For many years, the management of ACL ruptures has been quite uniform. The main debate was what type of graft a patient should choose for their surgery. And that graft selection was strongly tied to your surgeon. You went to either a hamstring guy or a patella tendon guy.
The One Size Fits All approach to ACL care is:
Get injured > Book surgery > Rehab it for the rest of your life.
Although this is still the most likely course of treatment for anyone who sustains an ACL injury, it needs to change.
Just as every patient is different in their age, sporting goals and life situation, every ACL tear is slightly different too. For too long, we thought the injury was binary, and that once the ligament was damaged, it was useless. ‘Doing’ your ACL was like getting pregnant – you’ve either done it or you haven’t – haha. Many also used the belt analogy: Once the belt is loose, it doesn’t hold up your pants, so it’s useless even if it’s slightly damaged. One can only speculate on how these beliefs became globally accepted as truisms. In reality, ACL injuries are on a spectrum, and a slightly lax ACL does provide stability.
The decisions and management should be individualised. The main decisions are whether to attempt a bracing protocol, what protocol to follow, whether to have surgery, and what type of surgery to perform. Certain cases are much better suited to a certain treatment pathway than others and it begins with understanding the type of ACL tear.
Less damaged ACLs may heal at 40-90 degrees or, indeed, with no bracing at all. In the middle of the damage spectrum, the ligament is more likely to require approximation at 90 degrees for good healing, and at the end of the spectrum, the profoundly injured ACLs are unlikely to heal, even with a 90-degree bracing protocol.
We need to consider this scale of injury spectrum, together with other factors in the individual, from young to old and sedentary to active, to decide which management to choose. All these decisions should be made in a shared decision-making process, with the patients themselves selecting the best choice for them.
