Tiger Woods won the 2008 U.S. Open despite a torn anterior cruciate ligament in his left knee along with a double stress fracture of the tibia and damage to his joint surface. He underwent surgery in June of 2008.
Now a new study questions whether he should have even had surgery.
In the December issue of Arthritis Research, a group of scientists from Sweden enrolled 121 people with ACL injuries and randomly assigned them to either surgery and rehab or rehab only and followed them up to five years. After re-assessments for strength and functional ability, the authors concluded that reconstructive surgery
was not associated with a higher rate of return of muscle function or
functional performance at 2 to 5 years after injury and that ACL injury was associated with a high rate of
failed recovery of muscle function at 2 to 5 years, and this could predict
future OA.
"... There is no evidence to suggest that reconstruction of the
ACL prevents or reduces the rate of early-onset OA. On the contrary,
the prevalence of OA may be even higher in patients with reconstructed
ACL than in those with nonreconstructed ACL."
Do you want to tell Tiger or should I?
There's a problem with this study though. About 50% of the subjects never came back for follow up and about half of those were in the training only group. Maybe that's because they felt fine and had all the function they wanted. Who knows. One of the authors of the study summed it up like this:
"....because
more than half of the nonparticipants had been treated with training
only, the finding of no differences between the surgical and
nonsurgical treatment groups would probably have been more conclusive
if nonparticipants had participated." - Eva Ageberg, PT, PhD, from Lund University in Lund, Sweden.
But I wonder. If the two groups each have the same risk of developing OA, had the same relative function of the leg, and both groups underwent rehab, doesn't that call into question the nature and type of rehab? Maybe the issue here isn't the surgery but what happens after surgery.
Physical Therapy is not a treatment. It's a profession. And, within any profession there are variances due to technical competence, experience, and judgment. Rehab following ACL reconstruction is very difficult to standardize to the degree that you can apply it two two groups like a medication. Some people with ACL injuries also have cartilage or bone injuries like Tiger did. The rehab for that problem is very different than for a person with just an ACL injury. To draw a valid conclusion, the groups need to be homogeneous and having an ACL injury does make the groups homogeneous. The subjects have to be grouped according to the nature of their injuries, rehab designed for the respective groups, and then apply the rehab to the homogeneous groups.
Tiger had a unique combination of injuries. He needed surgery and he'll need specialized rehab; rehab that can help restore the health and strength of his joint surface and not just his muscles.
I hope that's what's happening.
Doug Kelsey
*Ageberg, E., R. Thomee, et al. (2008). "Muscle strength and functional performance in patients with anterior cruciate ligament injury treated with training and surgical reconstruction or training only: A two to five-year followup." Arthritis Rheum 59(12): 1773-9.
**
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Tiger Woods won the 2008 U.S. Open despite a torn anterior cruciate ligament in his left knee along with a double stress fracture of the tibia and damage to his joint surface. He underwent surgery in June of 2008.
Now a new study questions whether he should have even had surgery.
In the December issue of Arthritis Research, a group of scientists from Sweden enrolled 121 people with ACL injuries and randomly assigned them to either surgery and rehab or rehab only and followed them up to five years. After re-assessments for strength and functional ability, the authors concluded that reconstructive surgery was not associated with a higher rate of return of muscle function or functional performance at 2 to 5 years after injury and that ACL injury was associated with a high rate of failed recovery of muscle function at 2 to 5 years, and this could predict future OA.
"... There is no evidence to suggest that reconstruction of the ACL prevents or reduces the rate of early-onset OA. On the contrary, the prevalence of OA may be even higher in patients with reconstructed ACL than in those with nonreconstructed ACL."
Do you want to tell Tiger or should I?
There's a problem with this study though. About 50% of the subjects never came back for follow up and about half of those were in the training only group. Maybe that's because they felt fine and had all the function they wanted. Who knows. One of the authors of the study summed it up like this:
"....because more than half of the nonparticipants had been treated with training only, the finding of no differences between the surgical and nonsurgical treatment groups would probably have been more conclusive if nonparticipants had participated." - Eva Ageberg, PT, PhD, from Lund University in Lund, Sweden.
But I wonder. If the two groups each have the same risk of developing OA, had the same relative function of the leg, and both groups underwent rehab, doesn't that call into question the nature and type of rehab? Maybe the issue here isn't the surgery but what happens after surgery.
Physical Therapy is not a treatment. It's a profession. And, within any profession there are variances due to technical competence, experience, and judgment. Rehab following ACL reconstruction is very difficult to standardize to the degree that you can apply it two two groups like a medication. Some people with ACL injuries also have cartilage or bone injuries like Tiger did. The rehab for that problem is very different than for a person with just an ACL injury. To draw a valid conclusion, the groups need to be homogeneous and having an ACL injury does make the groups homogeneous. The subjects have to be grouped according to the nature of their injuries, rehab designed for the respective groups, and then apply the rehab to the homogeneous groups.
Tiger had a unique combination of injuries. He needed surgery and he'll need specialized rehab; rehab that can help restore the health and strength of his joint surface and not just his muscles.
I hope that's what's happening.
Doug Kelsey
*Ageberg, E., R. Thomee, et al. (2008). "Muscle strength and functional performance in patients with anterior cruciate ligament injury treated with training and surgical reconstruction or training only: A two to five-year followup." Arthritis Rheum 59(12): 1773-9.
**
New to the View? Consider subscribing to my RSS feed: Subscribe to this blog's feed. Or sign up to get email updates in the box at the top left hand corner of my blog and then share this blog with your friends.