By Trying Knee Rehab First, Many May Avoid ACL Surgery July 21, 2010 -- Many patients with a torn ACL -- the ligament that stabilizes the knee -- may avoid surgery by delaying the operation and first giving physical therapy a try. One of the most feared sports and work injuries is a torn anterior cruciate ligament or ACL. It's the tough piece of tissue that keeps the
knee from bending sideways when you plant your foot and pivot. Nobody is exactly sure of the best way to treat a torn ACL. Yet every year, at least 200,000 Americans undergo ACL reconstruction, in which the ACL is restored with tendon grafts. Most patients undergo this surgery soon after their injury. But that may not be the best strategy for everyone,
suggests a clinical trial by physiotherapist Richard B. Frobell, PhD, of Sweden's Lund University, and colleagues. Frobell's team randomly assigned 121 young, active adults -- many of them highly competitive, non-professional athletes -- to two different treatments. Both groups
underwent a highly structured rehabilitation program in which they worked up from improving balance and coordination to knee strengthening exercises. One group underwent ACL reconstruction within 10 weeks of injury. But the other group delayed ACL reconstruction until it became obvious they needed it -- or until they healed. Two years later, both groups had good results. Neither treatment strategy was better than the other. But there was one big difference: 60% of
those who delayed surgery found they never needed the operation. "A lot of people say you need ACL surgery if you want to return to sports. But our results show we might be better off if we start with rehabilitation," Frobell tells WebMD. "Then we can reduce the number of people needing surgery." Mayo Clinic orthopaedic surgeon Bruce A. Levy, MD, is full of praise for the Frobell study. But he
warns that some patients risk further damage to their knees by delaying ACL reconstruction. The injury that rips the ACL may damage other parts of the knee, particularly the meniscus -- the piece of cartilage that cushions the bones of the knee. "If you have a large meniscus tear and you fix the meniscus and not
the ACL, there is a very high likelihood the ACL will fail," Levy tells WebMD. On the other hand, a patient who is a relatively low-level recreational athlete -- Levy offers the example of a 35-year-old cyclist -- may be better off with bracing and rehabilitation. Only if such patients have further ACL problems would surgery be the preferred option. But a collegiate soccer player might not be able to return to play without ACL reconstruction. "When a patient presents with an ACL tear
in the knee, we have a long discussion with the patient and family on the pros and cons of operative and nonoperative treatment," Levy says. "The decision is based on many factors. First and foremost is the patient's activity level, and the sport and work demands the knee would undergo." Frobell fully agrees with Levy that the study does not give patients or doctors a one-size-fits-all solution to treatment of ACL tears. "Our study does not answer the question of
specifically who needs ACL surgery. It does not look into what factors a patient has to have to need surgery to do well," he says. "We need a lot of more high-quality science in this area." Some of that data may be coming soon. Levy says he'd like to see how Frobell's patients do in the long term. Frobell says the last patient in the study is just completing five years of follow-up observation. More information is on the way. The Frobell study, and an editorial by Levy, appear in the
July 22 issue of the New England Journal of Medicine. Rehabbing Your Torn ACL Without SurgeryWhat Can You Do Without ACL Reconstruction Surgery?Without surgery, after rehabilitation, you should be able to:
Some people decide against surgery and successfully return to activities or sports that normally do not involve twisting the knee. You may be able to resume alpine skiing, for instance, even if a fall on the slopes was how you tore your ACL. While you might be able to enjoy these activities, performance might be below your preinjury experience. (Even with reconstruction surgery and complete rehabilitation, most people report achieving something less than their full preinjury sports capability.) Two Other ACL Surgery Decision FactorsIn addition to the five main ACL surgery decision factors, there are two others to consider when deciding whether to have ACLR surgery:
Possible Downsides of No SurgeryWithout surgery, your ACL will remain torn. The knee might heal—the swelling and pain will stop. But a torn anterior cruciate ligament does not reattach or heal itself. You may still be able to live how you want by strengthening your leg and core (your hips contribute to leg strength and function) and adjusting your activities. If your desired activities require maintaining strength to avoid injury, you will need to continue training as long as you participate. Possible long-term downsides of not having ACL surgery:
What to Do if You Don’t Want SurgeryThe recommendations immediately following an ACL injury are similar whether or not you plan to have surgery:
Why Do I Need Rehab if I Don’t Have Surgery?An ACL injury is traumatic. It causes acute weakness in your leg, swelling, bleeding into the joint (hemarthrosis), loss of motion and reflex inhibition in your quad muscle. Following your injury, there will be immediate swelling. You may be unable to straighten your leg. Your knee may be unstable. A weak leg without an ACL can allow the knee to move in unintended ways. This can injure other parts of your knee. With or without surgery, rehabilitation is critical to recovering leg strength and functional control. You’ll benefit from at least a basic rehabilitation program and then keeping your leg and core strong. The more active you want to be, the more you’ll want to restore strength and control in your leg. Another rehabilitation benefit? Regular evaluation by a professional familiar with ACL injuries. Physical therapists and athletic trainers can identify and remedy weaknesses to keep your program on track. They can also advise and encourage you when you are ready to return to activities. Everyone’s Injuries and Bodies Are DifferentYou might be able to return to activities others cannot. And what others can do—especially someone reporting a miraculous return to sport or work—might not be possible for you. Read the studies about non-surgical outcomes carefully. Look for data on what activities those not having surgery can perform and at what level. Also note how long after injury someone is reporting on their return to activity and their level of performance. A report at six months is less informative than at two or six years. Younger patients especially will want to discuss with their doctor the impact of living without a functioning ACL. The recommendation? Discuss your objectives with your surgeon and physical therapist or athletic trainer, then make the choice that you believe works best for you. How to Decide? Look at Five FactorsThere are five primary factors in the decision to have ACL reconstruction surgery. Discuss them with your surgeon and physical therapy and athletic training professionals, family and other advisors. If you’ve also injured other ligaments (especially your medial collateral ligament), your meniscus or articular cartilage (the soft and slippery substance covering the ends of the thigh and shin bones in the knee), surgical reconstruction is recommended. Without a functioning ACL, it will be difficult to return effectively to sports, work or other activities with aggressive jumping, cutting and pivoting. The more competitive the sport, the more it stresses the knee and the higher performance you want, the lower the probability you can return without ACL reconstruction. Most people who try to rehab without surgery do not return to sport. Your sport, position and the level of competition—or the kind of work you do—create specific and different stresses on your knee. Skiing is different from soccer. Running back is different from defensive lineman. High school is different than college Division 1. This is why you want to discuss your situation with your medical professionals. Not having surgery skips recovery from the operation. It usually lessens the rehabilitation time you need to return to normal activities. But if you want to return to play or aggressive jumping, cutting and pivoting, your “no-op” rehab program will be similar to the post-surgery regimen. And, as noted above, without surgery, the odds are against a successful return to any sport with aggressive movement. It can take months of rehab to find out if you can achieve the strength and functionality you want without surgery. If not, you’ve added those months to the typical nine-month (or more) return-to-sport program after ACL reconstruction surgery. Rather than risk missing a second season, athletes frequently elect surgery as soon as recommended after their injury. Was This Content Helpful?How long does an complete ACL tear take to heal without surgery?It can happen to athletes who play sports like football, basketball, soccer and volleyball, and to those who work physical jobs. There are surgical and nonsurgical treatments. Most people recover from an ACL tear within six to nine months.
Can you live with a completely torn ACL?Living with a torn ACL: Some patients choose to live with a torn ACL. For younger people, it may not be advisable to live a lifetime with this ligament torn. Although in some cases the ACL ligament can scar onto the PCL and act stable, more often instability occurs and it should not be ignored.
What happens if a torn ACL is not repaired?If nothing is done, the ACL injury may turn into chronic ACL deficiency. Your knee may become more and more unstable and may give out more often. The abnormal sliding within the knee also can hurt cartilage. It can trap and damage the menisci in the knee and can also lead to early osteoarthritis.
Can a Grade 2 ACL tear heal without surgery?Grade 2 tear: A partial tear. The knee joint has lost functionality. The prognosis for a partially torn ACL is good. Physical therapy will likely be required, but rehabilitation and recovery can happen within 3 months without surgical intervention.
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