Is a corticosteroid injection indicated after an Anterior Cruciate Ligament (ACL) tear?

From the Guidelines

Steroid injections are generally not recommended after an ACL tear, as they may interfere with the natural healing process and weaken the ligament tissue, potentially leading to increased morbidity and mortality, and decreased quality of life. In the acute phase following injury, the standard treatment approach includes rest, ice, compression, and elevation (RICE protocol) initially, followed by physical therapy to restore strength and range of motion 1. Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) are typically used for pain management instead. If surgery is planned, steroid injections are particularly discouraged as they may increase infection risk and compromise graft healing 1. In cases where there is significant inflammation and pain that doesn't respond to other treatments, a physician might consider a very limited corticosteroid injection (such as methylprednisolone 40mg or triamcinolone 20-40mg), but this would be approached with caution and is not standard practice. The focus should remain on appropriate rehabilitation exercises and, if necessary, surgical reconstruction to restore knee stability and function.

Some key points to consider in the management of ACL tears include:

• The importance of early accelerated rehabilitation, characterized by joint mobilization and weight-bearing within 3 days after surgery, as the mainstream approach in isolated ACL surgeries 1
• The use of physical therapy modalities as an adjunct in the early phase of rehabilitation, when pain and other post-operative issues are present, but with caution due to conflicting evidence and potential adverse effects 1
• The need for a comprehensive rehabilitation protocol that combines strength and motor control training, with progression criteria based on objective physical and psychological criteria, rather than time since surgery alone 1
• The consideration of patient-specific characteristics, such as comorbidities, skeletal maturity, and future desired activity, in the choice of treatment for ACL injuries 1

Overall, the management of ACL tears requires a careful and individualized approach, with a focus on minimizing morbidity and mortality, and optimizing quality of life. This can be achieved through a combination of appropriate rehabilitation exercises, surgical reconstruction when necessary, and careful consideration of the potential risks and benefits of different treatment options.

From the Research

Steroid Injection After ACL Tear

• The use of steroid injections after an ACL tear is a topic of interest, with some studies investigating its effects on postoperative infection rates 2.
• A 2023 study found that postinjury aspiration and corticosteroid injection (CSI) of the knee before ACL reconstruction (ACLR) did not increase the risk of postoperative infection 2.
• The study included 693 patients, with 273 receiving postinjury and preoperative aspiration and CSI, and found no postoperative infections in the entire cohort 2.
• The upper 95% confidence bounds for the infection risk were calculated for each cohort, with results showing that CSI is a safe intervention that can be used before ACLR 2.

Treatment Options for ACL Tears

• Treatment options for ACL tears include conservative management or surgical intervention, with the latter being the better option for patients who want to return to a high level of activity 3.
• A 2019 study outlined the three main treatment options for ACL rupture: rehabilitation as first-line treatment, ACL reconstruction (ACLR) and post-operative rehabilitation, and pre-operative rehabilitation followed by ACLR and post-operative rehabilitation 4.
• The study also emphasized the importance of patient-related factors associated with a worse ACL-rupture outcome and the need for evidence-based rehabilitation 4.

Rehabilitation After ACL Injury

• Rehabilitation after ACL injury is a critical component of successful recovery, with physical therapy playing a key role in both surgically and non-surgically managed patients 5.
• A 2022 review of current literature and recommendations for ACL rehabilitation found that new protocols emphasize early weight bearing, open kinetic chain exercises, and alternative modalities such as neuromuscular electrical stimulation and blood flow restriction 5.
• The review also highlighted the importance of addressing the psychosocial impacts of ACL injury, recovery, and the anxiety around return to sport 5.