ACL Injury in Elite Athletes: Should More Be Managed Conservatively?

There is an evolving body of literature that shows non-elite patients who have sustained an ACL injury have similar knee outcomes up to 5yrs post-op than those who elect to have surgical reconstruction (Frobell et al, 2013) - see more details of this in evidence based blog by Adam Culvenor and Christian Barton here. The question therefore needs to be asked; if the results for surgical management and conservative management in non-elites are similar, why do almost all elite athletes have ACL reconstruction?

I understand that the weekly physical and psychological demands of elite sport are different beasts compared to running around in a social game of soccer once a week, but maybe not all elite athletes need to have an ACL reconstruction - and there is a successful return to sport case study of an elite professional soccer player to prove this.

And in the professional world where looking to reduce time-loss after an injury is a major goal for the player and the organisation, avoiding surgery could certainly allow the injured player to return to sport a hell of a lot quicker than the current recommendation of at least 9 months after ACL reconstruction.

At this stage I can only find 1 published case study of a 32 year old elite, premier league soccer player being managed conservatively and who successfully returned to sport 8 weeks after ACL injury; and was still playing (a significant role for the club mind you) at 18 months follow-up! (Weiler et al, 2015). Full text link to case study can be found here. This case is a gutsy move by the player, medical staff and club, and it flies in the face of conventional practice and wisdom.

You could argue that this older player had nothing to lose, as a lengthy stint in rehab could really limit his contract extension negotiations, or easily allow other clubs to overlook him for younger talent. I'm certainly not privy to the inside management of this case..but maybe there were other motivations to avoid surgery? Would the club have tried conservative management in a younger male athlete? Or would have they attempt conservative management in a female soccer player?

Lots of questions still remain, and I am completely aware that not all elite athletes will be able to be managed conservatively, however what it does show us is that it is possible to make a successful return to elite sport without reconstruction, and in a significantly shorter timeframe.

The only question left to ask is, which player, medical staff and club are willing to be bold and roll the dice on another case study of elite level conservative ACL management to build on this evidence?

For more on all things ACL injury, download my ACL rehab guide by clicking here, and/or watch my online ACL tutorials by clicking on the following links:

1) www.mickhughes.physio/lectures (delayed access, password required)

2) www.learn.physio/videos/100018 (instant access) References:

1) Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ. 2013;346:f232.

2) Weiler R, Monte-Colombo M, Mitchell A, Haddad F. Non-operative management of a complete anterior cruciate ligament injury in an English Premier League football player with return to play in less han 8 weeks: applying common sense in the absence of evidence. BMJ Case Reports. 2015:bcr2014208012.