Cruciate ligament tears
Anne Brennan
A few years ago I was testing the knees of a young school netball player who had sharp knee pain. I used the ‘Drawer’ test which glides the shin bone(the tibia) forward and then back to test if the cruciate ligaments (which run between the thigh bone (femur) and the tibia) were sound. One knee slid well forward suggesting a serious tear and an unstable knee. Surprisingly, however, this was her ‘good’ knee. The painful knee tested fine.
Coincidentally I had a weekend sports seminars on knee injuries and surgery not long after. These aren't for the faint hearted. Surgeons slow motion and replay the moment when a player lands awkwardly twisting their knee/ankle gruesomely. Next comes the footage of the surgery. And, finally, the player is shown, happily, returning to sport. One surgeon/speaker said it was a no brainer: he operated to reconstruct all knee cruciate ruptures. Another described an Olympic ski jumper who had re-torn her cruciate ligament after surgery but completed the season before going back for a second reconstruction. Remarkable, I thought, on two counts: first that she ski jumped with a ruptured cruciate and, secondly, why would she have more surgery?
The second surgeon suggested there was a good case for avoiding surgery. I have to say it wnat an option for teenagers in the low socioeconomic area I worked in, so that was releif.
This was several years ago. Recently, I was surprised to see a television report (on the ABC’s 7.30 report) that promoted knee reconstruction surgery for children. The surgeon had been testing a procedure that used a parent’s donated tendon to repair their child's knee.
This is an (edited) letter I wrote to the presenter, Leigh Sales.
Dear Leigh Sales
I was concerned by your report last night ( ABC’s 7.30 Report (16/11/2016)) on knee surgery for children.
Cruciate surgery (or knee reconstructions) have been under scrutiny over the last ten years. The research by Mr Roe compares like with like (one type of tendon transfer and material against another), but doesn't consider less invasive alternatives such as exercise.
In contrast, the Swedish longitudinal trial (the KANON study) compared two groups of young patients. One underwent knee reconstruction surgery to repair cruciate tears and another, instead, underwent an exercise program to develop balance and stability. This research showed that, five years after the procedure, those who did the exercises had the same or less pain symptoms and radiographic outcomes (the bones didn't look more damaged as many feared) to those assigned to surgery and rehabilitation(Frobell et al., 2013). That is, teenagers who exercised rather than surgery probably fared better that those who had surgery. The surgery group did NOT improve short term or long-term symptom outcomes (Culvenor et al., 2013).
This research counters Mr Roe’s unsubstantiated claims that surgery is essential to prevent damage. Worryingly, the Swedish research found that many who had surgery had excessively tight knees, which may explain their propensity to snap again.
The loss of strength and weakness following pain and injury needs to be reversed by active movement exercises [1]. These require time and commitment which is compromised by the belief (perpetuated by programs such as yours) that surgery is essential.
I have been a physio for many years and seen many with joints described by surgeons as unworkable due to torn ligaments. Yet they recover and resume soccer or tennis if prepared to do the hard yards and train their muscles up. Knees are over engineered to survive one or two tears (even cruciate ligaments) and these can be sacrificed to prevent bone fractures. The theory that surgery is essential is not backed by science.
My letter ended here. I got a call back from a reporter but the issue was not addressed again on the show. It is a concern that children plus their parents were being sent to surgery. One mother mentioned that months after the surgery she still had pain.
So think about it before signing up for surgery. At the very least do ALL the exercises prescribed to help recovery from surgery but do them before the surgery and do them little and often. And get a lot of help tailoring and progressing exercises, preferably upgrading them every third day. And be patient: it can take the same amount of time to recover from pain as it does to recover from major surgery(three months). And don't see someone who hands out a tear off sheet,or gives everyone the same gym program and/or encourages expensive electrical treatment. This won’t substitute for the hard yards.
Culvenor, A. G., Lai, C. C. H., Gabbe, B. J., Makdissi, M., Collins, N. J., Vicenzino, B., . . . Crossley, K. M. (2013). Patellofemoral osteoarthritis is prevalent and associated with worse symptoms and function after hamstring tendon autograft ACL reconstruction. British Journal of Sports Medicine.
Deyo, R. A. (1993). Practice variations, treatment fads, rising disability: do we need a new clinical research paradigm? SPINE, 18(15), 2153-2162.
Frobell, R. B., Roos, H. P., Roos, E. M., Roemer, F. W., Ranstam, J., & Lohmander, L. S. (2013). Republished research: treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. British Journal of Sports Medicine, 47(6), 373.
NHMRC. (2003). Evidence based management of acute musculoskeletal pain. Retrieved 12 April 2012