ACL SURGERY: JUST SAY NO!

Welcome to the first ever blog written by an overly anxious and (previously)

uneducated physical therapy student. If you find yourself here, that means you know a thing or two about knowing a thing or two and are familiar with Bridge

Physical Therapy and Performance. Like our mascot the mighty platypus, take a dive and follow along with me as I discuss something that might be shocking to some. ACL TEARS CAN HEAL!

Now, some ground rules before we begin, it should be noted that if you are an athlete reading this, this probably does not apply to you. You need that danged ole ACL ligament to provide stability so you can get back to running, jumping, and cutting as soon as possible. Or if you’re a 25 year old dude and your knee buckles when you open the fridge (seriously I’ve actually heard that one). But, for the rest of us average joe’s out there that don’t really have to run a ton, and maybe play some recreational sports here and there, this is for you!

If you’ve torn your ACL (or you’re a PT working with someone who has), here’s a little dose of optimism: the ACL might be more resilient than we’ve given it credit for. And before you reach for that shiny new iPhone 17 to call the surgeon (Hyde I hope yours gets delivered soon), maybe try out some physical therapy and see how it goes for you. An article originally published in The New England Journal of Medicine took 121 “young active adults with acute ACL tears” and gave them 2 options: structured rehabilitation plus early ACL reconstruction or structured rehabilitation with the option of later ACL reconstruction if needed. The group that was given the second option of rehab with the later ACL reconstruction if needed consisted of 59 individuals, and here’s the kicker, 36 individuals did not undergo ACL reconstruction. They were able to beat that dastardly ACL tear with rehab alone. This study used the Knee Injury and Osteoarthritis Outcome Score (KOOS) to measure outcomes, pretty much it’s a 0-100 scale with 100 being the best (think Indiana football) and 0 being the worst (think FIU football). When it was time for the 2 year follow up, the mean KOOS score for the early ACL reconstruction group improved by 39.2 points, the mean score for the optional or

delayed ACL reconstruction group improved by 39.4 points.

So maybe you’re my age, 25 years old, and thinking “If I tear an ACL now, I can

probably just rehab it and be fine for a few years without needing surgery, but what about when I’m 30? Will I need it then?” Well good news for you, the same researchers who did the previously discussed study did a follow up at 5 years with the same patients! The mean change in KOOS score was once again higher, 44.9 points, in the rehab first and optional or delayed ACL reconstruction group. The early ACL reconstruction group’s mean KOOS score improved by 42.9 points. The wonderful researchers who conducted this study concluded it by saying, “These results should encourage clinicians and young active adult patients to consider rehabilitation as a primary treatment option after an acute ACL tear.” Hopefully we actually start to listen to these guys.

If you’ve made it this far, maybe you’re just thinking that rehab worked so good and those patients just got super strong quads and they were able to just live their lives without an ACL. BUT, let me bring this before you, a systematic review was done in2021, it included 9 different studies and 734 participants. Each study used MRI findings to measure healing potential of the ACL in terms of fiber continuity. Buckle up for this quote, “All included studies reported spontaneous healing. Furthermore, none of the included studies reported the absence of healing.” All studies, (incredible I must say) showed that the ACL can heal on its own. Some of the studies actually classified the tear based on location, and those findings showed better restored fiber continuity with proximal ACL tears. If that doesn’t give you hope that an ACL tear doesn’t need surgery, I’m not sure what will.

Now that we’ve seen the research, what does this really mean? Not all ACL tears

demand autopilot surgery. If you’re a relatively young, active but not professional-athlete person, maybe with a proximal tear, starting with a structured rehab program (strengthening, neuromuscular training, stability work, controlled loading) may give your knee a shot at recovering enough for everyday life (and the occasional Wednesday night slow pitch softball game). “Healing” doesn’t always equal “as good as new.” Even in studies where MRI shows fiber continuity or patients report good function, the restored ACL may not have the same strength as a pristine ligament (or a surgical graft). That means high-demand sports involving pivots, jumps, and cutting might still carry risk. But if you were to ask my opinion, and you fit into the whole “young adult who’s kinda active but not a pro athlete” category, I’d say give rehab a shot before slicing your knee open. And if the rehab doesn’t work and surgery is your best option, at the very least the rehab you tried before the surgery will help you tremendously in your post surgical rehab journey.

References

1.Frobell RB, Roos EM, Roos HP, Ranstam J, Lohmander LS. A randomized trial of

treatment for acute anterior cruciate ligament tears. N Engl J Med. 2010;363(4):331–342. doi:10.1056/NEJMoa0907797 PubMed+1

2.Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ. 2013;346:f232. doi:10.1136/bmj.f232 PubMed+1

3.Pitsillides A, Stasinopoulos D, Giannakou K. Healing potential of the anterior cruciate ligament in terms of fiber continuity after a complete rupture: a systematic review. J Bodyw Mov Ther. 2021;28:246–254. doi:10.1016/j.jbmt.2021.06.003 PubMed+1