POP! Now What? Surgical vs. Conservative Treatment

“Let me tell you something you already know. The world ain’t all sunshine and rainbows. It’s a very mean and nasty place, and I don’t care how tough you are, it will beat you to your knees and keep you there permanently if you let it. You, me, or nobody is gonna hit as hard as life. But it ain’t about how hard you hit. It’s about how hard you can get hit and keep moving forward; how much you can take and keep moving forward. That’s how winning is done.” – Rocky Balboa

Wow. What a quote, right? Pretty profound stuff for a boxing movie made over a decade ago. I remember tearing my ACL for the third time at UConn and thought long and hard about this concept. Life can pack a pretty hard punch… whether it be a potentially career-ending injury, the loss of a loved one, a tough break-up, whatever. What defines us as human-beings is how we respond to these hardships.

And trust me, I’m not someone who should be giving advice on how to grieve. Everyone grieves differently. Heck – my grief is essentially what has driven me to found this site. If you don’t know why I started Just For Kicks, take a look at the About Me section.

As many of you know, I polled the audience this past week on my instagram account. If you don’t already follow me, go check out @drjhubbsy and take a peek at my content. I recently posed the question: “What do you want to know about ACL rehab?” and got a lot of really terrific answers. Thanks for that! I plan to address all of them over the coming weeks, but one in particular really resonated with me.

“Everything. I just tore my ACL this past week and I don’t know what to do :(“

Okay, so we’ve already gone over mechanism of injury in last week’s post. You decelerated, cut, pivoted, or landed funky and heard that characteristic “POP!” @%#$!!!! Now what?

If you’re anything like me, you probably laid on the ground for a while and went through approximately 500 different scenarios in your head (catastrophizing is my specialty). But trust me when I say that gets you nowhere. So, once you catch your breath – get up off the ground. Dust your shoulders off and go see your doctor. He or she will do a clinical exam, and if suspected, will send you for x-rays and additional imaging (called an MRI). Toss some ice on your knee and remember to keep it elevated. An ACE wrap might be helpful, and investing in a pair of crutches may be necessary.

Once your doctor breaks the news, grieve. It’s okay. Elisabeth Kübler-Ross came up with the five stages of grief – denial, anger, bargaining, depression, and acceptance. Go through each one, and when you are ready, get back on the horse. In college, my certified athletic trainer and second mom (shout out – you know who you are) would say, “Jules, you have the weekend to be sad… and then we get to work.” What a powerful lesson to learn. Thank you for that. Be kind to yourself. Take your time. But once you are done processing exactly what an ACL tear means, start to brainstorm. Life has a funny way of screwing up your plans, so you better get good at making contingency plans (aka Plan B’s).

You will be faced with two options. You can either (1) manage your ACL tear conservatively or (2) manage the condition surgically. Conservative management means that you will undergo formal physical therapy or rehabilitation to strengthen the muscles of your leg to help stabilize your knee. No blood. No knives. No scar. Surgical management means that you will have the ACL reconstructed using either an autograft (patellar tendon, hamstring, quad tendon) or allograft (cadaver). There are also some new and exciting methods being tested here in Boston using stem cells and scaffolding (Bridge-Enhanced Anterior Cruciate Ligament Repair or BEAR Procedure), but for right now, everything is experimental.

As a physical therapist, it is my job to constantly re-assess the latest evidence (this is called “evidence-based practice”). It basically means, that we must continue to stay current with all of the latest techniques and interventions for treatment of different conditions and pathologies. We must constantly be asking Why? How come? Can you prove it? And as a person, that is just who I am. I am wildly curious and also a little bit skeptical when someone tells me something new (which can be both a good thing and a bad thing, but I digress). So here are some cold, hard facts for you. Take them as you will…

In a recent Cochrane Review by Monk et. al in 2016, the authors compared surgical versus conservative intervention for treating anterior cruciate ligament injuries. After conducting a review of the literature, the authors identified a randomized controlled trial reporting the results of 121 young, active adults who had an ACL injury in the preceding four weeks. The study compared surgical (ACL reconstruction and structured rehabilitation) and conservative (structured rehabilitation alone) management of ACL injury.

Results showed that there was no difference between surgical and conservative treatment in patient-reported knee outcome scores at two and five years. BUT before you run away with the idea that you don’t need to have surgery, please continue reading. There were a couple of limitations to this review. The results did not take into account the number of complications patients experienced. For example, it failed to consider surgery-related complications (re-injury, etc.), as well as conservative-treatment related complications like knee instability. Furthermore, only one study was analyzed and clinicians were not blinded to experimental conditions. This report, however, continues to be the most up-to-date and comprehensive resource on the topic.

Of the surgically managed group, three patients experienced graft rupture/failure. As we know, 1 in 5 patients with ACL reconstruction will experience a subsequent ACL tear within 2 years. There were also several cases of unstable knees in the conservative-treatment group. Perhaps more interesting is that 39% of participants in the conservative-treatment group elected to have reconstruction of the ACL and/or repair of the meniscus within 2 years, and 51% underwent surgery of that knee within 5 years. Many practitioners believe that cutting open the knee predisposes it to the development of early onset osteoarthritis.  This Cochrane review provided very-low grade evidence of this. But then you’re caught in a bit of a Catch 22.

Sure. Surgery can predispose the knee to osteoarthritis. But you know what else can? A meniscal tear or chondral damage resulting from an unstable knee. With conservative treatment, participants were more likely to sustain subsequent meniscal tears due to increased load and shear between the thigh and shin bones. The meniscus is a soft piece of fibrocartilage that acts as a cushion between the femur and tibia. When it frays or tears, the hyaline cartilage on the end of the femur and tibia are more likely to absorb load and degrade, resulting in the condition known as osteoarthritis.

Many doctors have differing opinions on conservative versus surgical treatment of the anterior cruciate ligament. I recently had the opportunity to hang out with Dr. Adam Tenforde at Brigham and Women’s Faulkner Hospital in Boston. In our conversation, he actually referenced the study mentioned above. He also said that while conservative and surgical treatments have similar outcomes, it is important to look at the needs of each individual patient and athlete. He stated that conservative treatment of an ACL tear would be a great option for the 40-year old sedentary man who works a desk job and enjoys low-impact hobbies. The 80-year old female triathlete, on the other hand, might actually benefit more from an ACL reconstruction, due to the multidirectional loading and demands of her knee (what a bright dude – also showing that ageism has no place in medicine).

So… what should you do? Only you can make that decision. Talk with your doctor and/or parents about your options and consider all of the evidence. Do you enjoy high-impact sports with lots of acceleration/deceleration, cutting, pivoting, jumping, or landing? It might actually be more conservative to have the ACL reconstruction and save your knee-joint from additional trauma.

In my next blog, I will discuss graft choice, the pro’s and con’s of each, and how rehabilitation differs slightly for each one. I hope you found this post helpful and somewhat informative. Please feel free to share it with a friend or teammate who may unfortunately be going through this process. Until next time, be well.

References

  1. Monk AP, et al. Surgical versus conservative interventions for treating anterior cruciate ligament injuries. Cochrane Database Syst Rev 2016; 4: CD011166.
  2. Frobell RB, Roos EM, Roos HP, Ranstam J, Lohmander LS. A randomized trial of treatment for acute anterior cruciate ligament tears. New England Journal of Medicine 2010; 363(4): 331–42.
  3. Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ 2013; 346(7895): 232.
  4. Lohmander S. Surgical versus non-surgical treatment of anterior cruciate ligament (ACL) injuries: a randomised prospective clinical trial. http://www.controlled-trials.com/ ISRCTN84752559
  5. Murray MM, Flutie BM, Kalish LA, et al. The Bridge-Enhanced Anterior Cruciate Ligament Repair (BEAR) Procedure: An Early Feasibility Cohort Study. Orthopaedic Journal of Sports Medicine. 2016;4(11):2325967116672176. doi:10.1177/2325967116672176.

 

2 Comments Add yours

  1. Ricardo says:

    Very good read and Informative!!

    Thank you 🙏

    Liked by 1 person

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