Exploring ACL Injury Management: Beyond the Default to Surgery

If you’ve just suffered an ACL injury you’re likely facing a whirlwind of decisions about your recovery. Traditionally, many people assume surgery via ACL reconstruction is the only path forward, especially if you’re active or involved in sports. But emerging evidence suggests that this may not always be the best option depending on individual factors.

This blog explores non-surgical management first, including physical rehabilitation alone and its long-term outcomes, before discussing surgery. We will also introduce an innovative non-surgical method called the Cross Bracing Protocol as a potential viable alternative for suitable candidates to heal the ACL without the need for surgery. This is for informational purposes only and we recommend a full consultation for more personalised advice.

An easy to digest flow chart to your road to recovery.

Non-surgical ACL Management: Physical Rehabilitation Alone 

Non-surgical Physical Rehab

Non-surgical treatment focuses on structured physiotherapy to build strength, neuromuscular control and knee stability without operating. This approach avoids surgical risks and can behighly effective for individuals who choose not to participate in pivot shift sports such as Soccer, Basketball, Football, Tennis or Skiing.

Long-term Outcomes

Research tracking patients over decades shows promising results for non-operative patients more than 30 years after initial non-surgical treatment for ACL injuries and found acceptable knee function with a relatively low prevalence of symptomatic osteoarthritis despite high radiographic osteoarthritis.

Similarly, a 20-year follow-up study comparing operative to non-operative treatments reported no significant difference in knee Osteoarthritis rates between the two groups.

For those not returning to Pivoting sports

If you don’t plan to resume high-demand activities that include pivoting, changing direction quickly, cutting or twisting – Non-surgical management is often more suitable. In these cases, long-term results are similar to surgery, including knee function and OA rates but with fewer risks and complications that are accompanied with surgical intervention.

For low-demand lifestyles such as walking, cycling, swimming or regular daily activities of living, non-op physiotherapist guided rehabilitation can restore sufficient stability and function without the invasiveness of surgery with risks like infection (1%), graft failure (up to 25%) and other surgical complications avoided.

PROS TONO SURGERY ON ACL INJURY

• Cheaper
• Similar long-term outcomes to surgical route when not returning to high-level sport
• Avoid all surgical risks
• No graft harvest site pain or weakness

CONS TO NO SURGERY ON ACL INJURY

• Risk of knee instability & Secondary damage
• A portion of people choose surgery due to giving way episodes
• Difficult / less likely to return to high-level sport

ACL reconstruction: The Surgical route

SURGERY FOR ACL EXPLAINED

Going the surgical route is recommended for individuals looking to get back into high-functioning sports, the surgical graft offers better structural support for the knee given the internal ligament will act as it is physiologically intended to stop anterior translation of the Tibia in relation to the femur bone. This will mean people wanting to participate in shifting sports will avoid feelings of “giving way”, osteochondral injuries of the joint and bone surface or onset of OA associated with playing sports on a knee with poor stability.

Surgery may offer a faster return to function than non-operative management alone, which requires time to trial rehab and assess failure before switching, potentially extending overall recovery. Ultimately, the decision hinges on your risk tolerance, post-recovery physical demands, and other personal factors; discuss with your healthcare provider.

PROS of ACL surgery

• More reliable knee stability for high-demand sports
• Potentially shorter total time off than non-op if conservative management fails
• Lower chance of “giving-way” episodes.

CONS of ACL surgery

• Surgical risks: Infection, graft re-rupture, stiffness
• Graft harvest site issues
• No proven superiority in knee health at 10-20+ years at preventing arthitis.

Cross-bracing method for ACL recovery

What is the Cross-bracing Method?

The cross-bracing method is a new method of ACL recovery that involves fixing the knee in a flexed position, reducing the distance between the two ends of the torn ligament which increases the likelihood of the ligament healing on it’s own.

The severity of the injury often correlates with how much force the knee underwent at the time of injury. Larger force amplitudes have a proportionate disruption of the ACL anatomy inside the knee joint.

Bracing may facilitate healing in some cases, this depends highly on patient factors such as time to bracing, adherence to the bracing protocol, co-morbidities, medications, and lifestyle factors like smoking/vaping. The likelihood of success also comes down to MRI imaging factors such as the disruption of anatomy and other potential knee injuries that were sustained in the incident.

PROS of the Cross-bracing Method

• Supports potential restoration of ‘Normal’ Anatomy of the native ACL
• Lowers financial costs
• Avoids Graft morbidities
• Safer for Paediatric patients
• Preserves option for future surgery if required

CONS of the Cross-bracing Method

• Inconvenience of bracing
• Non-weight-bearing period
• Leg blood clotting risk from prolonged inactivity
• Risk of non-union healing which delays recovery
• Muscle atrophy and joint stiffness from prolonged bracing
• Limited long-term data

What’s best for you with your ACL recovery?

To assist with understanding your options, it is best to speak with your treating doctor or physio. A resource to help with accessing more information about treatment options, pros, cons and what the experts say, we direct you to this website that lays it all out in an easy to understand way so you are better equipped for conversations about how to best treat your knee.