After receiving the confirmation of an ACL injury with an MRI as mentioned in our previous blog (https://www.avolveperformance.com.au/i-think-i-may-have-torn-my-acl-what-should-i-do/), the next step is to have a discussion with your trusted medical professional about the different treatment options in regards to your rehabilitation. It has long been assumed that surgical reconstruction of your ACL is required in order to help stabilise the knee and facilitate a return to sports. However, in more recent times, the ability of the ACL to heal sufficiently without surgery has been shown to be greater than what we originally thought. Giving hope to those who wish to avoid surgery, as well as offer up potential options for treatment that may suit individuals better than others. 

What are the three main options?

1. Surgical Reconstruction with Exercise Rehabilitation 

The most common and widely accepted treatment option is surgical reconstruction with a ~9-12 months+ exercise rehabilitation to follow. When we tear our ACL we lose its stabilising and proprioceptive functions. By implementing a graft, the aim is to replicate these functions as best as possible. Although the ACL graft will not provide the complete proprioceptive functions benefits as the original ACL, we aim to alleviate this through other means. 

During the operation, a surgeon will use either an allograft (a donor ACL) or an autograft (tissue taken from the same individual) to create a new ACL. Some common tissue sites of autografts are the patella tendon, hamstring tendon and the quadriceps tendon. Each different graft type will each have its unique set of pros & cons and thus potentially better suited to different individuals depending on their needs. 

When selecting what graft will be best suited for you, it is important to take into account various patient-specific factors. Each patient is unique, and factors such as age, activity level, previous injuries, and anatomical considerations play a significant role in determining the most suitable graft option. This selection process should be a collaborative decision between the athlete and the operating surgeon, and the athlete should be aware of all of their options, including the benefits and drawbacks of each. 

2. A Trial of Exercise Rehabilitation Alone With the Option of Delayed Reconstruction 

It has long been assumed that once you have torn your ACL, it must be surgically repaired as the ACL is unable to heal on its own. However, more recent research has challenged this assumption, with early data suggesting that the ACL does have the capability to heal! What is more interesting is that for those who’s ACL does heal, some even report superior outcomes compared to those that don’t heal and also those that have surgery (Filbay et al 2022).  

This groundbreaking ‘KANON’ trial compared early surgical intervention vs exercise rehabilitation alone. The trial showed that ⅓ of the 120 participants, who were not randomised to the early surgery group showed evidence of healing. This is in spite of not doing anything to aid or facilitate healing other than exercise rehabilitation alone. 

This is not to say that everyone will heal without surgical intervention, however a conversation with your orthopedic specialist, physiotherapist and family about the potential of trialing exercise rehabilitation alone might be worth considering before racing to the operating room. 

3. A Trial of the Cross Bracing Protocol With the Option of Delayed Reconstruction

As we know now, the ACL has been shown to have a healing potential. More recently however,  there has emerged a bracing protocol to greatly facilitate this healing potential. The Cross Bracing Protocol (CBP), created by Dr Tom Cross in Sydney, is a method whereby the knee is put in a brace for 12 weeks. The brace is initially locked at 90 degrees for the first four weeks, designed so that the two ends of the ruptured ACL can be reduced together so they can start healing. From there, over the next five weeks in weekly increments, the brace is unlocked and provided with increased available range of motion. During the final 3 weeks, the brace is kept on but is unrestricted in range of motion. 

Over this period of time, patients undergo intense physiotherapy based rehabilitation including exercises to ensure that the healing ACL has adequate mechanical stimulus to heal strongly, as we reduce muscle and strength losses. So far the results have been fantastic, with 90% of all participants showing signs of healing at 3 months (Filbay et al. 2023). 

There is a window of opportunity though when it comes to starting the CBP, which means speaking with a physiotherapist experienced with the CBP method and getting an MRI to confirm an ACL injury ASAP is critically important. Starting the CBP around day 5 post injury is ideal, while patients have had successful outcomes starting around 3 weeks post injury. This is due to the ruptured ACL tending to heal over itself, and thus removing the chance to heal together, unless it is accurately braced at the ideal angle. Not all ACL ruptures are good candidates for the CBP and this will depend on your MRI results. 

Comparisons 

All three treatment options are valid, evidence based, have their respective pros and cons and all will require an extensive 9-12 months+ exercise based rehabilitation. One treatment option may be better suited compared to another depending on your own personal needs, goals and presentation. In order to have all three options available, it is critical to have an early diagnosis with an MRI and to have an informed discussion with your trusted physiotherapist who has had experience in rehabbing the three treatment options. 

If you think you may have injured your ACL, or have just got confirmation of an ACL tear, and are looking for a discussion around the best treatment options for YOU please feel free to reach out to us below. Our team of rehab professionals would love to help guide you on the best path back to the sporting field.