6 Myths for ACL Injuries in Soccer
By Alex Earl, DC DACRB DNSP
In the bustling landscape of outpatient physical therapy clinics and chiropractic offices across America, a concerning trend has emerged in the treatment of Anterior Cruciate Ligament (ACL) injuries – especially ACL injuries in soccer. Despite advancements in medical technology and rehabilitation techniques, a critical oversight persists in the approach to ACL injuries in soccer.
While patients may swiftly regain range of motion, the focus on this aspect alone often neglects crucial elements essential for long-term success in returning to sports. Today’s article aims to serve as a clarion call to reassess and revamp our current practices, aiming for a more holistic and effective approach to ACL injuries in soccer – specifically for soccer players in 2024.
Let us first dive into the most obvious misconceptions surrounding ACL injuries and recovery.
Myth #1: You can’t recover from ACL injuries in soccer if you don’t get surgery
A prevalent misconception often perpetuated, particularly by orthopedic surgeons, is the notion that individuals can engage in straight-line running without an ACL but require surgery to resume participation in other sports. However, this assertion is unequivocally debunked by both empirical evidence and real-world examples.
Numerous elite athletes continue to excel in their respective sports despite the absence of an ACL, challenging the belief that surgical intervention is imperative for athletic performance beyond linear movements.
In the annals of American football history, there stands testament to the resilience of athletes who defied the conventional wisdom surrounding ACL injuries. Joe Namath, the legendary Jets quarterback, suffered an ACL tear during his college years in the 1960s, an era of sports medicine that completely lacked surgical remedies.
Despite this setback, Namath rebounded, donning a brace for a brief period before embarking on a storied journey to a Hall of Fame career. Similarly, Hines Ward, a standout wide receiver for the Pittsburgh Steelers, navigated his entire football tenure without an ACL, showcasing remarkable skill and endurance throughout his illustrious career. He was fun to watch, too.
In a study by Grindem et al. (2012), a comprehensive analysis was undertaken to evaluate the return to pivoting sports following ACL injury, comparing outcomes between surgical intervention and nonoperative treatment cohorts.
Surprisingly, the study revealed no discrepancy in the rate of return to sport between the two groups within the cohort of 138 individuals, standing at 68.1%. Interestingly, the nonoperative group exhibited superior performance on hop tests and attained higher scores on knee function scales, challenging traditional assumptions regarding the necessity of surgical intervention for optimal outcomes.
Myth #2: ACL injuries in soccer can’t heal on their own.
Oftentimes, this is the first thing that comes to an athlete’s mind. They might even innocently ask, “When is your surgery scheduled?”
Not knowing that you might not ever need surgery to properly recover from ACL injuries in soccer…
The phenomenon of spontaneous healing in human ACL ruptures has been documented as far back as 1996, as demonstrated by Ihara. In this relatively obscure research involving 50 ACL injuries, a remarkable 74% exhibited natural healing within a mere 3 months, obviating the necessity for surgical intervention.
Despite this longstanding knowledge spanning nearly three decades, the prevailing perception still perceives ACL injuries in soccer as irreversible injuries necessitating surgical correction, highlighting a significant disparity between scientific evidence and clinical practice.
However, a contrasting perspective emerges from studies such as that of Blanke et al. (2022), which observed a considerably lower rate of spontaneous healing in ACL ruptures. Their research, involving 381 cases, revealed only 14% experiencing natural recovery within the initial 6-9 weeks post-injury.
Their findings suggest varying healing probabilities based on the location of the tear, with femoral attachment tears exhibiting the highest likelihood of healing, followed by mid-substance tears, while tears at the tibial attachment demonstrated a poorer prognosis.
In a notable secondary analysis conducted by Filbay et al. (2022) on the KANON trial by Frobell et al. (2013), MRI confirmation highlighted a significant rate of ACL healing. Their investigation revealed that 30% of 54 completely ruptured ACLs had spontaneously healed within two years.
Remarkably, upon excluding individuals who underwent reconstruction surgery within the two-year timeframe, the healing rate increased to 53% among 30 ACL ruptures.
Building upon these findings, Filbay et al. (2023) introduced a novel intervention termed the “Cross Bracing Protocol” aimed at enhancing ACL healing.
This protocol involves immobilizing the knee at 90° of flexion for four weeks, gradually extending over 12 weeks before brace removal. By bringing the torn ACL ends closer together, the protocol enhances the likelihood of reconnection.
Encouragingly, their study demonstrated promising outcomes, with 90% of participants experiencing ‘healed’ ACL ruptures, underscoring the potential efficacy of this innovative approach. Moreover, even among the minority where healing did not occur, notable instances of ACL attachment to the lateral wall or the posterior cruciate ligament (PCL) were observed, providing additional knee stability.
The growing body of evidence underscores the considerable potential for healing in many ACL tears, including cases of complete discontinuity. However, the landscape of ACL treatment is heavily influenced by the economic incentives surrounding ACL reconstruction surgery, which generates approximately $7 billion annually.
Consequently, there exists a significant disincentive for orthopedic surgeons to explore nonoperative avenues of care. Those who advocate for nonoperative approaches often face scrutiny, ridicule, and marginalization within the medical community, further perpetuating the dominance of surgical interventions in ACL management.
Myth #3: You are at greater risk of meniscal tear if you don’t get surgery after ACL injuries in soccer.
A frequently cited rationale for opting for ACL surgery after suffering ACL injuries in soccer is its purported ability to safeguard other knee structures, particularly the meniscus, from future damage.
The menisci, which are vital cartilaginous pads within the knee joint, are presumed to be more susceptible to tears or degradation in the absence of an intact ACL.
However, Ekas et al. (2020) contested this notion, asserting that there is inadequate evidence to support the notion that early ACL reconstruction, as opposed to nonoperative management with the possibility of delayed reconstruction, reduces the risk of new meniscal tears.
This skepticism is echoed by three additional literature reviews conducted by Delincé & Ghafil (2012), Smith et al. (2014), and Monk et al. (2016), all of which failed to identify substantial discrepancies in rates of subsequent meniscal tears between surgical and non-surgical interventions.
A critical limitation of studies favoring surgery to prevent future meniscal issues is their comparison of a surgically treated group with exemplary postoperative rehabilitation to an untreated group, leading to the inference that nonoperative patients face a heightened risk of meniscus tears.
Contrary to popular belief, the primary determinant of post-ACL rupture knee damage risk lies not in the choice between surgical or non-surgical intervention but in the adequacy of rehabilitation and strengthening measures following the injury. Turns out, ACL injuries in soccer recover along a similar path of nearly all other musculoskeletal injuries – with a multitude of reasons!
Myth #4: You are at greater risk of knee osteoarthritis if you don’t get surgery.
In 2018, Van Yperen conducted a retrospective analysis of 50 patients with ACL ruptures. Among them, 25 individuals with unstable knees following three months of rehabilitation underwent surgery, while the remaining 25 with stable knees opted for nonoperative treatment. Over a 20-year follow-up period, both groups exhibited osteoarthritis rates of 80% and 68%, respectively, with no statistically significant difference observed. However, this study’s reliability is compromised by its small sample size and retrospective nature.
Contrary to the notion of surgical intervention reducing the risk of knee osteoarthritis (OA) in the long term, an umbrella review by Webster et al. (2022), encompassing 13 systematic reviews and meta-analyses, revealed that surgical reconstruction does not offer such protection. Approximately one-third of individuals who undergo ACL surgery are estimated to experience knee OA.
Several other reviews, including those by Delincé & Ghafil (2012), Smith et al. (2014), and Monk et al. (2016), similarly found no significant disparities in pain, knee function, symptomatology, return to sport, or future meniscal tears between operative and nonoperative groups. Notably, there was a slightly higher incidence of OA in those who underwent surgery. However, it’s essential to acknowledge that these studies primarily assess radiographic signs of knee OA, which may not always correlate with symptomatic presentation.
The primary risk factors for knee OA include quadriceps weakness (Øiestad et al., 2015) and surgical procedures involving meniscal removal (Migliorini et al., 2023). Intriguingly, partial meniscectomies on degenerative menisci have demonstrated outcomes comparable to placebo at five years, indicating limited efficacy in improving knee function (Sihvonen et al., 2020). Moreover, reports indicate that up to 89% of patients undergoing meniscectomy develop osteoarthritis (Rangger et al., 1997).
Ultimately, the risk of knee OA is predominantly associated with the ACL injury itself rather than the choice of surgical intervention. While statistical significance in OA rates between surgical and nonoperative approaches is lacking, there is a suspicion that reconstruction may contribute to higher rates of radiographic OA, as evidenced by research findings favoring ACL reconstruction patients.
Myth #5: You can’t do open-chain exercises with ACL injury in soccer.
One common myth regarding ACL injuries in soccer and the rehabilitation process is the notion that performing open chain knee extensions is detrimental or “dangerous” for recovery. Despite this belief, there’s no inherent danger in any exercise; it’s the interpretation and application of exercises that may pose risks.
Contrary to the belief that open chain leg extensions lack functionality, they offer comparable benefits to squats in strengthening the quadriceps, with minor differences in muscle activation. Research shows no significant differences in knee laxity between ACL patients who avoid open-chain knee extension exercises and those who include them in their rehab regimen.
Furthermore, leg extension machines excel in isolating quad muscles, preventing compensatory movements commonly observed in squats. Starting with unilateral knee extensions helps identify and address weaknesses in the injured leg without interference from the healthy leg’s strength.
Erik Meira, a renowned figure in ACL rehab, advises against striving for full range of motion initially on leg extension machines to maximize load and strength gains. Research suggests that training within a range of 90-60° of knee flexion minimizes ACL strain without compromising effectiveness.
Ultimately, incorporating a full range of motion in knee extension exercises is beneficial for ACL strength and stability, particularly focusing on near-terminal knee extension where ACL injuries in soccer often occur.
Myth #6: Healed on an MRI does NOT mean healed in real life.
A common critique of non-surgical ACL research is the challenge of equating image captured healing with functional stability. In the recent Filbay 2023 study, they utilized a grading system ranging from 0 to 3 to categorize “healed” ACLs, revealing variations in ligament integrity and thickness. Grade 0 represents a normal ligament, while grades 1 and 2 indicate varying degrees of abnormality. Interestingly, none of the ACLs in the study fully returned to grade 0 status, with 50% reaching grade 1 and 40% achieving grade 2. Notably, those with grade 1 ACLs exhibited no stability issues, while 60% of grade 2 ACLs did.
However, even among those with grade 2 ACL healing, 40% demonstrated knee stability, underscoring the multifaceted nature of stability determinants. Factors such as age, activity levels, muscle mass, neuromuscular adaptations, and anatomical considerations contribute to this variability. Notably, the integrity of other knee structures, like the Medial Collateral Ligament (MCL), plays a crucial role in compensating for ACL deficiency.
Additionally, adequate knee muscle strength and control are pivotal for enhancing stability. Research suggests that ACLs continue to adapt positively to physical loads, as evidenced by increased ACL volume in athletes exposed to regular training stimuli. This adaptation underscores the dynamic nature of ACL healing and highlights the importance of tailored rehabilitation programs.
Summary
So there you go! Everything that’s been rattling around in my head for the past few months all typed out and properly organized into one article. I hope this critical look into some of the common myths of ACL injuries in soccer has been useful and has given you something to think about. For those of you who didn’t care to read the whole article but want the gist of it…
- ACL injuries in soccer CAN heal on their own WITHOUT surgery.
- Oftentimes, a healed ACL provides a more stable knee even in dynamic sports like soccer.
- Surgery does NOT improve the chances of returning to sports, especially soccer.
- Surgery does NOT reduce your risk of further issues or injuries in soccer.
- Not rehabbing completely after ACL injuries in soccer IS the far bigger risk of further injuries in soccer.
Do this next!
- Share this Article with a Friend or Family member who has recently suffered ACL injuries in soccer or who has (sadly) just torn their ACL and want to know their options for recovery. Surgery is not always the answer!
- Text “ACL” our office at (630) 765-0575. We will schedule an Complimentary ACL Second Opinion Discovery Call as quickly as possible.
- Keep an eye out for next week’s article!
References:
- Ihara, H., Miwa, M., & Deya, K. (1996). Spontaneous healing of a tear of the anterior cruciate. https://pubmed.ncbi.nlm.nih.gov/8606246
- Grindem, H., Eitzen, I., Engebretsen, L., Snyder-Mackler, L., & Risberg, M. A. (2012). https://pubmed.ncbi.nlm.nih.gov/14623667/
- Filbay, S. R., Culvenor, A. G., Ackerman, I. N., & Russell, T. G. (2019). https://pubmed.ncbi.nlm.nih.gov/31304118/)
- Myrick, K. M., Cortes, D. H., McGuire, R. A., & Leppla, L. (2017) (https://journal.iusca.org/index.php/Journal/article/view/182)
- Beynnon, B. D., Uh, B. S., & Johnson, R. J. (2020) https://pubmed.ncbi.nlm.nih.gov/32867579/)
- Fleming, B. C., Beynnon, B. D., & Renström, P. A. (2018). https://pubmed.ncbi.nlm.nih.gov/29685058/)
- Filbay, S. R., Culvenor, A. G., Ackerman, I. N., & Russell, T. G. (2019). https://pubmed.ncbi.nlm.nih.gov/31304118/)
- Filbay, S. R., Ackerman, I. N., Russell, T. G., & Crossley, K. M. (2013). https://pubmed.ncbi.nlm.nih.gov/23015853/)
- Grindem, H., Eitzen, I., Engebretsen, L., Snyder-Mackler, L., & Risberg, M. A. (2012). https://pubmed.ncbi.nlm.nih.gov/14623667/)
- Collins, M. J., Arns, T. A., & Leroux, T. S. (2012). https://pubmed.ncbi.nlm.nih.gov/22962290/)
- Culvenor, A. G., Collins, N. J., Guermazi, A., Cook, J. L., Vicenzino, B., Khan, K. M., … &
- Crossley, K. M. (2015). https://pubmed.ncbi.nlm.nih.gov/25917066/)
- Amin, S., Guermazi, A., Lavalley, M. P., Niu, J., Clancy, M., Hunter, D. J. & Felson, D. T.
(1997). https://pubmed.ncbi.nlm.nih.gov/9017860/)
Alex Earl
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