By Luqman Shaikh – Sports Scientist – Founder Prehab 121
‘A lot of patients ask me whether I need surgery or no. Will I ever play competitive sports after surgery’ ‘Will I’ question has a significant effect on their motivation and therefore telling the patient what is right is very important and also explaining the process of long term rehabilitation. Knowing what the patients expect of their rehabilitation and return to sport process can help to guide them in setting realistic goals and being more satisfied with their outcomes.
In making the decision of whether or not to undergo Anterior Cruciate Ligament Reconstruction (ACLR), one of the things you would want to know is what the long term outcomes are for patients who undergo ACLR and for those who do not.
A recent showed that there are very few differences in course of treatment in the first two years after ACL injury between patients who chose non - surgical approach and those who chose to undergo early ACLR. (1) Another study demonstrated that over half the ACLRs could be avoided without any major differences in a 2 year outcome report (2)
These studies show that there are very few differences in long term outcomes of patients who choose to undergo early ACLR and those who don’t, and that we should not rule out a non-surgical approach to ACL injury for some patients.
Another study looked for early predictors of a successful outcome in those who decided not to undergo ACLR after 2 years. They found that patients who were older, female, and had good knee function early after an ACL injury may do better with a non-surgical approach. (3)
A study showed that young, active patients and those whose symptoms seem more severe early after the initial ACL injury may benefit from beginning with exercise therapy prior to considering ACLR. This gives the knee a chance to decrease effusion, improve range of motion, and provide a more optimal environment in the knee for healing opposed to undergoing early ACLR which causes even more trauma to the already injured knee. A 5 week rehabilitation protocol prior to undergoing ACLR has shown to improve patients outcome measures and knee function which includes physiotherapy and neuromuscular strength (4)
So is it all in the rehab?
What I and my team of expert sports scientist and physiotherapists usually do is focus on getting the rehab program right, regardless of whether the patient has surgery or not. After an ACL injury, it is crucial that quadriceps strength reaches at least 90%. We also need to make sure that objective measures are being taken appropriately and often enough to help guide the rehab program. It is also vital to assess patients’ psychological readiness and patient reported knee function through questionnaire.
Deciding whether or not to undergo ACLR after an ACL injury can be a difficult decision. What we now know is that we should not simply rule out a non-surgical or optional delayed surgical approach, and that maybe patients would do better with beginning a knee rehab program like the Prehab 121 Knee Rehab protocol program and then deciding on whether to have surgery or not. Regardless of the decision, the importance of a good, effective rehabilitation program cannot be overstated.
At Prehab 121, we have designed a Knee Rehab Protocol Program specifically for knee injuries which includes Pre-operative phase (6 weeks rehab) and post operation 6 phases of rehab. With over 500 patients going through the pre-operative rehabilitation phase in our Prehab 121 clinics in India, we have reported a drastic change in their outcome measures both prior to surgery and post 6 months of rehab.
1. Grindem et al. Nonsurgical or surgical treatment of ACL injuries: knee function, sports participation, and knee reinjury. J Bone Joint Surg Am. 2014;96:1233-41
2. Frobell et al. A randomized trial of treatment for acute ACL tears. N Engl J Med 2010;363:331-42.
3. Filbay SR, Roos EM, Frobell RB, et al. Delaying ACL reconstruction and treating with exercise therapy alone may alter prognostic factors for 2-year outcome: an exploratory analysis of the KANON trial.Br J Sports Med 2017;51:1622–1629.
4. Grindem et al. Anterior cruciate ligament injury – who succeeds without reconstructive surgery? The Orthopaedic Journal of Sports Medicine, 6(5), 2325967118774255 DOI: 10.1177/2325967118774255