Is Surgery Needed For My ACL Injury?Jo Clacher
Article by Zoe Russell
Is Surgery Needed For My ACL Injury?
The Anterior Cruciate Ligament (ACL) is one of the main stabilising ligaments of the knee. It contributes in conjunction with your muscles, other ligaments and receptors in the joint capsule and surrounding tissues to maintain the knee’s stability.
An ACL injury is often seen as a devastating injury, with treatment decisions often made in the timeframe early after injury, often favouring a surgical reconstruction.
Did you know there are 3 options for treatment after you have injured your ACL?
- Early Surgical Reconstruction
- Delayed Surgical Reconstruction after 3 months of Rehabilitation
- Non – Surgical Management.
Evidence currently demonstrates that rehabilitation, with a decision regarding surgical intervention delayed until 3 months, may have the best long term outcomes in recreationally active individuals (Grindem et al., 2014). This is different to elite athletes, where we often see an early surgical approach.
Treatment choice differs in different populations, based upon the specific individual characteristics of the injured person and the available evidence that guides clinical practice (Ardern et al., 2014). Everyone who has injured their ACL should have a structured rehabilitation program, with testing conducted
How do you decide what to do?
Treatment choice is determined by several individual factors, specifically.
- Activity level
- There is good evidence to suggest that to remain recreationally active, and you may not require surgical reconstruction of your ACL injury (Frobell et al., 2010; Frobell et al., 2013)
- There is currently no research to suggest a non – surgical approach is successful in elite athletes (Frobell et al., 2013; Grindem et al., 2014).
- Current evidence suggests that if you wish to return to a sport that requires cutting or change of direction (known as Level I Sports), you may favour a surgical repair of your ACL injury. However, this should not stop you from completing pre-surgical rehabilitation before making a decision.
- Future Goals
- Having a specific understanding of where you are currently and where you want to be with your goals is an important consideration.
- Stability of the Knee
- Some individuals can stabilise their knee dynamically (i.e., with their muscles) in the absence of a deficient ACL. This can be determined by completing a prehabilitation program that involves preoperative testing and reassessment of testing outcomes across the duration of your prehabilitation program (Rooney, 2018).
- Concomitant Injuries
- Injuries to adjacent structures such as the menisci (shock absorbing component of the knee) and the articular cartilage (surface of the bone) may influence the treatment choice and timing of any intervention (Frobell et al., 2010).>
- Past History
It is recommended that a shared decision-making process occurs between yourself, your Physiotherapist and your Orthopaedic Specialist (Ardern et al., 2014). This involved outlining all the options relative to your presentation and discussing all options to facilitate your rehabilitation and recovery plan! It is also strongly recommended that you have thorough outcome testing pre-intervention, during rehabilitation, and return to sport (Ardern et al., 2011; Grindem et al., 2017; Webster, 2020). These tests include physical tests, psychological screening specific to ACL injury and Quality of Life measures related to your injury (Ardern et al., 2015).
Research in this area is constantly evolving, and you must seek assistance from a Physiotherapist who is up to date with current with the latest research! Your PhysioWorks Physiotherapist can help discuss all these options. Best results have been shown when you start your rehabilitation program early, despite the chosen treatment strategy.
PhysioWorks offers prehabilitation and rehabilitation programs that are individualised and specific to your sport and your injury. As part of the rehabilitation program, we conduct testing to ensure that you are on track with your recovery to achieve your goals and communicate this directly with your treating specialist as required.
PhysioWorks offer same-day appointments for the prompt diagnosis and rehabilitation plan.
More information: Common Knee Injuries
Kinesiology tape has a comprehensive array of therapeutic benefits. Because kinesiology taping can usually be left on for several days or up to a week, these therapeutic benefits are available to the injured area 24 hours a day, significantly accelerating the healing process from trauma, injuries and inflammatory conditions.
Benefits of Kinesiology Taping
Pain Relief via Structural Support for Weak or Injured Body Parts
Kinesiology tape is a flexible elastic tape that moves with your body. The supple elasticity provides supports to your body parts without the tape slipping.
By supporting your body part, kinesiology tape can provide you with pain relief and muscular support to help control body parts affected by muscle inhibition.
Kinesiology tape potentially assists your muscle strength via physical assistance. It also provides tactile feedback through the skin, e.g. proprioception boost. This phenomenon may help both the non-disabled athlete to enhance their performance and hypotonic, e.g. children with low muscle tone.
Kinesiology provides a passive lift to your skin via its elastic properties. This vacuum effect allows your lymphatic and venous drainage systems to drain and swollen or bruised tissue quicker than without the kinesiology tape.
It is also thought that this same principle can assist the removal of exercise byproducts like lactic acid that may contribute to post-exercise soreness, e.g. delayed onset muscle soreness (DOMS).
More info: Strapping & Supportive Taping
ACL Tear Symptoms
Individuals who experience ACL tears describe a feeling of the joint giving out or buckling. You'll commonly hear a "pop."
Signs You May Have Sustained an ACL Tear:
- Sudden giving way of the knee
- Hearing a 'pop' at the time of injury
- Sudden swelling of the knee joint
- Pain in the knee when walking
How is an ACL Tear Diagnosed?
A well trained Sports Physiotherapist, Sports Physician or Orthopaedic Surgeon will generally be able to confirm the diagnosis of an ACL tear within the clinic and from your injury history.
An MRI scan can confirm your ACL tear and identify other knee injuries that may have occurred when your ACL was ruptured. These accessory injuries commonly include meniscal tears, bone bruising and collateral ligament injuries.
Confirmation of an ACL tear is essential since the treatment differs from a common knee ligament strain or a meniscus tear.
What to do if you have a Ruptured ACL?
Please be guided by your trusted healthcare practitioner for an ACL tear. Successful rehabilitation options vary depending on your age, activity level and extent of the injury. For specific advice, please consult an experienced knee physiotherapist, knee surgeon or sports doctor.
Can You Live Life Without An ACL?
When an ACL injury occurs, the knee becomes less stable. The ACL injury is a problem because this instability can make sudden, pivoting movements difficult, and it may make the knee more prone to developing arthritis and cartilage tears.
If your knee is unstable, a common complaint of a sensation that the knee will 'give out' from under them. When this giving way sensation is because of an ACL injury, the knee joint is sliding too much. Joint sliding can be a problem because each episode of instability (the 'giving way' sensation) can cause damage to the knee cartilage. Therefore an ACL injury makes patients more prone to developing knee arthritis and meniscus tears.
Athletes often have particular difficulty once they have sustained an ACL injury. Many sports require a functioning ACL to perform common manoeuvres such as cutting, pivoting, and sudden turns. These high demand sports include, but are not limited to:
- Snow Skiing
- Hockey (Ice and Field)
Patients may function in their normal daily activities without a normal ACL, but these high-demand sports may prove difficult. Therefore, athletes are often faced with the decision to undergo surgery to return to their previous level of competition.
ACL Tear? Things to Consider
Patients who suspect they have an ACL tear should seek a professional assessment by their physiotherapist or sports doctor. An ACL tear may be misdiagnosed immediately after the injury because of associated pain and swelling. There may also be muscle spasm that contributes to making the knee challenging to examine. Therefore, it may not be possible to conclusively determine the presence of an ACL tear soon after the injury. If an ACL tear is suspected, you will return for a follow-up evaluation with your orthopaedic surgeon.
How Does Your Physiotherapist Make the Diagnosis of an ACL Tear?
The presence of a suspected ACL tear occurs whenever a patient has an injury to their knee. In the clinic, knee instability assessment occurs via specific manoeuvers performed by your physiotherapist or doctor. These manoeuvers test the function of the ligament to determine if an ACL tear is present. The most commonly used tests to determine the presence of an ACL tear include the Lachman Test and the Pivot Shift Test.
What Are Other Tests Recommended To Diagnose An ACL Tear?
A complete examination of the knee is also necessary to determine if other injuries may have occurred that could be causing your symptoms.
Your physiotherapist or doctor will also evaluate X-rays of the knee to assess for any possible fractures, and an MRI may evaluate ligament or cartilage damage. However, MRI studies may not be needed to diagnose an ACL tear. The physical examination and history are just as good as an MRI in diagnosing an ACL tear. Many patients are concerned when their doctor or physiotherapist does not order an MRI. While the MRI may be necessary in some cases, it is not required to diagnose most ACL tears if there are laxity and a predisposing mechanism of injury.
What To Do If You Have A Ruptured ACL?
We recommend professional guidance for an ACL tear. Successful rehabilitation options vary depending on your age, activity level and extent of the injury.
What is the Main Function of the ACL?
The anatomy of the knee joint is critical to understanding this relationship. Mostly, the femur (thigh bone) sits on top of the tibia (shin bone), and the knee joint allows movement at the junction of these bones.
Without ligaments to stabilise the knee, the joint would be unstable and prone to dislocation. The ACL prevents the tibia from sliding too far forward.
The ACL also contributes stability to other joint movements, including the angulation and rotation at the knee joint. The ACL performs these functions by attaching to the femur on one end to the tibia at the other.
ACL Injury. Does It Require Surgery?
The decision as to whether or not to operate on an ACL tear is dependent on several factors. Some patients who experience ACL tears can resume normal daily activities without surgical reconstruction of this ligament. There are some important factors to consider in deciding as to whether or not operative treatment of an ACL tear is needed.
These factors include the age of the patient, the activity level of the patient (both recreational and occupational), the expectations of the patient, the ability and willingness of the patient to undertake postoperative rehabilitation. Plus, the degree of instability of the joint and any other associated injuries to the knee (e.g. other ligamentous or meniscal problems).
What is the Surgical Treatment for ACL Reconstruction?
ACL reconstruction is usually not performed until several weeks after the injury. Studies have shown improved results when ACL reconstruction surgery is delayed several weeks from the time of injury. This time allows the inflamed and irritated knee to cool down. Swelling decreases, inflammation subsides, and range of motion improves. Resolution of swelling and stiffness before ACL reconstruction surgery improves the postoperative function of the joint.
Can the ACL be Repaired?
ACL reconstruction surgery is common. Unfortunately, a torn ACL cannot be "repaired." It is not possible to repair the torn ACL by simply reconnecting the torn ends. Rather, the torn ligament's replacement is a healthy graft or donor tissue.
How is the ACL Reconstruction Performed?
The surgical procedure for an ACL reconstruction is variable but commonly involves using a segment of another larger ligament or tendon to replace the damaged ACL.
The graft options for ACL reconstruction include:
Peroneus longus tendon
Allograft (Donor Tissue)
The ACL reconstruction surgery lasts about 1 1/2 to 2 hours, depending on the graft choice and any other work that may need to be done in the knee joint. Your physiotherapist will coordinate your postoperative rehabilitation and guidance.
What to do if you have a Ruptured ACL?
We highly recommend professional medical for an ACL tear. Successful rehabilitation options vary depending on your age, activity level and extent of the injury.
Post-ACL Reconstruction Rehabilitation
Post-operative ACL rehabilitation is probably the least emphasized and most crucial aspect of care for a torn ACL. Whether or not a patient is diligent about their therapy determines how well their knee will perform after ACL reconstruction. Most patients experience a full recovery and resume their previous lifestyle, including professional athletes. However, some patients complain of pain, stiffness and limited motion in the joint for months or years following ACL reconstruction surgery.
The best outcome is when your physiotherapist guides your rehabilitation in ACL Reconstructions.
What is the Timeline for Return to Activities after ACL Reconstruction?
Initially, following ACL reconstruction, patients can expect to be using crutches from one to three weeks. Early in rehabilitation, the emphasis is to control swelling, the flexibility of the joint, and return of strength. As the range of motion improves, an increased focus is on recovering strength.
Swimming and cycling are excellent methods of strengthening the muscles around the knee. Muscle strengthening is critical to recovering muscle mass lost due to surgery and improve the joint's stability as increased muscle strength reduces stress on the joint ligaments. Finally, regular (not high-demand) activities (e.g. running) can resume at about four months in most cases following surgery. Most athletes in high-demand sports with cutting and lateral movement (e.g. soccer, basketball) can expect to return about six to twelve months after surgical reconstruction.
Over 90% of patients can resume their previous level of activity after ACL reconstruction. A small percentage of patients m persistent pain or instability; however, changes in activity level following ACL reconstruction surgery are often due to choice rather than limitations of the knee joint.
What to do if you have a Ruptured ACL?
We highly recommend physiotherapy guidance for any ACL tear. Successful rehabilitation options vary depending on your age, activity level, the extent of injury what sporting demands that you are planning to resume.