What are the treatment options for old Anterior Cruciate Ligament (ACL) injuries?

From the Guidelines

Treatment for old ACL injuries should prioritize a combination of physical therapy, pain management, and possibly surgery, with a focus on strengthening the quadriceps, hamstrings, and calf muscles to provide stability to the knee joint, as recommended by the American Academy of Orthopaedic Surgeons clinical practice guideline summary 1. The goal of treatment is to improve patient outcomes, decrease ACL graft failure rate, and enhance functional scores, particularly in young and/or active patients.

• A typical rehabilitation program includes exercises like straight leg raises, wall sits, hamstring curls, and balance training, performed 3-4 times weekly for at least 8-12 weeks.
• For pain management, NSAIDs such as ibuprofen (400-600mg three times daily) or naproxen (250-500mg twice daily) can be used for short periods.
• If conservative treatments fail to provide adequate stability and the patient experiences frequent giving way or limitations in activities, surgical reconstruction may be recommended, with autograft considered over allograft to improve patient outcomes and decrease ACL graft failure rate, particularly in young and/or active patients 1.
• Post-surgery rehabilitation is crucial and typically lasts 6-9 months, with a focus on progression criteria, including objective physical and psychological criteria, to ensure knee and graft protection 1.
• Bracing may be beneficial during sports activities to provide additional support, and the success of treatment depends on the degree of instability, presence of other knee injuries, and the patient's activity goals, as the ACL provides crucial rotational stability to the knee joint during pivoting movements. Key considerations in rehabilitation after ACLR include the use of exercise interventions as the mainstay of treatment, with a combination of strength and motor control training, and the importance of psychological factors, particularly fear of reinjury, in returning to sport 1. The Aspetar clinical practice guideline on rehabilitation after anterior cruciate ligament reconstruction provides evidence-based recommendations for the various interventions during rehabilitation, including the use of physical therapy modalities, and proposes return to running and return to sport criteria based on the current literature and clinical expertise 1. Overall, the treatment of old ACL injuries requires a comprehensive and individualized approach, taking into account the patient's specific needs and goals, and prioritizing evidence-based recommendations to optimize outcomes and minimize the risk of reinjury.

From the Research

Treatment Options for Old ACL Injuries

• The treatment options for old ACL injuries include rehabilitation as first-line treatment, ACL reconstruction (ACLR) and post-operative rehabilitation, and pre-operative rehabilitation followed by ACLR and post-operative rehabilitation 2.
• ACL reconstruction in active patients older than 60 years without arthritis can restore knee stability and show good results on functional recovery, without increasing the risk of midterm functional knee deterioration or evolution of knee arthritis 3.
• ACLR may be performed in middle-aged patients (≥50 years) without concern for inferior clinical and arthrometric results compared with younger patients (<50 years) 4.

Rehabilitation After ACL Injury

• Rehabilitation after ACL injury has shifted from conservative, standardized length protocols to more accelerated, individualized protocols that vary in length and modalities based on patient-specific findings and preferences 5.
• New protocols emphasize early weight bearing, open kinetic chain (OKC) exercises, and other alternative modalities such as neuromuscular electrical stimulation and blood flow restriction 5.
• Rehabilitation strategy has become increasingly patient-dependent, and the new modalities being utilized are accelerating patient recovery 5.

Long-Term Outcomes of ACL Reconstruction in Older Patients

• The long-term outcomes of ACL reconstruction in patients older than 50 years show a low failure rate and a high level of patient satisfaction, despite osteoarthritic progression in a significant percentage of cases 6.
• Concomitant meniscal procedures were associated with more severe osteoarthritic progression 6.
• The overall KOOS was high, and the majority of patients were satisfied or very satisfied with the results of the procedure 6.