Nearly 200,000 ACL reconstructions were performed in Australia between 2000 and 2015. The incidence of ACL reconstructions in Australia is the highest in the world, and is increasing (Vertullo et al 2018). At Excel, we are getting more and more patients with ACL tears. This is mainly from recreational sport players also known as our ‘weekend warriors’. AFL, netball, soccer, and basketball seem to be the main culprits. I have a strong interest in the rehabilitation of patients with ACL tears and recently attended a course run by the Australian Physiotherapy Association on Non-Surgical Management where all the latest research was presented. Whether you have had multiple surgeries for your ACL, considering surgery, or want to prevent it from happening, I want to share some personal insights and a summary of what I’ve learnt.
What is the ACL?
The anterior cruciate ligament, or ACL, is an important ligament that is deep in the knee. It is composed mainly of collagen fibres, with a small proportion of elastic fibres, thereby giving the ACL high tensile strength. Its function is to provide passive rotational stability for the knee and prevents your shin from sliding out forwards relative to your thigh.
How is it injured?
It is usually non-contact with a sudden pivoting and twisting motion while the foot is planted. It can also happen during incorrect landing position after a jump with or without contact mid air. My patients tell me they felt their knee give way, instant pain, sometimes heard a click and the knee blows up with swelling within the first two hours.
What does the research say about treatment options?
In Australia, majority of patients who have ACL tears have surgical reconstructions. However, current research shows that this may not be the best course of treatment. In a systematic review and meta-analysis comparing ACL reconstruction versus non-operative treatment, it was concluded that people following ACL rupture should receive non-operative interventions before surgical intervention is considered (Monk et al 2016, Smith et al 2014). The first high quality randomised controlled trial indicated that a strategy of rehabilitation plus early ACL reconstruction did not provide better results at a five-year follow up than a strategy of initial rehabilitation with the option of having later ACL reconstruction. Results did not differ between knees surgically reconstructed early or late and those treated with rehabilitation alone (Frobell and Roos 2013).
How will physiotherapy help?
Whether you have had surgery or not, physiotherapy is essential. Physiotherapy should focus on sport-specific exercise rehabilitation, range of motion deficits, lower limb strength, neuromuscular agility training, patient education, goal setting, and a progressive return to pain free function and sport. For us at Excel, this is what we focus on to help you return to your specific activity.
How long will it take to get better? When can I return to sport?
Every patient is different. We tailor treatment and rehabilitation accordingly and therefore timeframes will differ. Typically, if you have had an ACL reconstruction, it will take 9-12 months to return to sports with rehabilitation. However, without surgery, the timeframe could be a lot shorter. Studies show that ACL reconstruction is not a pre-requisite for returning to sports (Delincé & Ghafil 2013). Non-operated patients can return to high level activities without symptom complaints or episodes of instability (Hurd et al 2009). At the elite level, athletes such as Tiger Woods (Golf), Dejuan Blair (NBA), Sean Elliott (NBA), Philip Rivers (NFL), and Jess Rich (Winter Olympics) have returned to their sports with torn ACLs.
Prevention is the way
ACL tears are getting more common in Australia and millions of dollars each year are spent for surgical reconstructions. Regular neuromuscular agility programs, which help develop healthy movement patterns and muscle strengthening commonly injured joints, can shave off 50 to 80 percent of ACL injuries (Vertullo et al 2018). There are great resources such as the FIFA 11+, Australia’s Netball Knee Program, just to name a few. If you want to learn more about ACL and its prevention and treatment, please give us a call on 1300 650 510.