The anterior cruciate ligament (ACL) is important for maintaining the stability of the knee joint, especially during activities such as weaving, pivoting or kicking. ACL injuries are relatively common among soccer players, skiers, and gymnasts. Injuries can range from mild to severe and are rated using a rating system. The most common mechanism of injury is non-contact. An example is a cut and plant movement. Demographics are important for differential diagnosis because women are three times more likely to damage their ACL than men.
Deep Dive in ACL Rehabilitation with Luke O’Brien
Traditionally, it is believed that surgical repair of an ACL is the only way to get back to exercise or to maintain a stable, pain-free knee. We know that for those who are, surgical treatment is likely to have a more favorable outcome than conservative treatment. under 35 years of age; those who are physically active; those who are better educated and those with additional soft tissue injuries. There is far less evidence as to which factors would indicate a more favorable outcome with conservative treatment.
The Delaware-Oslo ACL Study
Grinden et al. Did the Delaware-Oslo ACL study to find out when conservative management is preferable to operational management. The precise aim of the study was to identify early predictors of a successful 2-year outcome in non-surgically treated patients with an ACL injury. A secondary goal was to assess whether predictive models would be different before and after a 5 week rehabilitation program.
The study included 300 participants who had not undergone ACL reconstruction and 182 participants. All participants had a diagnosis of unilateral ACL rupture, which was diagnosed by MRI. Participants were between 13 and 60 years old and participated in regular physical activity. They were excluded if they sustained an additional soft tissue injury during the break or had previously traumatic injuries to the knee.
All participants went through an initial short rehab plan to correct effusion and ROM deficit independently of a reconstructive operation or not. All participants then went through a 5-week rehabilitation program aimed at restoring muscle strength and appropriate neuromuscular responses.
After the 5-week rehabilitation program, the tests were repeated and surgical or non-surgical treatment was decided. If the participant experienced instability or wanted to return to sports that involved jumping, cutting, or panning, surgical reconstruction was recommended regardless of progress in outcome measures.
Conservative treatment of ACL ruptures
The rehabilitation program consisted of single and multi-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. The plyometric exercises continued gradually. These exercises focused on the quality of movement and were tailored to the patient's individual needs based on the patient's specific goals. The disorder training was carried out according to the study protocol and consisted of dynamic stability exercises on a roller board, a seesaw board and a platform.
Of the 300 patients, 118 (39.3%) did not remain surgically treated 6 months after the injury. The mean age at baseline was 28.6 ± 10.5 years and they were slightly more likely to be female.
Plan for cardiovascular and strength training
Clinical considerations
Essentially, non-surgical management should be considered for athletes who are female, older and have good knee function early after an ACL injury. The simple measures used in this study can provide predictions for two years and should be used in early decision making. That being said, this is a single RCT examining conservative treatment options for ACL ruptures. It is important to evaluate other research on this topic to ensure that the right clinical decisions are being made for your patients. Luke O’Brien assessed the evidence for you in a short, high quality online course to ensure you make the right decision.
This post was originally published in July 2018 and has now been updated for freshness, accuracy and completeness.
