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[edit | edit source]

The main objective of ACL reconstruction is to restroe the normal joint mechanics for successful return to sports and prevention on instability. The majority of ACL-deficiencies undergo surgical treatment[1].

Despite the wide use of reconstruction, the rate of recurrence is still high particularly in the first 24 months following the operation[2]. 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[3] despite successful outcome on knee impairment-based function scales.

For these reasons 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 candidates 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''[1].

Screening to Identify Copers[edit | edit source]

''Potential Copers'' are those who can potentially return to pivoting/cutting sports with conservative treatment. To identify them a cluster of screening tests[4] was developed:

[5]
[6]
[7]
[8]

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 results in patient identified as non-coper and hence surgery will be recomended[1].

Activity Modification[edit | edit source]

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[9].

Sports such as football, basketball, soccer, and skiing are identified as level I/II pivoting and cutting activities requiring 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 better chance successful return to their sports with a non-operative course[1].

Rehabilitation[edit | edit source]

Neuromuscular training[edit | edit source]

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 pahse, patient must meet the following criteria:

  • Full ROM
  • Full resolution of swelling
  • Sufficient lower limb strength

Perturbation training comprises of a series of balance tasks with unanticipated perturbations to the unstable surface such as rocker board progressed to roller board[10]. Maintianing balance on unstable surface with perturbation has been reported to improve knee kinematics, gait mechanics and reduced episodes of giving way[1].

[11]

Return to Sport[edit | edit source]

Completion of a series of perturbation training without any reported wpisodes of giving way is essential before returning to sport. In addition, demonestrating sufficient quadriceps and hamstring strength on isokinetic testing >90% compared to the contralateral limb[1].

A functional performance brace is recommended when returinig to pivoting/cutting sports. A reduction of anterior tibial translation and improved proprioception is believed to be the function of the a functional performance brace thus improving the sense of stability[1].

Conclusion[edit | edit source]

ACL reconstruction is superior to conservative treatment in the evidence[12].

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Paterno MV. Non-operative care of the patient with an ACL-deficient knee. Current reviews in musculoskeletal medicine. 2017 Sep 1;10(3):322-7.
  2. ↑ Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of second ACL injuries 2 years after primary ACL reconstruction and return to sport. The American journal of sports medicine. 2014 Jul;42(7):1567-73.
  3. ↑ Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med. 2011 Jun 1;45(7):596-606.
  4. ↑ A decision-making scheme for returning patients to high-level activity with nonoperative treatment after anterior cruciate ligament rupture
  5. ↑ Single Leg Hop for Distance _Old . Available from:https://www.youtube.com/watch?v=ACRD1uAZ2_4 [last accessed 18/09/19]
  6. ↑ Single leg Triple Hop Test for Distance . Available from:https://www.youtube.com/watch?v=iRdcsj2DRTI[last accessed 18/09/19]
  7. ↑ Single Hop/Crossover Hop/Triple Hop for Distance Test . Available from:https://www.youtube.com/watch?v=Uh-EDK1RezA [last accessed 18/09/19]
  8. ↑ Single Leg 6m Timed Hop Test. Available from:https://www.youtube.com/watch?v=QBppGOIb3iI[last accessed 18/09/19]
  9. ↑ Hurd WJ, Axe MJ, Snyder-Mackler L. A 10-year prospective trial of a patient management algorithm and screening examination for highly active individuals with anterior cruciate ligament injury: part 2, determinants of dynamic knee stability. The American journal of sports medicine. 2008 Jan;36(1):48-56.
  10. ↑ 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.
  11. ↑ The ACL Road to Recovery - Advanced Balance and Perturbation Training . Available from: https://www.youtube.com/watch?v=XCvfIhequOc [last accessed 18/09/19]
  12. ↑ Smith TO, Postle K, Penny F, McNamara I, Mann CJ. Is reconstruction the best management strategy for anterior cruciate ligament rupture? A systematic review and meta-analysis comparing anterior cruciate ligament reconstruction versus non-operative treatment. The Knee. 2014 Mar 1;21(2):462-70.
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