Anterior Cruciate Ligament Tear: conservative or surgical treatment?

22 Ene Anterior Cruciate Ligament Tear: conservative or surgical treatment?

When someone tears their Anterior Cruciate Ligament it is very common that surgery would be chosen as the treatment. However, as sports medicine and science keep advancing, it has come to realization that the conservative route can be a good option.

Which treatment is better?

Recent studies have demonstrated that neither is better than the other one, the treatment chosen depends a on the case. (Krause et al., 2018)

This means that when and ACL tear happens, there are several factors to analyze before taking a decision on what to do:

1. Analyze if the patient still presents a great amount of pain after a couple of weeks after the Anterior Cruciate Ligament tear.
2. Explore to see if there is any other structural damage done to the knee. For example, the meniscus, MCL, any bony structure, etc.
3. Test to see if the knee buckles during flexion or extension.
4. Observe if there is any inflammation in the knee.

Once the analysis is done, then it is decided on which treatment to take.

What differences are there between a conservative and surgical treatment?

The biggest difference between both treatments would be the recovery time. For example, there is a case study from a former Premier League player who chose a conservative treatment, and returned to play football after 8 weeks (Weiler et al, 2015). However, this will not always be the case. The recovery time in someone who chooses a conservative treatment depends on how the knee behaves as time passes by and the goals/demands the person wishes to achieve.

When surgery or ACLR is chosen, the recovery time is much longer. The worldwide protocol states that it is about 9 to 12 weeks of rehabilitation. However, returning to play a sport has more to do than just the time frame (this applies to both treatments).

If time is not the definitive factor to clear an athlete, that what is it?

90% of relapses or failed treatments are related to physical deficiencies. (Keays et al., 2019).
There are several physical aspects that must be well trained for full clearance to be possible. These are:

1. Ensure that there is the minimum difference in strength between the injured leg and the other one. In structural terms it would be to observe that there is a similarity in the strength in muscle groups like the quadriceps, glutes, hamstrings, etc. But I consider it more important to observe differences in sports movements and gestures.
2. Basic movements to observe would be: squats, hip extensions, strides, thrusts, pulls, and rotational actions. There must be control, no pain, and the individual must demonstrate confidence when performing their sport.
3. Sports gestures to observe would be: Jumps, landings, direction change, collisions, continuous running,  sprints, etc. (THIS IS THE MOST CRUCIAL PART, AS THESE GESTURES CAN FORM PART OF THE INJURY MECHANISM OF AN ACL TEAR)

So time should not be an evaluation factor, there are cases like Kristap Porzingis´ where it took him two years to return to play in the NBA. The hardest thing after this injury is not to return to «normal» life. The complicated thing is to return to the sport and to be able to recover the performance that was had before the injury.

If evidence demonstrates that not one of the two types of evidence demonstrates to be better, then what will keep an athlete competing after suffering and Anterior Cruciate Ligament tear?

Statistics in football (also apply for other sports) mark that 50% players do not keep playing within 10 years after suffering and Anterior Cruciate Ligament tear (Stein & Mandelbaum, 2020). With this I want to highlight again the importance of the three points mentioned to consider a full clearance, since these gestures will be responsible for keeping the athlete playing or not.

It is a complex process, since you have to go back and start training very basic movements of the human body seeking to improve motor control and strength. What brings you back to the sport is the what will keep you competing.

I am attaching here a link to a return to play protocol from Melbourne, Australia. Created by Mick Hughes, someone I consider an expert and well experienced professional who deals with a great amount of people suffering and recovering from an Anterior Cruciate Ligament tear: https://www.melbournehipandknee.com.au/pdf/acl-guide-melbourne-hip-and-knee.pdf

Delincé, P., & Ghafil, D. (2013). Anterior cruciate ligament tears: conservative or surgical treatment?. Knee surgery, sports traumatology, arthroscopy, 21(7), 1706-1707

Keays, S. L., Newcombe, P., & Keays, A. C. (2019). Nearly 90% participation in sports activity 12 years after non-surgical management for anterior cruciate ligament injury relates to physical outcome measures. Knee Surgery, Sports Traumatology, Arthroscopy, 27(8), 2511-2519.

Krause, M., Freudenthaler, F., Frosch, K. H., Achtnich, A., Petersen, W., & Akoto, R. (2018). Operative Versus Conservative Treatment of Anterior Cruciate Ligament Rupture: A Systematic Review of Functional Improvement in Adults. Deutsches Ärzteblatt International, 115(51-52), 855.

Stein, S. M., & Mandelbaum, B. R. (2020). Editorial Commentary: Anterior Cruciate Ligament Injury and Reconstruction in Soccer Players: The Major Challenge Is Always Going for Our Goals!

Weiler, R., Monte-Colombo, M., Mitchell, A., & Haddad, F. (2015). Non-operative management of a complete anterior cruciate ligament injury in an English Premier League football player with return to play in less than 8 weeks: applying common sense in the absence of evidence. Case Reports, 2015, bcr2014208012.