Research on ACL outcomes

I just now read a new column on NY Times website about a two yr study in Sweden involving 121 healthy, active, athletic young adults who had ACL injuries.Original study was published late July in New England Journal of Medicine.

Half had PT followed by ACL reconstruction. Half had PT alone.
To quote the article by Tara Parker-Pope:
"At the end of the two years, both groups showed considerable improvement. The scores for the surgically repaired knees had risen by 39.2 points. The scores for the more conservatively treated knees also had risen, by 39.4 points. In other words, the outcomes for the two groups were virtually identical."

Another, earlier study based on 10 years observation, published last yr in British Journal of Sports Medicine, showed (again, quoting Parker-Pope) that "The surgically repaired knees were notably more stable. But they weren't fundamentally healthier. The surgically reconstructed knees and the conservatively treated joints experienced similar (and high) levels of early-onset knee arthritis, a common occurrence after an A.C.L. tear. The treatments were almost identical, too, in terms of whether the athletes could return to sports and whether they reported subsequent knee problems."

possibly of interest<

Some injuries, however, are so deeply rooted in larger neuro-physio-anatomical problems that traditional rehab protocols only touch the surface. Athletes with these injuries return to their sport but don't recover fully. They require a more in-depth assessment and whole-body rehabilitation.

Janet Rosen wrote: "The surgically repaired knees were notably more stable. But they weren't fundamentally healthier.

Having a hard time getting my head around this statement... How can a "notably more stable" knee not be considered healthier? I would think that the added stability would at least contribute to less chance of re-injury. Even being able to exert with less trepidation would be an advantage. Maybe one of you medicos out there can 'splain how I should be understanding this.

Clark Bateman wrote: Having a hard time getting my head around this statement... How can a "notably more stable" knee not be considered healthier?

Measure of stability, as far as it was ever checked on me and others I know, was a hands-on manipulation of the leg focusing on the knee joint for the practitioner to assess the actual play in the joint.
I know of several people who always did terribly on this measure due to torn ACL but because of excellent overall condition were very active (one was a pro soccer player) and yes had healthy knees in the sense of being totally functional.

Larger issue, for me, is one of comparable rehab.

For instance, even Kaiser - who loves preventive medicine and doesn't make money by offering surgery - doesn't offer a lot of PT for an injury. Maybe a few weeks.

If you have an ACL, though, you have many months of covered PT based on the surgeon's post-op regimen, before you are released to resume prior activities.

If it had been presented to me that the same PT WITHOUT surgery would likely have offered the same outcome as with surgery, I'd have been spared surgery w/ all the attendant risks and pains, and Kaiser would have been paying for a lot of PT but not for the OR, anesthesiologist, surgeon, etc.

Janet Rosen wrote: Larger issue, for me, is one of comparable rehab. For instance, even Kaiser - who loves preventive medicine and doesn't make money by offering surgery - doesn't offer a lot of PT for an injury. Maybe a few weeks. If you have an ACL, though, you have many months of covered PT based on the surgeon's post-op regimen, before you are released to resume prior activities. If it had been presented to me that the same PT WITHOUT surgery would likely have offered the same outcome as with surgery, I'd have been spared surgery w/ all the attendant risks and pains, and Kaiser would have been paying for a lot of PT but not for the OR, anesthesiologist, surgeon, etc.

Hi Janet,
It is very disappointing.
You are a nurse right?
How much do you think a patient should own his/her own rehab?
How much do you think we should _trust_ the system/doctors/etc. versus doing everything you can, yourself?

There are obvious dangers both ways, right? Ignorant people can hurt themselves...but sometimes trusting in doctors may lead the same way. Do you have any wise words to share?

Thanks in advance,
Josh

Had a partially torn ACL a while back. Since the lovely wife is in the medical biz, I got a referral to a great Orthopod. His advice was simple. He shrugged. His comment (on my case in particular) was that he could go in, repair, and I'd have to do some PT, wear a brace, and be back at things quickly. Or I could skip surgery, have a lot more PT, wear a brace, and get back more slowly. Long term he said he really couldn't say which would be better in the long term.

He did say that going in sometimes he can find things not visible on the MRI and do "extra" repairs. Sometimes that can make a difference in overall health of the knee. But in my case it was pretty much a coin toss.

I went with extra PT and no surgery. The knee is pretty good, not 100%, but eventually I got it mostly back. One drawback, however, was dealing with the Insurance Company (insert obligatory comment about evil corporate pencil pushers). They refused to pay for the brace because they didn't feel I needed one since I didn't also have the surgery. I was told that if I had the surgery the brace wouldn't have been turned down because it would be obvious I needed the brace. But because I opted to skip surgery I obviously didn't need the brace.

Josh Philipson wrote: Hi Janet, It is very disappointing. You are a nurse right? How much do you think a patient should own his/her own rehab? How much do you think we should _trust_ the system/doctors/etc. versus doing everything you can, yourself? Josh

Yep, Josh, RN x over 30 yrs.

We are all of us, patients and providers, constrained by a number of things outside our control: First by available information. I can't "own" my own rehab if nobody sits down and really talks about the options, benefits, risks. Sometimes info is simply not available (this latest research on outcomes was not done, hence not available, when my injury happened over 10 yrs ago). Second constraint is local or regional resources and practice - rural areas have limited resources compared so cities; standards of care or common practices vary across larger regions. Third, insurance constraints (per my experience w/ PT and Keith's above note re the brace).

It is important to have providers you can trust but the question is, what does trust mean to you as a patient? There is no one right answer. For some it means blindly following what the doctor orders. For others it means feeling the doctor has one's best interests at heart so you can engage in an open conversation.

Some people don't want to do their own research because it is overwhelming and they don't know how to sort it out or prioritize the issues. Some people want to do their own research but don't know how to sort out quacks or how much import to give anecdotal reporting. Some people, due to lack of access or to cognitive issues, are in no position to do their own research.

There's the whole spectrum of possible treatments, and then there's what's available. When Bode Miller blew out his knee in 2001 (I believe), he had surgery of a sort at the Steadman-Hawkins Clinic in Vail. This is a clinic that has pioneered a number of surgical techniques and other treatments for orthopedic injuries, particularly knees -- it's the clinic of choice for the US Ski Team. As best I recall, what Bode got was less of a repair and more of a technique to help the body heal itself: they drilled into the femur, let it leak onto the injury site, and a year later Bode won two Olympic medals.

Now the catch: Steadman-Hawkins doesn't take insurance. If you want treatment there, it's straight cash. homey -- and it ain't cheap. The many practitioners who do take insurance are limited in what they're allowed to do (and have it covered by insurance), and most of us non-elite athletes have neither the cash nor a sugar daddy to say "make it so" and get us access to all possible treatments.

No ACL problems here, but I did suffer a torn meniscus in March. There was no specific injury, just a terrific pain and my reaction to the pain created an instability - it hurt like Hell and I would instantly take all the weight off and fall down. I went to an urgent care center and got a referral to a nearby orthopedic group. The doc examined the knee, read the x-rays and diagnosed me with a quadriceps tendon strain. He prescribed the ubitquitous RICE regimen and gave me some exercises to do on my own. Six weeks later, I had no improvement and diddybopped off to a renowned sports orthopod who had treated several friends in addition to local pro and amateur athletes.

A quick exam and an MRI later, he determined that I had a torn medial meniscus and gave me the choice of surgery or PT and learning to live with it. I elected the surgery and when he got in there found the lateral meniscus was also torn. He did all his magic doctor stuff and off to PT I went a week later.

She Who Must Be Obeyed is a veteran nurse and nursing instructor so being involved in our own care is the watchword around here. Both my surgeon (who parenthetically is a sandan in karate) and the PT folks took the time to listen to me about Aikido and the movements required and designed my therapy around those concerns. I'm now eight weeks post-op and can do everything I could before the injury, although sitting seiza is still a big challenge as I still have some internal swelling and fluid.

The bottom line to this lengthy tale of woe is that the PT was critical to my recovery. Making them understand what I do and needed was critical to the PT. Somehow finding the self-discipline to do all the exercises at home also proved important. I was lucky that my insurance covered virtually everything except a small co-pay. I think being aggressive and really talking with the surgeon was paramount to the recovery I've enjoyed.

Michael Hackett wrote: The bottom line to this lengthy tale of woe is that the PT was critical to my recovery. Making them understand what I do and needed was critical to the PT. Somehow finding the self-discipline to do all the exercises at home also proved important. I was lucky that my insurance covered virtually everything except a small co-pay. I think being aggressive and really talking with the surgeon was paramount to the recovery I've enjoyed.

And of course having your own home nurse

In all seriousness... communication w/ PT is truly crucial. A longstanding joke among me, my husband, my sister and brother-in-law is that we have to remind our PTs that we actually follow what they say 100% - we have noticed they seem to assume folks will not do this, and overprescribe at home exercises; we end up doing every thing to the letter and overdo things. Ouch.

Glad you are recovering well, Michael!

I ruined my right ACL in a motorcycle accident in 1984. It wasn't until I started aikido in 1992 that it began to be bothersome. Wanting to continue with aikido I opted for surgery. Had the ACL replaced with hamstring muscle/graft in 1999. Very stable now, full flexion and extension is easy although prolonged full extension can result in some pain. Seiza and shikko, if not prolonged, is no problem. Prior to the surgery it was a major problem. Recently began with a myofascial release practitioner who helped immensely with some other aspects the accident brought forth. Took me six months of pretty hardcore PT before I could get back on the mat.....

Cheers,

Russ

Janet,

You raise an interesting point about people not following through on the PT. I never paid any attention to those around me at the therapy place as they whined about the pain and how tired they were. I just assumed they were tired and in pain and needed to quit. Since I've never found anything worth doing that wasn't worth overdoing, if they asked me for three sets of ten, I'd do four sets of fifteen reps - if a little is good, then a lot must be great, right? This time it worked out, but I can see how one could seriously overdo it and set himself back in healing.

Funny sidenote.....one of my at-home exercises was the wall sit where you would lean back against the wall in a sitting position and hold that posture for thirty seconds. We have textured walls, so I chose to lean back against the downstairs bathroom door. Good plan, poor planning. About fifteen seconds into the third rep, the door burst open and I did beautiful ushiro ukemi on the hard tile floor. Naturally, She Who Must Be Obeyed was watching, just shook her head with a look of disgust and walked away.

Two morals to this story.....only lean against a door that closes in the direction of the lean, and if you're married to a nurse, don't expect any sympathy, particularly when you do something stupid.

Michael Hackett wrote: You raise an interesting point about people not following through on the PT. I never paid any attention to those around me at the therapy place as they whined about the pain and how tired they were. I just assumed they were tired and in pain and needed to quit.

This may sound uncharitable but writing as a pretty compassionate community health nurse who has had many clients who undermine themselves: I think the main reason PTs overprescribe is that they know many folks, especially the whiners, are not really interested in maximizing their rehab and won't do all they suggest. The population of those referred to PT is not necessarily mostly athletes and martial artists...

Michael Hackett wrote: and if you're married to a nurse, don't expect any sympathy, particularly when you do something stupid.

Reminder to self: keep Mr. Hackett away from Stu lest they start comparing notes... Actually the really tough thing, from what I'm told, is being the child of an E.R. nurse!

Oh yeah, just ask our kids. SWMBO has 20 plus years in a trauma setting. The mantra around home always was "Stop snivelling, its a long ways from your heart!" I always loved it when she took an interest in the children.

I saw that article too and found it very interesting. I completely tore my ACL and had a conservative doctor at the time, who recommended two months of intense physical therapy before even getting an MRI to consider surgery.

After the physical therapy, I was able to run, bike, and swim. I even ran a marathon on my bad knee. However, aikido was completely impossible - one pivot and the knee collapsed. And that did not improve after two months of physical therapy. It's anecdotal of course, but I don't see how I could have continued with aikido or any sports with pivoting or cutting motions without the surgery.

Hello everyone. This is my situation: March 3, 2020 I injured my right knee throwing someone with Koshi-Nagi. I tore my MCL and meniscus, and my ACL was ruptured. I had to let the MCL heal before I could have the ACL replacement graft which was done on May 27, 2020. I did well with my rehab at physical therapy and also going to the gym and bike riding in yoga. So my question is it's Ben 10 months since my surgery and has anybody had this injury and return to Aikido in less than a year after surgery? I was told to wait a year before returning because it takes that long for the graph to become a part of your body. So anybody have any thoughts about this? I went to the dojo and did a few rolls backwards and forwards and also some falls in my knee did not hurt. Plan on seeing my orthopedist again to see if I need to wait the whole 12 months.