Surgery & physical therapy equally effective in knee ligament tears: study

By Dr. Ananya Mandal, MDJul 21 2010

A new study released this Wednesday compared intense physical therapy with surgery in common knee ligament injury and found that both techniques had similar outcomes. The study was published in the New England Journal of Medicine. Initial rehabilitation in the tears of anterior cruciate ligament (ACL), which lies beneath the kneecap and attaches the thigh bone to the shin bone, could improve outcome of surgeries and reduce surgeries by half say researchers. ACL tears are fairly common and 200,000 ACL reconstructions are done in the United States each year at a cost of billions of dollars.

According to Richard Frobell of Lund University in Sweden, lead researcher treatment of “an acute ACL injury should start with structured rehabilitation rather than early ACL reconstruction.” His team studied 121 people aged 18 to 35, none of them professional athletes. However most of them were soccer and volleyball players. Around half of them received surgery and others were given rehabilitation in hopes of delaying the operation. 23 of the 59 in the rehabilitation group needed surgery. Assessment at two years after surgery showed that people in both groups were doing just as badly as the others. The ratings were made on the basis of pain, ability to function and play. The authors conclude, “Surgical reconstruction was avoided in 61 percent of the subjects without compromising the results.”

According to a commentary by Dr. Bruce Levy of the Mayo Clinic in Rochester, Minnesota, “It confirms what we have always intuitively thought and known, and that is that not all patients need their ACLs reconstructed and that the decision to perform an ACL reconstruction really needs to be individually tailored.” However he cautioned that waiting too long for a much needed surgery can cause harm. “There's solid evidence that people who have ACL tears and do not have reconstruction, if they go on to have frequent giving-way or instability episodes, they are at an increased risk of doing damage,” he said. But he said it was hard to predict which patients will need surgery, and said longer-term data are needed.

According to Dr. Kurt Spindler of Vanderbilt University, the rehabilitation group showed more signs of trouble with the meniscus, a rubbery, cushioning disc in the knee. This could raise their risk of getting osteoarthritis.

At present authors are planning to follow-up these patients over five years mainly to look for early signs of arthritis with X-rays and other medical imaging.