Conservative Management for ACL Tear / Rupture – Physiotherapy
By Dr Daniel Meyerkort, Knee Surgeon, Perth Orthopaedic & Sports Medicine Centre
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
Better function on hop testing
Quicker ACL surgery recovery
Can I strengthen / heal my ACL without surgery?
The ACL rarely heals after without surgery (rare cases do exist) however your knee can regain full motion and stability with a good Physiotherapy strengthening program.
What is ACL deficiency?
ACL deficiency is the term used for tear or rupture of the ACL ligament. It is commonly associated with tears of the meniscus. You can manage long term with an ACL deficient knee if your knee is stable, your meniscus is uninjured and you no longer play pivoting sport.
What is the best exercise for a torn ACL?
Your Physiotherapist will go through a full exercise program to strengthen the muscles around the knee. Exercises may include passive knee extensions, half squats, isometric quads contraction, heel slides, passive knee extension, hamstring exercise / stretches and neuromuscular exercise.
Is walking good for ACL recovery?
After 6 – 12 weeks after injury expect brisk walking, light jogging and building into plyometric exercise.
Can I do squats / gym work with a torn ACL?
Yes, as your pain and swelling subside your Physiotherapist can introduce a gym based rehabilitation program.
How long does it take the ACL to heal without surgery?
True healing of the ACL does not usually occur. Recovery from pain and full functional recovery can be as short as 3 months without surgery compared to 12 months with surgery.
What are the long term risks of a torn ACL?
Knee function, pain and arthritis are similar in patient who are treated with a conservative Physiotherapy program or surgical reconstruction. Surgery results in a higher degree of knee stability. If your knee has ongoing instability (giving way) after your Physiotherapy program you would benefit from surgery to decrease your risk of subsequent meniscus or cartilage injury.
Can I play sports with a torn / ruptured ACL?
Most patients can return to non pivoting sports with conservative management of their ACL tear / ACL rupture. Sports include walking, jogging, swimming, cycling, gym work, tennis and golf. It is possible to return to high impact pivoting sport with conservative treatment of ACL injury however this risks secondary injury to the meniscus and cartilage.
Should I have surgery for my torn ACL?
This is a decision that is individualised and should ideally be made in conjunction with your Physiotherapist and Surgeon. Many factors are involved including your age, sport participation, work and the injury pattern.