Arguments for (g)anterior cruciate ligament surgery, 8 considerations.
The anterior cruciate ligament injury
A torn anterior cruciate ligament occurs in young and old, athletic or not and is gender independent. What is noticeable is that it occurs more often in women than in men. Each person has their own goals, desires and ambitions. Everyone experiences the complaints and limitations in his or her own way. For this reason, there is no one-size-fits-all treatment for a torn cruciate ligament. Caregivers treat people, not knees, and therefore a personal consultation should determine which treatment is best. 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 whether or not to have surgery. In this blog, we will discuss the 8 most important factors.
8 arguments for (g)anterior cruciate ligament surgery:
- Severity of injury
- Degree of knee instability
- Type sport
- Level of sport
- Instability in daily life after a course of physical therapy
- Discipline and motivation
- Goals, expectations and ambition
1. I twisted my knee.
An anterior cruciate ligament can stretch, completely- or partially-tear. Moreover, an isolated anterior cruciate ligament injury is almost uncommon. It is often accompanied by other injuries such as bone bruising, meniscus, cartilage, collateral ligament and/or capsule injuries. In severe but more rare cases, there may be bone fracture, vascular and/or nerve injuries.
The severity and treatment of an anterior cruciate ligament injury
A stretched, partially torn or completely torn cruciate ligament does not necessarily make a difference in treatment. In all three situations, there may be an insufficiency of the anterior cruciate ligament. In other words, the passive stability of the knee is not sufficiently guaranteed. This is an indication for anterior cruciate ligament surgery. Nevertheless, it is also possible that the knee remains passively stable. Conservative treatment is then an option.
If multiple ligaments are involved in the injury, it is referred to as a multi ligamentous 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 preference is to operate even in the acute phase. At this stage during surgery, the structures are still readily identifiable for the physician to repair.
It is important to always have the knee evaluated by a knee specialist to determine the best treatment. Want to read more about whether surgery is necessary and if speed plays a role in this read our blog click here.
2. I suffer from 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 controlled 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.
Knee ligament injury can result in a passively unstable knee. If the muscles are properly trained then active stability may be in order. This is one explanation why people may experience little to no symptoms in everyday life. In addition, cyclical sports such as running and cycling are usually not a problem.
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).
Partly for this reason, it is important to take your time and properly train the muscles around the knee. In this way, it can be determined whether the knee is functionally stable and a careful assessment can be made as to whether sports rehabilitation is possible.
For intensive sports like soccer, basketball etc, a stable knee is necessary. Usually without anterior cruciate ligament reconstruction you cannot return to your old level of sports. The type of sport is important here.
Obviously, the knee should be evaluated by an experienced physician and/or physical therapist to give you specific advice.
3. Can I 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 requirements for the knee. To give some insight and differentiate between the various sports, here is an overview.
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 active stability (muscle system) is in order.
Level 2 sports the risk is 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 good active muscle 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. If necessary, you may 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. It is also advisable to continue to maintain the muscles through targeted strength training to reduce the risk of recurrence.
4. Can I return to sports at my old level?
Top and professional athletes are generally always operated on. Of course, there are always exceptions. Level 1 athletes will usually lean toward anterior cruciate ligament reconstruction. Especially if the ambition is to continue playing sports at the old level. If there is minor passive instability then you may consider playing a level/class lower. An alternative option is to take up another sport at level 2 or 3. Stepping back or choosing an alternative can potentially prevent cruciate ligament surgery. Also realize that not everyone can return to their former level of sports after an anterior cruciate ligament reconstruction. In all situations, it is advisable to consult your physical therapist and/or physician for personalized advice.
5. I continue to suffer from instability after a course of physical therapy.
If you have persistent instability symptoms in daily life after targeted rehabilitation with the physical therapist, then you have an indication for anterior cruciate ligament reconstruction. There is an increased risk of meniscus injury and early wear and tear.
If you have no instability symptoms in daily life, then anterior cruciate ligament reconstruction is not necessary. This means that life without a cruciate ligament is usually quite possible. However, in order to return to sports at the old level, reconstruction is a personal choice.
6. Is anterior cruciate ligament reconstruction age-related?
An anterior cruciate ligament reconstruction is age independent. However, as indicated, the indication must be there to undergo the surgery. Just a torn cruciate ligament is no reason to opt for reconstruction. An unstable knee in daily life is, and if that person is twenty or fifty years of age doesn't matter much.
In practice, however, a twenty-something has higher demands for exercise and sports (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 their twenties, and the outcome is also less easy to predict. It may be a consideration to take a step back in one's athletic career. For level 1 sports and daily life, it is usually sufficient for the fifty-something to properly train the muscles around the knee.
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, working out regularly and doing so week in and week out. Working out two, three or four times a week in addition to work, school, study or other things requires 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 is really going to have on your life. Nevertheless, for optimal results from the surgery, it is relevant to estimate this for yourself.
- It can help to train in groups.
- Create short-term goals
- Provide a realistic and achievable main goal.
- 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 primarily to regain the stability of the knee and not be hindered in daily life. In addition, most people want to return to playing sports at the old level. Looking at the numbers, about 65 percent return to their old level of sports and about 55 percent actually play games at this level again. Consider these figures when considering whether to have surgery. The chances of returning to the old level depend largely on your own personal effort and circumstances.
In practice, we find that athletes are driven to get back to their former level and generally consider surgery. It is important to realize what you are choosing. An anterior cruciate ligament reconstruction means intensive rehabilitation for an average of 9 to 12 months. On average, rehabbers train 3 times a week for 1.5 hours at practice in addition to homework exercises. However, the outcome of 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 elite sports; another may continue to experience some discomfort. Also realize that new knee injuries are common and therefore it is important to rehabilitate as well as possible.
So it may be an informed choice to take a step back with this information. If you choose a different and more safe sport then you may consider, in consultation with your doctor, conservative rehabilitation. For options, look again at points 3 and 4. Conservative rehabilitation does not rule out 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 sports fields, surgery is easily the logical choice. Not everyone necessarily wants to return to their former level of sports or chooses to pursue another sport or hobby. Therefore, it is always important to put the cards on the table and discuss and weigh the pros and cons.
For adults who are already a little further along in life, different expectations apply and have different goals than at a younger age. It always remains a personal consideration, but if you want to play soccer for one or two more years, for example, is surgery and long-term rehabilitation worth it? Playing soccer with friends or with your children usually works. If you notice after a while that you still can't, you can always consider surgery. Besides sports, there are plenty of other reasons and goals to postpone or forgo surgery. Think of a (long) vacation, study, (foreign) internship, children, sports wishes, etc.
The fact is that over the years, sports activities become less and the type of sport shifts from team sports to individual sports (running, fitness, group classes, etc). The demands we place on our bodies decrease (complex movement patterns to simple movements). Thus, the need for anterior cruciate ligament reconstruction is decreasing. If you still have an unstable knee after rehabilitation, or over the course of months or years, surgery is always an option.
To undergo anterior cruciate ligament reconstruction or not. It remains an individual quest. Talk to other sufferers, talk to the doctor and/or physical therapist about your wishes, goals and ambitions. In addition, read yourself well and hopefully the blogs on Thekneeclub.com will give you additional guidance to think about the issues that matter.
Do you have any arguments for (g)anterior cruciate ligament surgery leave a message in the comments.