Most people who have a common knee ligament injury fare just as well with intense physical therapy as they do with surgery, according to a study comparing the two techniques.
Researchers said that focusing on rehabilitation first could prevent more than half of operations done to repair a tear in the anterior cruciate ligament (ACL), which lies beneath the kneecap and attaches the thigh bone to the shin bone.
Such tears are the most common type of knee ligament injury, often affecting athletes. About 200,000 ACL reconstructions are done in the United States each year at a cost of billions of dollars.
Treatment of "an acute ACL injury should start with structured rehabilitation rather than early ACL reconstruction," Richard Frobell of Lund University in Sweden, whose study appears in the New England Journal of Medicine, said in an e-mail.
The team looked at 121 people aged 18 to 35, none of them professional athletes. About half received surgery. The others were given rehabilitation in hopes of delaying the operation. Twenty-three of the 59 patients in the rehabilitation group eventually ended up having the operation anyway.
After two years, people assigned to the surgery group were not doing better than those who got physical therapy as a first option. The assessment was based on various measures of pain, symptoms, and the ability to function.
"Surgical reconstruction was avoided in 61 percent of the subjects without compromising the results," the Frobell team concluded.
Dr. Bruce Levy of the Mayo Clinic in Rochester, Minn., who wrote a commentary on the study, said the findings support what doctors already do.
"It confirms what we have always intuitively thought and known, and that is that not all patients need their ACLs reconstructed, and that the decision to perform an ACL reconstruction really needs to be individually tailored," Levy said in a statement.
He cautioned that longer-term evaluations have shown that delayed ACL reconstruction in some people poses a risk of damaging other parts of the knee.
"There's solid evidence that people who have ACL tears and do not have reconstruction, if they go on to have frequent giving-way or instability episodes, they are at an increased risk of doing damage," he said in a telephone interview.
Frobell said the risk cited by Levy is based on doctors observing what happens to patients who have not had surgery, but there may not be a direct cause and effect.
In his commentary, Levy said the new research "confirms that some patients who are not elite athletes can function with an ACL-deficient knee."
But he said it was hard to predict which patients will need surgery, and said longer-term data are needed.
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