Researchers continue to try to crack the code on the best way to manage a torn anterior cruciate ligament (ACL). In the Netherlands, sports scientists again tackled the issue by randomizing 167 volunteers with a torn ACL to either an immediate surgical repair group or a conservative rehab (with the option to repair after three months) group. The researchers measured primary and secondary outcomes before the intervention and three, six, nine, 12, and 24 months after randomization.
Eighty-five subjects received early ACL reconstruction, while 82 participated in a therapeutic intervention right after injury. Half of the conservative management group opted to undergo surgical reconstruction an average of 10.6 months after inclusion in the study. These 41 participants demonstrated the recommended conditions for reconstruction, namely rotational instability, repeated knee giving out, and a positive pivot-shift test.
The primary outcome measures included the participant’s score on the International Knee Documentation Committee (IKDC) test, which tested the patient’s perception of their knee function and symptoms. The Knee Injury and Osteoarthritis Outcome (KIOO) score, Lysholm score, return to sport status, the incidence of the injured knee giving way, Tegner score, pain rating, and treatment satisfaction score were secondary outcomes.
Results and practical implications
At the initial follow-up three months after randomization, the conservative management group showed a significant improvement in the IKDC scores compared to the surgical group. This trend shifted to favor the reconstruction group at the nine-month follow-up. At the end of the two-year study period, both groups showed improvement in their IKDC scores. However, the reconstruction group showed significantly better progress in this score.
There’s no doubt that the conservative group achieved a better return to functional status in the first few months after injury. That they were not in the acute stage of surgical recovery may account for the initial surge of improved IKDC scores in this group. However, patients who experienced continued knee instability and giving out likely plateaued in their functional improvement. In contrast, those in the repair group continued to make gains at six and nine months after surgery.
The early repair group also showed better secondary outcome scores in the KIOO and the Lysholm tests at the two-year evaluation. Pain scores did not differ significantly between the groups. As should be expected, the surgical group demonstrated significantly fewer incidences of the knee giving way 24 months after randomization. A greater percentage of the repair group participants (43% versus 31%) returned to their prior level of sport. Interestingly, the rates of those subjects satisfied with their treatment were quite high and nearly equal in both groups (92.6% of the surgical group and 91.3% in the conservative group).
Testing the effectiveness of surgical interventions against no intervention is difficult. This study was unique in its access to patients – offering participation to 282 qualified patients. However, only 167 agreed to participate. Subjects were assigned randomly without consideration of which management approach might be best for them. Therefore, half of the conservatively managed patients received later reconstruction because they met the criteria for this approach.
Despite the delay in treatment for those in the conservative group, both groups exhibited high satisfaction ratings two years after the initiation of the study. The later surgery for half of the rehab group may account for their lower outcome scores. With the average surgical delay of 10 months, half of this group was also delayed in their post-op rehab. They might still have decreased function, increased pain, and may not have been ready for return to sport despite the 24 months since their injury. The researchers did not separate out the results of those who were managed conservatively from those who later received surgical repair. Therefore, while an interesting exercise, this study lacks any real clinical relevance except to suggest that guidelines for evaluating the need for surgical repair might effectively predict those who will eventually need surgical intervention.
Alicia Filley, PT, MS is the former editor and a long-time contributor to Sports Injury Bulletin and its sister publication Sports Performance Bulletin, she has 30 years’ experience working in rehabilitation, sports injury, and sports performance. Alicia holds a bachelor's and a master's degree in physical therapy. She is a practicing physical therapist and avid hiker, runner, and cyclist. When not writing and researching, Alicia can be found putting our findings to the test outside on the ...
Register now to get a free Issue
Get a free issue of Sports Injury Bulletin when you register.
Practical injury prevention advice, diagnostic tips, the latest treatment approaches, rehabilitation exercises, and recovery programmes to help your clients and your practice.
Dr. Alexandra Fandetti-Robin, Back & Body Chiropractic
"The articles are well researched, and immediately applicable the next morning in the clinic. Great bang for your buck in terms of quality and content. I love the work the SIB team is doing and am always looking forward to the next issue."
Elspeth Cowell MSCh DpodM SRCh HCPC reg
"Keeps me ahead of the game and is so relevant. The case studies are great and it just gives me that edge when treating my own clients, giving them a better treatment."
William Hunter, Nuffield Health
"I always look forward to the next month’s articles... Thank you for all the work that goes into supplying this CPD resource - great stuff"
Subscribe Today
Weekly Magazine
Online Library
Email Newsletter
Practical injury prevention advice, diagnostic tips, the latest treatment approaches, rehabilitation exercises, and recovery programmes to help your clients and your practice.
Dr. Alexandra Fandetti-Robin, Back & Body Chiropractic
"The articles are well researched, and immediately applicable the next morning in the clinic. Great bang for your buck in terms of quality and content. I love the work the SIB team is doing and am always looking forward to the next issue."
Elspeth Cowell MSCh DpodM SRCh HCPC reg
"Keeps me ahead of the game and is so relevant. The case studies are great and it just gives me that edge when treating my own clients, giving them a better treatment."
William Hunter, Nuffield Health
"I always look forward to the next month’s articles... Thank you for all the work that goes into supplying this CPD resource - great stuff"
Subscribe Today
Weekly Magazine
Online Library
Email Newsletter
Practical injury prevention advice, diagnostic tips, the latest treatment approaches, rehabilitation exercises, and recovery programmes to help your clients and your practice.
Be at the leading edge of sports injury management
Our international team of qualified experts (see above) spend hours poring over scores of technical journals and medical papers that even the most interested professionals don't have time to read.
For 17 years, we've helped hard-working physiotherapists and sports professionals like you, overwhelmed by the vast amount of new research, bring science to their treatment. Sports Injury Bulletin is the ideal resource for practitioners too busy to cull through all the monthly journals to find meaningful and applicable studies.
Sports Injury Bulletin brings together a worldwide panel of experts – including physiotherapists, doctors, researchers and sports scientists. Together we deliver everything you need to help your clients avoid – or recover as quickly as possible from – injuries.
We strip away the scientific jargon and deliver you easy-to-follow training exercises, nutrition tips, psychological strategies and recovery programmes and exercises in plain English.
Part of Green Star Media Ltd. Company number: 3008779
We use cookies so we can provide you with the best online experience. By continuing to browse this site you are agreeing to our use of cookies. Click on the banner to find out more.