Surgical or Non-Surgical Management of Anterior Cruciate Ligament (ACL) Rupture?
Acute rupture of the anterior cruciate ligament (ACL) is an extremely common and serious sports injury, necessitating a prolonged period of absence from sport. Debate continues over whether surgical or non-surgical management produce the best results. In this post we explore both options.
The anterior cruciate ligament is one the four major ligaments offering support to the knee joint, the others being the posterior cruciate ligament (PCL), the medial collateral ligament (MCL) and the lateral collateral ligament (LCL). Functionally, the ACL prevents excessive forward movement of the tibia (shin bone) relative to the femur (thigh bone).
The classic mechanism of injury to the ACL is weight bearing, with knee in semi-flexion and a rotational force added. Commonly the injury is seen where the playing surface is hard or firm. In GAA, the injury regularly occurs on landing from catching a ball or sliotar and attempting to turn quickly on landing. Rupture of the ACL is followed very quickly by immediate excruciating pain, painful giving way and rapid swelling of the knee joint. Players are unable to continue to play and describe feelings of instability in the knee.
Diagnosis of ACL rupture can be made quickly by the skilled clinician on examination of the athlete. MRI is often required to confirm the exact diagnosis and assess associated damage (often meniscus and/or collateral ligament injury). Once a firm diagnosis is available the athlete in conjunction with their chartered physiotherapist must decide on a management approach.
The major decision with respect to management of ACL injuries is whether to proceed with a surgical or conservative (physio, rest, rehabilitation) approach.
Surgically, the ACL may be repaired, essential through construction of a new ACL with a graft harvested from either the patella tendon or the hamstring tendons. The graft used by the surgeon will depend on a number of factors including; their personal preference, whether or not the athlete is still growing, and the sport or activity that they do. Regardless of the graft used the operation appears to produce similar results.
An alternative to surgical management of acute ACL rupture is conservative management or rehabilitation. Many sports people who have suffered from ACL ruptures have successfully returned to their sports without a surgical procedure to replace the ruptured ACL. The rehabilitation and time commitment to successfully avoiding surgery are significant, however results are comparable in the long term.
Much of the rehabilitation involves strengthening of the hamstring and quadriceps muscle groups. The hamstrings in particular can be trained to effectively do the job of the absent ACL (i.e. prevent forward movement of the shin bone relative to the thigh bone). Similar timeframes for successful return to sport are reported from surgical and conservative approaches.
Surgical Vs Conservative
The decision to go with a surgical versus a conservative management approach should be considered in light of a number of factors, including:
- Athlete’s age
- Type of sport played (twisiting/turning involved)
- Desire to return to sport
- Degree of knee instability
- Presence of associated injuries to collateral ligaments or meniscus
- Occupation or other factors
Take as an example a young Garda in his 20’s who plays GAA and has strong desire to get back to doing so. He has suffered associated medial collateral ligament damage and has an inherently unstable knee. This patient would perhaps best be advised to consider a surgical approach to the management of his condition.
On the other hand, take a professional gentleman in his late 40’s who ruptured his ACL playing 5-a-side football and has little desire to get back to doing so but who would like to be able to play 18 holes of golf once a week. This gentleman would perhaps be considered a candidate for a conservative approach to his injury management.
Each of these cases are clear cut examples. In practice there’s rarely such an obvious answer and both approaches have their merits and results can be similar. Ultimately either approach may be suitable for the injured athlete. The decision should be made by the athlete in conjunction with the medical team at their disposal once all the options have been laid bare.