5 things to know after an ACL injury/ before an ACL reconstruction

Is surgery needed?

Sometimes. 

The research shows that after an ACL injury, people fall into 3 categories:

1)        “Copers” – these people regain their stability after the injury. Through healing, scarring or anatomy, they are left with a stable knee once the dust settles

2)        Non-copers – these people have disproportionate instability and suffer from giving way episodes from very early and, at 12 weeks, are still showing signs of instability 

3)        Potential copers – these people have instability to start with, but following rehabilitation and healing, they regain stability in their knees

Everyone responds differently, and it’s important to understand which group you belong to in order to make the best decision.

It takes around 10 weeks of hard work to understand whether someone is a coper or a non-coper (and it has nothing to do with your personality). 

The research shows that copers can return to their everyday pre-injury activity levels (or get very close) with good rehabilitation but no surgery.  Copers may opt for surgery if they foresee returning to a high-pivoting sport (see below)

Non-copers will often need surgery followed by rehabilitation to return to their everyday pre-injury lives. Individuals cannot live a safe and healthy life if their knee repeatedly gives way during normal daily activities like walking, climbing stairs, or turning.

For potential copers, a more flexible approach is taken. Discussions can be had at multiple time points to monitor rehab progress, physical safety, quality of life, physical activity aspirations.

Reminder: Circumstances sometimes change, particularly for potential copers; therefore, decisions can be changed if they no longer suit you.

Is there an optimal time to have surgery?

Sometimes.

It is crucial to talk about the outcomes when discussing timing. The outcomes are:

1) risk of re-injury

2) successful return to sport

Research shows no outcome-related time pressure exists for copers and potential copers.  Those who delay have a just as good an outcome than those who decide to have it a bit earlier.

Other research suggests that non-copers benefit from surgery sooner rather than later. However, we know that even non-copers do better by gaining full movement, reducing swelling, and strengthening the quadriceps, which can take up to 3 months.

Use the surgeon and physiotherapist to help you understand which group you fall into. 

Disclaimer: If you have an additional meniscus injury that has caused a locked knee, surgery is recommended as soon as possible to fix it. You may have the ACL done at the same time. Your surgeon will discuss this with you.

Why do my activity levels matter?

People without an ACL can return to lots of sports with rehabilitation alone.  Returning to sport becomes less likely as the sport becomes harder on the knee. 

Sports that involve significant pivoting (rotating/spinning on the knee), such as football, hockey, and netball, place a substantial demand on knee stabilisers. Returning to these sports may be unattainable without an ACL (a crucial stabiliser).

Sports with less pivoting, such as tennis, badminton, handball, padel, downhill skiing, and jogging, place less demand on knee stabilisers. So, even without an ACL, you still have a good chance of returning to them.

Does my age matter?

Age plays a role due to the age-related changes that can occur in our joints. A ligament reconstruction is less likely to succeed if your knee shows signs of age, such as osteoarthritis or cartilage wear.  

However, people age at varying rates, meaning decisions are made considering your biological age (joint and cartilage health) and not your chronological age (date of birth).

Does having the surgery to prevent osteoarthritis?

No.

ACL injuries, in addition to injuries such as meniscal, fractures, or multiple ligaments, may further contribute to accelerated age-related changes on a scan.  

However, scans and symptoms are two different things. Research shows that seeing age-related changes on a scan alone is a poor predictor of whether it will become painful. So, due to the lack of evidence, ACL injuries are not performed to reduce future osteoarthritis.