Outcomes and Aging.

To the Editor:

I am writing to you regarding the report on anterior cruciate ligament (ACL) rehabilitation by Fitzgerald et al and your subsequent discussion with Mark DeCarlo, James Irrgang, and Kevin Wilk in the February 2000 issue of the Journal. I read the report with great interest that is not only clinical in origin but also personal in origin, about which I will explain shortly.

I have reason to suspect that the long-term outcome of the "successful" participants of the study may not be as positive as the short-term outcome. This suspicion is based on my personal experience and leads me to wonder about the status of the patients who participated in the nonoperative ACL rehabilitation programs as they age. I am a physical therapist currently practicing in an outpatient clinic with a mixed patient population in terms of ages and diagnoses.

I will tell you a succinct version of my own story in chronological order, as it is easier to explain. I played soccer competitively beginning in junior high school and throughout high school and college. At the beginning of my sophomore year of college (early in the fall soccer season), I tripped one night over a ball and tore my ACL. At the time, I had moderate swelling and pain that lasted 2 or 3 weeks. However, I returned to play at 3 weeks with no rehabilitation--this was because I did not even know that I had torn my ACL! I subsequently played the next 3 years nonstop (fall outdoor, winter indoor, and spring outdoor) without instability or any overt knee problems. During those years, I was the team captain and sweeper and therefore played heavily (I sometimes played the entire game). Midway through my senior year, I quit playing soccer because of spinal stress fractures and did not resume play for the next 9 years. Over the intervening years, I stayed moderately active after becoming a mother; thus, when I began to play soccer again, I was only moderately fit. I played weekly without incident (obviously unbraced) for 4 years. Three months ago, I was playing and performed a simple stopping/pivoting motion (no contact with another player) and had an episode of instability in which my knee collapsed and I fell down. I was seen a week later by an orthopedist, who suspected an ACL tear. Subsequent magnetic resonance imaging confirmed an old ACL tear and showed no other new damage except a tibial plateau contusion. I had 3 episodes of instability within 2 weeks postinjury and none thereafter.

I tell you this because clearly I am the rare patient who had excellent neuromuscular control such that I played for years afterward with no knowledge of my injury. The only factors that have changed are my fitness level and my age. I therefore suspect the same for the subjects without nonoperative management in the study--as they age and have a concurrent decreased level of fitness, they may experience increasing instability. I do not know whether I can trust my knee now for return to playing soccer with any level of rehabilitation. After all, I had years of so-called "success" and then instability without warning.

I am now left wondering whether, even if I give up soccer (I am currently rehabilitating my knee, but not yet to the point that I would even consider returning to play), I will have increasing episodes of instability as I get older.

I believe research needs to be done longitudinally to determine outcomes as patients age, comparing patients who have had surgical management with patients who have had nonsurgical management. We may discover that all patients ultimately require surgery for long-term function. I have decided to give my knee the best rehabilitation I can (the report helped with ideas), give it a couple of years, and then decide whether I will need surgery.

I thought this anecdotal information might interest you after the thoughts expressed in the Conference following the report.

Cindy Myers, PT, MSPT
Senior Therapist, Stafford Pointe
Physical Therapy
Hendricks Community Hospital
Indianapolis, Ind

Author Response:

We appreciate Ms Myers' interest in our article and the opportunity to respond to some of her questions and concerns. As we have not examined Ms Myers, however, we cannot comment on her specific problem. We believe that her clinical history is not consistent with the types of patients who were included in our study. The patients in our study had confirmed diagnoses of an ACL rupture, and they all met our criteria for nonoperative management and underwent a comprehensive rehabilitation program prior to returning to competition. None of our patients had recurring episodes of giving way of the knee from the period between their initial injury and the time of the screening.

The intent of our nonoperative anterior cruciate ligament (ACL) program (which includes both patient selection and rehabilitation) is to provide some individuals with an option to delay surgery and return to competition, at least temporarily, with less risk of sustaining further damage to their knees. The decision to offer the option of nonoperative return to high-level physical activity is dependent on the patient's ability to meet our selection criteria and successfully complete the rehabilitation program. We are not offering a long-term alternative to surgery for patients who are ACL deficient and want to continue long-term participation in high-level activity. We are offering a method that may help clinicians and patients to determine whether it is worth the risk to delay surgery, undergo nonoperative rehabilitation, and try to finish the season when special circumstances--such as scholarship eligibility, competing in an upcoming tournament, or employment issues--have to be factored into the decision making.

We do not have enough data to determine the consequences of long-term participation in high level physical activity for individuals who have participated in our program and who have elected not to undergo ACL reconstruction. Thus far, we have some patients who opted not to have surgery, are continuing to compete in their respective sports, and are doing well a few years out. However, we would not consider this anecdotal information to be sufficient for predicting long-term outcome.

Ms Myers expresses concern for an increased risk of reinjury as individuals age and their levels of fitness decline. We would add that this is a reasonable concern even in individuals who have never had an ACL injury. It would make sense that the risk of injury would increase for individuals who continue to participate in high-level physical activities but are unable to maintain a level of fitness required to meet the physical demands of the activities.

G Kelley Fitzgerald, PT, PhD, OCS
Assistant Professor
University of Pittsburgh
Department of Physical Therapy
School of Rehabilitation and
Health Sciences
6035 Forbes Tower
Pittsburgh, PA 15260
([e-mail])

Michael J Axe, MD
Orthopedic Surgeon
First State Orthopaedics
Newark, Del

Lynn Snyder-Mackler, PT, ScD
Associate Professor
Department of Physical Therapy
University of Delaware
Newark, Del