You’ve got a bum knee. Now what?

New re­search sheds light on treat­ment choices for torn knee lig­a­ments.

Health & Nutrition - - ARTHRITIS SPECIAL -

A30-year-old soc­cer player takes a sharp turn on the field and hears a dreaded “pop” in his right knee. He has rup­tured the an­te­rior cru­ci­ate lig­a­ment (ACL) – a band of tis­sue that’s im­por­tant for sta­bi­liz­ing the joint. After ic­ing, com­press­ing, and el­e­vat­ing his swollen knee, he vis­its the doc­tor. Now it’s time to de­cide on treat­ment. If he’s an elite sports­man or has ad­di­tional knee dam­age, the choice is fairly clear: Re­con­struc­tive surgery to re­place the ACL, plus in­tense phys­i­cal ther­apy. But if he’s a week­end ex­er­ciser who doesn’t do many knee-stress­ing sports, for­go­ing surgery in favour of re­ha­bil­i­ta­tion through phys­i­cal ther­apy may be a sen­si­ble ap­proach. A re­cent study by re­searchers in Swe­den and Den­mark con­firms this. The in­ves­ti­ga­tors fol­lowed 121 young, ac­tive adults with ACL tears, half of whom were ran­domly as­signed to have phys­i­cal ther­apy and surgery, while the oth­ers had phys­i­cal ther­apy with surgery as an op­tion later. Two years after their in­juries, peo­ple in both groups had “sub­stan­tial im­prove­ment:” in their knee con­di­tion, and there were no ma­jor dif­fer­ences in five knee-re­lated cat­e­gories such as pain, other symp­toms like swelling, and func­tion in daily liv­ing and sports ac­tiv­i­ties. The re­sults sug­gest a wait-and-see ap­proach may be right for some with torn ACLs and that more than half of ex­pen­sive ACL re­con­struc­tions could be avoided “with­out ad­versely af­fect­ing out­comes,” the in­ves­ti­ga­tors wrote in the The New Eng­land Jour­nal of Medicine. In other words you can take the time to weigh your choices in­stead of rush­ing into surgery.

TWIST OF FATE

The ACL has been de­scribed as the seat belt for the knee ( see il­lus­tra­tion). It runs through the mid­dle of the knee joint and keeps the shin­bone (tibia) from slid­ing for­ward past the thigh­bone (fe­mur). The ACL is one of four main lig­a­ments in the knee – and one of the most com­monly in­jured ones. The ACL can be stretched, torn, or both dur­ing a sud­den or awk­ward twist, turn, or stop, typ­i­cally while peo­ple

are play­ing sports that re­quire sud­den changes in di­rec­tion (piv­ot­ing and cut­ting) or jumping. The sports on that list in­clude bas­ket­ball, foot­ball, ski­ing, soc­cer, ten­nis, mar­tial arts, volleyball, and some kinds of aer­o­bic dance. Col­li­sions aren’t nec­es­sary: about 70% of ACL tears oc­cur with­out di­rect con­tact with another player or ob­ject. Although ACL tears are usu­ally a sports in­jury, they do oc­cur out­side the gym and play­ing field like among dancers, ac­tive adults whose jobs in­volve piv­ot­ing or hard cut­ting, and in­di­vid­u­als who do heavy man­ual work. Peo­ple get their ACLs torn in car crashes. A sim­ple trip or fall that twists the knee can also re­sult in a tear. Women ap­pear to be more vul­ner­a­ble to ACL in­juries, due to dif­fer­ences in

mus­cle strength, align­ment, and es­tro­gen lev­els that can loosen lig­a­ments. There’s also some ev­i­dence that women are more likely than men to turn their knees in­ward when chang­ing di­rec­tion sud­denly, plac­ing added strain on their knees and ACLs.

PROM­ISE OF THE SCALPEL

Di­ag­no­sis of an ACL tear usu­ally in­volves sev­eral hands-on tests and an MRI scan. Then it’s time to choose a treat­ment. Sur­gi­cal re­con­struc­tion in­volves re­plac­ing the in­jured lig­a­ment with a piece of ten­don taken from the per­son’s own leg or from a ca­daver. When the pa­tient’s own tis­sue is used, it of­ten comes from ei­ther the patel­lar ten­don be­low the knee or from ten­dons in the thigh. Us­ing tis­sue from ca­dav­ers has be­come in­creas­ingly common, in part be­cause it avoids the pain caused by re­mov­ing the pa­tient’s ten­don tis­sue. Doc­tors have tried re­pair­ing the ACL by sewing the torn pieces to­gether, but that has gen­er­ally proved to be in­ef­fec­tive. Th­ese days, ACL surgery is usu­ally done arthro­scop­i­cally, through small in­ci­sions. That ap­proach has short­ened the re­cov­ery pe­riod, but you can still feel a fair amount of pain in the days and weeks after the op­er­a­tion. Months of phys­i­cal ther­apy are needed to re­store strength, co­or­di­na­tion, and range of mo­tion. As with all surgery, there are risks,

like in­fec­tion; in some cases, the op­er­a­tion fails to sta­bi­lize the knee.

WHO NEEDS SURGERY?

Re­plac­ing the torn lig­a­ment with ten­don does tend to make the joint more sta­ble than phys­i­cal ther­apy re­hab alone, which is an ad­van­tage for peo­ple who place a lot of stress on their knees. Your knee has suf­fered sub­stan­tial dam­age. Surgery may also be the pre­ferred route if there are ad­di­tional in­juries – for ex­am­ple, if a menis­cus has been torn.

POST-OP WOES

With a long-term suc­cess rate of 82% to 95% many peo­ple – esp sportspersons – who get re­con­struc­tive surgery re­sume their prein­jury ac­tiv­i­ties; But doc­tors say the joint never quite works ex­actly the way it did be­fore the tear, and more re­search is needed to un­der­stand why. Another big dis­ad­van­tage of hav­ing surgery is a slow re­cov­ery. And therein lies the irony: Peo­ple who don’t get surgery nor­mally re­cover enough to be ac­tive again within two or three months. Whereas it takes about six months for surgery pa­tients to get back on their feet re­searchers find. It takes longer to re­cover from surgery be­cause ten­don graft used to re­place the ACL needs to fully heal and be ready to with­stand the stress that play­ing sports can put on it. Early-on­set os­teoarthri­tis is another common com­pli­ca­tion of ACL tears, prob­a­bly caused by in­creased wear on the leg bones and shock-ab­sorb­ing car­ti­lage in the knee over time. It’s not clear whether surgery re­duces the risk of os­teoarthri­tis.

NO -KNIFE AP­PROACH

The ACL doesn’t heal on its own but there are no-knife ways to cope with a bum knee. Phys­i­cal ther­apy can strengthen the mus­cles around the knee enough so they com­pen­sate for the non-work­ing ACL. Treat­ing an ACL tear with phys­i­cal ther­apy alone is worth con­sid­er­ing if it’s a par­tial tear or if you’re not very ac­tive. Cus­tom-made knee braces may be use­ful for ten­nis, soc­cer, or other ac­tiv­i­ties that in­volve twist­ing if you’re a week­end war­rior and not a pro player. Find a new sport Adults who are ac­tive but do “in line” ac­tiv­i­ties such as cy­cling or run­ning might also do well with just phys­i­cal ther­apy be­cause those sports don’t usu­ally in­volve turn­ing and twist­ing the knee. The best way to treat an ACL in­jury can be a judg­ment call that fac­tors in ex­tent of the in­jury, the your age, and your ac­tiv­i­ties. Each sit­u­a­tion is a lit­tle bit dif­fer­ent. It’s im­por­tant to get a sec­ond opin­ion and care­fully weigh your op­tions.

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