BRINGING SCIENCE TO TREATMENT

A consensus on surgical versus conservative management of ACL injuries

18/4/16Arsenal’s Jack Wilshere receives treatment after sustaining an injuryAction Images via Reuters / Matthew Childs

Anterior cruciate ligament injuries remain one of the most common sports injuries(1). While sports injury science has made strides toward understanding the causes of injury and prevention strategies, many young athletes still suffer from ACL tears and ruptures. In 2019, sports professionals from various disciplines gathered in Pittsburgh, Pennsylvania, to reach a consensus on the best way to manage ACL injuries. After a presentation of the best recent information on managing ACL injuries, delegates to the 2019 Panther Symposium discussed their thoughts on 12 overarching statements on injury management(1).

  1. The 23 members agreed unanimously that both surgical and non-surgical approaches are appropriate ways to manage ACL injuries. Many factors contribute to the decision to repair the torn ligament, such as age, desire to return to sport, which sport the athlete plays, and their ability to control the knee while injured.
  2. Nearly 83% of the delegates agreed that deciding which is the better method for dealing with the injury should be a shared endeavor. The patient’s aspirations, expectations, and current functional status are relevant in deciding the next steps. They caution practitioners to be aware that collateral stakeholders may have different motivations besides the athlete’s wellbeing and may try to influence decision making to meet their needs, not the patient’s.
  3. All panel members agreed that the condition of the other supporting structures within the knee contributes to whether the knee is best handled via surgery or conservative measures. A finding of concurrent meniscus and ligament damage almost always requires surgical intervention.
  4. Anatomical variances may influence decision making. Bony alignment and structure, such as tibial slope, affects the biomechanics within the knee joint. Thus, take these aspects of anatomy into consideration when evaluating solutions for ACL injury.
  5. An isolated ACL tear is not an emergent condition. Therefore, delegates agreed that patients might first try a conservative treatment approach. It appears that a progressive rehabilitation program may improve function and help avoid surgery. However, if the athlete does require surgery, they’ll be the better for the pre-hab efforts to regain strength and mobility in the knee after the acute injury.
  6. What to do if this conservative approach fails? All members agreed that unstable knees that give out during advanced sporting movements, despite a course of progressive physical therapy, require surgical repair.
  7. The group agreed 100% that the development of osteoarthritis after an ACL injury depends on many factors. Whether the knee undergoes surgical repair isn’t the only consideration. Osteoarthritis can develop in the knees regardless of the management option. More research is needed in this area.
  8. The group unanimously supports the idea that those athletes who want to return to sports that require pivoting, cutting, and jumping should strongly consider surgical repair to the damaged ACL.
  9. The reason for the consensus on surgery for more active patients is, because without repair, the athlete is at a higher risk of damaging the other structures within the knee.
  10. Ten of the 23 delegates agreed that despite this need for surgery, athletes who want to return to sport more quickly, say to finish out the season, may return to play after a course of rehabilitation and defer surgery until a later date. The other members caution that this approach may not be worth the risk it poses to the rest of the knee’s structures.
  11. One-hundred percent agreed that those athletes that play sports that don’t rely on rotational movements might well be suited for a course of conservative treatment.
  12. The group concluded that knee instability that interferes with activities of daily living in this population should also undergo surgical repair.

The consensus presents both surgical and non-surgical management of ACL injuries as viable options. The patient and their health provider should consider multiple factors when making this decision, such as the desire to return to sport, which sports the athlete plays, their current functional status, and the presence of other damage to the knee joint. Together, both patient and provider can weigh the options and agree on a course of action.

Reference

  1. Br J Sports Med. 2021;55:14-22
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