A Coper with Suspected ACL Tear: Tell Him It's Torn OR Not?

"I was confronted with the ethical dilemma, do I tell him his ACL is likely torn or not."

​I was recently working with a 16 year old, active young man who injured his knee while playing rugby 6 days prior. During the initial evaluation, he reported quickly decelerating on the field while pivoting his body. He only had minimal pain, and his swelling was quickly improving with each day following his injury. Additionally, he had a rugby tournament overseas in 2 weeks that he needed to be in good athletic condition to play.

As I continued to the examination, I performed the Lachman's Test, which was positive, as well as a positive Anterior Drawer Test. Despite the positive finding, he denied any buckling, locking, or catching. His clinical examination was negative for meniscal pathology and other ligament insufficiency. At this point, I was confronted with the ethical dilemma: Do I tell him his ACL is likely torn or not? On one hand he was making good progress with rest and gradual return to activity. Would the diagnosis of a torn ACL create thought viruses that would hinder his progress with conservative treatment? On the other hand, if he had a torn ACL, does he potentially have other associated injuries? Segund fractures are present in 75-100% of ACL tears. Lateral meniscus tears occur in 54% of acute ACL injuries. 

Ethical Decision

As the patient, he had the right to know my clinical findings. I told him his mechanism of injury and clinical presentation are consistent with an ACL tear. Additionally, I educated him and his mother on the treatment options, copers vs. non-copers, risk of future injuries, and risks of surgery. 

The family made the decision to see an orthopedic specialist, who ordered an MRI. The MRI identified a fully torn anterior cruciate ligament and bucket handle tear of his medial meniscus. 

"The MRI identified a fully torn anterior cruciate ligament and bucket handle tear of his medial meniscus." 

The following week, he travelled with his rugby team and played in several matches. Upon his surgeon's recommendation, he would have surgery after the tournament to reconstruct his ACL and repair the meniscal tear. In this case, should surgery have been avoided? Was his ACL surgery really necessary? 

Is ACL Surgery Really Necessary? 

For many many, a torn ACL was synonymous with surgery. However recently, the optimal management of ACL injuries has been placed under question. Recent research, 'A Randomized Trial of Treatment for Acute Anterior Cruciate Ligament Tears,' identified that ACL reconstructive surgery was NOT superior to conservative management of ACL tears in young active adults. A second study by Meuffels et al, found similar outcomes between surgical and non-surgical groups at 10-year follow. The authors concluded, "we found no statistical difference between the patients treated conservatively or operatively with respect to osteoarthritis or meniscal lesions of the knee, as well as activity level, objective and subjective functional outcome."

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If the outcomes are similar, why are surgeons still being performed at an alarming rate? As with most questions in physical therapy, the answer depends on a variety of factors. Clinically, I try to identify if the patient is a 'coper' or a 'non-coper.' Copers are individuals who can function at their desired level despite having a torn ACL. Non-copers are individuals who are unable to function at their prior level following an ACL injury. Copers will demonstrate good quadriceps strength, no buckling or giving way in their knee, and strong, pain free hop tests following conservative rehabilitation. Non-copers will continue to have giving way of their knee, pain that limits function, and subjective reports of decreased quality of life. Regardless, whether someone is a coper or non-coper, it is important to educate them on the pro's and con's of both surgery and rehab. 

Final Thoughts

As research continues to develop, we know at least one thing, the ACL is not vital for stability of the knee. Complications and risks will exist on either side of the equation. Patients can have success with both rehab and surgery. The job of a good physical therapist is to present the best available evidence and guide the patient in deciding which treatment option is MOST appropriate for them.
-Jim Heafner PT, DPT, OCS

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References:
1. Frobell RB, Roos EM, Roos HP, Ranstam J, Lohmander LS. A randomized trial of treatment for acute anterior cruciate ligament tears. N Engl J Med2010;363:331-42.
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2. Meuffels DE, Favejee MM, Vissers MM, Heijboer MP, Reijman M, Verhaar JA. Ten year follow-up study comparing conservative versus operative treatment of anterior cruciate ligament ruptures: a matched-pair analysis of high level athletes. Br J Sports Med2009;43:347-51.