The anterior cruciate ligament (ACL) is an important ligament in the knee. It runs from the thigh bone (femur) to the shin bone (tibia) and helps stabilise the knee joint.

Injuries to the ACL, often called a “tear” or a “rupture”, are common in sport. While a ruptured ACL has just sidelined another Matildas star, people who play sport recreationally are also at risk of this injury.

For decades, surgical repair of an ACL injury, called a reconstruction, has been the primary treatment in Australia. In fact, Australia has among the highest rates of ACL surgery in the world. Reports indicate 90% of people who rupture their ACL go under the knife.

Although surgery is common – around one million are performed worldwide each year – and seems to be the default treatment for ACL injuries in Australia, it may not be required for everyone.

What does the research say?

We know ACL ruptures can be treated using reconstructive surgery, but research continues to suggest they can also be treated with rehabilitation alone for many people.

Almost 15 years ago a randomised clinical trial published in the New England Journal of Medicine compared early surgery to rehabilitation with the option of delayed surgery in young active adults with an ACL injury. Over half of people in the rehabilitation group did not end up having surgery. After five years, knee function did not differ between treatment groups.

The findings of this initial trial have been supported by more research since. A review of three trials published in 2022 found delaying surgery and trialling rehabilitation leads to similar outcomes to early surgery.

A 2023 study followed up patients who received rehabilitation without surgery. It showed one in three had evidence of ACL healing on an MRI after two years. There was also evidence of improved knee-related quality of life in those with signs of ACL healing compared to those whose ACL did not show signs of healing.

Regardless of treatment choice the rehabilitation process following ACL rupture is lengthy. It usually involves a minimum of nine months of progressive rehabilitation performed a few days per week. The length of time for rehabilitation may be slightly shorter in those not undergoing surgery, but more research is needed in this area.

Rehabilitation starts with a physiotherapist overseeing simple exercises right through to resistance exercises and dynamic movements such as jumping, hopping and agility drills.

A person can start rehabilitation with the option of having surgery later if the knee remains unstable. A common sign of instability is the knee giving way when changing direction while running or playing sports.

To rehab and wait, or to go straight under the knife?

There are a number of reasons patients and clinicians may opt for early surgical reconstruction.

For elite athletes, a key consideration is returning to sport as soon as possible. As surgery is a well established method, athletes (such as Matilda Sam Kerr) often opt for early surgical reconstruction as this gives them a more predictable timeline for recovery.

At the same time, there are risks to consider when rushing back to sport after ACL reconstruction. Re-injury of the ACL is very common. For every month return to sport is delayed until nine months after ACL reconstruction, the rate of knee re-injury is reduced by 51%.

Historically, another reason for having early surgical reconstruction was to reduce the risk of future knee osteoarthritis, which increases following an ACL injury. But a review showed ACL reconstruction doesn’t reduce the risk of knee osteoarthritis in the long term compared with non-surgical treatment.

That said, there’s a need for more high-quality, long-term studies to give us a better understanding of how knee osteoarthritis risk is influenced by different treatments.

Rehab may not be the only non-surgical option

Last year, a study looking at 80 people fitted with a specialised knee brace for 12 weeks found 90% had evidence of ACL healing on their follow-up MRI.

People with more ACL healing on the three-month MRI reported better outcomes at 12 months, including higher rates of returning to their pre-injury level of sport and better knee function. Although promising, we now need comparative research to evaluate whether this method can achieve similar results to surgery.

What to do if you rupture your ACL

First, it’s important to seek a comprehensive medical assessment from either a sports physiotherapist, sports physician or orthopaedic surgeon. ACL injuries can also have associated injuries to surrounding ligaments and cartilage which may influence treatment decisions.

In terms of treatment, discuss with your clinician the pros and cons of management options and whether surgery is necessary. Often, patients don’t know not having surgery is an option.

Surgery appears to be necessary for some people to achieve a stable knee. But it may not be necessary in every case, so many patients may wish to try rehabilitation in the first instance where appropriate.

As always, prevention is key. Research has shown more than half of ACL injuries can be prevented by incorporating prevention strategies. This involves performing specific exercises to strengthen muscles in the legs, and improve movement control and landing technique.

Anthony Nasser, Senior Lecturer in Physiotherapy, University of Technology Sydney; Joshua Pate, Senior Lecturer in Physiotherapy, University of Technology Sydney, and Peter Stubbs, Senior Lecturer in Physiotherapy, University of Technology Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.

According to the World Health Organization, about 280 million people worldwide have depression and about one billion have a mental health problem of any kind.

People living in the ancient world also had mental health problems. So, how did they deal with them?

As we’ll see, some of their insights about mental health are still relevant today, even though we might question some of their methods.

1. Our mental state is important

Mental health problems such as depression were familiar to people in the ancient world. Homer, the poet famous for the Iliad and Odyssey who lived around the eighth century BC, apparently died after wasting away from depression.

Already in the late fifth century BC, ancient Greek doctors recognised that our health partly depends on the state of our thoughts.

In the Epidemics, a medical text written in around 400BC, an anonymous doctor wrote that our habits about our thinking (as well as our lifestyle, clothing and housing, physical activity and sex) are the main determinants of our health.

2. Mental health problems can make us ill

Also writing in the Epidemics, an anonymous doctor described one of his patients, Parmeniscus, whose mental state became so bad he grew delirious, and eventually could not speak. He stayed in bed for 14 days before he was cured. We’re not told how.

Later, the famous doctor Galen of Pergamum (129-216AD) observed that people often become sick because of a bad mental state:

It may be that under certain circumstances ‘thinking’ is one of the causes that bring about health or disease because people who get angry about everything and become confused, distressed and frightened for the slightest reason often fall ill for this reason and have a hard time getting over these illnesses.

Galen also described some of his patients who suffered with their mental health, including some who became seriously ill and died. One man had lost money:

He developed a fever that stayed with him for a long time. In his sleep he scolded himself for his loss, regretted it and was agitated until he woke up. While he was awake he continued to waste away from grief. He then became delirious and developed brain fever. He finally fell into a delirium that was obvious from what he said, and he remained in this state until he died.

3. Mental illness can be prevented and treated

In the ancient world, people had many different ways to prevent or treat mental illness.

The philosopher Aristippus, who lived in the fifth century BC, used to advise people to focus on the present to avoid mental disturbance:

concentrate one’s mind on the day, and indeed on that part of the day in which one is acting or thinking. Only the present belongs to us, not the past nor what is anticipated. The former has ceased to exist, and it is uncertain if the latter will exist.

The philosopher Clinias, who lived in the fourth century BC, said that whenever he realised he was becoming angry, he would go and play music on his lyre to calm himself.

Doctors had their own approaches to dealing with mental health problems. Many recommended patients change their lifestyles to adjust their mental states. They advised people to take up a new regime of exercise, adopt a different diet, go travelling by sea, listen to the lectures of philosophers, play games (such as draughts/checkers), and do mental exercises equivalent to the modern crossword or sudoku.

For instance, the physician Caelius Aurelianus (fifth century AD) thought patients suffering from insanity could benefit from a varied diet including fruit and mild wine.

Doctors also advised people to take plant-based medications. For example, the herb hellebore was given to people suffering from paranoia. However, ancient doctors recognised that hellebore could be dangerous as it sometimes induced toxic spasms, killing patients.

Other doctors, such as Galen, had a slightly different view. He believed mental problems were caused by some idea that had taken hold of the mind. He believed mental problems could be cured if this idea was removed from the mind and wrote:

a person whose illness is caused by thinking is only cured by taking care of the false idea that has taken over his mind, not by foods, drinks, [clothing, housing], baths, walking and other such (measures).

Galen thought it was best to deflect his patients’ thoughts away from these false ideas by putting new ideas and emotions in their minds:

I put fear of losing money, political intrigue, drinking poison or other such things in the hearts of others to deflect their thoughts to these things […] In others one should arouse indignation about an injustice, love of rivalry, and the desire to beat others depending on each person’s interest.

4. Addressing mental health needs effort

Generally speaking, the ancients believed keeping our mental state healthy required effort. If we were anxious or angry or despondent, then we needed to do something that brought us the opposite of those emotions.

This can be achieved, they thought, by doing some activity that directly countered the emotions we are experiencing.

For example, Caelius Aurelianus said people suffering from depression should do activities that caused them to laugh and be happy, such as going to see a comedy at the theatre.

However, the ancients did not believe any single activity was enough to make our mental state become healthy. The important thing was to make a wholesale change to one’s way of living and thinking.

When it comes to experiencing mental health problems, we clearly have a lot in common with our ancient ancestors. Much of what they said seems as relevant now as it did 2,000 years ago, even if we use different methods and medicines today.

If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14.

Konstantine Panegyres, McKenzie Postdoctoral Fellow, researching Greco-Roman antiquity, The University of Melbourne

This article is republished from The Conversation under a Creative Commons license. Read the original article.