This week I saw an “old” patient for a “new” problem and got to catch up on how she was going following non-operative management of an ACL injury from a year ago.
Jodi is a 51 year old lady who injured her ACL playing tennis in May 2017. She consulted me early after her injury with a goal to return to tennis (which she enjoyed twice a week) and to avoid surgery.
Clinically, she described a classic injury – changing direction and the “something – nothing” knee with early swelling. Examination revealed an effusion and evidence of ACL instability – positive Lachman and pivot-shift tests. The medial collateral ligament (MCL) was intact.
Jodi underwent MRI which confirmed the clinical diagnosis and the recent instability episode (typical bone bruising pattern) and excluded significant meniscal or MCL injury.
Jodi was braced at 10-20 degrees for 3 weeks and engaged in rehab under the supervision of an experienced physiotherapist. Further clinical examination of ACL laxity was avoided for the next 4 weeks. (Note: I have no idea about the value of bracing, the range to use nor the duration! There doesn’t appear to be any consensus in the literature).
After 8 weeks of rehab, clinical examination was repeated – NO SIDE-TO-SIDE DIFFERENCE COULD BE NOTED! Another sports physician blinded to the diagnosis also examined Jodi and reported her examination as symmetrical and “normal”.
Progress MRI demonstrated improved alignment of ACL fibres and altered signal consistent with ongoing remodelling. This was an indulgence – Jodi could obviously have been managed clinically without the MRI at this point, but I was really keen to look-see!
Jodi returned to her previous level of tennis in 8 weeks and has had no episodes of instability nor any further problems with her injured knee. Her IKDC at 12 months (because I wasn’t checking these last year) is near perfect (98/100).
Patients with an ACL injury often get fast-tracked through the surgical route. I am so keen to know the answer to this question-
Which patients with ACL injury succeed at returning to sport with rehabilitation alone?
We plan to publish more blogs on ACL injuries and how patient reported outcome measures can be used to guide shared decision making around treatment options and return to play.
- Jodi not her real name.