To Reconstruct the Anterior Cruciate Ligament or Not? – Put into Panther Perspective

The anterior cruciate ligament, AKA the ACL, is the number one ligament of attention to the sports medicine professional. No other has received research and public attention like the ACL injury. Everyone knows and dreads it, from athlete to coach and young to old!

Forty years ago, the ACL injury retired most pivoting sport athletes, and the big game-changer came in the late 80s when “the cure” arrived. The ligament was then primarily reconstructed with one’s own tendon tissue, and the instability problem solved long-term. The narrative around the ACL injury changed…it was no longer career ending. Problem solved – except not quite.

I’ll never forget my first sports physical therapy conference in the United States. In a symposium debate on ACL injury, the conversation was entirely focused on graft choice – seemingly overlooking rehab as a first option. I was flabbergasted when the panel and floor together discussed and consented that the allograft was graft choice for the “couch potato,” due to it not being as strong/good as an autograft. But, did I hear this “consensus” right? When we know 50 percent of athletes who go through rehab first with optional delayed surgery, can proceed without surgery for the first 2-5 years!^1,2 Unfortunately, I did! The idea of a specific graft type waiting for all who rupture their ACL is not driven by the scientific evidence. While ACL surgery is not cost-effective in the public healthcare system,³ it may be “cost-effective” in the private health care system – at least for those getting paid to do it. This may provide different perspectives and difficult conversations among healthcare professionals from different health care systems.

Recently, the Panther consensus paper was released, including healthcare professionals from different countries and healthcare systems.⁴ The Panther consensus panel agreed 100% that both operative and non-operative care for ACL injury is acceptable⁴ – so far so good. However, whether rehab first with optional delayed surgery is an acceptable approach was not clearly addressed, although tackled in high-level randomized controlled trials.^1,2 The Panther group disagreed on delayed operative care as an option for temporary return to athletic participation, following non-operative care and accepting the risk of additional injury.⁴

According to the experts, the elite athlete competing in pivoting sports needs a reconstruction⁴ - but despite lots of ACL research, we still only have Level 5 evidence from consensus.⁴ Even if we as experts promote shared decision-making,⁴ the expectations from younger athletes are already so high,⁵ and the procedure offered so quickly, that it seems questionable if athletes are ready and receptive for grasping mean outcomes and return to sport odds. Can we expect them to make truly informed and thoughtful decisions in a few weeks?

So, how does it go with those who receive the procedure? Several graft choices later, the injury and its devastating consequence for many athletes still prevails.^6,7 Many do not return to play at their pre-injury level, and of those who do, many have their sports career significantly shortened.^6,7 At the same time, the rehab period these days is long – suggested to be up to two years⁸ – so many career dilemmas for the elite athlete exist. Future knee health may only play a small part in the decision on surgery and return to play times. The dream of ACL reconstruction as a career savior is understandable and a more attractive initial mind-set than the uncertainty around odds for successful recovery. But do we “sell” them a dream by suggesting immediate surgery?

Why not delay the final decision and increase the athlete’s experience in life without an ACL? Why not see delayed optional surgery as a way to provide athletes with individual experiences on dynamic knee stability, strength and performance,⁹ as well as to form realistic expectations concerning different rehab strategies? It is suggested that the question “should you return to play?” needs posing.⁶ But is asking this question early in the process even feasible? In less than 50 milliseconds the life and identity of an athlete is turned upside down. With such an injury comes both shock and a grieving process!¹⁰ Athletes finding themselves again require time – not immediate surgery nor definite career decisions. ACL rehab is much more than graft choice, open versus closed kinetic chain exercises, and return to sport at pre-injury level. Psychological recovery and support may be important for athletes who want to return to sport - but what about those who can’t or won’t? They need just as much support. So, more focus and research on these perspectives, please, for the benefit of all athletes! The ligament “fixation” has stolen too much of our attention.