Thursday, February 26, 2015

Do I need an ACL to play sports?

We all hear how ACL injuries are season-ending for professional athletes. But what if an athlete could return to sports without ACL surgery?

Do I need an ACL to play sports?

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We all hear how ACL injuries are season-ending for professional athletes. But what if an athlete could return to sports without ACL surgery? 

There have been many articles showing that patients can return to activity, including sports, without ACL reconstruction. A recent study by Hetsroni et al in the August 2013 journal of Knee Surgery, Sports Traumatology, Arthroscopy showed that a quarter of recreational skiers with ACL injuries can be treated non-operatively. However, most people go on to have continued episodes of instability causing additional injury if they return to sporting activities without surgery. So what are the risks of playing without an ACL and how do we know who can and can’t play without surgery?

The ACL is the main stabilizing ligament in the knee.  It prevents excessive rotation of the knee joint that can occur with cutting and pivoting motions such as those in football, soccer, basketball and other similar sports. When the ACL doesn’t work, these rotational forces are transmitted to the other knee structures resulting in tearing of the meniscus and damage to the joint surface cartilage. Cartilage is the Holy Grail of orthopaedics and sports medicine.  We do a very good job a reconstructing the ACL but our results with cartilage repair are adequate at best. 

Joe Namath was the first famous athlete to return to sports without ACL surgery, which in his day was usually career-ending. What Broadway Joe proved is that a torn ACL, despite bracing, results in severe damage to the knee joint. Research shows that 90 percent of people with a torn ACL have significant problems or re-injury and only 10% of the patients did ok without surgery. These problems include persistent giving way, swelling, locking and pain. 

What about braces? Braces simply do not work in preventing injury to other knee structures after ACL injury and this has been proven with a multitude of studies. The risk of playing with an ACL injured knee is severe and permanent damage to the remaining meniscus cartilage and the joint surface cartilage. We can fix the ACL but we don’t do a good job at fixing the joint surface cartilage. Injury to this cartilage means early and progressive arthritis.

There is now a testing battery that can identify players who can function without the ACL.   Athletes that can return to activity without ACL surgery have been described as “copers” (being able to cope without an intact ACL). But it turns out that most people do not qualify as copers and the risk of returning to play without having corrective surgery is so great that most will not choose that route.

There are a few circumstances where an athlete might choose to rehab and play without surgery such as the national championship game for a college player or the state championship event for a high school player. For athletes, because the risk of permanent damage is so great, we advise against non-operative treatment.

In general, an ACL injury occurring in a young athlete or in a middle aged athlete unwilling to change his or her activity level requires surgery to safely return to sports. The risk is too great for permanent damage that would ultimately lead to the need for knee replacement at a later time.  The good news is that with minimally invasive arthroscopic surgery and aggressive rehabilitation, we are very successful at returning athletes to their pre-injury level of activity.

 


 

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Whether you are a weekend warrior, an aging baby boomer, a student athlete or just someone who wants to stay active, this blog is for you. Read about our growing list of expert contributors here.

J. Ryan Bair, PT, DPT, SCS Founder and Owner of FLASH Sports Physical Therapy, Board Certified in Sports Physical Therapy
Brian Cammarota, MEd, ATC, CSCS, CES Partner at Symetrix Sports Performance
Ellen Casey, MD Physician with Drexel University Sports Medicine
Desirea D. Caucci, PT, DPT, OCS Co-owner of Conshohocken Physical Therapy, Board Certified Orthopedic Clinical Specialist
Michael G. Ciccotti, M.D. Head Team Physician for Phillies & St. Joe's; Rothman Institute
Julie Coté, PT, MPT, OCS, COMT Magee Rehabilitation Hospital
Peter F. DeLuca, M.D. Head Team Physician for Eagles, Head Orthopedic Surgeon for Flyers; Rothman Institute
Joel H. Fish, Ph.D. Director of The Center For Sport Psychology; Sports Psychology Consultant for 76ers & Flyers
R. Robert Franks, D.O. Team Physician for USA Wrestling, Consultant for Phillies; Rothman Institute
Ashley B. Greenblatt, ACE-CPT Certified Personal Trainer, The Sporting Club at The Bellevue
Eugene Hong, MD, CAQSM, FAAFP Team Physician for Drexel, Philadelphia Univ., Saint Joe’s, & U.S. National Women’s Lacrosse
Julia Mayberry, M.D. Attending Hand & Upper Extremity Surgeon, Main Line Hand Surgery P.C.
Jim McCrossin, ATC Strength and Conditioning Coach, Flyers and Phantoms
Gavin McKay, NASM-CPT Founder/Franchisor, Unite Fitness
Kevin Miller Fitness Coach, Philadelphia Union
Heather Moore, PT, DPT, CKTP Owner of Total Performance Physical Therapy, North Wales and Hatfield, PA
Kelly O'Shea Senior Health Producer, Philly.com
Tracey Romero Sports Medicine Editor, Philly.com
David Rubenstein, M.D. Team Orthopedist for 76ers; Main Line Health Lankenau Medical Center
Robert Senior Event coverage, Sports Doc contributor
Justin Shaginaw, MPT, ATC Athletic Trainer for US Soccer Federation; Aria 3B Orthopaedic Institute
Thomas Trojian MD, CAQSM, FACSM Associate Chief of the Division of Sports Medicine at Drexel University
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