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Keays S.L.1,2, Newcombe P.A.3, Keays A.C.4
1The University of the Sunshine Coast, School of Health and Sports Sciences, Sippy Downs, Australia, 2Private Practice, Sunshine Coast, Australia, 3The University of Queensland, School of Psychology, Brisbane, Australia, 4Private Othopaedic Practice, Sunshine Coast, Australia
Background: Surgical reconstruction is generally regarded as the treatment of choice following ACL rupture especially in high demand young sportsmen and women. It is considered that surgery as compared to conservative management will delay the development of osteoarthritis (OA). However conservative treatment may be the preferred option for some patients who are older, have lower physical demand or have minimal or no functional instability. Whereas numerous studies have reported long term outcomes of reconstructive surgery, far fewer studies have assessed long term results following conservative/physiotherapy managem.
Purpose: This study aimed to assess stability, strength, radiology and return to sport at 6-30 years post injury in patients with an ACL rupture who did not undergo reconstruction.
Methods: 54 conservatively treated patients from an orthopaedic physiotherapy practice took part in this study. They were followed up and recalled on average 14 years (SD 7.6) post injury. These 32 males and 22 females, aged 42 years (SD 9.2) were 28 (SD 9.8) years old at the time of injury. All patients were diagnosed with a ruptured ACL on MRI, arthroscopy or clinically by an orthopaedic surgeon. Three patients had bilateral ACL ruptures, 35 had meniscal injuries. All patients received physiotherapy treatment focusing on strengthening and dynamic stability training at some stage post injury. Assessment included KT 1000 instrumented stability testing measuring manual maximum anterior tibial translation and subjective stability testing using the Trust questionnaire. Quadriceps and hamstring strength were assessed using a Cybex 11 dynamometer.OA was assessed on four x-ray views and graded according to a modified Kellgren-Lawrence scale. Return to sport was scored on a 5-point scale according to whether patients did not play sport, engaged in safe sports, engaged in running, in non-strenuous twisting sports, in recreational or competitive team sports. Descriptive data of outcomes were reported pending further inferential analyses.
Results: There was a 39% increase in anterior tibial translation comparing injured to uninjured sides, an 8% loss of quadriceps strength and a 2% loss of hamstring strength. Thirty-four patients (63%) patients had developed tibiofemoral OA and 23(43%) had developed patellofemoral OA. Six patients had not returned to sport, 10 returned to safe sports namely swimming, cycling, walking, four retuned to running and 16 to non-strenuous sports involving twisting namely golf, surfing and skiing. Twelve patients had returned to team sports including hockey, cricket, rugby at a recreational level and six to similar team sports at a competitive level.
Conclusion(s): Despite the loss of stability and strength, 88% patients were still engaged in sporting activity. However most commented that they changed or modified their sporting activity. In particular they thought about their knee and planned their movement. Most patients were happy with their decision not to have had surgery especially as they got older. Although 63% had developed OA (mostly mild), only 8 (15%) experienced minimal pain with walking.
Implications: With conservative management of ACL injury, most patients modify their sporting activity and are unlikely to achieve their sporting potential. However one third of ACL deficient patients may still be able to engage in team sports.
Funding acknowledgements: The cost of radiographs was covered by the Private Practitioners Fund, at the Nambour General Hospital, Queensland, Australia.
Topic: Sport & sports injuries
Ethics approval: The University of Queensland Approval number 2008000964
All authors, affiliations and abstracts have been published as submitted.
