Is Surgery Always Needed After an ACL Tear?
As patients and as providers we have always been told that the ACL (anterior cruciate ligament) can’t repair itself. Without surgery, you would have significant instability in the knee for the rest of your life. Strengthening exercises could help stabilize the knee, but if you wanted to have an active lifestyle, surgery really was necessary to prevent that feeling of your knee slipping or giving out. A recent research trial involving bracing the knee after ACL rupture showed fascinating results! Although, more research is needed this study definitely raises the question whether surgery is always the best option.
A common belief among surgeons and therapists has been that a ruptured ACL has limited healing capacity. This belief has shaped current treatment following an ACL tear and usually surgery followed by a long rehabilitation period is recommended. However, studies have demonstrated that the ACL does have a rich blood supply and can go through the normal phases of healing after injury.
Even after surgery and rehab many people with ACL injuries experience poor long-term outcomes, including sport and activity limitations, persistent pain and early onset of osteoarthritis. Considering the suboptimal outcomes with current management strategies, different treatment options should be investigated.
80 people with acute ACL rupture agreed to participate in a trial of bracing the knee instead of opting for surgery. The patients’ knees were at braced bent at 90 degrees of flexion. Patients were advised to keep the knee fixed in the brace at all times for the first 4 weeks, including during sleep and showering. After 4 weeks, the brace was adjusted to allow slow increases in motion of the knee. The brace was removed at 12 weeks. Patients completed exercises while the brace was on and continued a rehabilitation program after the brace was removed. Return to sport was not recommended until 9-12 months after the injury.
After 3 months, 72 out of the 80 participants (90%) showed evidence of ACL healing on an MRI. Patients were also given questionnaires to rate their knee function and stability. When patients showed more healing on the MRI, they also self-reported better knee function and stability. In other words, healing on the MRI correlated to the knee feeling better in daily activities.
After the initial ACL injury, the participants’ tear was graded on a scale of 1-3. With 1 being a smaller tear and 3 being a more significant injury. Those with a grade 1 tear showed more healing on the MRI and demonstrated normal stability of the knee at 3 months as compared to those with more severe tears. 92% of participants with a grade 1 injury returned to their sport as compared to 64% of individuals with a grade 2 or 3 tear.
This study provides evidence of the healing potential of the ACL! More studies are needed to determine which people will heal best with bracing and who would benefit from surgery. In the future, the potential for the ACL to heal may be an important consideration when deciding whether to have surgery or choose a non-surgical treatment option.
References: Filbay, Stephanie, et al. Healing of acute anterior cruciate ligament rupture on MRI and outcomes following non-surgical management with the Cross Bracing Protocol. British Journal of Sports Medicine.
