, each athlete had to pass a battery of functional tests. This was necessary to be cleared for full return to preinjury activities.

    The authors concluded that a blanket prescription for surgery to repair a deficient ACL may not be in the best interest of all people. Sometimes athletes are in the middle of a season and want to wait to have surgery. In countries where surgery isn't available right away, athletes need guidance in what to do and what not to do while they wait for their number to come up.

    The University of Delaware screening tool for patient selection can help with these decisions. It is a conservative but effective approach. Anyone who qualifies for nonoperative care but who experiences any signs of knee instability (pain, swelling, buckling) are advised to return to their physician right away.

    Wendy Hurd, PT, PhD, et al. Management of the Athlete with Acute Anterior Cruciate Ligament Deficiency. In Sports Health. January/February 2009. Vol. 1. No. 1. Pp. 39-46.

  • Share this page