Should I Have ACL Reconstruction Surgery?

To Cut, Or Not To Cut? That Is The Question

Making a decision regarding having ACL reconstruction surgery is not always straightforward. Following complete ACL rupture, many athletes find they are unable to participate in cutting, or pivoting-type sports. Failing to do so, due to feelings of instability.  Others however, find they have even more limitations. Experiencing instability during normal activities of daily living. Simply doing housework, jogging, walking downstairs…  There are however, individuals following complete ACL rupture find they can still participate in sports without any feelings of instability. Henceforth, making a decision regarding having ACL reconstruction surgery verses taking a more conservative approach is something to be made on a “case by case” basis.

Despite ACL reconstruction surgery being considered a “successful” surgery. A surgery with low complication rates, and most patients having their symptomatic instability eliminated post surgically. Still, clearly not everyone who ruptures their ACL, will ultimately make the decision to have reconstructive surgery.

ACL Reconstruction Surgery Demands An Extended Post-Surgical Rehabilitation Process

One of the biggest barriers when talking to patients about the pros and cons around undergoing any ACL reconstruction surgery. Is the significant time frame post-surgically with regard to returning to pre-injury functional levels and sport. The rehabilitation program itself is very involved. Typically demanding around 12 post-surgical visits with your physiotherapist. These sessions will be spaced out over a period of 9-12 months. As well as the necessary commitment to a progressive home-gym based exercise program and sport specific training progressions.

Simply waiting 8-12 months post-surgery before returning to play once the “time is up” is not a responsible way to approach any ACL reconstruction surgery rehabilitation. Such approach is setting yourself up for potential re-injury and disappointment. Recovery requires equal measures of time and commitment to a progressive rehabilitative physio and return to sport program.

Key Factors In Any ACL Reconstruction Surgery Decision Process

A young, active adult, who is a competitive athlete, in my experience will almost always elect to have knee reconstruction surgery over choosing the conservative pathway.  Especially so for individuals involved in playing competitive sports which involve rapid changes in direction and regular pivoting movements. Including the football codes, netball, and basketball.. Having knee reconstruction surgery will ideally give this athlete both a clinically and subjectively more stable knee. Therefore, better allowing performance of cutting and pivoting actions with confidence.  Generally, it is someone’s goals regarding returning to specific activities and any necessary recreational and vocational activity levels. Rather than age, that ultimately determine whether or not a surgical intervention pathway is chosen.

Nonsurgical Management Of ACL Tears

Typically, at Sydney Physio Clinic we find that patients electing against having an ACL reconstruction surgery are those less active individuals.  If not currently involved in, and feel unlikely to be involved in regular sport, or activities involving rotational changes of direction and pivoting in the future. Patients may well decide not to undergo reconstruction surgery and the long post surgical rehabilitation process.

Collateral Damage May Be The Deciding Factor

It is important to consider that when someone tears their ACL, an ACL rupture may not be the only injury sustained. Approximately 50 percent of all ACL injuries will occur in combination with some additional damage. Disruption to other structures in the knee, such as the meniscus, articular cartilage, bone bruises, and medial ligament.  Specific collateral damage associated with the ACL rupture, may drive surgery to be strongly recommended.

Patients with a ruptured ACL experiencing significant functional instability has a high risk of developing secondary knee damage. Secondary damage either acutely on return to activity, or chronically over time. Therefore these individuals should strongly consider having an ACL reconstruction.  It is possible secondary damage may occur in patients who have repeated episodes of instability due to their ACL injury. In patients with chronic instability, the risk of meniscal and articular cartilage damage years down the track is significantly increased.

Good Candidates For Nonsurgical Management

It is worth noting, that of late there has been a rise in the number of patients opting for taking the non-surgical path following an ACL tear. Even so in the more active athletes. Individuals who traditionally would have undergone a knee reconstruction. There are some interesting case studies popping up comparing the outcomes between surgical and non-surgical management of these individuals.  As always, more research is required, but Australia as a nation has an extremely high ACL reconstruction rate. It is therefore always a good idea to investigate the cost-benefit ratio of any intervention (surgical or otherwise).  It will be interesting to see in 10-20 years time, if the incidence of ACL reconstruction surgeries in Australia increase, or decrease. Changing as we understand more around the long-term consequences of taking either pathway.

As it currently stands. Taking a conservative, non-surgical management approach for ACL injuries in individuals with partial tears, and no instability symptoms is an acceptable approach. As it is for any, individuals with isolated complete tears without symptoms of knee instability during low-demand activities. Assuming the patient has no need, or desire to be involved in high-demand sports/activities in the future.  Generally, this relates to individuals living relatively sedentary lifestyles, participating only in very light manual work, or activity.

Cross Bracing Method

Recent findings regarding the Cross Bracing Protocol for ACL rupture management could be a game changer in non-surgical ACL rupture treatment. Locally here in Sydney Dr Tom Cross and his father Merv Cross have created an alternative approach which can lead to ACL healing via the Cross Bracing Protocol. The protocol involves immobilising the leg at 90 degrees for four weeks and then gradually increasing the range of motion via a specific schedule. Doing so, until full extension is reached and the brace can be removed. To date this Cross Bracing Protocol has had very promising results, showing ACL healing in around 90% of cases. Should this trend in successful outcomes continue then the Cross Bracing Protocol will make surgery not the only option for achieving a functional ACL.

Disclaimer: This information is provided as an educational service, and is not intended to serve as a substitute for personalized medical advice.  Sydney Physio Clinic does not endorse any treatments, procedures, products mentioned in this post.  Anyone seeking specific advice, or assistance around making a decision regarding having “ACL reconstruction surgery” should consult his, or her physiotherapist, orthopaedic surgeon, general practitioner, sports medicine specialist, or otherwise appropriately skilled medical practitioner.