Tearing up myths about ACL surgery

 

Kieran Richardson will discuss the non-surgical management of anterior cruciate ligament (ACL) tears when he presents a course in South Australia early next year.

What motivated you to research into the area of non-surgical management for ACL tears?

Having worked in the hospital sector, then moving into an extensive career in private practice, I have long seen the outcomes after elective surgeries such as ACL reconstruction. My interest in ACL tears was really piqued after managing two very distinctively contrasting cases almost simultaneously during my musculoskeletal specialisation training. The first was a young female patient who presented on a four-wheeled walker, in distress and in agony, about four years after her original ACL tear, having undergone five surgeries at that point.

A patient of similar demographics requested my opinion four days after a non-contact mechanism playing sports, without having yet undertaken high-powered imaging. She was adamant that no matter what the scan showed, she was opting for non-surgical management due to friends having poor outcomes from knee surgery—an MRI later confirmed a full thickness ACL tear. We outlined a plan for management, she completed her prescribed home exercise program and returned to field hockey in four months—and has remained symptom-free. This then launched me on an investigative journey into the available scientific data, as well as interviewing world-expert physiotherapist and surgeon researchers in the field.

Why are patients likely always offered surgical care for an ACL tear?

For me, three critical drivers of these trends are beliefs around the ligament itself, current healthcare models and mainstream media. Our understanding of ACL tears has shifted from ‘what does the ACL do as a ligament?’ to ‘what do the best-designed studies show that compare the two groups of attempting to reconstruct the ligament and receiving rehabilitation, versus undertaking physiotherapy and exercise alone?’ We used to think that ACL reconstructive surgery prevented osteoarthritis after an injury; we now have evidence the technique may be increasing the risk (Nordenvall et al 2014, Culvenor et al 2019, Bowes et al 2019). Studies now show that, if left, ACL can heal, and has a high intrinsic healing capacity (Ihara et al 1994, Fujimoto et al 2002, Costa-Paz et al 2012, Ihara & Kawano 2017)

In Australia at least, where we have the highest rates of reconstruction in the world, our public and private healthcare models are set up to speed-up and fund early MRI, surgical opinion and surgery. Physiotherapy and exercise as ‘treatment and management’ of ACL tears is not routinely advertised, funded or recommended through government systems or private insurance companies, so both clinicians and patients are unaware of the quality of the research for the intervention they may receive.

There is a pervading view in mass media of alarmism and devastation when a player injures their knee, with commentators often ‘fearing’ the worst. The emotion follows as the assumption is the athlete has injured their ACL and will require surgery and need nine to 12 months off their sport. This false narrative needs to be replaced with a rational explanation of the most substantive data, and educate players (and the general population) that many can function at the elite level without the need for invasive surgery.

What can participants expect to take away from the course?

Participants will gain a thorough knowledge of the best comparative literature between surgery and exercise therapy for ACL tears, the risks and benefits of either approach and how to carry out a comprehensive management plan for an ACL-injured patient to return to high-level activity—without surgery.

References

ACL tears: non-surgical management course will be held on 8 February 2020 in Kent Town, South Australia. Register at australian.physio/pd.

Kieran Richardson is a Specialist Musculoskeletal Physiotherapist (as awarded by the Australian College of Physiotherapists in 2016) and is the director of Global Specialist Physiotherapy, a consultancy service that provides formal mentoring, latest evidence professional development and second opinions for complex patient presentations to a number of private practices in Australia. He also provides online ACL non-surgical management courses for physiotherapists.
 

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