Chiswick-Physio BLOG

Knee Recovery: Surgical vs. Non-operative ACL Rehabilitation
Knee, ACL

What is an ACL rupture?

An Anterior Cruciate Ligament (ACL) rupture, is a tearing or overstretching of the Anterior Cruciate Ligament, a key ligament in the knee joint. The ACL helps stabilise the knee by preventing excessive forward movement and rotation of the tibia (shin bone) in relation to the femur (thigh bone). ACL ruptures often occur during sports activities involving sudden stops, changes in direction, or direct impact to the knee. This injury can result in knee pain, swelling, instability, and limitations in knee function. Treatment options include both non-operative management and surgical intervention, depending on the severity of the injury and individual circumstances.

In this blog we will discuss the advantages and disadvantages of ACL reconstructions (ACLR) versus non-operative management of ACL injuries.

What are the risks and benefits of surgical treatment?

ACL reconstructions (ACLR) have been the primary treatment for ACL injuries for the past three decades. Recent advancements in imaging technology, such as MRI scans, and the surge in sports participation have significantly increased the prevalence of ACLR procedures.

Procedure Overview

Surgical intervention involves the arthroscopic removal of the torn ACL, followed by the insertion of a graft (connective tissue) in place of the damaged ligament. Common graft sources include the hamstring, patellar, or quadricep tendon. The graft choice is determined by surgeon recommendations, patient preferences, and individual factors like age, the type of sport, and previous knee injuries.

Graft Options

Hamstring Tendon

The hamstring tendon graft involves stripping one or two hamstring tendons, typically the semitendinosus and semimembranosus. These tendons are then intertwined to form the hamstring graft. Proper rehabilitation of the hamstring is crucial post-surgery to prevent any long-term issues.

Patellar Tendon

The middle portion of the patellar tendon is stripped to create the graft. Known for its strength and thickness, the patellar tendon graft significantly contributes to quadriceps strengthening, especially during the initial stages of rehabilitation.

Quadricep Tendon

A relatively newer graft option, the quadricep tendon, has gained popularity due to improved graft technique options and fixation technology. The advantages include more reliable graft size and thickness and increased strength compared to hamstring tendons. However, limited research exists on the long-term implementation of this graft.

Types of Grafts

Autograft

The autograft involves using a tendon graft from one area to another within the same individual. This is the most common graft type.

Allograft

The allograft entails using a tendon graft from one individual to another. This method is often chosen when a person has undergone multiple ACL reconstructions in the past, depleting their tissue resources. 

As the field of ACL treatment continues to evolve, surgical intervention remains a key player in providing individuals with effective and personalised solutions for their ACL injuries.

 

Advantages of Surgical Intervention

Knee Stability

The primary objective of ACLR is to enhance overall knee joint stability by replacing the ruptured ACL with a graft, thereby reducing movement of the tibia (shin bone) on the femur (thigh bone). This intervention aims to minimise long-term meniscus and cartilage trauma. While ongoing debates question the validity of this claim, some studies support the notion that surgical intervention contributes to improved knee stability.

Return to Sport

There is a cultural trend towards early reconstruction for individuals wanting to return to sport, especially those sports requiring pivoting activities. However, we can’t predict early who is going to do well with or without surgery after their sport injury

Current research does agree that surgical intervention proves to be a more effective strategy for individuals with ACL injuries accompanied by meniscus, cartilage, or other ligament injuries.

Disadvantages of Surgical Intervention

Cost

The financial burden of ACL reconstruction includes surgical expenses, which can range from £6000 upwards, and the substantial costs associated with the extended 9-18 month rehabilitation period. While non-operative management also involves rehabilitation costs, the financial impact is comparable, and return to sport typically occurs around the 12-month mark.

Barriers

Financial constraints, along with challenges in adhering to rehabilitation protocols, work commitments, family obligations, and other lifestyle factors, can impede the successful completion of rehabilitation. Studies indicate that individuals facing fewer obstacles during rehabilitation tend to report higher satisfaction, are more likely to return to sport within 12 months, and can return to their previous activity levels.

Post-Operative Symptoms:

Following ACL reconstruction, immediate issues such as knee pain, disability, swelling and reduced function are common. While these post-operative symptoms tend to subside within the first few weeks, they can be challenging in the early stages of recovery.

Long-Term Knee Health:

Studies comparing long-term knee function and health between surgical and non-surgical interventions suggest that as non-operative management improves, the differences in outcomes diminish. Research spanning 5 to 15 years post-injury indicates no significant variance in the development of knee osteoarthritis or meniscus pathologies between the two treatment options. It is essential to recognise that surgery does not guarantee superior long-term knee health. 

Conclusion 

 

In conclusion there is a bias towards surgery but there has been research dating back to the late 1980’s that not all clients need surgery. Current research recommends exhaustive rehab should take place before reconstructive surgery.  If there is repetitive swelling, pain, locking, or persistent episodes of giving way then surgery may be indicated.

What are the risks and benefits of non-surgical treatment?

In the last decade, non-operative management has become a viable approach for treating ACL injuries. This method involves intensive rehabilitation aimed at restoring knee function to a stable and controlled state during various activities, such as pivoting, landing, and sudden changes of direction. 

Ongoing research on non-operative management is expanding, with potential shifts in advocacy expected over the next 5-10 years.

It is important that your physiotherapist and surgeon know your goals and  lifestyle aims to best help you determine whether a surgical or non-surgical approach is the best for you. 

Advantages of Non-Operative Management

Return to Sport

While the typical recovery period for ACL reconstruction (ACLR) ranges from 9 to 18 months, evidence suggests that the timeframe for returning to sport remains consistent, regardless of surgery or non-surgery. 

Recent studies, applying strict criteria for non-operative management, show promising outcomes, with up to 79% of individuals returning to pre-injury activity levels without episodes of instability.

Knee Stability

Emerging research highlights the positive impact of a controlled motion brace within four weeks post-ACL injury, significantly enhancing the long-term stability of the knee joint when coupled with a structured rehabilitation program. Initiating a non-operative program within two weeks, post-ACL rupture has similarly demonstrated considerable improvements in knee joint stability, challenging the notion that surgical intervention is the sole contributor to structural stability.

 

Risk of Osteoarthritis

Knee osteoarthritis (OA) is a common concern following ACL injuries, but studies indicate that the likelihood of developing knee OA is higher regardless of a surgical or non-surgical approach. Long-term knee health appears to be more influenced by the meniscus than the ACL alone. 

Individuals with isolated ACL injury face a 4.2 times greater risk of knee OA, while those with isolated meniscus injury or combined ACL and meniscus injury face even higher risks. This challenges the misconception that ACL reconstruction is the only preventive measure against OA, as both surgical and non-surgical approaches show similar outcomes over time.

Cost

One notable advantage of non-operative management is the reduction in overall ACL care costs. While physiotherapy consultations are still essential to ensure proper rehabilitation and minimize ongoing complications, the financial burden is generally lower than that of surgical interventions.

Conclusion

In conclusion, non-operative management at Chiswick Physio offers a compelling alternative for individuals with ACL injuries, presenting advantages regarding return to sport, knee stability, risk of osteoarthritis, and cost-effectiveness. We can’t predict early who will do well with or without surgery. As research continues to evolve, understanding the nuanced benefits of each approach becomes crucial in guiding informed decision-making for optimal long-term outcomes.

 

What option gets better outcomes?

 

Determining the optimal choice for better outcomes is a complex matter. Currently, surgery remains the preferred option, especially for patients with additional injuries alongside the ACL, such as meniscus tears or cartilage damage. Substantial research supports the efficacy of operative ACL management, with physiotherapists well-versed in the rehabilitation of ACL reconstructions (ACLR) to facilitate a return to sports.

 

Conversely, individuals meeting specific criteria may find advantages in foregoing ACL reconstruction. Non-operative management, a relatively newer approach compared to surgery, requires further research for a comprehensive understanding. Presently, there is no discernible distinction in long-term knee health outcomes between those opting for ACLR and non-operative methods. Consequently, patients with isolated ACL injuries might find non-operative management beneficial.

Every aspect must be taken into account. For individuals aged 15-30 engaging in sports involving directional changes and pivoting, surgical intervention may be more favorable. Conversely, those returning solely to straight-line running may not necessitate surgery. 

Consultation with both your physiotherapist and specialist is crucial to determine the most suitable option based on your goals and expectations.

Frequently asked questions ACL

Can you heal an ACL tear without surgery?

Yes, some individuals with ACL tears may opt for non-operative management, which involves physical therapy and rehabilitation. There is no high quality research that the ACL can not heal.However, the success of non-surgical approaches depends on factors like the severity of the tear and individual circumstances.

How long does it take to recover from non-surgical ACL rehab?

Recovery periods are similar whether surgical or non-surgical. The main difference during the rehab programme is that during a non-surgical route you will wear a brace where the knee is fixed at a right angle for the first 4 weeks. Knee range of motion is gradually increased over the following 4-8 weeks.

How long does it take to recover from surgical ACL rehab?

Most people don’t realise the level of commitment they need to adhere to fully recover after surgical repair of the ACL. Recovery periods range from 9 -18 months. At Chiswick-Physio, a minimum of 12 months of rehab is recommended to return to sport. Every month you return to sport before the 9 months, you have a 50% chance of re-injury.

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Why should you avoid ACL surgery? Your Title Goes Here

Avoiding ACL surgery may be considered to prevent potential surgical risks, reduce costs, and avoid a lengthy recovery. However, the decision depends on factors like injury severity and individual goals. Non-surgical options require careful consideration and may be suitable for certain individuals based on their circumstances and preferences.

Will my knee ever be repaired from an ACL injury?

While an ACL injury cannot be fully “repaired” like new, both surgical and non-surgical approaches aim to restore stability and function. Successful rehabilitation can significantly improve the condition, allowing individuals to return to activities.

What is the hardest part of ACL recovery?

The most challenging aspect of ACL recovery is often the lengthy rehabilitation process. The journey involves overcoming physical and mental hurdles, adhering to a structured program, rebuilding strength and stability, and patiently awaiting clearance for a gradual return to normal activities and sports.

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