The earth is crying for people who make sound judgement and informed decisions.
— Sunday Adelaja
Calvin Green Knee

Anterior Cruciate Ligament (ACL) tear is a common knee injury. It's time the patients put the onus on themselves to be informed about the latest scientific research on how to treat them. 

In the last month I have seen over half a dozen patients who have either had a second rupture of Anterior Cruciate Ligament (ACL) after having got an ACL reconstruction done by the top names in the game, or haven't been able to get to playing their previous levels of activities, whether it be sports or non-sporty. It bothered me immensely that something was definitely not right. Young active people to whom their sports (football, frisbee, cricket, basketball etc) is a big part of their lives, did everything right, from going to the doctors as soon as possible after the injury, getting all the possible investigations being asked for and then getting surgeries done by the top surgeons. They were great patients too when it came to following advice on rest and rehab. What was going on here? It would have been to easy to put the blame on luck.

I am going to be unapologetic about my comments below because I am going to back up everything I state below. They are facts based on latest medical research published in top medical journals, esp. British Journal of Sports Medicine. They are not my opinions. 

ACL rupture isn't a fun injury. It has consequences that might mess up your future plans if not managed properly. ACL injuries leads to muscle weakness, functional deficits, lower sports participation increased risk of knee re-injury and knee osteoarthritis (OA). There is also a higher of getting meniscus injury, which further raises the chances of getting knee OA in the future. 

Point being, we do need to recognise that we can't take the management of ACL injury lightly. Something intense has to be done. Does that mean surgery?

A Swedish study (1) published online first in British Journal of Sports Medicine (BJSM) looked at a total of 78 clubs with 4,443 individual players from the highest national leagues in 16 countries were followed over a varying number of seasons from January 2001 to May 2015 (365 club-seasons and 10,157 player- seasons included for analysis). I almost bore you with all these numbers to make a point that what I am going to say next isn't coming from thin air, or based on side-y study done by some cow-boys on 10 patients. It's as good or better study as it gets.

This study, done over 15 years, found that the return-to-play, at the same level three years later as before the surgery, was only two-third after ACL reconstruction, i.e. 65%. These were top players in the world, with access to the top surgeons in the world. There was all the possible intention to get these players back again playing at the top level because there is a lot of money riding on them. 4% of them re-ruptured their ACLs even before the rehabilitation period was over.

So, what was (is) going wrong here? 

"Five to ten years ago it was common for orthopaedic surgeons to assure their ACL injured patients that 90–95% of the time they would have a good to excellent result with surgical reconstruction. We suspect that such advice can still be heard in orthopaedic offices."(2) I am told by patients that is definitely true even today.

To me, even with good intentions, if you are raising expectations of the other even if it is to motivate them, inspite of knowing otherwise, qualifies as a lie. I was told by a certain dean of a renowned university that this is called marketing. I find that statement unbecoming of being a human, leave alone a professional of any kind. 

A Norwegian study (3) again published online first in BJSM found that 30% get re-injured in the first 2 years of returning to previous level of activity / sports after ACL reconstruction. A study (4) published in January in American Journal of Sports Medicine found 7% failure after the ACL reconstruction surgery. It also found 8% risk of injury to the other earlier uninjured knee as well. These total risk of 15% (7% + 8%) jumps to 23% failure rate for athletes under the age of 25.

What should be of a lot of interest to all of us is that players who return-to-sport at 9 months or later after surgery and more symmetrical quadriceps strength markedly reduced their re-injury rate.(3) 

I am glad that I get mad at my ACL patients and therapists even when their pains are better but I don't see their quadriceps to be up to the mark. It almost seems research is catching up with me :)

I also make a very simple point to my patients. 'Do they only want to play or run for another few times and never again, or for life (as long as possible)?' If the answer is for life, I tell them that they will have to stick to my timelines for rehab and going back to their previous levels of sports. Surprisingly, most of them comply, even though they are most likely to be type A personalities. It probably is because I am myself triple type A personality or them knowing I run a 100 odd kms at a drop of a hat even though I have a couple of disc bulges. 

Time is a great healer but only if you do something appropriate with it. Appropriate rehabilitation becomes very crucial. Don't rush, because the injury might come rushing back even sooner. 

To think a little beyond, ACL preventive programs should be mandatory in athletes involved in sports where there is a higher risk of ACL injuries. I'll soon come out with an article on pre-hab, rehab and preventive programs. 

A note from Ira Leinonen, a friend, after having read this article:

Good one. I had ACL injury 22 years ago playing soccer. I was told I needed surgery. My team mate had gone through same surgery and was not in better position after 9mths...and re injured when eventually returned to play and has knee issues still today. I was told that I was never going to play sports again at age of 18 but I read some stuff and rehabed my knee by series of stability and strength stuff. 22years on after where 10 of them I did kickboxing where jumping and landing on the knee was comon practice I have maintained the principle of rehabing my knee to this date. I plan to go on with the active lifestyle till the end.

To sum it up, I'll quote Prof Don Shelbourne, father of accelerated rehabilitation,  from a BJSM podcast (5), who has performed more than 6,000 ACL reconstructions since 1982.

Patients prefer a bit of instability with full range of motion than a stable knee. Stiff knee is a time bomb for osteoarthritis. Many surgeons overlook the loss of motion as a risk factor. If you are wondering whether to have surgery or not after ACL injury - go for (appropriate) conservative management first.

What led me to put this piece together was a provocative title of an article (2) published online first on 26 May 2016 in BJSM, 'Time to be honest regarding outcomes of ACL reconstructions: should we be quoting 55–65% success rates for high-level athletes?' Thanks a million miles Dr McCormack and Dr Hutchinson. 

Other relevant articles:

References:

1. Waldén M, Hägglund M, Magnusson H, et al. Br J Sports Med Published Online First: 31 March 2016 doi:10.1136/bjsports- 2015-095952

2. McCormack RG, Hutchinson MR. Br J Sports Med Published Online First: 26 May 2016 doi:10.1136/bjsports-2016-096324

3. Grindem H, Snyder- Mackler L, Moksnes H, et al. Br J Sports Med Published Online First: 9 May 2016 doi:10.1136/bjsports-2016- 096031

4. Wiggins AJ, Grandhi RK, Schneider DK, et al. Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Am J Sports Med 2016. http://dx. doi.org/10.1177/0363546515621554

5. The father of accelerated rehabilitation, Prof Don Shelbourne, on history and managing ACL injuries. BJSM Podcast. 27 May 2016.

Comment