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Author Comment

	Introduction

 
We appreciate the opportunity to respond to and clarify some of the issues raised during this provocative discussion of our article. The program we described is designed to help clinicians both identify and manage athletes with an anterior cruciate ligament (ACL) injury who may have the ability to return, at least temporarily, to premorbid levels of physical activity after nonoperative treatment. We view our treatment approach not as an alternative to ACL reconstruction but as a method for improving the risk/benefit ratio for nonoperative management in special circumstances—that is, when patients want to delay surgery and play out the remainder of the season.

Mr Wilk questioned whether the randomization failed with respect to the level of physical activity to which our subjects returned after rehabilitation. He also questioned whether the screening and rehabilitation are timely enough for an athlete to return for a competitive season. At the time subjects returned to full sports participation, mean scores in both groups for the global rating of knee function (Fig. 6) and the Sports Activity Scale (Fig. 7) were greater than 90%. As indicated in Table 2, 5 subjects in the standard group and 7 subjects in the perturbation training group returned to competition at the collegiate, high school, semiprofessional, or senior Olympic levels. Nine subjects in the standard group and 5 subjects in the perturbation group returned to recreational athletics. In addition, one of the collegiate football players (defensive end) in the perturbation group made second team All-Conference Team, even though he missed the first half of the season. The second football player (kick-off return specialist and running back) in the perturbation group not only completed the season, but opted not to have surgery and completed the entire football season the following year without an incident of injury. The high school field hockey player in the standard group made the All-Conference Team in her season following rehabilitation, and the recreational tennis player in the perturbation group placed second in a regional singles tennis tournament within the 6-month period following rehabilitation. We are confident that the distribution in activity levels between groups was similar and that our program allowed subjects in both groups to return to premorbid levels of physical activity.

Mr Wilk suggested that subjects in this study were not consecutive patients and may have been unconsciously "pre-selected" by Dr Axe for participation in the study. In fact, Dr Axe referred, and continues to refer, all patients with a new ACL injury who meet the screening criteria (regular participants in level I and II sports, no concurrent grade II or III multiple ligament injury, no meniscal damage requiring surgical repair, and no evidence of chondral defects larger than 1 cm associated with the ACL injury).¹ We examined more than 90 patients with our screening examination to obtain the 28 subjects who met the inclusion criteria in the study. Patients who were screened and who did not meet the criteria for participating in the study ultimately went on to have ACL reconstructive surgery.

Dr Rothstein contended that our study may provide inspiration but not evidence for all patients with ACL injuries because subjects in our study were not necessarily representative of the typical patient with an ACL injury who is examined and treated by most physical therapists. The subjects in our study—whom we classified as rehabilitation candidates after passing the screening examination and who ultimately attempted nonoperative management of their injuries—are indistinguishable, we believe, from the typical patient with an acute ACL injury in most ways. They are young, active, and anxious to get back to full activity. They are part of the 60% who do not have concomitant significant pathology, those whom therapists and surgeons are most likely to allow to "try" to play out the season.^2,3

The results of our randomized clinical trial provide ample evidence that a subgroup of patients with ACL injuries benefited from the intervention program; however, evidence exists to suggest that the overall approach we used is applicable to all patients with ACL injuries. We are now in the midst of the fourth year of performing preoperative screening examinations on patients with an acute ACL injury. Data from the first 2 years of this demographic study,¹ in which all patients in a population were accounted for, demonstrated that the patients who pass the screening examination comprise more than 20% (39/181) of the population of those with acute ACL injuries, including those with concomitant serious pathology, and more than 40% (39/94) of those with "isolated" ACL injuries. In our opinion, this percentage is hardly insignificant. The Conference discussants expressed an opinion that our subjects belong to a population of individuals who would not be typically examined or treated by physical therapists; we believe that the demographic data do not support that opinion.

The comments that few patients need this approach because most have surgery right away are culturally biased. Although this scenario may be true in the United States, Europe, and Canada, patients elsewhere often wait a year or more for elective surgery such as ACL reconstruction. The patient classification process used alone and the patient classification used in combination with the treatment procedures described in our Journal article better the odds over the historical success rate, as pointed out both in the paper and by Mr Wilk and Dr Irrgang. The screening and treatment procedures can be performed by physical therapists in virtually any clinical setting. We are happy that our results may be inspiring. The results of our randomized clinical trial also provide evidence that matching appropriate patients with the intervention program outlined in this study improves the likelihood that a significant subgroup of individuals with an ACL injury can safely return to high-level sports for the season without surgery.

	References

Top Introduction References

 

1. Fitzgerald GK, Axe, MJ, Snyder-Mackler L. A decision-making scheme for returning patients to high-level activity with non-operative treatment after anterior cruciate ligament rupture. Knee Surgery, Sports Traumatology, Arthroscopy. In press.
2. Daniel DM, Stone ML, Dobson BE, et al. Fate of the ACL-injured patient: a prospective outcome study. Am J Sports Med.1994; 22:632–644.[Abstract/Free Full Text]
3. Shelton WR, Barrett GR, Dukes A. Early season anterior cruciate ligament tears: a treatment dilemma. Am J Sports Med.1997; 25:656–658.[Abstract/Free Full Text]

This Article Full Text (PDF) Submit a response Alert me when this article is cited Alert me when Rapid Responses are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Fitzgerald, G K. Articles by Snyder-Mackler, L. Search for Related Content PubMed Articles by Fitzgerald, G K. Articles by Snyder-Mackler, L.