Perfection Myth: every injury has to be immediately fixed.
The growing research on anterior cruciate ligament injuries is pointing toward substantially delayed or no surgical intervention. The difficult part about making the decision is the simple fact that it has to be very, very difficult to tell an athlete who is in substantial pain and has definitive diagnostic findings that it is far better to wait the situation out before immediately jumping into a surgical intervention.
The twist in the research seems to go against what we would intuitively think. If the athlete has both a ruptured ACL and has concurrent meniscal damage (along with a high level of pain and meniscal symptoms), immediate surgery actually has worse outcomes down the road compared to skipping surgery initially and beginning an structured exercise program.
Below you will find a quick view of the abstract.
Delaying ACL reconstruction and treating with exercise therapy alone may alter prognostic factors for 5-year outcome: an exploratory analysis of the KANON trial.
Identify injury-related, patient-reported and treatment-related prognostic factors for 5-year outcomes in acutely ACL-ruptured individuals managed with early reconstruction plus exercise therapy, exercise therapy plus delayed reconstruction or exercise therapy alone.
Exploratory analysis of the Knee Anterior Cruciate Ligament, Nonsurgical versus Surgical Treatment (KANON) trial (ISRCTN84752559). Relationships between prognostic factors (baseline cartilage, meniscus and osteochondral damage, baseline extension deficit, baseline patient-reported outcomes, number of rehabilitation visits, graft/contralateral ACL rupture, non-ACL surgery and ACL treatment strategy) and 5-year Knee Injury and Osteoarthritis Outcome Score (KOOS) pain, symptoms, sport/recreation and quality of life (QOL) scores were explored using multivariable linear regression. Estimates were adjusted for sex, age, body mass index, preinjury activity level, education and smoking.
For all participants (n=118), graft/contralateral ACL rupture, non-ACL surgery and worse baseline 36-item Short-Form Mental Component Scores were associated with worse outcomes. Treatment with exercise therapy alone was a prognostic factor for less knee symptoms compared with early reconstruction plus exercise therapy (regression coefficient 10.1, 95% CI 2.3 to 17.9). Baseline meniscus lesion was associated with worse sport/recreation function (-14.4, 95% CI -27.6 to -1.3) and osteochondral lesions were associated with worse QOL (-12.3, 95% CI -24.3 to -0.4) following early reconstruction plus exercise therapy. In the same group, undergoing additional non-ACL surgery and worse baseline KOOS scores were prognostic for worse outcome on all KOOS subscales. Following delayed reconstruction, baseline meniscus damage was a prognostic factor for less pain (14.3, 95% CI 0.7 to 27.9). Following exercise therapy alone, undergoing non-ACL surgery was prognostic for worse pain.
Treatment-dependent differences in prognostic factors for 5-year outcomes may support individualised treatment after acute ACL rupture in young active individuals.
Br J Sports Med. 2017 May 17. pii: bjsports-2016-097124. doi: 10.1136/bjsports-2016-097124. [Epub ahead of print]