ACL: All about injury mechanism, conservative treatment vs surgery and more
- Will surgery or conservative care be better for long term knee health?
- Is surgery the right choice for me? or could I go for a conservative try?
- How long is is going to take until I'm back at the field?
- What is the mechanism of ACL rupture?
...knee laxity = passive intraarticular translation of the tibiofemoral joint as measured by manual testing or device
functional instability = patient percieved instability of the knee joint
funcitonal stability can be gained after both ACLR or ACL with rehab only through neuromuscular exercising.
2019 paper showed: best available evidence does not indicate that an individual is at greater risk of subsequent injury if they are managed with rehabilitation as the first-line treatment as opposed to ACLR
it is possible to return to sports after rehab alone, without surgery.
rationale for decision makeing should be:
"As the only randomized trial on the topic did not support a superior outcome with early ACLR [35], it is prudent to suggest a period of rehabilitation before surgical decision-making for most patients with ACL rupture. This strategy is also supported by the findings that preoperative rehabilitation improves postsurgical outcomes in those who go on to have an ACLR [62e64]. There is clinical agreement that patients who have functional instability after rehabilitation are likely to benefit from ACLR" On the other hand, if the athlete sustains an ACL rupture close to an important event and has no signs of functional instability, having an early ACLR would mean they could not compete in this event. He or she might therefore choose to participate in the event before considering whether surgery is likely to be of additional benefit to rehabilitation. The key to the treatment decision is to agree on a realistic treatment plan that sets the patient up with the best opportunity to achieve his or her goals.
To point out: Although it is not necessary to have surgery immediately after ACL injury, for those people in which ACLR is indicated, waiting for surgery should not take longer than 3 months, as risks for cartilage or meniscal injury might start to increase.
Copers vs non-copers:
Copers are classified as people who have a "stable" knee even after ACL rupture (= no giving way episodes), making them great compensators. While non-copers are those who will suffer from episodes of dynamic instability. This classification, usually made early after ACL rupture is not static. A neuromuscular training program for 10 sessions has been shown to get nearly half of people classified as non-copers into the copers group. Meaning that good prehab can changer coper classification.
Copers = people with >80% symmetry on timed hop; KOS-ADLS >80% and global rating score >60%; give-way episodes <1 (Thoma et al., 2019).
Copers have been shown to have better outcomes, whether they opt for conservative or surgical care, compared to non-copers who chose ACLR (2.9 times higher odds of success). Early progressive rehab, after rupture and before surgery is strongly recommended for everyone, to improve long-term outcomes.
Knee stability rupture can be divided as mechanical and dynamic. Dynamic knee stability is measured by observing function (watching someone move/perform) while mechanical stability is tested passively (anterior tibial translation). ACLR will restore mechanical stability to the knee joint, but dynamical stability can be achieved without the ACL and has been shown to correlate more strongly with functional success (copers vs non-copers) (Thoma et al., 2019).
People with higher quadriceps strength and activation pre-surgery also presented with better numbers post-surgery. Making another point as to why a 5-6 week prehab intervention is important.