Are you a coper?

ACL Surgery vs. Conservative Management

ACL rupture is perhaps the most notorious injury in the sporting world. It is one of the most commonly studied injuries in orthopaedic research. We have covered ACL injury, management and the stages involved in return to sports in our previous two blogs. However, today will be more about whether ACL reconstruction is right for you. So, are you a coper? Let’s find out!

ACL Reconstruction (Surgery)

The main objective of ACL reconstruction is to address the anterior-posterior and rotational joint instability of the knee joint and prevent further degradation in the long-term. The majority of ACL deficient athletes go through reconstruction with options ranging from hamstring tendon graft to the quadriceps or patellar tendon (figure 2). However, the recurrence rate for ACL remains high within the first 24-month post-operative period despite the wide-use of reconstruction.

Risk factors associated with ACL recurrence

• Type of sports pre-injury i.e. physical, contact, non-contact but with pivoting/ start and stop motion

• Midsubstance ruptures

• Integrity of ACL bundle

In addition, ACL reconstruction can be costly and time consuming with rehabilitation up to 9-12 months before return to play. Purely restoring the joint mechanic does not guarantee competency of return to sports either. Reportedly, approximately up to 82% of athletes with ACL reconstruction returned to sports after rehabilitation, 63% returned to pre-injury level of performance and only 44% had returned to the competitive scene. Moreover, the evidence suggests that the chance of developing osteoarthritis 14 years post-ACL reconstruction remains a potential risk.

Are you returning to pivoting or cutting sports?

This is probably the most asked question to our fellow ACL deficient athletes. Sports such as basketball, football, soccer and netball are identified as pivoting and cutting activities which challenge the limit of your knee stability. These activities may not be suitable for people who chose not to go for surgical approach. Straight-line sports such as running/ jogging or cycling may be more suitable for this population.

In addition to considering whether to go for surgery, there are a few criterias that can be used to screen if you are a potential candidate or ‘coper’ for conservative management.

1. Isolated ACL injury with normal knee range of motion

   1. Complex injuries can often involve other structural deficiency such as medial meniscus and/or medial collateral ligament

   2. Chondral deficiency often presents with latent swelling the next day and reduced knee range of motion

2. >80% limb symmetry on all hopping tests

   1. Hop tests include: single leg hop for distance, triple hop, triple crossover hop and 6m timed hop test

3. >80% on the Knee Outcome Survey - Activity of Daily Living Scale (KOS-ADLS)

   1. Refer to figure 3 for example

4. >60 on the self-report of global knee function

   1. Asks participants to rate their current knee on a scale from 0 to 100, with 0 being inability to perform any activity and 100 being the level of knee function prior to injury, including sports

5. No episode of self-reported knee giving way

6. Dedication to rehab with a physiotherapist for at least 3 months.

If you fail to meet all the above-mentioned criteria, you are considered to be a non-coper for conservative management and surgery is generally recommended.

Timing of Surgery

There are many factors to consider when deciding whether you opt for surgery.

• Preoperative status of the knee

• Obligation to the club or school

• Timing during the season

• Mental preparedness

Although there is no supporting evidence suggesting difference in outcome of when to opt for surgery, however, late surgery of more than 5-months has been associated with more complications. This is mainly due to the instability of the knee predisposing the athletes to other new soft-tissue related injuries commonly involving the medial knee compartment such as the meniscus or cartilage.

Choosing whether to go for ACL surgery can be a big decision. We have summarised key factors to consider for ACL deficient athletes.

Copers

• Should be able to return to pivot and cutting sports through conservative means

Non-copers

• Likely need surgical intervention to return to pivot and cutting sports

• If adamant to avoid surgery, may need to modify activity to straight-line sports

The above information is supposed to be informative and acts as a guideline. We still recommend you seek professional advice through your physiotherapist or specialist to help you make this decision. So, are you a coper?