The ACL Rupture, When to have surgery and is Physiotherapy before surgery worthwhile?*
Your Anterior Cruciate Ligament (ACL) joins the Femur (upper leg bone) with the Tibia (lower leg bone) and is one of the main four ligaments of the knee.
The ACL tends to get injured during a rapid change in direction, stopping suddenly or during direct contact such as in a football tackle.
Patient's with ACL injuries often ask us "should I have surgery?", "when should I have surgery?" and "how can I benefit from physiotherapy Prehab?". So let's answer these common questions.
Should I have surgery?
It all depends! Is there more damage than just the ACL? An ACL tear can occur in isolation or in conjunction with other damage to the knee such as a meniscal tear or another ligament tear. In such instances surgery is often strongly recommended.
Is the knee stable?
After a period of rehabilitation an ACL deficient knee can become stable and fully functional which means surgery is not indicated. However, if it remains unstable and therefore vulnerable, surgery will be required to improve things.
Is the knee painful?
Pain after a knee injury can cause local muscles to become less active, in turn this makes the knee unstable. Pain and instability together put the knee at risk of further injury so surgery is often the best option.
In my experience out of all the people with ACL ruptures I see:
1/3 of them do nothing! These individual's tend to be non-sporty and their knee feels fine after the injury and they are happy to just carry on with
their daily routine minus an ACL.
1/3 do rehab and improve their knee control, alignment and stability to a level whereby they can return to their sport of choice confidently and pain
1/3 have an ACL reconstruction (ACLR) because after a course of rehabilitation they still have pain or instability in their knee.
Every ACL injury is different so the treatment plan will be specific to the patient in question. It is always right to get a Knee Specialist to assess the injury appropriately and discuss both the surgical and non-surgical interventions.
When Should I have surgery?
Literature varies on recommended time to wait before having and ACL reconstruction. There are lots of variables which need to be taken into consideration. Some good research (3) concluded that ACL reconstruction should not be carried out until the deficit of the thigh muscles on the injured side is no more than 20% of the uninjured side (2,3).
Is physiotherapy before surgery valuable?
Most patient's get a diagnosis of ACL injury and are told by an orthopaedic surgeon that they need to have surgery. The time scale between injury-diagnosis-surgery can be around 8 weeks plus, during which time the patient might have pain and swelling, be walking/moving around awkwardly and avoiding normal exercise. All of the aforementioned, are bad for the injured knee.
Not only will the thigh muscles waste and become weaker, so will the whole leg from buttock to foot. Research has shown that balance and
proprioception (the body's ability of keeping track of a joint's position/actions) deteriorate. Patient's may put on weight due to being inactive which can in turn have psychological effects on them.
Through our own experience as therapists, along with good quality Sport and Exercise Medicine Research we can prove that pre-operative physiotherapy sessions (for even as little as 3 weeks) can improve patient outcomes post-operatively (1)
In summary, not every one needs to have surgery. With good pre-operative physiotherapy the outcomes post ACL surgery can be improved. The question as to when to have surgery is not so clear, however, it would appear that better outcomes are seen when surgery is delayed and carried out when thigh muscle strength is no more than 20% less than the non-injured leg.
1. Alshewaier S, Yeowell G, Fatoye F. The effectiveness of pre-operative
exercise physiotherapy rehabilitation on the outcomes of treatment
following anterior cruciate ligament injury: A systematic review. Clinical
rehabilitation. 2016 Feb 15. PubMed PMID: 26879746. Epub 2016/02/18. Eng.
2. Krutsch W, Zellner J, Baumann F, Pfeifer C, Nerlich M, Angele P. Timing
of anterior cruciate ligament reconstruction within the first year after
trauma and its influence on treatment of cartilage and meniscus pathology.
Knee surgery, sports traumatology, arthroscopy : official journal of the
ESSKA. 2015 Oct 16. PubMed PMID: 26475153. Epub 2015/10/18. Eng.
3. Eitzen I, Holm I, Risberg MA. Preoperative quadriceps strength is a
significant predictor of knee function two years after anterior cruciate
ligament reconstruction. British journal of sports medicine. 2009
May;43(5):371-6. PubMed PMID: 19224907. Epub 2009/02/20. eng.