To most people it won’t be a surprise to hear that the knee joint is the second most commonly injured joint in the body after the ankle, and is the leading cause of sports related surgeries. Injuries to the knee, specifically those to the anterior cruciate ligament (ACL) are among the most economically costly sporting injuries and have one of the longest lengths of rehabilitation prior to return to sport (Joseph et al, 2013).

What is the ACL?
The ACL is one of the four major ligaments that support the knee joint. It passes from the femur (thigh bone) to the tibia (one of the two bones in the lower leg) and is responsible for stopping the tibia from translating forward on the femur.

How is the ACL injured?
The ACL can be injured in a number of ways. Most commonly injury occurs with rapid change in direction, stopping suddenly, landing from a jump incorrectly or direct collision.

What is the best treatment for an ACL injury?
It is important to highlight that not all ACL injures need reparative surgery. Although this has been the most common form of treatment in the past, there is now strong evidence to suggest that approximately 50% of patients can cope without their ACL for at least five years post injury and that they have similar outcomes to those patients who do have ACL reconstructive surgery (Frobell et al 2013). Additionally, a recent high-quality research article revealed that at 20 years follow up, there was no difference in knee function and quality of life in those who did not have ACL reconstructive surgery when compared to those who did (van Yperen et al, 2018).

Having an ACL reconstruction does not guarantee return to pre-injury sport and unfortunately it doesn’t guarantee graft survival. Research shows that approximately 60% of non-professional patients are back playing pre-injury sport two years after surgery (Ardern et al 2014). This may be due to insufficient rehabilitation, poor compliance with home exercise programs, or even not attending regular physiotherapy for a guided rehabilitation program.

Surgery is not commonly performed immediately after an ACL injury. It has been proven that it is best to allow initial swelling to settle and regain range of motion and strength in the muscles around the knee. It is recommended that you perform a “pre-habilitation” exercise program as advised by your physiotherapist before undergoing surgery. Evidence shows that pre-operative strengthening results in better knee function and an increased likelihood of return to pre-injury sport within two years of initial injury (Failla et al 2016).

Alchemy’s physiotherapists are well trained and qualified in how to get the best results out of you prior to having your knee reconstructed to ensure you are back at your highest level of function as quickly and safely as possible.

Who needs an ACL reconstruction?
Not all people. The research has shown that some people can cope without an intact ACL when playing multi-directional sports. There is a battery of tests that will be done by your physiotherapist to help determine whether conservative management is worth pursuing. Having surgery is not a sure fix, you need to do this in conjunction with a progressive rehabilitation program addressing strength, balance, range of motion and return to sport progressions. Some people find this early rehabilitation can be a good trial to determine whether they can commit to the rehab necessary after having an ACLR. Returning to sport prior to 9 months post operatively has been shown to increase the risk of ligament re-rupture by 50%. In summary some people cope well without an ACL and some people need a reconstruction. Irrelevant of this, you will need to commit to a physiotherapy led rehabilitation program and be guided by your physiotherapist on your return to sport.

Who may not need an ACL reconstruction?
You are less likely to need surgery if you have a partial tear in your ACL that may heal with rest and rehabilitation, if you do not participate in change of direction sports and if you are older than 55 years of age. The battery of tests conducted by your physiotherapist enables them to determine whether you are likely to cope without an ACL reconstruction or if you will need ACL reconstructive surgery.

How do you know if you require an ACL reconstruction?
An assessment and discussion with your physiotherapist will help determine if you require ACL reconstruction surgery.

Regardless of whether you require surgery or not all patients who have an ACL injury will require extensive rehabilitation on their knee to regain range of motion, strength and stability. If conservative management is the right option for you, your period of rehabilitation prior to return to sport will be significantly reduced to approximately three months as opposed to 12 months for surgical patients.

Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med. 2014;48:1543–1552.

Failla MJ, Logerstedt DS, Grindem H, Axe MJ, Risberg MA, Engebretsen L, Huston LJ, Spindler KP, Snyder-Mackler L. Does extended preoperative rehabilitation influence outcomes 2 years after ACL reconstruction? A comparative effectiveness study between the MOON and delaware-Oslo ACL cohorts. Am J Sports Med2016;44:2608–14.

Filbay SR, Culvenor AG, Ackerman IN, Russell TG, Crossley KM. Quality of life in anterior cruciate ligament-deficient individuals: a systematic review and meta-analysis. Br J Sports Med. 2015;49:1033–1041.

Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS. Treatment for acute anterior cruciate ligament tear: five year out- come of randomised trial. BMJ. 2013;346:F232.

van Yperen DT, Reijman M, van Es EM, Bierma-Zeinstra SMA, Meuffels DE. Twenty-year follow-up study comparing operative versus nonoperative treatment of anterior cruciate ligament ruptures in high-level athletes. Am J Sports Med. 2018;46:1129–1136.

Joseph, A. M., Collins, C. L., Henke, N. M., Yard, E. E., Fields, S. K., & Comstock, R. D. (2013). A multisport epidemiologic comparison of anterior cruciate ligament injuries in high school athletics. Journal of athletic training, 48(6), 810–817.