If you’re a keen follower of football or sports in general, there’s a fairly high chance you’ll have heard or read about the season-ending consequences of anterior cruciate ligament (ACL) damage.
NFL star Tom Brady, footballer Zlatan Ibrahimovic and England rugby’s Sam Simmonds are three examples of top-level athletes who’ve been sidelined for more than six months by such injuries.
More often than not, the media reports on the necessity of surgery to fix a full rupture but the approach to recovery is not without debate.
We spoke to Mr. Robert Marston, a knee and hip specialist at St John and St Elizabeth Hospital, to find out what the best course of action is to getting back on your feet.
Mr. Marston, who has worked with professional footballers as well as the English National Ballet Company, says, “Anterior cruciate ligament injuries are very common in contact sport particularly in football because they are tackling with the leg fully extended. If they have contact with someone else they can get a torsional injury and that can cause both a shin fracture or an ACL injury.”
ACL injuries used to be very common in professional rugby until they changed the rules relating to tackling and rucking. Mr Marston says, “About 15 years ago a very large number of the England rugby squad had an ACL deficient knee but because their hamstring muscles were so well developed this would compensate for the forward movement of the shin bone in relation to the thigh bone which is what the ACL prevents.”
This is interesting because it plays counter to the assumption that if someone has an ACL injury they automatically need reconstruction surgery.
Mr Marston says, “There are two schools of thought: one approach which is common in America is that no knee should be without an ACL. There is another group of people, a more European view, that if you give a patient rehab, particularly working on the hamstring muscles, you can compensate for either a badly sprained ligament or indeed a completely ruptured ligament.”
A study in ACL injury at Lund University in Sweden ten years ago has subsequently shown that the latter approach is more sensible.
Mr Marston says, “For this study, they put patients with ACL injuries, all of whom were a similar age and similarly active, into two groups. One group had ACL reconstruction straight away and the other group had hamstring and ACL rehabilitation to start with and only going on to have reconstructive surgery if this failed.
“The people who suggest all ACLs should be reconstructed straight away did so on the belief that, if the patient has a potentially unstable knee and if they have an episode where the knee gives way, it could lead to additional injury to other parts of the knee including the cartilage, the meniscus or another ligament. What this study showed however, is that even for those that failed rehabilitation, they didn’t suffer additional injuries. Ultimately, it was concluded that reconstruction surgery is only necessary for people who fail conservative management and that is pretty groundbreaking.”
This is important because reconstruction surgery in itself can cause problems down the line.
Mr Marston says, “There is evidence that a lot of ACL reconstructions were too tight – a surgeon can determine how tight you make the ligament between the two bones – and that over stabilizing the knee was increasing post-traumatic osteoarthritis.”
While cases of injury are never one and the same – and it is important to distinguish between an injury involving just the ACL or one with multiple ligament damage – patients with the former can take some comfort in the fact they won’t automatically need surgery, something that is not without risk and involves plenty of down time.
If you would like to book an appointment with Mr Marston, please call on 020 7432 8328