ACL injury – the end of a sporting career? Or is there a different narrative?
Australia has the highest reported rate of ACL injuries in the world and in the last 15 years it has increased by 74% in under 25s. This poses an ongoing, expensive and painful public health problem. Direct hospital costs of ACL reconstruction surgery in 2014–15 were estimated to be $142 million. Research has also shown that the incidence of revision ACL surgery is increasing more rapidly than that of primary ACL reconstructions. With this narrative it is no wonder that people perceive an ACL injury as career-ending. This is where physiotherapists and other medical professionals need to help change the narrative.
How does an ACL injury occur?
It is usually through a non-contact movement with a sudden pivoting and twisting motion while the foot is planted. It can also happen during an incorrect landing position after a jump or with or without contact mid-air. My patients frequently tell me they physically felt their knee give way, instant pain, sometimes heard a click and that the knee blows up with swelling within the first two hours.
What does the research say about treatment options?
In Australia, the majority of patients who have ACL tears have early surgical reconstructions. However, current research shows that this may not be the best course of treatment. In a systematic review and meta-analysis comparing ACL reconstruction versus non-operative treatment, it was concluded that people following ACL rupture should receive non-operative interventions before surgical intervention is considered (Monk et al 2016, Smith et al 2014). These studies advocate for a delayed ACL reconstruction. The first high quality randomised controlled trial indicated that a strategy of rehabilitation, along with early ACL reconstruction did not provide better results at a five-year follow up than a strategy of initial rehabilitation with the option of having later ACL reconstruction. Results did not differ between knees surgically reconstructed early or late and those treated with rehabilitation alone (Frobell and Roos 2013).
How will physiotherapy help?
Whether you have had surgery or not, physiotherapy is essential. Physiotherapy should focus on sport-specific exercise rehabilitation, range of motion deficits, lower limb strength, neuromuscular agility training, patient education, goal setting, and a progressive return to pain free function and sport.
Prevention is the way to go:
Several studies have also found that specific training programs are effective as preventive measures and can prevent up to 50- 80% of ACL injuries (Zbrojkiewicz, Vertullo and Grayson 2018). There are great resources such as FIFA 11+ and Australia’s Netball Knee Program, just to name a few. Physiotherapists are perfectly equipped to design and implement these programs for individuals or within sporting clubs or teams.
