Non-Surgical Management of ACL Injuries

'Coper/non-coper' screening and targeted rehabilitation programs for the conservative approach of isolated anterior cruciate ligament injuries of the knee

Every person, athlete and non-athlete, responds differently to a complete anterior cruciate ligament (ACL) rupture. Following trauma and isolated injury of this ligament, as per the scientific literature indications and other European countries guidelines on this matter, the conservative/non-surgical approach should always be evaluated as the first option through a period of high-quality neuro-muscular rehabilitation.

In Sports Rehab, patients following an isolated ACL injury are initially screened to distinguish the 'coper' (those who do not have episodes of subjective instability and who fall within some additional parameters - e.g. a non markedly positive pivot shift, regular results of the patient-reported outcomes/questionnaires, the execution with good quality of some motor tasks weight bearing on the injured leg, etc.) as well as in 'not-coper', i.e. those who complain of an unstable knee and present clinical parameters associated with rotational instability, etc.

Sports Rehab has developed a screening 'coper/non-coper' model, based on both the available scientific literature and the expertise gained by the physical therapy staff combined with the clinical research that is constantly conducted in our PT clinics. This screening aim to identify the 'coper', 'non-copers but potentially copers over time' and 'not-copers' subjects. The first two are offered a targeted and specialized rehabilitation porgram. In fact, studies have shown that through 5-6 weeks of qualitative physical therapy a part of the initially labeled 'not-coper' subjects can evolve into 'copers' thus potentially avoiding surgical reconstruction of the ACL. Therefore, dynamic knee instability due to ACL injury may improve with high-quality neuromuscular rehabilitation.

Ultimately, the goal for everyone is to return to pre-injury activity levels without perception of joint instability. Unfortunately, some individuals will retain the status of 'not-copers', effectively applying for surgery.

The 'coper/non-coper screening' of Sports Rehab follows the model that we define as '6+6': in the first 6 weeks the patient is rehabilitated and tested with specific criteria. If at the end of this period the patient does not pass a series of functional tests, he/she will have undergone in any case to a pre-operative rehabilitation program ('prehab') which will be followed by a ligament surgerical recosrtruction followed by post-operative rehabilitation. Prehab demonstrated any way to be the most appropriate course of action when planning to undergo ACL surgery, because of the better outcomes at 2 years following the surgical procedure compared to patients who underwent surgery straight away with no previous rehabilitation.

If, on the other hand, the tests are passed, a further 6 weeks of physical therapy and Strength & Conditioning program will follow to take the patient through the stages of Return To Run and Return To Train, to the final one of Return To Sport, each with tests and criteria to be met in order to advance throughout the rehabilitation phases. The 'coper' patient who progresses through these phases undergoes a rehabilitation program which is progressively similar to the one of patients who undergo an ACL surgical reconstruction, but that is on average shorter in terms of duration.

In fact, if a subject with an operated ACL takes at least 9 months for a safe RTS (actually, test batteries havce to be passed to be cleared for RTS since time is not a sufficiently valid parameter to guide the post-operative physical therapy), a 'coper' with an isolated ACL injury can realistically aim be ready for Return To Sport in 3-4 months. Even the 'copers' must target all the rehabilitation 'pillars' and then pass test batteries throughout their rehabilitation process to resume sporting activities with a minimized further injury risk.

We therefore created specific programs for our patients and athletes which adapt on the results of strength, endurance, balance, and motor control objective tests and measures. Such programs are intended to be carried out both in physical therapy and at home ('home exercise program') with our staff of physical therapists monitors the evolution.

Sports Rehab team has an Evidence-Based approach underpinned on the most recent scientific evidence regarding the conservative treatment following anterior cruciate ligament injuries of the knee.

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