ACL Knee Brace Non-Surgical Treatment

If the majority of ACLs will repair themselves in time, as a new study suggests, what’s the point of ACL reconstruction? Jim Newman unpicks the story behind the study.

It’s funny how some stories seem to take on a life of their own. Take a recent study of ACL (anterior cruciate ligament) tears by the University of Melbourne, which has generated a lot of headlines globally along the lines of ‘the majority of ACL tears will heal themselves so you don’t need surgery’. So what’s the truth of it?

 

The study and its findings

This was a study of 80 patients treated within four weeks of damaging their ACL. Each patient had their knee placed in a brace to keep the joint immobile for four weeks. Then, for the next eight weeks, each patient increased their range of motion under the supervision of a physiotherapist. The brace was removed at 12 weeks.

The study found that “90% of patients had evidence of healing on 3-month MRI.”

 

Stratifying risk

Perhaps the first thing to note about the way the study has often been reported (although this isn’t the fault of the study) is the suggestion that every ACL tear needs surgery. It doesn’t. Surgeons stratify ACL tears. Grade 1 tears (the lowest level of injury) often don’t require surgery. Major tears (level 3) almost inevitably do.

We’ll then talk to patients about their activity levels. If you have a level 3 ACL tear and you’re a professional footballer, you’ll want to be sure that your knee will be up to the many demands you’ll be placing on it. That probably means reconstruction surgery. On the other hand, if you work from home and suffer a level 1 tear tripping over the dog, you may escape with wearing a protective brace for the odd times in the year when you put your knee under real pressure (for example, when you go skiing). You may well avoid the need for an operation.

Of the 80 patients in this study, 50% had level 1 tears and only 10% had level 3.

 

“Evidence of healing”

It’s an interesting choice of words. “Evidence of healing” is not the same thing as “healed” although it seems many of the articles stemming from this didn’t make that distinction.

Lots of ACLs can look good on an MRI. What’s relevant, however, is not the appearance of the ACL but whether it functions well enough to withstand the usual activity levels of the patient.

It’s also worth noting that the ACL isn’t really predisposed to healing because of its poor blood supply.

> Discover more about ACL injuries
> Questions about your knee surgery?

 

The 4-week problem

The 80 patients in this study were all wearing knee braces by the fourth week after injury. In practice, such swift diagnosis is rare in the UK. Late diagnosis of ACL injuries is common because there’s often a temptation for patients to (quite reasonably) think that, once the initial swelling and pain subsides, the knee has recovered. It’s only with a little time that it becomes clear that the instability that characterises an ACL tear remains a problem.

Even then, it’s often possible for patients with lower grade ACL tears to carry on largely as normal without too much difficulty. Only when they start to twist and pivot on the knee does the true extent of the tear become apparent. These are the sorts of things you’ll spot extremely quickly if you’re a committed athlete. Issues may be less noticeable if your life is relatively sedentary.

So it might take you a while to contact your GP or attend a walk-in clinic. Then you’ll need a scan. Once the results are back you might then be referred to a consultant, but whether that’s on the NHS or privately, there’s a high chance the four weeks will be long gone by the time you see them. We need more research to understand how longer timescales might affect the study results. The study does acknowledge this.

 

The 3-month problem

This study reported on the progress of patients three months after injury, but recovery from a major ACL tear takes much longer. If you want to return to serious sport, you need to have a high level of confidence (and elasticity) in the knee. Even ACL reconstruction is far from perfect in achieving this, with failure in typically 5%-10% of cases.

Yet the reinjury rate in the study was 14% (I suspect this isn’t actually a reinjury but rather a case of the original tear failing to heal).

Again, we need to see data over a considerably longer period to be able to seriously compare the new bracing procedure with traditional reconstruction.

 

Will your ACL heal itself?

So where does this leave us? This is an interesting (albeit small) study, which shows some healing in the ACLs of 90% of patients, although 50% of those probably wouldn’t have been candidates for surgery anyway and the level of healing in the remaining patients is unclear. Those patients will have spent 12 weeks in a leg brace, which is a pretty uncomfortable experience and not without risk of, for example, DVTs. And we know that 14% of those will ‘reinjure’ themselves.

The takeaway from this, then, is that there may be some patients for whom the bracing approach does work, but we need a lot more research to understand how these results change with different patient groups presenting at different times.

In the meantime, if you’ve injured your knee and need swift diagnosis and treatment, please contact us, or phone us on 03453 052 579.

> Find out more about Jim Newman
> Discover more about ACL injuries
> Questions about your knee surgery?

James Newman

James Newman

Private appointments weekly at Spire Methley Park Hospital

Private Secretary

Sera Robertson
Spire Methley Park
01977 664 230
sera.robertson@nhs.net

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Email James

jn@yorkshirekneeclinic.com

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