Treatment decision

The ACL injury journey - a guide for patients.

This blog accompanies two infographics – published in British Journal of Sports Medicine – presenting the best available evidence, and designed with input from people who have experienced ACL injury. Both authors of the infographics are clinicians and researchers who work with many people of all ages and levels of sport after ACL injury. These infographics are designed to be used with your health professional, help guide your decisions and rehabilitation process.

BJSM: December 2020 >

Part 1: Treatment decision

Gathering your rehab team

After an ACL injury, it is common to feel angry, depressed, frustrated and uncertain about your future. First, you should gather members of your rehab team to help you make decisions, guide your rehabilitation and keep you motivated. Members of your team can include exercise professionals (e.g. physical therapist), a doctor / surgeon, a sports doctor, your coach, team-mates, your family, and your friends.

Starting rehabilitation straight away

You should begin high-quality rehabilitation immediately after an ACL injury. Most experts agree that after your ACL injury, the best course of action is to try to return normal knee function and delay the decision about whether to have surgery or not until after a period of rehabilitation.

Deciding whether to have surgery (or not)

Younger, more active patients are more likely to re-injure their knee but this is probably unrelated to whether you have surgery or not. Returning to high level pivoting sports is associated with more risk than running in straight lines, for example. Having other knee injuries, like meniscal tears, at the same time as your ACL injury is associated with worse outcomes but again the choice about surgery doesn’t seem to impact this outcome. However, some injuries may need to be repaired and this will be an individual decision. It is important to discuss factors like your age, other injuries and your plans to return to high level pivoting sports because you can talk with your rehabilitation team how to reduce your future injury risk. Remaining happy, healthy and active is a key consideration for anyone following ACL injury and this may or may not involve surgery.

There is no clear evidence that surgery is superior to undertaking high quality rehabilitation alone. There is only one published randomised trial comparing the two options. This reported no difference in pain, function or return to pre-injury activity levels at 1-, 2- and 5-years after an ACL injury. Current evidence suggests that, in the long-term, there is no difference in how many people develop osteoarthritis between people who have their ACL surgically reconstructed and people who don’t have surgery. It is clear that some people can cope without surgery following an ACL injury. Some people may even be able to return to high level pivoting sports without an ACL reconstruction. We recommend you think about the following things when talking to your rehab team and making your decision:

  • Do I have all the information?
  • What are my goals?
  • What are my values? (Time with kids, playing with friends)
  • What are the risk versus rewards for having surgery now?
  • Am I being listened to?
  • Have I been given enough time to make this decision?
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