An anterior cruciate ligament (ACL) injury is a major concern for athletes and active individuals alike. Traditionally, surgery has been the go-to treatment for ACL ruptures, but recent studies and clinical trials are showing that a non-surgical approach can often lead to successful outcomes. Understanding the choices, the risks, and the latest evidence is crucial for anyone facing ACL rehab.
The Stats You Need To Know
When it comes to ACL injuries, the numbers tell an interesting story. Research indicates that 50% of individuals are dissatisfied with their outcomes two years after an ACL injury, regardless of whether they had surgery or chose rehab. Even more concerning is the fact that 50% of people who suffer an ACL rupture will develop osteoarthritis (OA) within ten years.
Additionally, for young athletes, the risk of graft failure is high—about one in three will experience a tear of their graft within 2-9 years after surgery. Moreover, a staggering 90% of ACL reinjuries involve cartilage or meniscal damage, with 27% of these cases requiring a revision surgery.
The Two Paths After an ACL Rupture: Surgery or Rehab?
Following an ACL tear, individuals typically face two primary options: surgery or rehabilitation.
- Rehab alone: Research suggests that for individuals who opt for rehabilitation first, 50% can avoid surgery altogether. This non-surgical path is particularly appealing for those looking to recover functionally without the risks and downtime associated with surgery.
- Rehab plus surgery: In cases where rehab is delayed or chronic tears are present, clinical trials, such as the SNAPP trial, have shown that surgery may offer better outcomes compared to rehab alone, especially when dealing with long-term tears.
The Australian Trend: Why Do So Many Choose Surgery?
In Australia, the overwhelming majority of people—around 90%—opt for surgery right away following an ACL rupture. Of those who undergo surgery, 55% return to sport post-op. However, what’s particularly striking is that there is no significant difference in return-to-sport (RTS) outcomes between those who undergo surgery and those who choose rehab first. This raises an important question: Does surgery really offer a better long-term outcome?
Is Surgery the Answer for Everyone?
Studies show that opting for surgery does not necessarily correlate with a lower risk of further knee injury. In fact, an umbrella systematic review and meta-analysis revealed that individuals who undergo ACL reconstruction (ACLR) have a 4x higher chance of developing radiographic osteoarthritis (OA). While these bony changes may not always cause symptoms, they remain a critical factor when considering long-term joint health.
The KANON trial further explored the impacts of early surgery versus non-surgical management. It found that individuals who had early ACL reconstruction exhibited higher levels of inflammatory cytokines at 4 months, 8 months, and 5 years post-injury compared to those who had rehab alone or delayed surgery. Additionally, those who underwent early surgery experienced more bony changes in the knee.
Despite these findings, the KANON trial showed no significant difference in outcomes between individuals who underwent early surgery and those who chose rehab alone after 2 and 5 years of follow-up. This is a game-changer for those considering their treatment options.
What Happens When ACL Tears Heal on Their Own?
Interestingly, research is showing that ACLs can heal without surgery in many cases. A study by Filbay in 2023 investigated the healing and function of complete ACL tears two years after the injury. The results were promising—30% of participants still had a continuous ACL at the two-year mark. If we exclude those who eventually underwent delayed ACL surgery, 53% had a continuous ACL after two years.
Those who were managed with rehab alone and had a healed ACL at two years demonstrated better outcomes than those who had both early and delayed ACLR. This supports the idea that ACL rehabilitation, when done correctly, can lead to successful outcomes without the need for surgery.
The Swedish NACOX Study: Evidence for Non-Surgical Rehab
In Sweden, a cohort study called NACOX found that when patients were given the option, 46% opted for surgery after two years, while the remaining 54% chose to continue rehab. Notably, 62% of those who chose rehab had fiber continuity in their ACL, suggesting that they were likely enjoying better functionality and outcomes.
The Cross-Bracing Protocol: A Non-Surgical Option
One of the most exciting aspects of non-surgical ACL rehab is the cross-bracing protocol, which has been shown to offer impressive results. If the protocol is started within three weeks of injury, it can help stimulate healing and improve the likelihood of ligament continuity.
The protocol involves: weekly physio, comprehensive progressive exercise protocol and the use of a ranger brace for the first 12 weeks
- Weeks 1-4: Wear the brace fixed at 90° knee flexion, this may require use of a knee scooter.
- Week 5: Gradually increase range to 60-90°flexion.
- Week 6-7: Progress to 45-90°.
- Week 8-9: Progress to 20-120°.
- Week 10-12: Full range of motion and brace can be removed for sleep
- Week 12 remove brace and continue physio monthly
Research shows that 90-95% of those using the brace for this protocol had some ligament continuity at 3 months. Furthermore, 66% of these individuals exhibited an ideal “thick, taut” ligament appearance on MRI, and 92% were able to return to sport by 12 months post-injury.
The Takeaway: Surgery vs. Rehab
The evidence is clear—ACL injuries don’t always require surgery. The success of rehabilitation depends on several factors, including the timing of intervention, the individual’s activity level, and the presence of knee laxity. For many, intensive physiotherapy and a well-structured rehab program can lead to full recovery and a return to sport without surgery.
If you’re navigating an ACL injury, whether acute or chronic, it’s essential to discuss all of your options with a physiotherapist who understands the latest evidence and can guide you towards the best treatment path for you.
Want To Learn More About ACL Treatment Options?
Check out the comprehensive resources at www.aclinjurytreatment.com to learn more about ACL injury management and rehab programs.
Please call us 3200 8541 or book online at www.loganphysio.com.au to schedule a consultation with our experienced physiotherapists.
The landscape of ACL injury management is evolving, and it’s no longer a one-size-fits-all approach. Whether you opt for rehab, surgery, or a combination of both, knowing your options can help you make an informed decision and optimise your long-term knee health.
