Prognosis of non - surgical ACL tear treatment.

Prognosis of conservatively managed anterior cruciate ligament injury: a systematic review.

Muaidi QI, Nicholson LL, Refshauge KM, Herbert RD, Maher CG. Sports Medicine, 2007; 37 (8): 703-16.

http://www.ncbi.nlm.nih.gov/pubmed/17645372

Despite generally held opinion that prolonged functioning with ACL – deficient knee might lead to increased risk of meniscal injuries, cartilage lesions and early OA onset, some people decide to follow conservative management. Authors systematically reviewed scientific literature on the success of ACL rupture non – surgical management and to present factors potentially contributing to success of this treatment approach.

Fifteen manuscripts with variable methodological quality were analyzed. The main outcome measures were self – reported knee function, activity level, functional tests and knee proprioception.

Lysholm scale was used to measure self – reported knee function in eight studies. Mean knee function score in these studies was 87/100 at follow – up ranging from 60 to 66 months after injury. Activity level was measured with Tegner scale in nine papers, and while mean activity level score before injury was 7.1/10, there was decrease seen to mean score of 5.1/10 at follow – up ranging from one to three years. Most commonly used functional task in the studies included, was one – leg hop for distance. Limb symmetry index calculated from the ratio of distance hopped of the injured and uninjured legs was reported. At follow – up from one to three years, mean limb symmetry index was 96%. Only one study reported knee proprioception and there was seen impaired ability to detect passive motion at angles near knee extension at one and two months post – injury, but not at four and eight months. Also, no significant proprioceptive deficits were reported in terms of active reproduction or visual estimation tests. Prognostic factors were included in five studies. These were: age, gender, occupation, participation in sports activity, radiographic findings, knee laxity measures with KT – 1000, knee function scores and concomitant injuries.

Authors concluded, that considering self – reported knee function using Lysholm scale, activity level using Tegner scale and functional performance using on – leg hop for distance test, short to mid – term prognosis of non – surgical treatment of ACL tear appears to be good. At the same time, authors state that these results should be interpreted with caution. For instance, high Lysholm knee scale scores could be biased by involuntary low activity level, therefore might be over – optimistic and indeed there was 21% activity level decrease observed among those patients. Moreover, one – leg hop for distance might not be a reliable screening method due to its low sensitivity reported in several papers where 50% of ACL – deficient sample was performing well in the test despite regularly experiencing giving –way episodes during sports participation. Only one study reported knee proprioception sensitivity, therefore, again, this should not be taken for granted. Finally, most of the prognostic factors reported, lacked strong predictive value with only high level sports activity and increased tibial anterior translation measured with KT – 1000 were statistically significant predictive factors.

Do you know any more up to date review presenting prognosis for conservatively managed ACL injury? Would you recommend your patient/athlete to undertake surgery or just to focus on rehabilitation? Would you consider encouraging your patients to stop sports activity if he/she decides not to reconstruct ACL?
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