ACL tears are a common injury in the more active subgroup of society. Management of ACL injuries usually consists of early surgery, with a following prescription of physical therapy. But is this how it is supposed to be? Does this actually provide the best outcome?

In this blog, we’ll dive deeper into the most recent evidence on the non-surgical management of ACL tears, the concept of ACL healing, and the importance of shared-decision making. 

ACL reconstruction rates are very high in most western countries. But one small part of the western world stands out because of their high rate of non-surgical management. Scandinavian health-care models require patients to go to a non-surgical orthopedic specialist first. After a thorough examination, the majority of the patients undergo the “physio first”-route, which leads to fewer surgeries.

The physio first approach

The concept of physio first isn’t something that’s new to this world. In 1994, Daniel and colleagues already proved that there are a lot of patients that do well without surgery. In the 1980’s, prospective studies showed that some patients actually do need surgery while some can cope very well without. That leaves the following question: can we identify who becomes a coper?

It turns out we can, but only if enough time goes by. If you give patients long enough, about 6-12 months, the majority can become copers. However, we cannot predict early on who’s going to do well. Luckily, there are some objective markers that can be used to identify copers. Patients with less than one episode of giving way, who score >80% on a 6m timed hop test, >80% on the KOS ADL subscale and have a >60% global rating of knee function tend to do well in the long run.

Surgery vs conservative care

One of the most high-quality and elaborate studies on ACL management, the KANON trial, compared outcomes between individuals that received early surgery, followed by physical therapy, to people who received supervised exercise therapy first, with the option of having a delayed reconstruction if necessary. They concluded that the first option was not superior to the latter and even described poorer outcomes in the group that had early surgery. However, they did notice a lot of participants crossed from rehab to surgery because of beliefs.

Nowadays, there still is a strong bias towards early surgery, as people think it is necessary in order to go back to normal training and to obtain a better outcome. This shows how important mindset and psychology is to secure a good outcome and highlights the value of education during rehab. One thing remains sure, both surgical and non-surgical management come with risks and neither gives a ‘one way ticket’ back to sport, but considering the lack of any evidence that surgery is better, giving physio a chance and seeing who copes along the way is definitely worth a shot.

What about the risk of developing osteoarthritis, you might ask? It turns out, there’s actually no difference between conservative and operative subgroups, so this shouldn’t count as an excuse for early surgery.