8 reasons for anterior cruciate ligament surgery

A torn anterior cruciate ligament occurs in young and old, athletic or not, and is gender independent. What is striking is that it occurs more often in women than in men. Each person has their own goals, wishes and ambitions. In addition, everyone experiences the symptoms and limitations in their own way. For this reason, there is no ready-made treatment for a torn cruciate ligament. Healthcare providers treat people, not knees, and therefore a personal consultation should show which treatment is most appropriate. 

In Part 1 of this blog, we discussed that there is a choice to undergo anterior cruciate ligament surgery. There are a number of factors that influence the choice of whether or not to have surgery. In this blog we will discuss the 8 most important factors.

Content:

  • Severity of injury
  • Degree of knee instability
  • Type of sport.
  • Level of sport
  • Instability in daily life after a course of physical therapy.
  • Age
  • Discipline and motivation
  • Goals, expectations and aspirations

1. I twisted my knee.

An anterior cruciate ligament can stretch, tear completely or partially. In addition, an isolated anterior cruciate ligament injury is almost non-existent. It is often accompanied by other injuries such as a bone bruise, meniscus, cartilage, collateral ligament and/or capsular injury. In severe but more rare cases, there may be a bone fracture, vascular and/or nerve injuries.

Gescheurde voorste kruisband trauma moment
Here you see a knee injury and tear of the anterior cruciate ligament.

How does the severity of the injury affect treatment.

A stretched, partially or completely torn cruciate ligament does not necessarily make a difference in treatment. In all three situations, there can be an insufficiency of the anterior cruciate ligament. In other words, the passive stability of the knee is not sufficiently ensured. This is an indication for anterior cruciate ligament surgery. Yet it is also possible that the knee remains passively stable. Conservative treatment is then an option.

If multiple ligaments are involved in the injury then it is referred to as a multi-ligament ligament injury. These injuries are generally serious, but treatment varies depending on the structure involved. The capsule and inner ligament are structures that generally recover well. Some reluctance for surgical intervention is recommended. What factors into this consideration is that the outcome of an inner ligament reconstruction is almost always suboptimal. Some to minor laxity remains. 

The outer ligament and the corners of the knee (postero lateral and medial angle) are structures that usually, in combination with a torn anterior cruciate ligament, require surgical treatment. The preferred option is to operate even in the acute phase. At this stage during surgery, the structures are still easily identifiable for the physician to repair.
It is important to always have the knee evaluated by a knee specialist to determine which treatment is most appropriate. If you want to read more about whether surgery is necessary and whether speed plays a role in this read our blog click here.

2. I have an unstable knee.

Stability of the knee can be divided into three forms. The passive-, active-, and functional stability. Passive stability is ensured by the knee ligaments. Active stability is regulated by the muscular system. Both systems together form the functional stability. This is the stability you experience in everyday life, at work, and during sports.

Kniebandletsel kan resulteren in een passief instabiele knie. Zijn de spieren goed getraind dan kan de actieve stabiliteit op orde zijn. Dit is een verklaring waarom mensen in het dagelijks leven weinig tot geen klachten hoeven te ervaren. Daarnaast zijn cyclische sporten zoals hardlopen en fietsen meestal geen probleem.

Degree of knee instability.

If there is low passive instability with good active stability, it may be quite possible to participate in various sports (tennis, boxing, etc). 

It is also for this reason that it is important to take the time to train the muscles around the knee properly. In this way it can be determined whether the knee is functionally stable and a careful estimate can be made whether sports resumption is possible. 

For intense sports like soccer, basketball etc a stable knee is necessary. Usually without anterior cruciate ligament reconstruction you cannot return to your old sport level. The type of sport is important here.

Clearly, the knee needs to be assessed by an experienced physician and/or physical therapist to give you targeted advice.

3. I want to return to sports after my anterior cruciate ligament injury.

There are many different sports you can participate in. Each sport has its own risk profile and demands on the knee. To give some insight and distinguish between the different sports here is an overview.

Type of sport.

Low risk (level 3) to high risk (level 1) sports.

  • Level 3: sports without contact and rotation such as running, cycling, skating, swimming and climbing. 
  • Level 2: sports without contact but with rotation such as tennis and other racquet sports, volleyball, bag training boxing, dancing, skiing, snowboarding, surfing and other water sports.
  • Level 1: sports with rotation and contact such as soccer, basketball, handball and other team sports, as well as martial arts such as kickboxing.

Level 3 sports are generally possible without an anterior cruciate ligament. Prerequisites are of course that the active stability (muscular system) is in order. 

Level 2 sports is the risk increased for new knee injury with a passively unstable knee. However, it is possible to play level 2 sports without anterior cruciate ligament reconstruction provided there is low passive instability and a good active muscular system. 

Level 1 sports the risk is high for a new knee injury with a passively unstable knee. In the case of minimal passive instability and good active muscle system it might be possible to still participate. Possibly you can choose to adjust the level of sport. See also: Level of sport.

It is recommended that these choices be made in consultation with your physical therapist and/or physician. In addition, it is advisable to continue to maintain the muscles through targeted strength training to reduce the chance of a recurrence.

na een voorste kruisband blessure weer skiën
skiing is a high-risk sport for cruciate ligament injuries

4. I want to return to sports at my old level.

The top and professional athletes are generally always operated on. Of course, there are always exceptions.

Level of sport

Athletes at level 1 will usually lean towards an anterior cruciate ligament reconstruction. Especially if the ambition is to continue playing sports at the old level. If there is a slight passive instability, you can consider playing sports at a lower level/class. An alternative option is to play another sport at level 2 or 3. Taking a step back or choosing an alternative can possibly prevent a cruciate ligament operation. Also realize that not everyone can return to their former sporting level after an anterior cruciate ligament reconstruction. It is advisable to consult your physiotherapist and/or doctor for personal advice in all situations.

voorste kruisbad basketbal
basketballs goal of the operation
matias mena vpBCwSwryCc unsplash
Basketball is a typical level 1 sport.

5. I continue to suffer from instability after a course of physical therapy.

If, after targeted rehabilitation with the physical therapist, you have persistent instability symptoms in daily life then you have an indication for an anterior cruciate ligament reconstruction. The risk of meniscus injury and early wear and tear is increased.

If you have no instability symptoms in daily life then an anterior cruciate ligament reconstruction is not necessary. This means that life without the cruciate ligament is usually possible. To be able to return to sport at the same level as before, a reconstruction is a personal choice.

6. I am older and want anterior cruciate ligament reconstruction.

An anterior cruciate ligament reconstruction is age independent. However, as indicated, the indication must be there to undergo the operation. Only a torn cruciate ligament is no reason to opt for a reconstruction. An unstable knee in daily life is and if that person is twenty or fifty years old it does not matter. 

In practice, however, a person in their twenties has higher demands for exercise and sport (soccer, basketball, etc) than someone in their fifties (walking, running, cycling, fitness, etc). 

If you still want to play soccer in your fifties, an anterior cruciate ligament reconstruction can be considered. But rehabilitation is often more difficult than for someone in his twenties and the result is also more unpredictable. It can be a consideration to take a step back in the sports career. For the level 1 sports and daily life, it is usually sufficient for the fifty-year-old to train the muscles around the knee well.

7. I am disciplined and motivated for knee rehabilitation.

Surgery is exciting, but rehabilitation is what you need to recharge yourself for.

Doing exercises at home, following precepts, exercising regularly and doing so week in and week out. Training two, three or four times a week in addition to your work, school, study or other things asks quite a bit of your discipline and motivation. Keep in mind that you have to keep this up for an average of 9 to 12 months. It is hard to imagine what impact this will really have on your life. For an optimal result of the surgery it is still relevant to make an estimate of this for yourself. 

Tips:

  • It can help to train in groups. 
  • Make short term goals
  • Zorg voor een reël en haalbaar hoofddoel.
  • Do intermediate tests to make your progression objectifiable.
  • Train in a fun and challenging environment.

You do all this together with your physical therapist.

8. Short- and longer-term goals, expectations and ambitions.

An anterior cruciate ligament reconstruction is done initially to regain the stability of the knee and not to be hampered in daily life. Most people also want to return to their old level of sport. Looking at the figures, about 65 percent return to their old level of sport and about 55 percent actually start playing games again at this level. Take these figures into account when considering whether you want surgery. The chance of returning to the old level depends to a large extent on your own personal commitment and circumstances. 

In practice, we find that athletes are driven to get back to their old level and generally consider surgery. It is important to realize what you are choosing. An anterior cruciate ligament reconstruction means an intensive rehabilitation from an average of 9 to 12 months. On average, rehabbers train 3 times a week for 1.5 hours at the practice in addition to homework exercises. However, the outcome of the rehabilitation is not fixed. The knee will never be a 10 again, because the new cruciate ligament is not the original ligament and there is usually additional injury. But an 8 or 9 is still more than adequate. For one person, this is perfect and can return to top-level sports; another may continue to experience some discomfort. Also realize that new knee injuries are common and therefore it is important to rehabilitate as best as possible.  

So it may be a well-considered choice to take a step back with this information. If you choose for another and more safe sport, you can consider, in consultation with your doctor, to go for conservative rehabilitation. For the possibilities, look again at point 3 and 4. Conservative rehabilitation does not exclude surgery. 

The young athlete <30

Individual goals are important in deciding whether or not to have surgery. For teens and young adults who are active on the athletic fields, surgery quickly becomes a logical choice. Not everyone necessarily wants to return to their old level of sport or chooses to take up another sport or hobby. Therefore, it is always important to put the cards on the table and discuss and weigh the pros and cons.

Adults

For those adults who are a little further along in life, different expectations apply and have different goals than at a younger age. It is always a personal decision, but if you want to play soccer for one or two years, is surgery and long rehabilitation worth it? Playing soccer with friends or with your children is usually fine. If you notice after a while that it is not possible, you can always consider surgery. Besides sports, there are plenty of other reasons and goals to postpone or cancel surgery. Think of a (long) vacation, study, (foreign) internship, children, sports wishes, etc. 

The fact is that over the years sporting activities become less and the type of sport shifts from team sport to individual sport (running, fitness, group classes etc). The demands we make on our bodies decrease (complex movement patterns to simple movements). So the need for an anterior cruciate ligament reconstruction is decreasing. If after rehabilitation, or after months or years you still have an unstable knee, surgery is always possible.

To undergo an anterior cruciate ligament reconstruction or not. It remains an individual quest. Talk to other fellow sufferers, talk to the doctor and/or physical therapist about your wishes, goals and ambitions. Read up on the subject and hopefully the blogs on Thekneeclub.com will give you something extra to think about the things that matter.

opereren of conservatief
Opereren of niet wat is jouw beslissing?

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