Australia has some of the highest rates of anterior cruciate ligament (ACL) reconstruction surgery in the world (Zbrojkiewicz et al 2018). 

An estimated 90 per cent of Australians with ACL injury opt for early surgery, despite no evidence of additional benefit compared to initial treatment with exercise-based rehabilitation (Saueressig et al 2022). 

When acute ACL injury is managed with rehabilitation first, around 50 per cent of people avoid the need for surgery (Frobell et al 2010, Reijman et al 2021). 

Surgery is perceived by many patients and healthcare providers as having better outcomes than exercise-based rehabilitation, such as higher rates of return to sport and lower re-injury risk. 

In reality, the evidence suggests that return to sport rates are similar between treatment options and re-injury risk may be higher after ACL reconstruction (Selin et al 2024). 

Understandably, keeping up with the latest research as a busy clinician is a struggle, particularly when faced with conflicting research findings, opposing consensus statements and industry-funded research. 

Online patient-facing information about ACL injury management is also of low quality and often biased towards ACL surgery.

It is not surprising that many long-held beliefs about ACL injury management options persist among physiotherapists as well as other healthcare providers. 

Our recent mixed-methods study of Australian physiotherapists found that although 60 per cent of physiotherapists agreed that ACL surgery and rehabilitation alone result in similar outcomes on average, only 37 per cent reported regularly informing patients about this (Filbay et al 2024). 

Additionally, 79 per cent of physiotherapists informed patients that ACL surgery was the best treatment for returning to cutting and pivoting sport (Filbay et al 2024). 

To assist healthcare providers and patients to make an informed, shared decision about treatment, our team developed a patient decision aid for ACL treatment based on the most recent systematic review and clinical trial evidence and in partnership with key stakeholders. 

How was the ACL patient decision aid developed?

Our team surveyed 980 Australians with lived experience of ACL injury along with physiotherapists to understand current management of ACL injury in Australia. 

We also performed two qualitative studies with multidisciplinary healthcare providers and patients with and without ACL injury to identify decisional needs, explore beliefs and expectations about management options and identify barriers to and facilitators of making an informed decision. 

These identified needs were used to guide an extensive literature review to summarise the best available evidence on ACL injury management options, including outcomes, costs and benefits/risks of each management approach. 

The design of the decision aid was also informed by the findings from the interviews, alongside evidence-based recommendations for decision aid presentation, and the text was redrafted to be at or under a grade 8 level. 

We are piloting the decision aid with a group of patients and healthcare professionals who work with people with ACL injury and the tool will be adapted in response to feedback. 

What information should you give to patients with ACL injury?

Informed decision-making can only occur if accurate, evidence-based information about treatment options is provided to patients. 

Patients with an ACL injury need to be informed about different ACL treatment options and to have an understanding of likely outcomes and the pros and cons of each. When considered alongside their priorities and goals for treatment and with the support of a healthcare provider, this can help them make an informed decision. The ACL decision aid, freely available at aclinjurytreatment.com, is designed to lead people with an ACL injury through surgical and non-surgical treatment options and the pros and cons of each, in a step-by-step format. 

Step 1: get started 

To get people started, we provide background information about the decision aid, how it was developed and who it is designed for. 

This step of the website is also interactive, with five questions that users can answer to reflect on where they are currently at with their treatment decision. 

The questions are optional and cover whether they are currently leaning towards surgery or rehabilitation without surgery and how sure and supported they feel in that decision. 

These same questions are also asked at the end of the decision aid, allowing users to reflect on any changes in their decision. 

Step 2: learn about treatment options

In this step, the treatment options for ACL injury are laid out. 

The website describes what is involved in both surgery and rehabilitation without surgery, with expected timelines and goals. 

Importantly, different pathways through the options are explored. 

Patients should understand that they could experience a satisfactory or dissatisfactory outcome with either treatment option and that rehabilitation can be attempted as a first-line treatment.

If the patient does not achieve functional stability and is not satisfied with their knee function despite trying rehabilitation, then ACL surgery is likely to be a good option. 

Performing prehabilitation for one to six months before surgery has been shown to improve knee strength and function after
ACL reconstruction (Alshewaier et al 2017, Carter et al 2020, Giesche et al 2020).

Step 3: learn how outcomes compare

In step 3, the evidence on treatment outcomes is summarised, including where outcomes are likely to be similar or different between treatment options. 

Patients should be aware that multiple systematic reviews and clinical trials have found similar long-term patient-reported outcomes after surgery compared with rehabilitation without surgery for the management of acute ACL injury. 

This includes physical activity levels, return to sport rates, knee pain and symptoms, and quality of life (Alshewaier et al 2017, Carter et al 2020, Giesche et al 2020). 

A few outcomes do differ depending on treatment choice and the research evidence on these differences is laid out in this section. 

For example, there is systematic review evidence that people who are managed with ACL surgery have reduced knee proprioception and higher rates of radiographic knee osteoarthritis when compared to people managed with rehabilitation alone (Harris et al 2017, Lien- Iversen et al 2020, Webster et al 2021). 

On the other hand, rehabilitation alone can result in greater laxity of the knee seen in clinician testing compared to ACL surgery, although passive knee laxity is poorly correlated with functional knee stability (Smith et al 2014). 

This step in the website also contains information about the chance of ACL healing, the possibility of surgical graft rupture and the evidence on return to sport, the risk of further knee injury, strength and function, psychological impacts and the likelihood of developing knee osteoarthritis. 

Step 4: weigh up the pros and cons 

It’s important that people with an ACL injury are able to weigh up the risks and benefits of each treatment option so they can make an informed choice based on what is important to them. 

In this step, we list the pros and cons of both options side by side. 

For example, under ‘length of recovery’, we explain that the typical length of rehab after ACL surgery is 12–18 months. 

Rehab without surgery may take around 12 months and may therefore be faster than surgery. 

However, if patients decide to have surgery after trying rehab, this will delay their total recovery because they will now face 12 months or more of postoperative rehab. 

We make it clear that irrespective of treatment strategy, some people may take longer to recover or may never fully recover. Pros and cons are presented for each treatment option in relation to 12 key considerations. 

These include treatment cost, knee stability, convenience, muscle strength and function, further knee injury, return to sport, knee osteoarthritis and satisfaction with knee function. 

Step 5: arrive at a treatment decision

The final step of the decision aid allows users to reflect on what is important to them in their treatment choice. 

Users can rate the importance of each treatment outcome and consider the pros and cons in relation to what matters most to them. 

They are also asked the questions from the beginning of the decision aid about their treatment preference and how sure and supported they feel in that decision. 

This opportunity to clarify their values is included because evidence suggests it can improve preparation for decision-making and reduce long-term decision regret (Feldman-Stewart et al 2012). 

At the end of these questions, users can choose to print out a copy of their answers, giving them something to show and discuss with their physiotherapist and other healthcare providers. 

They can also save the entire decision aid content as a PDF and print this out for future reference. How can you use the decision aid in your clinical practice? 

The decision aid is designed to be used collaboratively between patients and their healthcare providers to facilitate shared decision-making. 

You may use this resource to provide patients with an overview of the existing evidence, prior to discussion of treatment options. 

By using the decision aid, patients should have had time to consider which outcomes and aspects of treatment matter most to them, which can be used to direct discussions about treatment options. 

The website will be updated regularly as new evidence becomes available. 

The research team is also planning a randomised controlled trial to evaluate the effectiveness of the decision aid in promoting evidence-based practice. 

Click here for references. 

To access the online ACL injury treatment decision aid, visit aclinjurytreatment.com

Associate Professor Stephanie Filbay APAM is a physiotherapist and principal research fellow in the Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, University of Melbourne. Stephanie has had three ACL injuries, giving her a personal insight into ACL injury management from a patient’s perspective. 

Bridget Graham APAM is a physiotherapy research assistant in the Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, University of Melbourne.