The ACL Debate - To operate or not?
Not everyone needs surgery after an ACL tear!
There’s a huge hype at the moment about trying to push people away from surgery and into conservative management, however, I don’t think we can place everyone into the same category.
This is where a screening system comes into play to classify those that may be potential ‘copers’ and be able to manage without a new ACL and the ‘non-copers’ who should follow the surgical pathway sooner.
So what does a potential ‘coper’ look like?
A coper is someone who is:
Able to return to jumping/cutting/pivoting sports without any instability or ‘giving way’ of the knee
Significantly less laxity in the joint upon clinical testing (i.e. less anterior tibiofemoral translation).
Fewer reported episodes of ‘giving way’
Return to significantly higher activity levels
So what differences are noted in those who are classified as non-copers?
Athletes who experienced giving-way episodes on resumption of pre-injury activities
Demonstrate a ‘stiffening’ strategy and higher muscle co-contraction
Poorer gait performance in terms of kinematics and time-distance variables after 4 months
Increased quad loading even during anticipated tasks
So how can we determine who is a coper and non-coper?
There are a few tests that we can perform in the clinic once the knee has settled that can help up classify each person.
A coper should be able to demonstrate:
>80% limb symmetry on a 6m timed hop test
>80% on a KOOS questionnaire
>60% on a global rating of knee scale
Have no reported episodes of instability
The current world BEST practice after ACL injury is to do 3 months of intense ‘pre-hab’ before deciding whether to have surgery or not.
Interestingly, Thoma et al (2019) recently found that 45% of those initially classified as a "non-copers", were able to turn themselves into a "potential coper" after 5 weeks of rehab (as per exercise protocol by Eitzen et al, 2010).
From this information, I think we should be discussing options with clients and at least try a period of rehab before rushing into surgery.