It is now common knowledge that not all ACL tears / rupture require surgery. Although healing of the ACL is rare, a percentage of patients with ACL rupture can develop stable, pain free knees that allows a good level of function. The information below is a guide as to whether your knee may be suitable for a conservative, physiotherapy program for your ACL injury. The best standard of care if you embarking on a conservative ACL program is combined management between your Surgeon & Physiotherapist.

Is my ACL rupture suitable for conservative, Physiotherapy management?

In general terms you may be suitable if you:

• Have an isolated ACL injury

• No meniscal injury

• No injury to collateral ligaments

• Not playing pivoting sports (i.e. you walk, jog, cycle or swim but are no longer playing netball / football etc)

• Age greater than 20 (Teenage athletes are at higher risk of serious re -injury without surgery)

What does a conservative Physiotherapy program involve?

In the acute phase, treatment involves swelling control and restoration of knee motion. This will then progress to:

• Knee range of motion and muscle strengthening

• Neuromuscular exercise (Feedback between balance control and muscle strength)

• Jogging / running

• Strength and conditioning

• Sport specific resumption

What is my chance of successful treatment with Physiotherapy alone – Results of the KANON trial

The KANON trial compared early ACL reconstruction with Physiotherapy alone with the option of delayed reconstruction if needed. The trial included active young patients, aged between 18 – 35 who had full thickness ACL rupture, without significant meniscal injury. Elite athletes were excluded from the trial. A link to the article can be found here. At 5-years follow up, the results are summarised below:

• Both early, delayed ACL surgery and conservative treatment alone can result in good functional scores and low levels of pain

• Rates of osteoarthritis between groups is similar

• Knee stability was better in the reconstructed ACL group

• 51% of patients who were treated with Physiotherapy alone required ACL reconstruction and a further 52% of non reconstructed knees required meniscal tear surgery at the 5-year mark, meaning that a total of 76% of patients treated with physiotherapy alone required either ACL surgery or meniscal surgery.

• Delayed reconstruction was as successful as early reconstruction, meaning for most patients there is no urgency for surgery.

The take home message from this trial is that ACL reconstruction is not an urgent procedure for most patients if the knee feels stable & pain free after a Physiotherapy program. Overall, there is still a high likelihood of patients requiring surgery over a 5-year period.

Can I do further damage to my knee with conservative treatment?

The meniscus is an important structure in the knee to provide stability and load distribution. Early surgery is far more likely to result in meniscal repair than resection. Meniscal repair has a lower long term risk of arthritis compared to meniscal resection and is desirable in young, fit and active patients. The risk of non repairable damage to the meniscus is debated with conservative ACL management. All surgeons who perform ACL surgery in Perth commonly see cases of non repairable meniscal damage after conservative management of ACL injury. You are at low risk of further damage to your knee if:

• Your knee feels stable (No giving way, swelling or pain) after your Physiotherapy program

• You no longer play pivoting sports (Jogging, cycling, swimming, hiking & gym work are low risk sports. Sports suchs as netball, soccer, AFL etc are high risk for further injury)

• ‘Older’ patient are lower risk than younger patients of further knee damage (Teenage athletes are very high risk of serious injury with conservative programs)

The benefits of Knee PREHAB (Exercise program before surgery)

If you decide to undergo early ACL surgery in Perth, there is benefit from seeing your Physiotherapist for a 6 – 12 week strength and conditioning program before surgery. This leads to superior outcomes. Benefits of prehab include:

• Better functional scores

• Less pain

• Better function on hop testing

• Quicker ACL surgery recovery