Non-operative Treatment of ACL Injury

Original Editor - Mariam Hashem

Top Contributors - Mariam Hashem, Kim Jackson, Jess Bell, Simisola Ajeyalemi and Tarina van der Stockt

Description

The main objective of ACL reconstruction is to restroe the normal joint mechanics for successful return to sports. The majority of ACL-deficiency 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. A systematic review investigated the rate of return to sports after reconstruction and reported 82% of participants return to sports participation, 63% returning to pre-injury level with only 44% had returned to competitive sport despite successful outcome in on knee impairment-based function scales.

For these reasons and due to other surgical complications some patients elict to undergo conservative treatment but due to the complexity and complications of ACL-deficiency there should be some crietria to identify the right candidate for nonoperative treatment.

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''

Screening to identify copers

Potential copers are those who can potentially return to function and pivoting/cutting sports with conservative treatment. To identify those patients a cluster of screening tests:

• 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
• the incidence of knee giving way
• a self-report functional survey (Knee outcome survey-Activity of Daily Living Scale—KOS-ADLS
• a self-report global knee function rating

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Potential copers are those who

• Presented without concomitant 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

Filure to meet these criteria result in patient identified as non-coper and hence surgery will be recomended.

Meeting the screening tests is essential if 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 follwed up with ACL patients who were identified as potential copers and found very little return to sport rates among this category.

Activity Modification/Indications to Nonoperative

Sports such as football, basketball, soccer, and skiing. Identified as level I/II pivoting and cutting activities requiring high level of stability and dynamic function may not be suitable for patients who chose not to undergo surgical treatment. Sedentart activities or less demanding occupations and sports. straight-line sporting activities such as jogging and cycling have a greater likelihood of succeeding with a non-operative course.

Single ACL injuries without concomitant.

Rehabilitation

Neuromuscular training

An essential phase in nonoperative rehabilitation when full ROM is achieved, full resolution of swelling with sufficient lower limb sterngth to allow participation in WB dynamic exercises.

Perturbation training can be introduced to specifically to improve knee stability in patients with ACL deficiency. Developed by investigators at the University of Delaware,designed to challenge the patient with ACL deficiency through a series of balance tasks enhanced with unanticipated perturbations to the unstable surface. Classically described as a 10-session program, the patient begins with stance on a rocker board and then progresses to a roller board (Fig. ​(Fig.5).5). While standing on the unstable surfaces, progressive perturbations are applied, challenging the patient to maintain balance, enhancing dynamic knee stability. Ideally, the task is designed to assist in the development of individualized patterns of muscle contraction, rather than global co-contraction, to facilitate dynamic knee stability. Multiple studies investigating the effects of perturbation training in the ACL-deficient population have reported improved knee kinematics [24], improved gait mechanics [25], and a reduction in episodes of giving way [26].

Completion of these series of exercises without giving way is essential prior to return to sports. In addition, the patient must present with sufficient quadriceps and hamstring strength, as demonstrated by isokinetic strength symmetry of >90% compared to the contralateral limb

Return to Sport

In order to return to pivoting/cutting sports, a functional performance brace is recommended. marginal reduction in anterior tibial translation and enhanced proprioception, both of which may contribute to a feeling of stability by the patient.

Asessment

ACL reconstruction is superior to conservative treatment in the evidence.