Non-operative Treatment of ACL Injury
Original Editor - Mariam Hashem
The main objective of ACL reconstruction is to restore the anterior-posterior and rotational joint stability for successful a return to sports, prevention of instability and long-term joint degeneration. The majority of ACL-deficiencies undergo surgical treatment.
Despite the wide use of reconstruction, the rate of recurrence is still high, particularly in the first 24 months following the operation. The restoration of joint mechanics may not be sufficient for returning to competency in sports. A systematic review investigated the rate of return to sports after reconstruction and reported 82% of participants return to sports, 63% returning to pre-injury level with only 44% had returned to competitive sport despite successful outcome on knee impairment-based function scales.
Surgical treatment can also be costly and time consuming for a percentage of the population.
The “rule of thirds” was described by Noyes et al. in 1983, stating that at least 1/3 of patients will benefit from nonoperative treatment without instability ''giving way''.
For these reasons and to avoid surgical complications some patients choose to undergo conservative treatment but due to the complexity and complications of ACL-deficiency there should be some criteria to identify the right candidates for nonoperative treatment.
Screening to Identify Copers
''Potential Copers'' are those who can potentially return to pivoting/cutting sports with conservative treatment. To identify them, a cluster of screening tests was developed:
- Four one-legged hop tests; single leg hop for distance, single leg triple hop, single leg triple cross over hop, and the 6-m timed hop test
- Incidence of knee giving way
- Self-report functional survey (Knee outcome survey-Activity of Daily Living Scale—KOS-ADLS)
- Self-report global knee function rating
Potential copers are those who:
- Presented without concomitant injuries: you can identify isolated ACL-injury in your subjective examination by asking about post injury swelling pattern. A two or three-hour post-injury swelling indicates an ACL injury. A delayed swelling, for instance in the following day, indicates associated chondral pathology or other injuries. Isolated ACL injuries are mostly presented with full ROM whilst restricted mobility can possibly be due to other associated injuries.
- Achieved a minimum score of 80% limb symmetry on all hop testing
- >80% on the KOS-ADLS,
- >60 on the self-report of knee function
- ≤1 subjective report of knee giving way: asking about instability after injuries. If the athlete doesn't sustain further buckling or giving way after injuries, then probably they can cope well with non-operative management.
Failure to meet all of these criteria results in a patient identified as non-coper and hence, surgery will be recommended.
Meeting the screening tests is essential if the patient is willing to return to pivoting/cutting sports. The other option is to return to modified activity or lower load sports. A 10-year cohort followed up with ACL patients who were identified as potential copers and found very little return to sport rates among this category.
Sports such as football, basketball, soccer, and skiing are identified as level I/II pivoting and cutting activities requiring a high level of stability and may not be suitable for patients who chose not to undergo surgical treatment. Sedentary occupations or those who participate in less demanding sports (straight-line sporting) such as jogging and cycling have a better chance successful return to their sports with a non-operative course.
In the acute phase after injury, the aims of rehabilitation are restoring joint homeostasis and ROM. A patient will be presented with haemarthrosis, inhibited quads and motion deficits. To address these deficits, you can include activities such as wall slides and stationary bike to improve the joint mobility and reduce swelling. Gentle quadriceps contraction can also be introduced starting with teaching patellar glide and progressing to terminal knee extension.
Following the acute phase, exercise parameters should be adjusted to meet the following rehabilitation phases:
- Running Capacity
- Speed and agility: starting with single-plane and progressed to multi-planes with speed to ensure returning to sports with less risk for instability.
- Return to training
- Return to sports
The rehabilitation frame is similar to post-operative rehabilitation which is discussed in further details in this page: ACL Rehabilitation: Rehabilitation Planning. If the athlete is keen on returning to twisting/cutting sports, Neuromuscular training should be included in the rehabilitation to restore joint stability.
Also known as perturbation training, neuromuscular training is an essential phase in nonoperative rehabilitation with the aim of improving knee stability. Prior to starting this phase, the patient must meet the following criteria:
- Full ROM
- Full resolution of swelling
- Sufficient lower limb strength
This phase can be introduced prior to building running capacity. Perturbation training comprises of a series of balance tasks with unanticipated perturbations to the unstable surface such as rocker board progressed to roller board. Maintaining balance on an unstable surface with perturbation has been reported to improve knee kinematics, gait mechanics and reduced episodes of giving way.
Return to Sport
Completion of a series of perturbation training without any reported episodes of giving way is essential before returning to sport. In addition, demonstrating sufficient quadriceps and hamstring strength on isokinetic testing at 90% or more compared to the contralateral limb. Hop tests can be used to evaluate the athlete's readiness to return to sport.
A functional performance brace is recommended when returning to pivoting/cutting sports. A reduction of anterior tibial translation and improved proprioception is believed to be the function of a functional performance brace thus, improving the sense of stability.
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- Single Leg Hop for Distance _Old . Available from:https://www.youtube.com/watch?v=ACRD1uAZ2_4 [last accessed 18/09/19]
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- Single Hop/Crossover Hop/Triple Hop for Distance Test . Available from:https://www.youtube.com/watch?v=Uh-EDK1RezA [last accessed 18/09/19]
- Single Leg 6m Timed Hop Test. Available from:https://www.youtube.com/watch?v=QBppGOIb3iI[last accessed 18/09/19]
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- Di Stasi SL, Hartigan EH, Snyder-Mackler L. Unilateral stance strategies of athletes with ACL deficiency. Journal of applied biomechanics. 2012 Aug 1;28(4):374-86.
- The ACL Road to Recovery - Advanced Balance and Perturbation Training . Available from: https://www.youtube.com/watch?v=XCvfIhequOc [last accessed 18/09/19]