I had a patient present last week who hurt her knee in the first few minutes of a social game of basketball. She reported that she was trying to side-step an opponent, felt a pop in her knee and immediate pain. She collapsed to the ground, was unable to play on, and noticed her knee swell within 2 hours. She presented to me the next day, and when I heard her history - and saw the size of her knee - I feared the worst for her. I referred her to a GP who subsequently referred for MRI. MRI performed 2 days later came back positive for ACL rupture.
Prepared that it was highly likely that she had an ACL injury, I asked her to come back to me after she had her MRI and had seen the GP, to talk about what she can do whilst we were waiting for an outcome. However she cancelled this appointment, leaving a message with reception saying that it was likely that she would have to have surgery sometime soon, and that she felt that there was "nothing that I could do for her".
Aaaaaaaand this is where I become disappointed.
Not mad. Just disappointed...
Don’t get me wrong, I’m not disappointed because I’m missing out on a patient visit and the financial gain that comes with a consult. For what it is worth, she definitely needs to see the orthopaedic surgeon to discuss surgical AND conservative treatment options. In my opinion, I think that surgery for ACL injury is necessary for young active teenagers and adults if they want to play sports that involve changes of direction. What I am disappointed about is the fact that it may take 6-8 weeks (if she is lucky) to have her orthopaedic consult and then have surgery, and she is going to sit around idly waiting for 6-8 weeks.
This is not helpful.
Not only will her quads function deteriorate in this period of time, so will her gluteal, hamstring and calf function. So will her proprioception and balance. Sitting around for 6-8 weeks may also lead to 1-2 kg of weight gain, maybe even more, and it is well documented that higher BMI is associated with worse outcomes in a number of conditions.
What I am more disappointed about is that there is plenty of high-quality evidence that proves pre-operative physiotherapy improves patient outcomes post-operatively in a number of different conditions. I will briefly summarise the evidence below for ACL surgery:
The most robust of the literature comes from a systematic review and meta-analysis that included 8 studies and 451 patients (1). The review concluded that pre-op physio for ACLR for 3-14 weeks is superior to control groups at improving strength and function for ACLR patients post-operatively. The 3-week trial included in this systematic review, showed significant results in favor of pre-op physio over no physio for ROM at the 3 month post-op period, and a battery of functional and participation outcome measures at 6 and 12 months follow-up (2). To compliment this evidence, ACLR patients who had superior pre-op KOOS scores resulted in better post-op outcomes 3-6 years after ACLR (3).
In regards to how long one should wait between the primary injury and surgery, there is a wide-range of time in the literature; 4 weeks – 6 months (4). The decision is never black and white, and a number of factors need to be considered. What may help the decision-making process easier for the general population, this study found that individuals who had greater than 20% quad strength differences between limbs prior to surgery, had persistent strength differences 2 years after their ACLR (5). This lead the authors to conclude that ACLR should not be performed until the quads deficit of the injured limb is no more than 20% of the uninjured limb.
So there you have it, a very strong argument to say that strengthening is not a waste of time prior to surgery.
In conclusion, based on the evidence provided above, it is clear that pre-operative exercise for as little as 3 weeks improves knee function and strength in the 12-month post-operative period. The time to which surgery is performed is a question of great debate, and based on the evidence provided above, if the patient is not a professional athlete who has to be back to sport in a timely fashion, it appears that better outcomes are seen when surgery is delayed to when quads strength is back to within 20% of the uninjured limb prior to surgery.
As for all my blogs, please feel free to comment, like and share my post. I feel that the more this information can spread far and wide, the better outcomes our ACLR patients will have not only now, but long into the future.
Have a great day!
1. Alshewaier S, Yeowell G, Fatoye F. The effectiveness of pre-operative exercise physiotherapy rehabilitation on the outcomes of treatment following anterior cruciate ligament injury: A systematic review. Clinical rehabilitation. 2016 Feb 15. PubMed PMID: 26879746. Epub 2016/02/18. Eng.
2. Amaravati RS, Sekaran P. Does Preoperative Exercise Influence the Outcome of ACL Reconstruction? Arthroscopy.29(10):e182-e3.
3. Mansson O, Kartus J, Sernert N. Pre-operative factors predicting good outcome in terms of health-related quality of life after ACL reconstruction. Scandinavian journal of medicine & science in sports. 2013 Feb;23(1):15-22. PubMed PMID: 22288718. Epub 2012/02/01. eng.
4. Krutsch W, Zellner J, Baumann F, Pfeifer C, Nerlich M, Angele P. Timing of anterior cruciate ligament reconstruction within the first year after trauma and its influence on treatment of cartilage and meniscus pathology. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2015 Oct 16. PubMed PMID: 26475153. Epub 2015/10/18. Eng.
5. Eitzen I, Holm I, Risberg MA. Preoperative quadriceps strength is a significant predictor of knee function two years after anterior cruciate ligament reconstruction. British journal of sports medicine. 2009 May;43(5):371-6. PubMed PMID: 19224907. Epub 2009/02/20. eng.