Sustaining an injury to an anterior cruciate ligament is a confusing time for people. They embark on a steep learning curve while dealing with their pain and emotions.
And for repair and healing the clock is ticking.
Sometimes, people believe that the surgery is a shortcut to recovery, but in reality, the journey back from surgery is usually longer than the journey back from injury. People look at the path most elite athletes choose and quickly assume it must be the best way. In reality, future sporting goals are one of the most critical factors in deciding whether to have surgery, try for a heal, or go on with their life without an ACL. And elite athletes have the highest goals of all. I have had patients say ‘I couldn’t be bothered with all the non-surgical effort, I’m just going to go for the surgery’.
Despite a push in many quarters to frame the ACL as superfluous, it is there for a reason and has evolved as a complex and highly effective structure that helps lock home the knee and prevent excess rotation. We should agree that having an ACL (healed or expertly reconstructed and rehabilitated) is better than not having one. But we need to work out if the juice is worth the squeeze. And if the person has the capacity to extract it.
In the case of healing, minimally injured ACLs may heal without bracing. Still, our understanding is now convincingly showing that a bracing protocol to keep the knee bent (in flexion) will maximise the chance and quality of healing. And spending 24/7 in a brace for 4-12 weeks is hard. In the case of surgery, it’s a secondary trauma to the knee, with inflammatory cytokines found in the knee five years post-op that are absent without surgery. Many times, I see patients pre-op doing well, and after their surgery, they hobble into the clinic looking like someone has whacked their knee with a baseball bat. It is disheartening – ’We were doing so well!!…..’
They have a long and arduous journey ahead to regain full knee function, and most don’t make it. Research shows that only about 20% of people can climb that post-op mountain. The reasons include insurance coverage, motivation, complications from the surgery, and often simply making peace with their sub-optimal level of function.
Most will diligently hobble into the physio 2-3 times a week in the first few weeks post-op but drift off the wagon 3+ months post-op when the physical demands of the rehab are high. Nigel Hartnett, an excellent knee surgeon based in Melbourne, tells his patients it’s like jumping off a bridge, stopping halfway by landing on a ledge, and deciding whether to jump further before returning. I created this crude graph to illustrate to patients how challenging the road back is and to prepare them mentally for the task ahead.
