So forget repairing your ACL tear huh?

Soapbox rant today: So forget repairing your ACL tear huh?

Just give it some deep thought before you decide rehab is enough for you. Don't get fully sucked into the non-surgery hype, sometimes there is value and purpose. We are not necessarily saying that we are pro-ACL surgery, but it does have a place when we are talking about a major ligament with many functions beyond articular vector restraint.

*Here is where we see the present problem with the "newer" rehab-only hype for ACL tears . . . . the follow up time frames of the research pieces that suggest that ACLR is sufficient, in our opinion are not long enough into the future (years) to substantiate that secondary instability is not occurring or not a risk. In fact, there are enough articles to substantiate that secondary instability (often deeply rotational) will occur if no ACL repair occurs.

But, other bad things can happen if the joint is not cinched up tightly.
"Increases in TFI (time from injury) are associated with medial meniscal tears, including irreparable medial meniscal tears, medial femoral condyle chondral damage, and early medial tibiofemoral compartment degenerative changes at time of ACLR. These findings highlight the importance of establishing a timely diagnosis and implementing an appropriate treatment plan for patients with ACL injuries. This approach may prevent further instability episodes that place patients at risk of sustaining additional intra-articular injuries in the affected knee. "
*in this study 47.2% were classified as playing competitive or professional sports versus recreational sport

There have been some therapists in the field around the world that have been promoting that ACL surgeries ** are seemingly becoming more and more unnecessary. Their stance seems to be that with hardcore rehab that the knees do just as well, that performance is not lost. Sure, this is possible this or next season, but what about in 2 years? 5 years ? And what will the consequences be then? This article outlines some thoughts.
So, lets just all be careful of the strong points of view we put out there for the consumer. We get their point, but it is foolish to dismiss that the ligament doesn't have a function and is never necessary to replace/repair as this article (and many others report). SECONDARY instability is a real thing, rotational instability in non-ACL repaired** knees is a real thing. Attenuation of secondary joint restraints over time is a real thing, and the cost that comes with those changes. The consequences to the joint structure as secondary instability sneaks in, are a real thing, they are most likely to occur, even if you rehab your client's knee deeply. So be sure that you educate your client, that without their ACL their knee will never be as good, even if you are a champion rehab guru, you are just not that good that you and your rehab can negate all of the rotational vectors of loading in your high level athletes. Time and load will win, just be honest. Just because you do not see consequences tomorrow, just because your top-tier athlete continues to perform this season at top levels without compliant, doesn't mean they will not be present next year. Just be up front with your clients.
And here is another thought to chew on. 24 months ago my Jui-jitsu master Prof Carlos Lemos Jr. tore his ACL. We rehabed and he did well, he even won his 4th world championship without his ACL. But, we had these talks, and he knew that even though he was able to perform at the top level, he knew that the leg was not like the other. He decided 6 weeks ago to have it repaired because we discussed many times the above kinds of long term possibilities. I placed what facts and experiences I have had over 20+ years, the research that is presently out there, and let him decide. He decided that "hope" only goes so far, that he knows he will not be exceptionally as strong on the long term rehab to the degree it was initially performed, and he did not want to risk subsequent internal joint damage that might ensue.
Yes, not everyone needs ACL surgery, especially those who are not highly active or sporting, or the aging/elderly, but we can make a case that just rehabing and dismissing repair is also going to miss some vital points. We are not saying that we are pro-ACL surgery, but it does have a place.
Just educate your client honestly, then let them decide the direction, and do good work.

If anyone wishes to debate here, lets do it. But come at us with 5-10 year post-rehab no-ACL surgery cases with MRI's showing no intra-articular cost. (Good luck with that.) But if you find such unicorns, we definitely want to see them so we can share it and adjust our stance more softly. We want to be as smart and accurate on our rants as possible, it is important.

**corrected/ammended 10:57central time

photo credit: thank you !

Orthop J Sports Med. 2018 Dec 11;6(12):2325967118813917.
Relationship Between Time to ACL Reconstruction and Presence of Adverse Changes in the Knee at the Time of Reconstruction.
Sommerfeldt M1,2, Goodine T2, Raheem A3, Whittaker J1,4, Otto D