The anterior cruciate ligament (ACL) is important for maintaining stability of the knee joint, particularly in activities involving weaving, pivoting or kicking. Injuries to the ACL are relatively common among footballers, skiers and gymnastics. Injuries can range from mild to severe and are scored using a grading system. The most common mechanism of injury is non-contact an example being a cut & plant movement. Demographics are important when it comes to differential diagnosis as women are 3 times more likely to damage their ACL than men.
Traditionally it is thought that surgical repair of an ACL is the only way patients can return back to sports or maintain a stable painfree knee. We know that operative treatment is predicted to have a favorable outcome over conservative management in those who are; under 35’s; those who are physically active; those who have a better education and those with additional soft tissue injury. There is far less evidence to suggest which factors would indicated a more favorable outcome if treated conservatively.
The Delaware-Oslo ACL Study
Grinden et al set out to discover when conservative management is preferable to operative management with the Delaware-Oslo ACL Study. the exact aims of the study was to To identify early predictors of a successful 2-year outcome in nonsurgically treated patients with an ACL injury. A secondary aim was to assess if prediction models would be different before and after a 5-week rehabilitation program.
The study included 300 participants who did not undergo ACL Reconstruction and 182 who did. All participants had a diagnosis of unilateral ACL rupture diagnosed by MRI, participants were between the ages of 13 -60 and participated in regular physical activity. They were excluded if they had suffered additional soft tissue injury during the rupture or had previous traumatic injuries to the knee.
All participants underwent an initial short rehab plan to resolve effusion and ROM deficit regardless of reconstructive surgery or not. All participants then underwent a 5 week rehabilitation programme which aimed to restore muscle strength and appropriate neuromuscular responses.
After the 5-week rehabilitation program, testing was repeated and surgical or nonsurgical treatment decided. If the participant experienced instability or wished to return to sports which involved jumping, cutting or pivoting, surgical reconstruction was advised regardless of progress of outcome measures.
Conservative Treatment for ACL Rupture
The rehab program consisted of single- and multiple-joint exercises; open and closed kinetic chain exercises; and concentric, eccentric, and isometric exercises with 3 to 4 sets and 6 to 8 repetitions per exercise. Plyometric exercises were gradually progressed. These exercises focused on the quality of movement and were tailored to individual patient needs based on that patient’s specific goals. Perturbation training was performed according to the study protocol and consisted of dynamic stability exercises on a roller board, rocker board, and platform.
Of the 300 patients, 118 (39.3%) remained nonsurgically treated at 6-months post injury. The mean age at baseline was 28.6 ± 10.5 years and it slightly more likely that they were female.
In essence non-surgical management should be considered for athletes who are female, older and have good knee function early after ACL injury. The simple set of measures used within this study can provide 2-year prognoses and should be used in early decision making. That being said this is a single RCT investigating conservative treatment options for ACL rupture. It is important to appraise other research on the topic to ensure the correct clinical decisions are being make for your patients. Luke O’Brien has appraised the evidence for you in a short high quality online course you you to make sure you are making the right decision.
This post was originally published July, 2018 and has now been updated for freshness, accuracy and comprehensiveness.