SELF-HEALING POTENTIAL OF THE ACL

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SELF-HEALING POTENTIAL OF THE ACL
http//www.virtualphysicaltherapists.com/
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A twist, a pop, a fall to the ground, pain, and
immediate swellingunfortunately, this experience
is too common in our young athletes. Anterior
Cruciate Ligament (ACL) ruptures cause
instability and potentially end sports activity
and careers, causing long-term physical and
psychological consequences. Is surgery the best
option, or is there a self-healing potential for
the ACL?
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• ACL Injury Stats
• More than 200 000 ACL injuries occur in the
  United States each year. Most occur during
  athletic activity involving pivoting and cutting
  sports affecting high school females 4-6x more
  often than their male counterparts. Most injuries
  result from non-contact and not a collision with
  another player. Change of direction (COD) has
  been identified as the leading cause of ACL
  tears. A quick turn adds a high load when the
  knee is flexed, rotated, and abducted. When the
  foot is planted on the ground, this quick change
  of direction causes stress on the ACL, and the
  addition of high-level force can be disastrous.
• The position of the knee during a change of
  direction is the key to reducing ACL trauma.

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• Surgery is Currently the Most Common Treatment
• Approximately 90 of Americans who tear their ACL
  eventually have surgery, replacing the ACL with a
  cadaver or using a piece of their infrapatellar
  or hamstring tendon.
• The ACL is the main stabilizer of the knee. An
  intact ACL is considered essential for athletic
  activity, especially sports that require pivoting
  and cutting. It is also thought that the ACL is
  incapable of healing because of inadequate blood
  supply.

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Therefore surgical repair is essential to return
to playing high-level sports, and opting not to
repair will lead to meniscal tears and early
osteoarthritis. Searching the internet will
produce site after site that the ACL does NOT
have blood supply because the fluid in the knee
that allows smooth movement blocks clotting, thus
preventing the ability of the ACL to connect and
heal. ACL repair is sold as the gold standard
enabling the return to play and preventing
further meniscal damage and osteoarthritis.
Research has shown that the outcomes of ACL
reconstruction are not as great as we are told,
with the increased risk of re-injury and future
risk of osteoarthritis.
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• Less Commonly Known ACL Surgical Outcomes
• Only 65 of those who underwent ACL
  reconstruction returned to their preinjury level.
  (1,2,3)
• Only 55 of individuals return to competitive
  sports following surgery. (1,2,3)
• There is a high rate (15x) of retearing the
  repaired ACL (9) or the contra ACL (20.5)
  within 2 years following ACL reconstruction.
• 25 of athletes (under 25 years of age) who
  return to high-risk sports go on to have a second
  ACL injury.
• Expectations for returning to the preinjury sport
  are often not met.
• High rates of reinjury suggest that there is
  insufficient neuromuscular training during rehab
  following ACL reconstruction.

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• A 20-year follow-up study on ACL tears found no
  difference in the amount of osteoarthritis in
  surgical repairs vs. rehab only.
• Potential surgery side effects infection, scar
  tissue, blood clots, kneecap pain,
  pain/weakness/tendonitis at the graft site
  (hamstring or patellar tendon), reaction to
  anesthesia
• Surgical outcomes have shown poor odds of
  returning to play and high incidences of retear.
• There is a FALSE ACL surgical narrative.. we
  need a Paradigm shift Rethink a rush to ACL
  Reconstruction.

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Non-surgical Outcomes Following a Complete ACL
Tear Surprisingly 2 and 5 years after an ACL
injury, the research found no significant
differences in outcomes of ACL surgery versus
those that completed a structured rehab program
instead of surgical repair. Even more surprising,
a twenty-year study found no difference in
arthritis between those getting surgery and those
doing conservative care. The anterior cruciate
ligament has healing capabilities, and
conservative management may provide some athletes
with optimal functional outcomes. Unfortunately,
very few studies compare surgical reconstruction
to rehab alone for ACL tears. The studies did
show that long-term results were much better in
non-surgical patients.
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Return to Play with Complete ACL Tear NO
surgical Repair But there are instances when a
complete ACL tear athletes have returned to play
without surgery. McDaniel and Dameron in 1983,
found that after14-years 76 of untreated
patients with ACL ruptures returned to strenuous
sports. They all had reduced incidences of giving
way but continued high rotary instability.
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• Despite What is Commonly Believed, the ACL has
  Self-Healing Potential!
• Over the years, a few cases of spontaneous
  healing of complete ACL tears have been reported,
  but this has not received as much attention as
  profitable surgery.
• Over 50 of ACL tears can heal by themselves with
  no focused treatment. Research has found that 56
  of tears spontaneously heal at 2 years and 58 at
  5 years.
• Instead of rushing to surgery, the focus should
  be on the self-healing potential of the ACL!

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A fracture requires 6-8 weeks to heal. We have
only begun researching ACL healing, so we do not
know the amount of time needed and the best
position, diet, exercise, etc., that will promote
this process. Unfortunately, very few studies
have been done, and little is known about what
facilitates and what stressors reduce ACL healing
other than our plasma is involved. If over 50
can heal without targeted treatment, then
significantly more with improve with proper care.
We do not have a protocol for large
double-blinded studies. Still, we do have smaller
studies and case reports on individuals that were
able to return to higher level sport activity
without surgery. Initially, the focus is on
stabilizing the knee to avoid additional trauma
and rotary stress on the injured ligament. This
is usually done by bracing and self-awareness by
avoiding movements or activities that may harm a
newly injured knee. As the weeks pass, the
individual will gain confidence and can wean from
bracing. We also know that weight bearing is
critical for ligamentous healing and maintaining
knee integrity. Physical loadings provide an
important stimulus for maintaining ligament
tissues normal structure and function.
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• Research of Spontaneous ACL Healing
• 1996 Ihara et al. analyzed 50 athletes with acute
  ACL ruptures treated without surgery using a
  specially designed brace. Eleven months later, 29
  patients showed a continuous ACL on MRI.
• 1996 50 cases of complete rupture after only 3
  months of early protected motion 74 of ACL tears
  showed healing.
• Two case studies were reported (1998) of
  spontaneous ACL healing. It was found that
  proximal injuries close to the bone should
  enhance the healing capability.

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4. 2001 case study of spontaneous healing of a
complete ACL tear after one year. 5. 2002
Fujimoto et al. followed 31 patients using an
extension block soft brace x2- 3 months.
All patients showed healing, 74 were stable at
16 months, and only 8 required surgery because of
instability 6. 2012 Costa-Paz et al. followed
complete ACL tears with no bracing or specific
rehab program. They found after 30 months no
instability and MRIs, showed end-to-end ACLs, and
were able to return to their previous sports
activity without bracing and specific rehab
parameters.
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• Surgery Instead of Replacing Enhance ACL
  Healing
• There have been exciting new developments in ACL
  restoration. Unlike ACL reconstruction, which
  replaces the torn ACL with a graft from the
  patient or donor, a bridge-enhancer known as BEAR
  reportedly can heal a torn ligament. The
  procedure uses an implant containing bovine
  collagen and the patients blood to fill the gap
  between the torn ends of the ACL to promote
  healing.
• BEAR (Bridge-Enhanced ACL Restoration) procedure
  uses a new device called the BEAR Implant, made
  from purified bovine (cow) collagen, to bridge
  the ACL stump to the bone using stitches to
  stimulate restoration. Instead of replacing the
  torn ligament, this new technique helps the ACL
  grow back together. Bear is a new procedure and
  is currently being studied across the nation.

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ACL Reconstruction does have a place after all
conservative care has failedBUT, we hope that
the promotion of the self-healing potential of
the ACL becomes the new gold standard of care
instead of ACL replacement.
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