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Navigating ACL injury: understanding the ligament to deciphering treatment decisions

16th Oct, 2023

Key Points:

  1. Strong evidence suggests that sex and moderate evidence suggests that knee joint laxity are not good predictors of the need for ACL reconstruction after nonoperative treatment.
  2. Limited evidence indicates that factors like age, height, weight, and preinjury activity level have conflicting or minimal associations with the need for surgical reconstruction.
  3. One high-quality study suggests that a more spherical shape of the femoral condyle might be associated with eventual ACL reconstruction after nonoperative treatment.
  4. Nonoperative management of ACL injuries holds promise, with many patients achieving successful recovery and a return to sports.

Introduction: Unravelling the mystery of ACL injuries and treatment 

The anterior cruciate ligament (ACL) is a vital component of the knee joint, playing a pivotal role in maintaining stability and supporting movement. A rupture of the ACL is a common injury that can have profound consequences for individuals. It not only affects their personal lives due to extended recovery times but also has broader societal impacts, leading to productivity loss and increased medical costs. Over the years, researchers have extensively explored treatment options, leading to nonoperative management emerging as a viable approach.

Understanding the ACL: The guardian of knee stability 

The ACL, a ligament within the knee joint, is responsible for stabilising the joint during activities that involve quick changes in direction, deceleration, and jumping. This ligament acts as a crucial connector between the thigh bone (femur) and the shinbone (tibia), preventing excessive forward movement of the tibia relative to the femur. Its role in maintaining knee stability is paramount, especially in activities that stress the knee joint.

The promise of nonoperative management for ACL injuries

Non-operative ACL success stories: 

Research has shown promising outcomes for nonoperative management of ACL injuries. Many patients who choose this route achieve favourable clinical results, including improved function and reduced pain. This underscores the potential of nonoperative treatment as a valid option for ACL injury management.

Return to sport after nonoperative treatment: 

The ability to return to sports activities is a significant concern for individuals with ACL injuries. Notably, studies have indicated that nonoperative management can lead to successful returns to sports, even in the long term. A recent randomised controlled trial by Frobell and colleagues demonstrated that patients treated nonoperatively achieved outcomes comparable to those treated with surgical reconstruction over a 5-year period. The absence of increased risk of osteoarthritis or meniscal surgery suggests that nonoperative treatment can facilitate a good level of function.

Factors influencing return to sport: 

While many patients recover well with nonoperative treatment, a subset may find their knee function unsatisfactory for certain activities. This dissatisfaction may stem from an inability to reach desired sports activity levels or recurrent episodes of knee instability. Such patients often opt for ACL reconstruction. However, it’s essential to recognize that the success of ACL reconstruction isn’t guaranteed. Ardern et al.’s review highlighted that only 63% of individuals return to sports after ACL reconstruction. 

“This implies that surgical intervention of ACL injuries doesn’t always translate to a smooth return to sports.”

Navigating treatment decisions: beyond predictors

Sex and knee joint laxity: 

The available evidence suggests that sex isn’t a reliable predictor of the need for ACL reconstruction after nonoperative treatment. Similarly, knee joint laxity, often assessed through tests like the pivot shift and Lachman test, doesn’t consistently indicate the necessity for surgical intervention.

Age, height, and weight: 

The relationship between age and ACL reconstruction remains complex, with conflicting findings across studies. Factors like height and weight also lack a consistent influence on the likelihood of requiring surgery.

Physical examination tests: 

Various physical examination tests, including those assessing knee joint stability and concurrent injuries, don’t consistently predict the need for surgical reconstruction. Quadriceps strength deficits and hop tests, although important in evaluation, do not significantly forecast the requirement for surgery.

Preinjury activity level: 

The impact of preinjury activity level on the need for ACL reconstruction is an ongoing debate. While some studies suggest a correlation between higher activity levels and the need for surgery, others find no significant association.

The role of femoral condyle shape:

An intriguing area of exploration involves the shape of the femoral condyle, a component of the knee joint. A study by Fridén et al. indicated that a more spherical shape might be linked to an increased likelihood of requiring surgical intervention after nonoperative treatment. However, this finding requires further validation through additional research.

Making informed decisions for an ACL surgery: 

The decision to opt for ACL reconstruction after nonoperative treatment is multifaceted and influenced by various factors. While research provides insights, it’s important to acknowledge the complexity of individual cases. Factors like sex and knee joint laxity may not strongly guide treatment decisions. Instead, clinicians must consider a comprehensive assessment of each patient’s unique circumstances, taking into account age, physical examination results, preinjury activity level, and potential anatomical variations.

Conclusion: deciphering ACL injury management 

The journey from ACL injury to recovery is intricate and requires informed decision-making. The ACL’s significance in knee stability cannot be overstated, and its rupture presents both personal and societal challenges. Nonoperative management has emerged as a promising option, demonstrating success in helping patients regain function and return to sports. While factors like sex and knee joint laxity may not definitively dictate treatment paths, a nuanced approach is necessary. By considering various elements, including individual characteristics and anatomical factors, clinicians can guide patients toward the most suitable treatment option for their unique situations.

Unsure if you should have a trial of Physiotherapy after your ACL injury? Thinking of speaking to someone with a more balanced view? Contact us to speak to our Physiotherapist so that you can make a more informed decision about your knee! 

REF: Eggerding V. et al. Factors Related to the Need for Surgical Reconstruction After Anterior Cruciate Ligament Rupture: A Systematic Review of the Literature. J Orthop Sports Phys Ther 2015;45(1):37-44. Epub 13 Nov 2014. doi:10.2519/jospt.2015.5183

ACL Injuries in Singapore

Do I need an opeation for my ACL tear?

What are the common causes of ACL injuries in Singapore?

In Singapore, common causes of ACL injuries include sports activities like football and basketball, accidents, and falls.

Do all ACL injuries require surgery in Singapore?

No, not all ACL injuries in Singapore require surgery. Nonoperative treatments have been successful, as shown in studies, especially for patients who meet specific criteria like minimal instability and good function. Your Physiotherapist will be able to discuss and work with you to help return you to sport. 

What are the success rates of ACL surgery in Singapore?

The success rates of ACL surgery are influenced by several factors, including the patient's pre-injury activity level, age, and individual preferences. The article indicates that successful nonoperative treatments can yield similar outcomes to surgery in some cases.

How can I prevent ACL injuries?

Preventing ACL injuries in Singapore involves exercises to strengthen the leg muscles i.e. your quadriceps, hamstrings and calf muscles as well as practising proper techniques during sports. Injury prevention is crucial, considering the impact on productivity and healthcare costs, as mentioned in the article. Consider speaking to our Physiotherapist to find out how to you prevent an ACL injury. 

What are the key factors to consider when deciding on ACL surgery?

Deciding on ACL surgery involves evaluating factors like the patient's pre-injury activity level, fear of not returning to previous sports levels, clinical knee instability test outcomes, age, and individual preferences. The article suggests that identifying prognostic factors early after an ACL injury is essential for determining the need for surgical reconstruction.

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