Norimasa Nakamura, Stefano Zaffagnini, Robert G. Marx and Volker Musahl (eds.)Controversies in the Technical Aspects of ACL Reconstructionhttps://doi.org/10.1007/978-3-662-52742-9_45

45. Nonoperative Management of ACL Rupture

Lynn Snyder-Mackler¹, Amelia Arundale¹, Mathew Failla¹, Elizabeth Wellsandt¹, Hege Grindem², Margherita Ricci³, Stefano Della Villa³ and May Arna Risberg²

(1)

Department of Physical Therapy and Graduate Program in Biomechanics and Movement Science, University of Delaware, Newark, DE, USA

(2)

Musculoskeletal and Sport Medicine Clinic, NIMI and the Norwegian Research Center for Active Rehabilitation, Oslo, Norway

(3)

The Isokinetic Medical Group, Bologna, Italy

Lynn Snyder-Mackler

Email: smack@udel.edu

45.1 Introduction

Anterior cruciate ligament (ACL) reconstruction is common after ACL injury, particularly in young, active individuals [39]. Anterior cruciate ligament (ACL) reconstruction is generally considered standard of practice in the United States for young, active individuals early after ACL injuries generally early after injury [4, 9, 11, 12, 21, 40]. In many other developed countries, active individuals are also counseled to have ACLR before returning to jumping, pivoting, or cutting sports. Athletes are also often informed that ACL reconstruction will decrease static knee joint laxity, minimize further damage to the menisci and articular cartilage, and facilitate their return to preinjury level of sport. While it is clear that knee joint laxity is reduced by ACLR, a differential outcome between those who are managed operatively and nonoperatively is not supported [55]. In the last decade, national and international ACL reconstruction registries and cohorts as well as better tracking overall have resulted in a plethora of information about actual return to play and reinjury numbers after ACL rupture and reconstruction [17, 33, 45, 53, 54, 57]. In addition, there is evidence that athletes are able to return to high-level sports participation without ACL reconstruction and with no difference in clinical, functional, and radiographic outcomes compared to athletes after ACL reconstruction [13, 24–27, 32, 42, 47, 56]. This chapter will discuss the controversies and provide current treatment recommendations for athletes with acute ACL rupture.

45.2 Defining the Problem: Outcomes of ACLR

Consensus among sports orthopedic surgeons and rehabilitation professionals in North America and Europe is that successful outcome after ACL injury and reconstruction is return to sports at the same level and no reinjury [38]. Does this happen? In surveys and reports from their own caseloads in the 1990s and early 2000s, return to sports rates were claimed to be high and reinjury rates low. All of this changed in the mid-2000s with the advent of national and multinational joint registries (notably the Scandinavian knee ligament registries) and the beginning of several multisite cohorts (e.g., Multicenter Orthopedic Outcomes Network (MOON)) in the United States and several in Australia [17, 33, 45, 53, 54, 57].

What are the outcomes of ACLR? Not all or even most athletes return to play. In the MOON cohort, 63 % of college and 69 % of high school American football players returned to play football [41]. Forty-three percent of the players were able to return to play at the same self-described performance level. Approximately 27 % felt they did not perform at a level attained before their ACL rupture, and 30 % were unable to return to play at all [41]. Seventy-two percent of soccer players in the MOON cohort returned [10]. Ardern et al. in a 2011 meta-analysis reported 63 % return to preinjury level of sports, with only 44 % to competitive sports, and more recently reported only 55 % return [5, 6]. Shah reported on a 10-year cohort where 61 % (31/49 players) returned to the NFL a mean of 11 months after surgery [52], and 86.1 % returned to play in the NBA after ACL reconstruction in another case series, although playing time, games played, player efficiency ratings, and career lengths were significantly and negatively impacted by the injury/surgery [30]. This reality needs to be contrasted with patient expectations. Feucht et al. studied patient perceptions and found that 94 % of primary ACLR and 84 % of revision ACLR expect to return to the same level of activity with no or only slight restrictions [19]. Clearly, the actual data about outcomes are not getting to the patients.

What about reinjury? A very recent meta-analysis concluded that athletes younger than 18 years who return to sport have a secondary ACL injury rate of 23 % [63]. Both younger age and return to high-level sports activity are independent risk factors for a second ACL injury [61]. These injuries generally occur early in the return-to-play period. The high rate of secondary injury in young athletes who return to sport after ACLR equates to a 30–40 times greater risk of an ACL injury compared with uninjured adolescents [63]. These numbers are not isolated and are remarkably similar around the world. Reinjury rates for soccer in the MOON cohort are 20 % in women, 20–30 % in young athletes in the Hewett prevention cohort, and 17 % in the Shelbourne cohort in those college age and younger [49, 53, 64]. For the Pinczewski cohort in those aged 18 and younger, a further ACL injury occurred in one of three patients over 15 years within the first 5 years after index surgery [8, 45]. A family history of ACL rupture significantly increases the risk for ACL graft ruptures [45]. In addition, osteoarthritis risk is 45–70 % 15 years after ACLR, higher in those who returned to strenuous sports, yet here too, 98 % of patients believe they have no or only slight increased risk of OA [19, 47]. So a significant percentage of athletes do not return to play at the preinjury level after ACLR, and those who do have a high risk of second ACL injury and osteoarthritis development.

45.3 Outcomes of Nonoperative Management

The biggest concern for surgeons is that patients will burn bridges by delaying ACLR. Does surgical delay help, hurt, or make no difference? The existing registries cannot currently shed light on this question. Patients who do not receive surgical treatment for their ACL injury are not included in the registries. Thus, no data on the outcome of nonoperatively treated ACL injuries can be obtained via these registries. Frobell and colleagues’ RCT of delayed or no reconstruction versus immediate reconstruction in athletes at 5 years shows that there is no difference in any outcome between those who were operated on straightaway, those who were operated on later, and those who did not have an operation at all [24, 25]. Eitzen et al. and the Delaware-Oslo ACL Cohort demonstrated that a 5-week progressive exercise therapy program in the early stage after ACL injury led to significantly improved knee function before the decision making for reconstructive surgery or further nonoperative management [16, 44]. The compliance to and tolerance for the program was high, with few adverse events.

Quadriceps weakness persists after ACL injury and/or reconstructions and is a strong predictor of outcome [14, 35, 36, 48]. Two methodologically strong studies found no differences in quadriceps strength between operatively and nonoperatively managed patients 2–5 years after ACL injury [2, 3, 18]. Grindem et al. reported at 2-year follow-up that 33 % of athletes who underwent reconstruction had strength deficits greater than 10 % compared to 23 % of athletes managed nonoperatively [25]. ACLR, therefore, is not a prerequisite for restoring muscle function.

Grindem et al. compared IKDC scores between athletes managed nonoperatively or with reconstruction at baseline and 2 years later. There were no significant differences between groups at baseline or at 2-year follow-up [26]. Using the Knee Injury and Osteoarthritis Outcome Score (KOOS), Frobell et al. compared patient-reported outcomes at 5 years after ACL injury and found no significant differences in change score from baseline to 5 years in those managed with early reconstruction versus those managed nonoperatively or with delayed reconstruction [25]. Outcomes after ACL injury, whether managed nonoperatively or with ACLR, have similar patient-reported outcome scores [32, 34]. Similar findings are reported for functional performance measures such as hop tests [15, 43].

45.3.1 Return to Sports

Despite common misconceptions, nonoperatively managed athletes can return to sport without the need for reconstruction. Fitzgerald et al. reported a decision-making schema for returning ACL-deficient athletes to sport to complete a competitive season, without further of meniscal or articular cartilage injury. Grindem et al. compared return to sport in operatively and nonoperatively managed athletes after ACL injury. They found no significant differences between groups in level I sports participation and higher level II sports participation in the nonoperative group in the first year after injury [27]. Case reports and reports in the lay press are rampant [62, 65]. Regardless, therefore, of the evidence, high-level athletes can and do return to full activity without ACLR, at least temporarily [23, 28, 62, 65].

In the only study in which the reduction in sport participation can be related to a control group, Roos et al. reported on elite soccer players 3–7 years after the ACL injury [51]. They foundthat only 30 % were still active in soccer 3 years after injury compared with 80 % in an uninjured control population. In addition, they showed that, after 7 years, none of the injured elite players were active regardless of the type of treatment [51]. Recent data from US professional athletes after ACLR show a profound effect on career longevity [30, 53]. Regardless of treatment, therefore, previously injured athletes retire at a higher rate than athletes without ACL injuries.

45.3.2 Subsequent Surgery/Reinjury

Sixty-one (51 %) knees, 29 treated with early anterior cruciate ligament reconstruction and 32 treated with initial rehabilitation with the option of a later reconstruction, had meniscus surgery over the 5-year follow-up period of the Frobell study [25]. When they accounted for repeated surgery on the same meniscus, there was a lower frequency of meniscus surgery procedures in patients treated with rehabilitation plus early anterior cruciate ligament reconstruction compared with those treated with initial rehabilitation with the option of having a later reconstruction [25]. Of 59 assigned to rehabilitation plus optional delayed ACL reconstruction, 23 underwent delayed ACL reconstruction; the other 36 underwent rehabilitation alone [24, 25]. Grindem et al. reported their ACLR-treated patients were significantly younger, more likely to participate in level I sports and less likely to participate in level II sports prior to injury than the nonoperatively treated patients [26]. Patients managed with ACLR were more likely to sustain a knee reinjury and to participate in level I sports in the second year of the follow-up period. After 2 years, 20 % had experienced knee reinjury. Overall, the incidence of late reconstruction in the nonoperative group was low [26].

45.3.3 Osteoarthritis

A recent systematic review compared operatively and nonoperatively treated patients at a mean of 14 years after ACL injury and found no significant differences between groups in radiographic osteoarthritis [7]. In the Frobell study, at 5 years, there was no difference in the radiographic development of tibiofemoral osteoarthritis treated with reconstruction, done early or as delayed procedures, and those knees that were treated with rehabilitation alone [25]. Fink found return to sports moderated OA development after ACL injuries managed operatively or nonoperatively. Return to sports may be the most important variable [20]. The prevalence of OA does not seem to depend on whether an ACL reconstruction was performed or not. von Porat et al. reported 78 % OA prevalence in both groups after 14 years, Fink et al. reported 78 %–83 % after 10–13 years, and Neuman et al. in a prospective cohort and Oiestad in her systematic review and Tsoukas and colleagues report overall rates that are similar regardless of management strategy [20, 46, 47, 59, 60]. Thus, there is no evidence to suggest that ligament reconstruction prevents future OA [29, 42].

45.4 Clinical Recommendations

45.4.1 Rehab in the Acute Phase

After acute ACL rupture, early treatment should aggressively resolve all impairments. Treatments to decrease effusion like cold, compression, elevation, and especially active motion are supported. Treatments to restore/preserve passive and active knee extension such as stretching and patellar mobilization are critical to outcome long term [1, 37]. Rehabilitation to increase/maintain quadriceps strength must include progressive resisted exercise in a structured program [1, 37, 58]. Neuromuscular electrical stimulation at high intensity also has strong evidence for effectiveness after ACL rupture [1, 37]. Rehabilitation to restore normal movement patterns/gait should be a component of all early rehab programs. Criteria for completion of the impairment resolution phase that should be achieved are minimal joint effusion, full range of motion, quadriceps contraction including SLR without a lag, and walking without a limp [1].

Just achieving a quiet knee, however, is not sufficient prior to surgery. Virtually across all studies, poor physical performance and residual impairments at the end of rehabilitation predicted worse patient-reported outcomes at 2–5 years regardless of whether patients are managed operatively or nonoperatively [18]. Short-term progressive exercise therapy programs should be incorporated in the early stage after ACL injury, to optimize knee function as a first step in the preparation to return to previous activity (or not) with (or without) surgery [16].

The evidence suggests that a 5-week period of progressive rehabilitation including neuromuscular training as described by Eitzen (which has previously been described in detail, including an appendix presenting the specific exercises, progression, and exercise dosage) results in better outcome [16]. The rehabilitation program consisted of heavy resistance strength training, plyometrics, and neuromuscular exercises and is initiated as soon after injury as impairments are resolved.

Return to activity should also follow a criterion-based progression. All active patients returning to sports after ACL injury, except skiers, should perform a running progression (Table 35.1). The running progression begins as a two-mile (3.2 km) activity with alternating jogging and walking. The ratio of run to walk distance is gradually increased and eventually increases to the patient’s preferred total mileage [1].

The rehabilitation specialist should incorporate agility drills; sport-specific activities, such as changing directions, accelerating, and decelerating; and plyometrics to train skills in a rehabilitation program that will transfer to return to competitive play [28]. All patients should pass strenuous return to activity sport (RTS) like those presented in Table 35.2. Once cleared, patients should not directly return to competition. Athletes begin with lower-level sports participation in practice following recommendations of Fitzgerald et al. and gradually build up back to competition with monitoring of pain, effusion, and ROM [22]. We recommend a systematic approach for return to sport participation that accounts for a patient’s level of pain and apprehension. Attention to factors such as confidence and motivation for return to sports also needs to be considered [50]. Late rehabilitation should also incorporate exercise and postures for secondary prevention.

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