Is StemWave therapy recommended for a 16-year-old patient with a partial Medial Collateral Ligament (MCL) tear and complete Anterior Cruciate Ligament (ACL) tear, before or after surgical repair?

StemWave Therapy for ACL/MCL Tears: Not Recommended Based on Current Evidence

StemWave therapy is not recommended for this 16-year-old patient with a complete ACL tear and partial MCL tear, either before or after surgical repair, as there is no evidence supporting its use in established clinical practice guidelines for ACL/MCL injuries.

Current Evidence-Based Treatment Approach

Management of Combined ACL/MCL Injuries

The MCL partial tear should be treated non-surgically with rehabilitation, while the complete ACL tear requires surgical reconstruction. 1

• In patients with combined ACL and MCL tears, non-surgical treatment of the MCL injury results in good patient outcomes 1
• Most grade I and II MCL injuries (partial tears) can be treated non-operatively, even when combined with ACL injuries 2
• Surgical treatment of the MCL may be considered only in select cases with persistent valgus laxity 1

ACL Reconstruction Timing and Approach

For this young, active basketball player, ACL reconstruction should be performed to prevent future meniscal damage and restore knee stability. 1, 3

• ACL reconstruction can be considered to lower the risk of future meniscus pathology or procedures, particularly in younger and/or more active patients 1
• In young patients (<30 years) with vigorous physical activities, early ACL reconstruction is preferable to provide knee stability and protect the menisci from subsequent injuries 3
• ACL tears indicated for surgery should be treated with ACL reconstruction rather than repair because of lower risk of revision surgery 1

Graft Selection Considerations

For this skeletally mature 16-year-old, either bone-patellar tendon-bone (BTB) or hamstring autograft can be used based on specific risk considerations. 1, 3

• Surgeons may favor BTB to reduce the risk of graft failure or infection 1, 3
• Hamstring grafts may be preferred to reduce the risk of anterior knee pain or kneeling pain 1, 3
• Single-bundle or double-bundle techniques can be considered because outcomes are similar 1

Why StemWave Is Not Recommended

Absence from Clinical Practice Guidelines

No major orthopedic clinical practice guidelines (AAOS 2023, British Journal of Sports Medicine 2023,2020) mention StemWave or similar shockwave therapies as part of standard ACL/MCL injury management. 1

• The most recent AAOS guidelines (2023) and Aspetar guidelines (2023) provide comprehensive rehabilitation protocols without any reference to shockwave or StemWave therapy 1
• Evidence-based rehabilitation focuses on exercise interventions as the foundation of ACL reconstruction rehabilitation 1

Lack of Evidence for Biologic Augmentation in This Context

While biologic approaches for partial ACL tears are being investigated, they remain experimental and are not established for complete ACL tears requiring reconstruction. 4

• Biologic augmentation approaches including growth factors, PRP, and stem cells have been reported for partial ACL tears but require long-term validation 4
• These approaches are not mentioned in any guideline for complete ACL tears requiring reconstruction 1

Evidence-Based Rehabilitation Protocol

Immediate Post-Injury Management (Pre-Surgery)

Begin immediate knee mobilization and address any extension deficit before surgery. 1

• A preoperative extension deficit (lack of full extension) is a major risk factor for an extension deficit after ACL reconstruction 1
• A preoperative deficit in quadriceps strength of >20% has a significant negative consequence for self-reported outcome 2 years after ACL reconstruction 1
• Prehabilitation ensures better self-reported knee function up to 2 years after ACL reconstruction 1

Post-Surgical Rehabilitation

Initiate immediate knee mobilization (within 1 week) and early weight-bearing as tolerated. 1

• Immediate knee mobilization should be used following ACL reconstruction 1
• Early full weight-bearing exercises should be used following ACL reconstruction 1
• When concomitant injuries (meniscal, cartilage) are present, the early rehabilitation phase should be adapted according to the surgeon's instructions 1, 3

Exercise Progression

Combine strength training with motor control exercises, prioritizing closed kinetic chain exercises initially. 1

• Close kinetic chain exercises should be prioritized in the first postoperative month to mitigate the risk of patellofemoral pain 1
• Open kinetic chain exercises (90–45°) can be added as early as 4 weeks (but without extra weight in the first 12 weeks for hamstrings graft) 1
• Strength and motor control training should be combined in the rehabilitation protocol 1, 3
• Isometric quadriceps strengthening exercises should be initiated from the first postoperative week (if not causing pain) 1

Adjunctive Modalities (Evidence-Based)

Cryotherapy and neuromuscular electrical stimulation may be used in the early postoperative period, but are not essential. 1

• Cryotherapy may be used immediately after surgery to reduce knee pain without increasing the risk of short-term adverse events 1
• Neuromuscular electrostimulation may be used in addition to isometric strength training at the first postoperative weeks 1

What NOT to Use

Functional knee braces are not recommended for routine use after isolated primary ACL reconstruction. 1, 3

• Functional knee braces confer no clinical benefit 1
• Continuous passive motion is not recommended 1

Special Considerations for This Young Athlete

Age-Related Factors

At 16 years old, this patient is at higher risk for progression of any residual ligamentous instability and should have aggressive rehabilitation. 5

• Age ≤20 years is a significant risk factor for progression of partial ACL tears to complete tears 5
• Young active patients practicing pivoting contact sports (like basketball) have increased risk of reinjury 5

Return to Sport Criteria

This patient should not return to basketball until meeting objective physical and psychological criteria, typically 9-12 months post-surgery. 1

• Isokinetic quadriceps and hamstring peak torque at 60°/s should display 100% symmetry for return to high demand pivoting sports 1
• Countermovement jump and drop jump >90% symmetry should be achieved 1
• Psychological readiness using patient-reported outcomes (ACL-RSI, Tampa Scale of Kinesiophobia) must be assessed 1
• Functional evaluation, such as the hop test, may be considered as one factor to determine return to sport 1

Common Pitfalls to Avoid

Do not delay ACL reconstruction beyond 3 months if surgery is indicated, as the risk of additional cartilage and meniscus injuries increases. 3

Do not assume the MCL requires surgical repair—most partial MCL tears heal well with conservative management. 1, 6, 2

Do not use unproven biologic therapies like StemWave when evidence-based exercise rehabilitation has strong support for optimal outcomes. 1