Over the last twenty years, physical fitness as a means to improve overall health has increased among the over-40 set. This is great, right? Yes, absolutely. Athletes who remain active as they age do a better job than non-athletes in retaining lean muscle mass. They also show improved bone density, bone structure and bone strength. However, what physicians are seeing are injuries related to the increased level of activity.
One area of interest is anterior cruciate ligament injury in the over-40 age group. The anterior cruciate ligament, or ACL, is one of the ligaments that connect the femur (thigh bone) to the tibia (shin bone), and it controls the back and forth motion in the knee. Specifically, it keeps the tibia from sliding too far forward, while also avoiding too much rotation in the knee.
Injuries of the ACL occur when there is a rapid change of direction or acceleration, a direct collision with the knee, or an awkward land from a jump or a height. Some ACL injuries can be rehabbed - meaning while the ligament never truly repairs itself or heals, some individuals can remain fairly active with a course of physical therapy and home exercise. Sometimes individuals do well with this regimen, and can continue not only their activities of daily life, but remain active as well. Usually though, hard cutting and pivoting sports are difficult to continue without an intact ACL, because the knee simply feels “loose” or unstable. And if the knee shifts around too much because that ACL is gone, then other injuries can occur - meniscus (your knee’s shock absorbing cartilage) tears, injuries to the smooth cartilage that lines the joints (which then can lead to arthritis), or the remaining supportive ligaments can be sprained or torn as well.
Suppose you’re a 40-something (or beyond), you love playing soccer, going downhill skiing and training with cross fit. You collide with another player in soccer, and now your ACL is torn. An ACL tear is an ACL tear, right? Yes and no. While the principles of how we reconstruct this ligament remain the same, we cannot ignore the changes that come along with age.
I hate admitting it...but yes...40 is (gasp) MIDDLE AGE.
So what? That means the older ACL is going to be more prone to injury. And even when reconstructed, it may take longer to heal. Some surgeons wait an entire year after ACL reconstruction before releasing an older athlete back to full sport.
Who needs to have the reconstruction, and who will do well with non surgical management? There’s a rule of thirds that was described over 25 years ago. One third of ACL-injured older athletes choose to rehab the knee, and with some activity modification that is acceptable to them, do well without instability symptoms. Another third rehab their knees and go back to everything they were doing before without instability. And the last third, despite rehab, have symptoms of instability with even everyday basic activities.
Many studies do show that older athletes can have improvements and good outcomes after ACL reconstruction. What ACL reconstruction does NOT do however, is prevent the risk of arthritis developing. Athletes who tear their ACL are at increased risk for arthritis whether the ACL is reconstructed or not...but the question for the athlete to ask is if their knee is stable enough for them to do what it is they want to do.
There are many benefits that far outweigh the risks of maintaining an active lifestyle after 40. So go out there and STAY FIT! But if you have an ACL tear, talk to your orthopaedic surgeon about your options.
Salzler MJ, Chang J, Richmond J, “Management of Anterior Crucate Ligament Injuries in Adults Aged >40 Years”, JAAOS Aug 15, 2018, 26(16), 553-561