Personal and narrative review of the current management of the injured anterior cruciate ligament of the knee in the UK with reference to surgical treatment versus rehabilitation

Rupture of the anterior cruciate ligament of the knee is a common injury occurring mostly in young athletic individuals taking part in pivoting, cutting and jumping sports. It is demonstrated by anterolateral rotatory instability on clinical testing. As yet there are no clear guidelines as to whom will benefit from surgical reconstruction as opposed to rehabilitation alone, apart from elite athletes (defined as varsity players or those participating in sport at national or international level). Also, some adolescent knees and those with combined injuries, usually meniscal tears, may benefit from surgery. Even after surgery there is an increased incidence of rerupture and the development of degenerative changes in the operated knee, particularly in the young athlete who has returned to a high level of sporting activity. Early diagnosis is essential to provide a focused care pathway and to avoid the consequences of chronic cruciate insufficiency. Currently, it seems that too many anterior cruciate ligament reconstructions may be undertaken where rehabilitation alone would have sufficed. Better preoperative clinical testing including improved arthrometric assessment, muscle and neurological testing and imaging including radiology and MRI may help refine the diagnosis, thus enabling a better decision on further management. There is also a requirement for better designed clinical studies reporting on the outcomes of treatment be it either surgical or conservative.