Shifting the ACL narrative
What happens when the best evidence challenges deeply engrained beliefs, opinions, trends and systems? Kieran Richardson discusses why wholesale changes are needed to current views on ACL tears.
The 2016 editorial by Handoll for Cochrane, critiquing interventions for treating anterior cruciate ligament (ACL) injuries, put it incredibly mildly—‘not quite what was planned’—when the systematic review by Monk et al 2016 found just one high- level trial comparing ACL reconstruction plus rehabilitation versus rehabilitation alone (it showed no difference between the treatment groups in patient-reported outcomes of knee function). Many of the current justiﬁcations for early ACL reconstruction (ACLR) are based on conceptual theory, anecdote, cultural trend, or studies of poor methodological quality, not the highest quality scientiﬁc data.
This produces an overwhelming cognitive dissonance in clinicians and patients alike, as most, if not all of us, assumed surgery to be the most advantageous care. Zandro and colleagues wrote a paper this year in the context of the Choosing Wisely campaign, arguing that there is emerging evidence of the overuse of health services for sport and exercise-related injuries with ‘surgical procedures providing similar outcomes to those of non-operative management, with ACLR yet to be evaluated against a placebo.’ It is clear now that we have all probably maximised or focused on the beneﬁts of ACL surgical procedures, and minimised or ignored the harms and risks.
Evidence of absence of evidence
To say we’ve been completely inundated in an ‘ACLR as best-practice’ narrative is a gross understatement. ACLRs have been promulgated as, and believed to be, the gold standard of care, with essentially all of the funding, research and emphasis being heavily directed towards surgery and graft types, with little or no thought for physiotherapy and exercise as standalone treatment or management. A 2017 review by Kay et al found that only one of 412 ACL randomised controlled trials actually compared ACLR with structured rehabilitation for acute ACL injury.
Billions of dollars are spent worldwide through these industries; it’s not just a problem isolated to Australia—where we now have the highest rates in the world, with the fastest growing rates in those under 18, where we have no level 1 data available. Last year it was revealed that, remarkably, kangaroo tendon is now being investigated as a legitimate consideration for human patients post a full-thickness tear (Gaffney 2018), emphasising how consumed as a society we are to ﬁnding a surgical ‘quick ﬁx’ for the ACL injury problem.
Currently, all of the private and public healthcare systems in Australia are set up to hasten patients for early surgical opinion and surgery, having being almost inadvertently cornered into a single decision. Given the lack of high-grade research literature to continue a one-size- ﬁts-all approach of ACLR to every young, active individual wanting to return to twisting sports, clearly we need to start being sceptical as to why we’re performing so many, and to fast-track and offer evidence- based, scientiﬁc non-surgical ways to solve this problem.
The Australian healthcare system needs to be prepared for a paradigm shift. There is now a realisation that we have been saturated with an ‘ACL reconstruction as best practice’ meta-narrative that is simply not supported by the top scientiﬁc material, carries many iatrogenic harms, is incredibly costly and is unsustainable. Physiotherapy needs to be presented as a sophisticated, optimum ﬁrst treatment and management to patients who sustain an ACL injury; this is in fact current world best practice (Rooney 2018). This information needs to be communicated via readily accessible, high-quality and understandable resources at a macro-level, to the general public, professional bodies and the media, and at a micro-level to clinicians and patients alike.
Some of the most positive elements of the physiotherapy profession—compassion for people, commitment to evidence-based practice and powerful communication to empower patient self-management—can all be utilised as we seek to rectify our healthcare models. All patients presenting to primary care with an ACL tear need to have their beliefs, expectations, preferences and goals deliberately elucidated at the initial session, so the most contemporary evidence can be communicated and a shared decision-making process can occur.
We need to redirect funding towards this effort, create resources and policies that support a physiotherapy-led approach, and empower physiotherapists to carry out the necessary change. It is our duty of care to provide patients with empirical evidence in order to make sound decisions about injury management and future activity participation. Given ‘there are no evidence-based arguments to recommend a systematic surgical reconstruction to any patient who tears his ACL’ (Delincé & Ghaﬁl 2013), it’s time for us to shift our thinking, healthcare systems and practice when it comes to the management of these injuries.
Kieran Richardson is a Specialist Musculoskeletal Physiotherapist (as awarded by the Australian College of Physiotherapists in 2016). Look out for Kieran’s ACL course in early 2020.
Handoll, H. H. (2016). "Not quite what was planned: accommodating the reality of clinical practice in Cochrane Reviews[editorial]." Cochrane Database of Systematic Reviews 4.
Monk AP, D. L., Hopewell S, Harris K, Beard DJ, Price AJ. (2016). "Surgical versus conservative interventions for treating anterior cruciate ligament injuries." Cochrane Database of Systematic Reviews(4).
Zadro, J. R., et al. (2019). "Choosing Wisely after a sport and exercise-related injury." Best Practice & Research Clinical Rheumatology.
Kay, J., et al. (2017). "A Historical Analysis of Randomized Controlled Trials in Anterior Cruciate Ligament Surgery." JBJS 99(24): 2062-2068.
Gaffney, D. (2018). "Can Skippy disrupt the sports injury repair market? ." from https://sydney.edu.au/news-opinion/news/2018/08/14/can-skippy-disrupt-th....
Rooney, J. (2018). "Investigation of Contemporary Conservative Management Programs for Anterior Cruciate Ligament Knee Injuries." The Winston Churchill Memorial Trust of Australia.
Delincé, P. and D. Ghafil (2013). "Anterior cruciate ligament tears: conservative or surgical treatment?" Knee Surgery, Sports Traumatology, Arthroscopy 21(7): 1706-1707.
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