Treatment for Acute
Anterior Cruciate Ligament Tear: Five Year Outcome of Randomised Trial
Anterior Cruciate Ligament Tear: Five Year Outcome of Randomised Trial
Frobell RB,
Roos, HP, Roos EM, Roemer FW, Ranstam J, & Lohmander LS. BMJ. 2013, 346:
f232. doi: 10.1136/bmj.f232
Roos, HP, Roos EM, Roemer FW, Ranstam J, & Lohmander LS. BMJ. 2013, 346:
f232. doi: 10.1136/bmj.f232
Anterior
cruciate ligament (ACL) tears occur frequently in athletics, and carry with it
the potential risk of osteoarthritis (OA).
ACL injury is often treated with surgical reconstruction in an effort to
reduce the risk of secondary injuries and progression to OA. Some people insist that an ACL reconstruction
is needed as quickly as possible; however, the timing of surgery or the lack of
surgery on longer-term outcomes has yet to be determined. The purpose of this extended follow-up of a randomizedclinical trial (link to original article) was to
compare the outcomes of patients that had immediate ACL surgery versus those
that had optional delayed ACL surgery.
One hundred twenty patients (ages 18 – 35 years) all underwent similar
rehabilitation, but were randomized to early (n = 61) or optional delayed (n =
59) ACL reconstruction surgery groups. Of
those that were assigned to the optional delayed group, 51% (n = 30) opted for
ACL surgery. At the 5 year follow-up,
there were no group differences in patient-reported outcomes (i.e., knee specific symptoms/function,
general health, Tegner activity scale), radiographic OA, or need for meniscal surgery. Mechanical knee stability (i.e., Lachman and
pivot shift) was significantly better in knees assigned to early ACL
surgery. Within ACL reconstructed knees,
more patellofemoral radiographic OA was found in knees that received the
patellar tendon in comparison to the hamstring tendon autograft procedures. Overall,
51% of participants underwent meniscal surgery during the 5-year follow-up and
24% of participants had radiographic knee OA.
cruciate ligament (ACL) tears occur frequently in athletics, and carry with it
the potential risk of osteoarthritis (OA).
ACL injury is often treated with surgical reconstruction in an effort to
reduce the risk of secondary injuries and progression to OA. Some people insist that an ACL reconstruction
is needed as quickly as possible; however, the timing of surgery or the lack of
surgery on longer-term outcomes has yet to be determined. The purpose of this extended follow-up of a randomizedclinical trial (link to original article) was to
compare the outcomes of patients that had immediate ACL surgery versus those
that had optional delayed ACL surgery.
One hundred twenty patients (ages 18 – 35 years) all underwent similar
rehabilitation, but were randomized to early (n = 61) or optional delayed (n =
59) ACL reconstruction surgery groups. Of
those that were assigned to the optional delayed group, 51% (n = 30) opted for
ACL surgery. At the 5 year follow-up,
there were no group differences in patient-reported outcomes (i.e., knee specific symptoms/function,
general health, Tegner activity scale), radiographic OA, or need for meniscal surgery. Mechanical knee stability (i.e., Lachman and
pivot shift) was significantly better in knees assigned to early ACL
surgery. Within ACL reconstructed knees,
more patellofemoral radiographic OA was found in knees that received the
patellar tendon in comparison to the hamstring tendon autograft procedures. Overall,
51% of participants underwent meniscal surgery during the 5-year follow-up and
24% of participants had radiographic knee OA.
This is the
first randomized clinical trial to explore this important question and it appears
that ACL surgery timing does not really seem to affect any major outcome at a 5
year follow-up. It is interesting to see
that early ACL surgery does not necessarily provide better outcomes. Furthermore, of those assigned to the
optional delayed surgery group, about 50% never needed surgery. There were no differences between those
surgically repaired early, late, or with rehabilitation alone. This may emphasize the importance of the
rehabilitation process, since all patients underwent similar rehabilitation
processes. The study controlled for
meniscal status, but did not report any correlations between meniscal status
and outcomes, which would be interesting to see. Based on this study it may be safe to delay
the ACL reconstruction to determine if the patient can tolerate conservative
management through rehabilitation and successfully return to play after an ACL
injury. I am extremely interested in
following these same patients out to a later time point. But ultimately, an ACL tear may not
necessitate surgery, and rehabilitation should be considered as a possible
option. Has anyone had any success with
conservative management of ACL injuries?
first randomized clinical trial to explore this important question and it appears
that ACL surgery timing does not really seem to affect any major outcome at a 5
year follow-up. It is interesting to see
that early ACL surgery does not necessarily provide better outcomes. Furthermore, of those assigned to the
optional delayed surgery group, about 50% never needed surgery. There were no differences between those
surgically repaired early, late, or with rehabilitation alone. This may emphasize the importance of the
rehabilitation process, since all patients underwent similar rehabilitation
processes. The study controlled for
meniscal status, but did not report any correlations between meniscal status
and outcomes, which would be interesting to see. Based on this study it may be safe to delay
the ACL reconstruction to determine if the patient can tolerate conservative
management through rehabilitation and successfully return to play after an ACL
injury. I am extremely interested in
following these same patients out to a later time point. But ultimately, an ACL tear may not
necessitate surgery, and rehabilitation should be considered as a possible
option. Has anyone had any success with
conservative management of ACL injuries?
Written by:
Nicole Cattano
Nicole Cattano
Reviewed by: Jeffrey
Driban
Driban
Related
Posts:
Posts:
Original Paper with 2-year Follow-up:
Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, & Lohmander LS (2013). Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ (Clinical research ed.), 346 PMID: 23349407
I am a Physical Therapist and tore my ACL almost 3 years ago. I rehabed myself and generally kept strong and active but don't participate in sports except downhill ski (beginner) so I don't have much lateral/rotational stress on my knee. I did very well until a life change caused me to stop working out and generally being as active. then I noticed my knee getting achy and loose feeling. SO, I feel that rehab is a legitimate short term alternative to surgery. What I haven't found is what the research is saying on much longer term effects. Even if my knee is ok for the next 20 years without surgery, then great, but I plan to live past 50. When I get older and my muscle tone is less, will I be more vulnerable to falls, etc? If you know of any research I would love to see it. Otherwise, just food for thought I guess.
I think I strongly agree with your statement, anonymous. Specially you have had a tore ACL as well. I have experienced almost the same problem.
I would like to share my story:
I have 28 years old and I injured myself 6 month back. MRI reports Laxity in my ACL. Orthopedic sent me for physiotherapy which I did for almost 3 month and helped a lot since I did not feel any instability or pain on my knee, being able to flex it 100%. However I did not do any sports, but could do a normal life.
After I took 1 month vacations, I didn't continue with my exercises, then I started to feel insecure with my knee and started to feel unstable. Now I started with the same exercises I was doing and again I have gained strength in my injured knee. My idea is to continue with the exercises at least for 6 month up to 1 year since I can't leave my job which I just got it and I would have to save the money for the surgery.
Therefore, If anyone that have been in similar situation or have proven track about it, can you please help me by giving your point of view about my concerns which are:
Would I be in high risk to damage my Meniscus if I Delay my surgery? I am mainly doing some exercise bicycle on daily basis and also some stretching and lifting and flexing my leg while laid down.
Any other activities that you would recommend which is beneficial?
And anonymous, you mentioned that you tore your ACL 3 years ago; so at the end, did you have the surgery nowadays or you still did not have it? And if not, are you planning to have the surgery? Have you kept on doing MRI on every 6 month or 1 year to see the evolution of your knee? Do you know if your delay have brought you any meniscus or any other parts of the knee have been damaged?
Also, you being a physical therapist, why did you choose you rehab yourself instead of having a surgery at first? Any reasons in special that you have experienced that made you choose that option?
Honestly, in my case I am afraid of surgery and also the post surgery side effects from this surgery or any surgery in a short and long term basis. So this is why I want you try out rehab to see if I can avoid the surgery, however as you (Anonymous) says, apparently it can only help as a short term alternative.
I hope I can get some points of view to make up my mind and decide what to do.
Anyone that have had successful rehab after ACL tear without surgery please share your story!!! Or if anyone have had rehab and have delayed surgery also share your story!!!
Thanks to all!!!!
I'm having the same dilemma! I'm a female in my early 20's and plan on playing sports for another 30 years. I play mostly basketball and ultimate frisbee. According to the MRI, my ACL is completely torn, LCL and MCL are sprained but everything else is okay. I have been getting mixed opinions about delaying surgery.
I am leaning towards surgery but my doctor is suggesting I try rehab first… But I mean if rehab alone can return the athlete back to competitive pivoting sports, why was this so unsuccessful back in the day before ACL reconstructions existed?
I have had 3 ACL tears – to the same knee and trialled all 3 opions.
Initially I chose to have the surgery straight away and had an extended period of rehab and significant muscle atrophy which I believe impacted on my recovery post surgery. It took over 6-8 weeks to resume weighted exercises in the gym and close to 3 months to start running on my knee.
Following a return to Australian Rules football (the source of my initial injury) I suffered another tear to the ACL. It took up to 2months to have this correctly diagnosed, I was sure I had torn the ligamnet althopugh reviews with my GP and a physio all suggested it was fine. Having finally requested my GP refer me to my surgeon he confirmed straight away that the ACL was torn. This time I decided to wait for 6-12 months before undergoing the surgery, partly due to financial constraints. I was completing gym based exercises (including instability work with a dura disc and swiss ball) as well as running, riding and swimming pre-op. After the operation my recovery was significantly enhanced compared to my first op. I didnt require crutches at all and was back performing basic resistance exercises and jogging on the treadmill 3-4 weeks post op. Again I returned to playing sport and continued to play for 7-8 years before again tearing my ACL approximately 4 years ago. At this stage I had an MRI scan (1st time I had undergone this) which surprisingly showed a healthy knee joint – almost no evidence of any articular cartilage damage to my knee. I still have not decided to have any surgery and have instead completed general strengtheing and aerobic exercise. I can complete almost any running and physical activity that does not involve decelaration and pivoting movements. I have been able to complete high intensity resistance training without concern and even run up to 15km without any symptoms. I have tried to join in sports training previously and my knee gave way twice in 5 minutes doing what I thought was fairly low level activity. Particualry deceleration activities cause my knee to buckle and I've realised any activty performed at speed places my knee in a vulnerable position to give way. Despite this I can still particpate in daily exercise or activty and have even been able to join in junior sports training with a team I now coach. If you ever intend to return to sport involving acceleration/deceleration and pivoting movements you would be highly unlikely to be able to have the high level reactive stability without the ligamentous support of the ACL
These are such great comments. Anonymous-there are studies that compare surgical ACL reconstruction to non-surgical management with just rehab, and that the rates of development of osteoarthritis are the same.
But I think it is important to stay up on the rehab as mentioned. If anyone is having having moments of instability, I would say that the meniscus would then become potentially vulnerable. But I think rehabilitation techniques have advanced so much over the years, which may be why we are having more successes with conservative management.
I would say it is a personal decision, but it has definitely opened my eyes up to the fact that surgery is not inevitable when someone tears their ACL. I don't know about anyone else, but I think that I would try the conservative route first. The only harm being a potential delayed RTP if you are unable to develop successful strategies to cope without getting the AC:L reconstructed.
Hello All – I am the first anonymous commenter, sorry it took so long to finally read these and reply.
Charles – as a physical therapist I am naturally stubborn and have never actually had an MRI, I just had a few PT friends look at it we all agreed it was most likely torn. I didn't get surgery because the thought of that is very scary to me. But then I got pregnant and the MRI/surgery was no longer an option for a while. as time has gone on I have just noticed more and more instability and pain. I am certain that if I were to get back on my regular exercises it would be better. But my primary concern is whether or not it is in my best interest to think about being 70 or 80 and can I still maintain enough strength to not have an unstable knee. I am just having trouble finding research on that long of a outlook. I am a big believer in not getting surgery if it is not necessary. But I can feel my knee getting more and more unstable and painful even with increasing my strength and activity in the last few months. Focusing on Hamstrings, quads, and glut muscles.
I know I should get a MRI so I can see how bad it actually is before I make an informed decision, but I will probably lean away from surgery as long as possible. I just wear a brace when I ski and I haven't played tennis since because all that sudden decelaration was killing me.
Thanks for all the thoughts and comments. I will definitely keep on looking at the research
Hello, I am wondering what it was like for you to have a torn ACL while pregnant? I recently have torn same leg acl for second time but my husband and I may for sure be pregnant. How were you able to function being pregnant with torn acl/do u think if we end up not being pregnant that someone in my situation should get acl surgery first or after pregnancy?
Hello Anonymous on July 24th!
Not sure if you checked this thread out yet. Lots of good links with people who are able to cope successfully:
https://www.kneeguru.co.uk/KNEEtalk/index.php?topic=62219.msg599082#msg599082
Hi I hurt my ACL to a complete tear almost 20 days back. Now I have been advised by the docs to go for a surgery to reconstruct the ACL.
I am doubtful of whether I shoud go for surgery or try with some rehab to strengthen my Knee muscle.
I am 30 : Weigh 106 Kg;
Hi Bunty: Unfortunately, we cannot offer medical advice online at this site because we are unable to do a proper evaluation. If you are hesitant about your current treatment you should seek out a second opinion.
Best wishes.
As medical professionals, we want to provide the best care possible for our patients. ACL tears are very common in sports. There should be more research on the benefits or threats associated with ACL surgery immediately, delayed, or not at all. The athlete's best interest and health should always be considered. However, with the lack of information and research on the best option to effectively rehabilitate an ACL tear it is hard for Athletic Trainers to help consult the athlete on the best decision to heal from the injury. Many athletes do not have health insurance. Therefore, the Athletic Trainer's rehabilitation protocol could possibly save the athlete from an unnecessary surgery which would save a lot of money and stress for that athlete. We need to work harder to make sure that our patients are aware of everything that can happen with or without surgery. We cannot continue to rely solely on gold standards of care to implement rehabilitation. It is easier to have patients receive the surgery because that is standard. However, if it is not the best option of care there should be more resources for alternative options. The successful recovery of our patients should come before the convenience of continuing to do the most recommened option for an ACL without it being proven to be the best by research.
Shani-I couldn't agree with you more. However, I do think that we need to continue to have a patient-centered approach regarding these decisions. What works for some may not work for all.
You bring up very interesting points about insurance issues. And if surgery is not NEEDED could it be considered as an OPTION…I fully agree that we still need a little more information on this prior to changing recommendations.
The interesting dilemna that we find ourselves in, is that the culture of medicine seems to be changing. We are starting to recognize that there may not be as much value to ACL reconstruction as previously claimed (knowing that osteoarthritis rates are comparable). I think that this is a tough sway in the way that we think because of many years of how "it has always been."
The question that I turn back to you is that if the athlete doesn't have insurance…should that change what is optimal for their successful recovery? Or does it become a best option based on the circumstances?
After reading this article, I am wondering one thing. If the ACL is never surgically repaired, won't the patient still experience instability and pivot shifting? How would rehabilitation alone eliminate or help fix these problems.
Brittany-the idea behind the rehabilitation would be to strengthen and proprioceptively train the muscles to act as better dynamic stabilizers given that the primary static stabilizer is gone. Some people respond really well to this, and have limited instability episodes. So the muscles are able to hold the tibia where it is supposed to be, or if the body "feels" a pivot shift happening, it can respond appropriately and not cause a giving way episode.
However, others do not respond well and despite their rehabilitation have frequent giving way episodes. I think it is important to take into consideration that what is right for one person, may not be right for the next. But options are always good.
Hi everyone,
My name is Nicole, I am 22 years old and I tore my ACL 1 1/2 months ago. I am 5ft 6" and about 115lbs. I have played competitive soccer my entire life and have never had an injury aside from hamstring pulls and ankle sprains. I joined a coed intramural team this fall and the games are played on astro turf. I always wore cleats on turf with no issues. About 20 minutes into the game I reached and planted my foot to play defense and noticed my entire body shift off balance. I looked down to see that my tibia and femur appeared to be totally out of place, as if the top of my knee did not match up to the bottom half of my leg. Then I heard the dreaded, "POP" and knew something wasn't right. My knee felt totally out of place and awkward and to be honest, I was in shock from what I saw and my anxiety kicked me into an attack. Everything went really fuzzy. I got up and thought I could walk it off. The pain just got worse. Throbbing through the outside of my knee, down into my foot. Sharp and shooting. Afterwards, I experienced absolutely no noticeable swelling, even throughout my entire experience. I honestly thought that I tore my MCL, so did my Ortho. MRI showed "Proximal ACL tear". I went and got a second opinion at the Hospital for Special Surgery. He said that its fully torn and I need surgery. Both doctors that I've seen said that the Hamstring Graft has been taking very well on women. I am PETRIFIED of surgery. I am a control freak and the thought of drugs and anesthesia really bother me. I've been rehabing my knee for a couple weeks now. It has helped a lot. I regained my range of motion. Still some pain when bending my knee all the way back and putting it completely straight, but I've made a lot of progress. I've been jogging to my bus stop every day because I'm always late and have had no issues or pain afterward. My knee definitely feels more lose than my good knee. The weather changes lately are no help either. My knee has been getting stiffer and achy since I've taken a week off of PT for Thanksgiving traveling and such. There are just a lot of intense decisions that come with this injury. With no surgery & without a brace- Soccer is over, competitive sports are over, running is risky, sprinting and cutting forget it. There is risk of tearing the meniscus, there is risk of not being able to chase after my kids and teach them how to play sports when i'm older, then comes later life issues. Right now, I can deal with soccer being over, I can accept that. But everything else really bothers me. I want to make decisions and be normal and do things that I did with a healthy ACL, but I do not want surgery. Is it even possible? Every single person that I meet in PT with a torn ACL has gotten surgery. It's crazy how much this injury has affected my anxiety and my life. I moved closer to NYC for work 2 weeks before this happened. I do not have my car with me and I rely on public transportation and my legs to get me around. I cannot afford to miss work so I only took off one day to get my MRI done. When this first happened I couldn't even put my own socks on. Walking to work was miserable. I am someone who walks like a maniac through NYC with no patience for anyone or anything so at first everything was really hard for me. The best thing that my Physical Therapist said to me was, "Nicole, stop limping. Stop protecting your knee. Control your own body, force yourself to use your full range of motion and learn how to walk through the pain and stiffness to bring your leg to a full rotation with no limp." I walk like hell now, speeding through the city with ease. It feels great. Mentally, timing is never right for surgery. Especially now that i'm feeling good, knowing that I have to go through more pain and frustration after surgery, sucks.
Your ACLess peer,
Nicole
This is actually very interesting considering everyone hypes up ACL tears and the need for surgery as soon as possible. Rehabilitation seems to work wonders for those with or without surgery considering the results were nor better or worse in either case. However, I'm curious if you have any recommendation on how you would go about an ACL tear and why? Would you recommend having surgery early, late or never??
Do you think someone should undergo ACL surgery regardless of all the advances of rehabilitation programs or do you believe that conservative treatment is the better way to go? If you do say ACL surgery is necessary when do you feel it is appropriate to undergo surgery, right away or later on?
Nicole-It certainly sounds like you are going through a tough time with your knee and your decision.
Regarding ACL surgery. .. There is no denying that the short term outcomes are extremely good. People typically return to the sport or activities that they love within a year. It is a tough road back, but hard work and rehabilitation does wonders.
Morgan mentioned all of the rehab advances… And I actually personally think that these advances are only going to do MORE harm in the long term. Such expedited return to play time lines do not allow for enough recovery post surgery.
Each decision regarding surgery or not, in addition to timing should be a patient centered decision. Working with college athletes, I often consider their year in school, timing of injury, what would the timing be like based on surgery date.
Clinically I am still seeing relatively quick surgery dates following injury (4-6 weeks). With ample time permitted prior to surgery for pre-hab restoration of ROM and strengthening.
If time is not a factor…I would rather try conservative management to see if a person could potentially be a successful coper. This would be how I would manage my own case.
This is not commonly seen in our society. However, I think research is showing us that we may be OK with a shift in our thinking.
Hi Everyone,
I've had mine, left knee, injured due to badminton last November 16. I was initially diagnosed with muscle strain and rested for 7 days with rice treatment before going back to work. Knowing that it wasn't serious, I didn't had any therapy and just continued on with the treatment.
I did some stretching exercises during week 5 until i was able to regain full mobility on week 8. There still is some minor pain on the right side of my injury and still didn't feel stable at times so i decided to request for an MRI.
The test ruled out an ACL tear and the Doctor was kind enough to elaborate that since I'm not earning from my hobby, i could change to a less straneous activity like cycling, do some strengthening exercises, and do away with the risks of surgery.
Like the rest, I am also concerned about the long term effect of not having my ACL reconstructed.
Thanks and great day to everyone!
Great article!
I think this is heading the same way as surgeries for low back pain and knee pain: not much difference. I think the case for NO surgery is more compelling considering they didn't have a sham surgery group. A lot of people tend to 'feel' better after a sham surgery you know. I think previous commenters who had questions should look up the inclusion criteria. They have excluded a few based on the extent of the injury. I would have loved to see some performance test to see if there is a difference, like squat or single leg jump or hop. Thanks for the nice article!
Anoopbal- I agree that objective outcome measures would be a great addition. And there is plenty of literature that supports the placebo effect. The last anonymous poster… When did you find out your ACL was torn? And how far are you from the original injury?
HI Everyone
My name is Sylvia. I tore my ACL skiing 3 weeks ago and am determined to give conservative management a go.
By 2 weeks I was pain free with full ROM and never any instabililty. I am an avid cyclist, so my strong leg muscles no doubt help compensate for the lack of ACL.
My question is, can I keep up the compensatory muscle strength and tone in to my 50s, 60s, 70s and beyond? People here have posted that not doing their PT for a week saw leg instability return.
I am hoping not to do surgery…who knows, in the future there may be revolutionary advanced in treatment.
Love to hear you thoughts and experiences
Thanks!
Hi to All,
I have an interested story,I have total tear in ACL since 20 years and i didn't do a surgery till date,i knew that i have ACL only one year before,My story started 20 years before when i was playing footbal and i have a sudden rotation then i heared pop in my knee and it became swell,i went to doctors who said that i have a tear in cartilage and i wasn't intrested to go for any surgery at that time,they told me,take care and try to avoid playing footbal and you can resume your normal activity,since this date till one year before i was playing footbal randomly with taking care and putting bracing on my knee,untill one year before i heared a pop in my knee during playing footbal,then i decided to do MRI to know exactly what i have in my knee,i did it and i was shoked where the results i have a total teat in my ACL,BUCKET HANDLE TEAR OF MEDIAL MENISCUS,RADIAL TEAR OF THE ANTERIOR HORN OF THE LATERAL MENISCUS,the point that i don't any pain in my knee,sometimes i have a little pain in my right side of left knee-i went to different doctors some told me you should do a surgery if you want to play footbal,finally i went to another doctor when he listen to my story he said to me that i have this ACL since 20 years,and he recommend to me some excecises which i am currently doing since 2 months,i am planning to play a footbal again i buy one knee support,but actually i am afraid to go to this step.
Dear all,
I'm 33 years old and I had surgery of my ACL last january. It was from a volleyball injury. Even if my knee was not unstable, I had blockages every now and then that did not allow me to have a normal life and practice sports such as volleyball, running, etc. My surgeon told me that you are in higher risk to develop an osteoartritis when i'm older if you don't opérate… I can tell you after few weeks of the operation that it is hard. But I believe that after the recovery i will be able to enjoy sports again, Independently of the knee injury, i think it is very important to keep your leg muscles strong. But undoubtedly, when you become older you cannot keep your muscle tone as good as it was and problems may come. If you are Young and active I believe surgery is the best thing to do.
Dear All,
I have read all comments and agree with most, and one thing we know with good rehab, we can get through without surgery, as far as later on in life when our muscle tone depletes is yet to be known.. I ruptured my right ACL in 2009 and was booked in surgery approximately 7 months later, with mini squats advised mainly by my surgeon. He cancelled the surgery and informed me my knee had stabilized. I was able to return to playing soccer and enjoyed many more years of play. Recently my left ACL let go, now 35 im faced with the same problem! Before making that decision, will re do the mri scan on the left… But with a little faith, rehab I am hopefull that I will avoid surgery again. But knowing that both ACLs are torn scares the hell out of me for later on in life..
As I sit in hospital and study each article with a fine tooth comb, I also wonder if surgery is the better option. A few days ago I was playing football, I turned and my knee popped. I was able to drag myself of the pitch but decided I still had another 5 minute in me. I returned to the playing field and jumped for the ball. On landing my knee popped again, this warning was enough for me to go an visit the hospital. I wish I would have listened to my body's first warning sign and stopped. I have completely torn my ACL and have a small fracture.
Its a dark moment and I feel lonely in making the decision to have surgery in the next few days, weeks or never.
Why is there no easy answer?
Does anyone have any links to research on this matter?
Thank you.
It's case by case regarding whether to have surgery or not based on the amount of information you receive but be careful. When I was looking at this surgery in 2010, there were not enough medical studies that researched arthritis risk of increase with ACLrs. There was more research on allograft vs autograft at the time I evaluated my options. I made the best decision at the time but in hindsight, wish I would have made the decision based on rational intelligence (conservative) vs. emotional (the need to play basketball). I would not recommend immediate surgery since surgery is almost always an option later.
I speak from experience — 5 years post surgery at the age of 35. I went with an allograft but in all fairness, I do not believe it's the ACL reconstruction that is the problem — it's the meniscectomy that will prove the most crucial in how you develop osteoarthritis based on my experience. Adrian Peterson is an example of an extremely rare gold standard that most may not be able to achieve . From what I've read, he did not have any tear to his meniscus and his Dr. mentioned his knee cartilage resembled the health of a child's knee. Remarkable and possibly owed to the balance of strength in his legs. This leads me to ask — should evaluations also consider knee cartilage health at pre-op more closely? Perhaps the de-facto standard should be to rehab for 1+ years before considering surgery? We see athletes rush to have surgery and sort of think that this is the de-facto thing (the right thing) when in fact, it probably isn't wrong…there's probably more of a right thing in waiting.
My experience — I injured mine playing basketball, had the surgery to get back on court, played a couple of years before tearing a meniscus again, and the diagnosis was that I would have full blown arthritis before 40 if I continued at that rate (2-3x a week). I did not opt for a second surgery to remove meniscus after the surgery. For me, this was the best decision as my body adapted to the tear over the next 3 months following the 2nd injury.
My surgical process: My surgery was performed about 3 weeks after the injury. I rehabilitated for 2 hours a day for 2 years straight after my surgery, never missing a day once I started (no exaggeration). I only experienced a bad reaction to the anesthesia (numbness, tingling) for a few days after the surgery. That resolved and I never felt pain again.
I would take your chances with rehabilitation from the start. I would seriously consider trusting your body at any age and build up the resolve that it will adapt. It will hurt at first I'm sure (much like my 2nd meniscectomy) but based on the studies, surgery will raise arthritis faster than not having surgery. And when it gets so bad that walking may be an issue, it will be time to move somewhere warm or replace that knee.
If you have had the surgery, just keep your knee strong and really take care of it. I can't even jack up 140 shots anymore (practicing) in around the world without feeling the repercussion.
These comments on this post have been so fascinating and engaging. Thank you to everyone for your participation and feedback.
Unfortunately, there are many unanswered questions with so many people suffering ACL injuries daily.
There is no "RIGHT answer that fits everyone. It is a patient-centered decision to be made after consultation with a physician and taking research into consideration.
It seems that so many people suffer multiple tears, and I completely agree with the anonymous posts regarding keeping your knee strong regardless of if you have surgery or not.
Here are a few links to some research articles surrounding the long-term debate:
https://www.ncbi.nlm.nih.gov/pubmed/25232663
https://www.ncbi.nlm.nih.gov/pubmed/25562459
I think that the most important approach is that an ACL injury results in a lifetime management of a risk factor that could lead to the early development of OA…management (whether conservative or surgical) is one that needs to be patient-centered, based on the individual's needs/goals.
Really interesting article and a fantastic thread as i sit here with my knee brace after a horrible soccer injury. I feel the need to contribute.
Im 35, fairly fit and in the last 2 mins of the game turn left to defend and i felt my knee cap go up and down my leg as it was locked in a straight position. In shock i tried to stand up and my left leg just buckled, i thought i broke my leg. Massive amount of pain the first few mins which subsided as i made my way to the hospital. Hospital discharges me with a bad hamstring and im over the moon thinking ill be back in a few weeks.
3 days later the swelling and pain kicks in, go to my local doc, he orders an MRI and that shows a compression fracture at the top of my tibia and ALL 4 ligaments have been damaged. LCL and MCL grade 1 strains and ACL and PCL grade 2. It resembled more of a motor accident than a sporting one.
Im sitting there in shock and disbelief knowing that the one thing i love (sport) is over. Everyone i know who has done their knee has had surgery and the thought of 12 months rehab made me feel sick and depressed. The specialist walks in and says "you have really done a number on your knee but you're pretty fit and healthy so take this brace and come back in a few weeks and we will start some physio"
I couldnt believe my ears, i asked him what about surgery and he told me that it couldnt get much worse so we will try the non invasive method. This was yesterday and ever since i have been trawling the net trying to find success stories of non surgical knee damage recovery.
I must say its very encouraging indeed as your doc wouldn't tell you about cases such as these on this thread. I have come to the conclusion that ill do everything i can to get my knee strong again and stick to only running, bike and weights (ive hung up the boots) and if after 12 months i need the surgery then fine. Its a win/win as you will go in to surgery with a strong knee and shorten your rehab but there is also the chance that you wont need surgery at all.
Like someone said in the comment above its been perceived the norm to get the surgery straight away because elite athletes have set this trend. Keep in mind these guys are getting paid a lot of money to get back to their sport asap. Everyday people have the luxury to alter their lifestyle and give PT or physio a chance. What happened in the old days when someone did their knee? The human body is amazing at healing itself.
One last comment i found intersting from one of my doctor mates was that he usually asks them if they have private cover and if so surgery is recommended. He is not a bad bloke its just business. Those on public health (medicare in oz) are told to give PT a go. Food for thought. I dont usually contribute to these things but found the info on this thread so useful that i wanted to pay it forward.
Good luck to you all and more importantly me 😉
Robbo
Have a torn ACL and meniscus, and sprainedMCL. happened 9 days ago. Was running fast and stopped at a strange pivot angle with my leg and felt it pop. Already had an MRI and saw the surgeon. He let me know that never having ACL surgery is an option, but would want to wear a brace for certain activities. He said that waiting 6 weeks before surgery is usually what they recommend. The timing of it was going to be very inconvenient for my job and family, and considering I can walk somewhat normal already, I'm going to wait until 3 and
1/2 months before doing the surgery, pretty sure I will still want to get it done, but after reading this, there's an outside chance I might want to skip it altogether. Thanks
36 year old male. I just tore my ACL playing flag football. went to cut hard past a defender and my knee popped and felt like it went sideways. I went down to the ground hard. after a couple of minutes of laying on the field in pain i had some teammates carry me off. shortly after that i could hobble around on the leg but was very careful about it. there was some swelling that day but over the next 2 days were the worst. my lower thigh near my knee all the way down to my ankle was swollen. so much so my skin was tight and i was concerned about getting any type of tingling in my toes. finally 3 days after initial episode my wife made me go to the DR. no MRI was done but he tested both my knees and diagnosed an ACL tear.
He did not immediately recommend surgery but instead said that some people can cope without having an ACL and that as long as my swelling went down and stayed down that he would not recommend immediate surgery. He did recommend physical therapy to rehab the knee. He also said there was a brace that could be custom fit to help stabilize the knee during activities as well as generic knee braces from sporting good stores that might help some. Other than that the only thing he really mentioned was we could do an MRI once the swelling went down to completely diagnose the torn ACL and see if there was any damage to meniscus, etc..
I've known the PT since HS and she said with what she has seen and with how active i am that she thinks surgery would be best and not to delay it to long. she has a PHD in PT if that matters to anyone.
The thought of surgery scares me. i don't want to do it, however, if i go to PT then i will meet my insurance deductible in about 2 weeks ($90 per 15 minutes PT, they want me in at least 2-3 times a week for 1 hour at a time)for an initial 6 week period. So now I'm considering surgery just because my deductible will have already been met! Anyways… it's been 4 days since this happened and my swelling today is a lot better than the previous 2 days. I've been walking better but still gingerly. today at work i stepped off of a 1" high mat with my bad leg, think middle of foot right on the edge of the mat, (my heel still on mat and toes on the floor) and i felt like my knee/leg slid forward and thought i may fall. i think i just got my first taste of what it may be like without an ACL. I definitely need to strengthen my other knee muscles as much as possible to stabilize it, and also possibly prepare for rehab if i get surgery but i share same concerns as others once i hit old age and can't keep up with workouts, then what will happen?
Thanks for everyone sharing their thoughts and stories.
At age 19 I tore my acl. I had no surgery or rehab. Thirty-one years have passed. Now I'm 50. I stopped sports. For the past 16 years I've been employed as a software programmer which involves sitting at a desk all day. I've lived with the feeling of a loose knee and a "pebble" in the middle of my knee. During the last year the discomfort in the menisci areas has increased. Perhaps my knee would feel better if I were to strengthen it. Sometimes the pain is hardly noticeable, but at other times I wonder how I'll cope 10 years from now. During the past month I got an MRI and the doctor recommends surgery. He was surprised I had no arthritis. I'm scheduled for acl replacement next week. I hope it's the best decision.
28 year old male – I did my ACL about a year ago, football typically, went into a challenge and my leg straightened out, I don’t recall hearing the pop but I was on the ground for about 2 mins unable to bring myself up. Bad swelling all around the knee for at least a week after and stupidly I went back a couple times trying to play and any more tense sporting movements it just buckled (very depressing) as I was an avid footballer beforehand, it also swelled again as it did the first time. I packed in the football and ultimately I’m not very active and work an office job. Dr. referred me for an MRI which confirmed the ACL tear. It’s been at least 6 months since then and I’ve just been managing but the idea of being the dad that can’t get on the bouncy castle and being active with my kids doesn’t bare thinking about. Saw a specialist today with the injury manageable but wanting to get back to football and worries over later life. They have recommended surgery so have put me on the waiting list and asked me to strengthen the knee in the meantime. As he was explaining I felt sick. I’ve never had surgery, the thought and rehab managing work and family scare me but I can’t see any other way forward. Strengthening may help temporarily but I look at it that the ACL is torn, it’s damaged and without physical repair I question whether you would get back to that normality… there are pros and cons but ultimately I want to get back to normal. I can’t even jump off of apparatus in a park 3 foot up without panicking my leg will give way… great read though and appreciate all the comments on everyone’s own experience. Thoughts on this welcome…
Bobby
43 yo female, tore my ACL and both meniscus almost 3 years ago wakeboarding. Did PT for 4 months then had reconstruction using my hamstring, also had a meniscotomy of one meniscus, the other had healed on its own thankfully. Did more PT and then was feeling great. I'll never strap my feet into a wakeboard again (I'm too nervous), but doing activities at the gym, mountain biking, jogging/hiking with zero to minimal pain.
Fastforward to last week (2 1/2 years post surgery), stepped off a step not realizing it was icy and POP, I fell to the ground and was in excruciating pain. Swelling followed. Met with my surgeon last week, he said I have re-torn the ACL and possibly meniscus….ugh. Have MRI in a couple days to confirm.
Trying to decide if should do surgery again. I think I like the idea of trying PT rehab to see if I can manage, but I am a KLUTZ and am worried about the instability and possibly doing more damage if I don't get it reconstructed. I don't do any pivoting sports but am active, and injury prone.
Bobby, if you haven't had your done yet I highly recommend considering getting the surgery. You are so young and active. The original surgery I had was great, just a freak accident I had re-tearing it.
I found this interesting and wanted to share my story in the hope it will help others. 50 yo male. Had ACL reconstruction on my right knee at 35. Tore my left meniscus at 46 on the soccer field. Learned that I had a complete ACL tear in the same knee at that time (it was diagnosed as chronic, meaning it had existed for some time). Most surgeons recommended surgery, although some suggested I might be able to get by with just the meniscus being sowed up. I got on the bike instead. When it is too cold to ride outside, I use the elliptical machine or spin in the gym. One hour a day. I also stretch, use roller bar and do leg exercises with 20 pounds around my ankle. I have not felt any pain or discomfort in over 3 years and am fully active in every way I was before the injury (although I have given up skiing for good). I recognize that the constant exercise is a lifetime commitment, but because of the tear I am healthier at 50 than I was at 40. If I have any regrets, it is that I had surgery on the right one 15 years ago.