Patients’ experiences of living with ACL reconstructed knee
We already know that anterior cruciate ligament (ACL) rupture is one of the most debilitating injuries in sport. Individuals undergo ACL reconstruction (ACLR) surgery for various reasons such as, to improve stability of the knee, to return to their pre-injury level of sports, and to maintain their quality of life in the long-term (Heijne, Axelsson, Werner, & Biguet, 2008). Surgical repair of the ACL injury may have a profound impact on individuals’ life. As a part of a bigger project, we were doing in the School of Physiotherapy, the University of Otago, I was interested to explore the participants’ experiences and perspectives about living with the ACLR knee from 2-10 years following the surgery. I wanted to see how the surgery has impacted people in relation to their physical activity, sports participation, occupation and quality of life.
What did I do?
Together with colleagues from the University of Otago, I designed and conducted an interview study; where we asked ten volunteers, who were 2-10 years post-ACLR, to share their experiences of living after the surgery. These individuals agreed to be interviewed. The interviews were recorded and transcribed word-for-word. Interviews were read multiple times by two researchers and themes indicating the main findings were generated. Those themes were discussed in the research team and finalised.
What did I find?
As a team, we were little astonished by some of the results; and were able to categories the results into two main themes:
1. ‘The ‘fear of re-injury’ versus ‘confidence’ continuum
When questioned about engaging in physical and sports activities, participants’ experiences ranged between having a fear of re-injury and confidence. They explained that there were times when they were confident with their knee during different activities, and then there were a few moments when they felt like holding themselves back (in effort to protect their knee) during sports, especially while performing twists and sharp turns. Some participants felt hesitant in the movements similar to the one during which they got their first ACL injury.
We were able to identify the factors contributing to the fear of re-injury and its behavioural manifestations. Contributors to fear of re-injury were related to the participants’ experiences with the injury, surgery, and rehabilitation as shown in Figure 1. As a behavioural manifestation, participants were concerned about the playing surface condition and had some hesitations with specific activities. From our results, it appears that ACLR may lead to long-term fear of injury and behavioural manifestations, with fluctuating levels of confidence during sports.
2. ‘Ongoing knee-health related problems and need of health professional advice’
Most participants described on-going knee-health related problems such as pain, stiffness, achiness, and pain after running, albeit at different levels. Participants had ongoing knee health-related problems and were concerned about the future risk of re-injury or osteoarthritis. Participants suggested a need for access to long-term health professional advice, either to improve their knee health or for reassurance related to their knee, such as graft site-related weakness, minor pain, soreness in the knee and maintenance of muscle strength.
What should be done about it?
Patients with ACLR should be informed by health professionals about the implications of such risks before surgery, along with providing individual-specific strategies to minimise such risks. Also, health professionals should consider long-term individual-specific maintenance programmes that improve and maintain confidence.
Considerations should include the individual’s specific sports-, recreation- or work-related goals and life priorities. Overall, the individual considerations demand including both the physical and psychological responses to the injury (Burland et al., 2018). Discussions may also be needed as to whether changes in physical activities or types of sports are recommended, particularly to those sports that may have a lower risk of re-injury of the knee. Thus, health professionals should continue monitoring the individual’s goals and ability to accept or control fear, anxiety or concerns related to re-injury and long-term knee health.
Summary
To summarise the results, I can say that the participants had long-term fear of injury and behavioural manifestations, with fluctuating levels of confidence in using their previously injured knee up to 10 years following ACLR. Maintaining thigh muscle strength and continuing with sports was seen to enhance confidence. Participants raised concerns for long-term risk of re-injury and of developing knee osteoarthritis. Health professionals should consider long-term individual-specific maintenance programmes that improve and maintain confidence and self-efficacy and promote physical activity in those that have undergone ACLR.
Academic readings
Heijne, A., Axelsson, K., Werner, S., & Biguet, G. (2008). Rehabilitation and recovery after anterior cruciate ligament reconstruction: Patients’ experiences. Scandinivian Journal of Medicine and Science in Sports, 18(3),325-335. doi.org/10.1111/j.1600-0838.2007.00700.x
Burland, J. P., Toonstra, J., Werner, J. L., Mattacola, C. G., Howell, D. M., & Howard, J. S. (2018). Decision to return to sport after anterior cruciate ligament reconstruction, part I: A qualitative investigation of psychosocial factors. Journal of Athletic Training, 53 (5), 452-463. doi.org/10.4085/1062-6050-313-16
Kaur, M., Ribeiro, D. C., Theis, JC., Webster, K. E., & Sole, G. (2019). Individuals’ experiences of the consequences of anterior cruciate ligament reconstruction surgery. New Zealand Journal of Physiotherapy, 48 (2), 76-93. doi.org/10.15619/NZJP/47.2.03