ACL Rupture: "When I get that feeling, I want....ACL healing!" (7 minute read)

Up until around 8 years ago I was ambivalent towards ACL tear injury management, and even as a Masters-trained Senior Physiotherapist if pressed probably assumed reconstruction was ‘gold standard’, as that’s what I’d read and seen everywhere.

It was 2 opposing cases I saw in quick succession as a trainee Specialist Physiotherapist that confronted me head on, forcing me to challenge any bias I had and avail myself to the best research literature (Caneiro, Bunzli and O'Sullivan 2020).

1 of the patients had experienced 5 ACL surgeries, presenting to my clinic on a 4-wheeled-walker (which was incredibly odd for a woman in her mid-30’s). She was stressed, depressed, anxious, suicidal and had clearly not received adequate supervised post-op education and rehabilitation over the 4 years her operations had taken place.

The second patient was a fresh ACL and meniscus injury, who was adamant on commencing rehabilitation without surgery, as her sports teammates had experienced failed elective knee surgeries. We crafted a management plan in a shared decision-making context, began rehab and she returned to play at 4 months, and at long-term follow-up remained sign and symptom free.?

This forced me to question the orthodoxy that is ACL recon as ‘best practice’, spending 100’s of hours investigating the most credible evidence, with help from both Surgeon and Physiotherapist researchers and expert clinicians. What I discovered was that Westernised culture was flooded with a one-sided narrative of ACL reconstruction as the best first choice based on old bio-plausible, pathoanatomical paradigms, with this Global multibillion-dollar per annum industry perpetually funded by governments, insurance companies and commission-style private hospital sectors, with the best-evidence and patients falling second place (Dhillon 2014).

Since that time, the ACL topic has absolutely mushroomed for me, whereby now I have overseen 1000’s of full thickness tears managed without surgery, including patients who have returned to high-level pivoting, jumping and cutting tasks.

Can ACL ruptures heal?

In the past 3 years, my management approach has shifted, due to a growing awareness of the healing capacity of ACL tears. I regularly see full thickness ruptures heal, with confirmation on repeat-MRI – this is a significant turn in clinical reasoning and management for me. A cursory Google search will reveal most initial websites suggesting “ACL tears never heal”, they have a “poor blood supply” and “surgery is necessary” to return to sports.

Fresh investigations have exposed online surgical advertising content by private elective orthopaedic groups that is targeted towards patients is frequently false or misleading (Ryan et al 2022, Gamble et al 2022), over-estimating the benefits of surgery and under-estimating the harms (Harris 2016), with calls for government regulators to intervene. We must wonder where the obsession with reconstruction experimentation will end, with kangaroo tendon and gold nanoparticles touted as the next big thing (Power 2018, Bellrichard et al 2022).

Last year, a systematic review by Pitsillides and associates revealed there IS peer reviewed literature showing ACL full thickness ruptures CAN heal, with strategies including bracing, rehabilitation and strengthening and even no management at all! (Costa-Paz et al 2012, Marangoni et al 2018). Shifting the burden of proof, the authors highlighted the revelation there are in fact no high-quality studies showing the ligament CAN’T heal! In a national debate on ACL tear management which I was a part of at the end of 2021 (which concluded with vast consensus), both Physiotherapist and Surgeon researchers and expert clinicians agreed ACL tears can heal. In this deliberation, pilot data from Australia due to be released in 2023 was discussed, with incredibly high rates (over 90%) of fully ruptured ACL’s showing healing with a novel bracing protocol, with normalised ligament stability tests and long-term return-to-play achieved by subjects.

Further analysis of the ground-breaking KANON study by Filbay and colleagues this year revealed 58% of those who did not cross over to surgery had MRI proof on healing at 5-year follow-up. High healing rates have also been proven in partial tears by Park et al (2021) with the use of a bracing protocol. Normalised anatomical, partial, lengthened ACL and non-anatomical (such as proximal ACL bundles attaching to the PCL) are all possible types of healing (Jacobi et al 2016, Nguyen et al 2014, Crain et al 2005). Orthopaedic surgeon Andrea Ferretti made the comment in 2020 the ACL’s “blood supply, whose anatomy was deeply investigated by an Italian researcher, is rich in vessels and anastomosis, providing adequate supply to all kinds and sites of tears (proximal, distal, and midsubstance),” with Takeuchi et al 2022 recently suggesting increased blood supply to the ligament following an ACL injury.

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Shared-decision making

Shared-decision making is key here (Elwyn, Frosch and Kobrin 2016), meaning patients must be told their ACL tear may or may not heal as a part of their management options, although I do worry that in the ‘real world’ it is a pipe dream given our post-evidence-based era (Greenhalgh, Howick and Maskrey 2014, Jureidini and McHenry 2022). A Telehealth client of mine in 2021 saw a medical specialist who informed her that “a bomb had gone off in her knee,” her “knee had exploded” and her “only option and solution was surgery:” She had a partial ACL tear – talk about nocebo.

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Not surprisingly, she burst into tears and under fear-mongered duress booked in for a reconstruction the following week. By chance, she was able to connect with me, we commenced a stabilisation protocol, with a follow-up MRI displaying near intact healing of the ligament; she returned to semi-professional soccer without surgery and at long-term follow-up is incredibly satisfied with her decision to wait and consider her options.

In my experience almost all patients aren’t given an objective shared decision-making process in the traditional medical pathway, frequently hemmed into a single decision for ACL +/- meniscal surgery, with upcoming research soon to be released in Australia confirming this assertion. This process takes time (more than a 10-minute consult), care, empathy and empowerment of patients with current best guidelines, education aids, infographics and resources (Filbay and Grindem 2019, Gledhill and Barton 2020, Gamble et al 2022).

Communication has to be a calm, unbiased and honest presentation from all stakeholders, with potential risks, harms and benefits of all treatment options clearly unpacked – these decisions don’t need to be rushed! A level-2 long-term cohort study by F?ltstr?m et al 2021 showed incredibly high knee re-injury rates, with 2 out of 3 reconstructed patients suffering further damage after return-to-sport; it is devastating as a therapist to encounter these patients, as they are often sold surgery as a “one-way ticket” to a normal knee and return to sport (Zadro and Pappas 2019).

Studies of poor methodological quality like Sanders et al 2017, which retrospectively compare ACL reconstruction and rehab to non-controlled or absent comparison arms, and mechanistic-theory like ‘a graft-ACL acts like a normal ACL’ cannot be used to justify early reconstruction. A common purported misconception is that ACL reconstruction prevents greater rates of meniscal tears to non-surgical management (Filbay 2019, Duncan 2022), with the balanced systematic review authored by research surgeons and Physiotherapists Ekas and co in 2020 highlighting the evidence is too weak to guide surgical treatment decisions. Both KANON and now the COMPARE randomised control trial have shown similar meniscal tear rates over time, with COMPARE actually showing higher future meniscal surgery in reconstructed patients (Frobell et al 2013, Reijman et al 2021).

Who should have early surgery?

We need to be advising all patients that the most empirical evidence shows no additional benefit of early ACL reconstruction, menisectomy or meniscal repair to rehabilitation alone for knee-injured patients, with the research-surgeon collaboration of Blom et al 2021 showing no high-quality studies proving superiority of these techniques over exercise therapy treatment or placebo surgery. A Professor of Orthopaedic Surgery I met commented that he tells ACL and meniscus-injured patients “to go away and complete 6 to 12 months of rehabilitation on their knee” and he will then “operate on their knee if they aren’t satisfied” because he “can’t promise their knee will be better long-term for being operated on early.”

None of this is to say reconstruction is not a viable option for patients who have recurrent episodes of hard instability, despite an early administered high-quality stabilisation protocol; I have reiterated this in mass media interviews and have collegial connections with pragmatic orthopaedic surgeons who I collaborate with and share more in common with in managing musculoskeletal pain and injury, than not.

I believe Physiotherapists can be the leaders of managing ACL injuries in a triage role, which has been successfully implemented in musculoskeletal pain and injury primary care policy shifts in countries like Denmark and the UK, which can have a multiplicity of benefits to governments, private insurers, the medical system, patients, and clinicians alike (Lewis et al 2020).

Kiadaliri et al (2016) suggest savings of over $20,000 (AUD) in direct and indirect costs per patient through a fiduciary shift towards a Physiotherapy-led approach, reducing resource consumption and decreasing the risk of unnecessary overtreatment, even with the option of reconstruction, if needed. Interprofessionally, we need to all work together to design large, multicentre trials to assess healing capacity of ACL tears in various demographics, so patients can hopefully be triaged early, and significant amounts of money saved… if only this had been done 60 years ago, when the theory that ACL tears can’t heal was propagated based on animal models like rabbits and dogs!

Conclusion

We as a profession will never be anti-surgery, but also need to represent patients as strong and confident expert non-surgical advocates by describing the best comparative evidence treating ACL and meniscus tears with exercise alone, weighed against surgery and exercise. If we won’t, who will??

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