Is surgery always necessary following ACL rupture? How effective is conservative treatment?
"The question of whether surgery is necessary or not is somewhat of a contentious one. To date, no one has carried out appropriately balanced randomised controlled trials to answer this question. The commonest reason given for undertaking surgery is to reduce the risk of future joint degeneration. Interestingly, recent prospective surveys (e.g. Myklebust et al. 2003, American Journal of Sports Medicine) have shown that whether or not surgery is undertaken for ACL injury the joint degenerates significantly more than in uninjured players. The same study also showed that regardless of intervention the majority of patients returned to elite level sport.
"The other reason given for surgical repair is to stabilise the joint. It must be remembered that mechanically speaking, the ACL is an incredibly complex structure and the grafts used to reconstruct it are very poor substitutes for the original. They lack the multi-band nature of the original which gives it isometric strength throughout knee movement, creating tension in some part of the ligament through the whole range of knee movement. This not only provides stability but also proprioceptive feedback. This would appear to indicate that only if the patient is neuromuscularly re-trained will the joint have any hope of becoming functionally stable, regardless of whether or not it is operated on.
Numerous studies have shown that the ACL reconstructed, or ACL deficient, patients fail to have the longevity in sport of their peers and, as mentioned above, have considerably greater joint degradation. The challenge to those in sports rehabilitation is to rehabilitate these players in such a way that they can not only return to sport, but perform as well as before with a longevity to their careers comparative to their peers and without long-term joint damage. It is for the researchers in this field to identify those players who can adapt to ACL injury (with or without surgery) and return to an uncompromised sporting career and recognise those players whose injury is the precursor to long term joint degeneration and poor functional outcome."