Surgery is the default treatment for ACL injuries in Australia. But it’s not the only way

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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.

PeopleImages.com – Yuri A/Shutterstock

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.

A diagram showing an ACL tear.
Experts used to think an ACL tear couldn’t heal without surgery – now there’s evidence it can. SKYKIDKID/Shutterstock

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%.

A physio bends a patient's knee.
For people who opt to try rehabilitation, the option of having surgery later is still there. PeopleImages.com – Yuri A/Shutterstock

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.

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    • Why a common asthma drug will now carry extra safety warnings about depression

      10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

      Australia’s Therapeutic Goods Administration (TGA) recently issued a safety alert requiring extra warnings to be included with the asthma and hay fever drug montelukast.

      The warnings are for users and their families to look for signs of serious behaviour and mood-related changes, such as suicidal thoughts and depression. The new warnings need to be printed at the start of information leaflets given to both patients and health-care providers (sometimes called a “boxed” warning).

      So why did the TGA issue this warning? And is there cause for concern if you or a family member uses montelukast? Here’s what you need to know.

      First, what is montelukast?

      Montelukast is a prescription drug also known by its brand names which include Asthakast, Lukafast, Montelair and Singulair. It’s used to manage the symptoms of mild-to-moderate asthma and seasonal hay fever in children and adults.

      Asthma occurs when the airways tighten and produce extra mucus, which makes it difficult to get air into the lungs. Likewise, the runny nose characteristic of hay fever occurs due to the overproduction of mucus.

      Leukotrienes are an important family of chemicals found throughout the airways and involved in both mucus production and airway constriction. Montelukast is a cysteinyl leukotriene receptor antagonist, meaning it blocks the site in the airways where the leukotrienes work.

      Montelukast can’t be used to treat acute asthma (an asthma attack), as it takes time for the tablet to be broken down in the stomach and for it to be absorbed into the body. Rather, it’s taken daily to help prevent asthma symptoms or seasonal hay fever.

      It can be used alongside asthma puffers that contain corticosteriods and drugs like salbutamol (Ventolin) in the event of acute attacks.

      What is the link to depression and suicide?

      The possibility that this drug may cause behavioural changes is not new information. Manufacturers knew this as early as 2007 and issued warnings for possible side-effects including depression, suicidality and anxiousness.

      The United Kingdom’s Medicines and Healthcare products Regulatory Agency has required a warning since 2008 but mandated a more detailed warning in 2019. The United States’ Food and Drug Administration has required boxed warnings for the drug since 2020.

      A child using an inhaler.
      Montelukast can help children and adults with asthma. adriaticfoto/Shutterstock

      Montelukast is known to potentially induce a number of behaviour and mood changes, including agitation, anxiety, depression, irritability, obsessive-compulsive symptoms, and suicidal thoughts and actions.

      Initially a 2009 study that analysed data from 157 clinical trials involving more than 20,000 patients concluded there were no completed suicides due to taking the drug, and only a rare risk of suicide thoughts or attempts.

      The most recent study, published in November 2024, examined data from more than 100,000 children aged 3–17 with asthma or hay fever who either took montelukast or used only inhaled corticosteroids.

      It found montelukast use was associated with a 32% higher incidence of behavioural changes. The behaviour change with the strongest association was sleep disturbance, but montelukast use was also linked to increases in anxiety and mood disorders.

      In the past ten years, around 200 incidences of behavioural side-effects have been reported to the TGA in connection with montelukast. This includes 57 cases of depression, 60 cases of suicidal thoughts and 17 suicide attempts or incidents of intentional self-injury. There were seven cases where patients taking the drug did complete a suicide.

      This is of course tragic. But these numbers need to be seen in the context of the number of people taking the drug. Over the same time period, more than 200,000 scripts for montelukast have been filled under the Pharmaceutical Benefits Scheme.

      Overall, we don’t know conclusively that montelukast causes depression and suicide, just that it seems to increase the risk for some people.

      CT images of the brain.
      We’re still not sure how the drug can act on the brain to lead to behaviour changes. Elif Bayraktar/Shutterstock

      And if it does change behaviour, we don’t fully understand how this happens. One hypothesis is that the drug and its breakdown products (or metabolites) affect brain chemistry.

      Specifically, it might interfere with how the brain detoxifies the antioxidant glutathione or alter the regulation of other brain chemicals, such as neurotransmitters.

      Why is the TGA making this change now?

      The new risk warning requirement comes from a meeting of the Australian Advisory Committee on Medicines where they were asked to provide advice on ways to minimise the risk for the drug given current international recommendations.

      Even though the 2024 review didn’t highlight any new risks, to align with international recommendations, and help address consumer concerns, the advisory committee recommended a boxed warning be added to drug information sheets.

      If you have asthma and take montelukast (or your child does), you should not just stop taking the drug, because this could put you at risk of an attack that could be life threatening. If you’re concerned, speak to your doctor who can discuss the risks and benefits of the medication for you, and, if appropriate, prescribe a different medication.

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

      Nial Wheate, Professor of Pharmaceutical Chemistry, Macquarie University

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

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    • Cannellini Protein Gratin

      10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

      A healthier twist on a classic, the protein here comes not only from the cannellini beans, but also from (at the risk of alienating French readers) a béchamel sauce that is not made using the traditional method involving flour and butter, but instead, has cashew protein as a major constituent.

      You will need

      • 3 medium potatoes, chopped (no need to peel them; you can if you want, but many of the nutrients are there and they’re not a problem for the recipe)
      • 1 can cannellini beans (also called white kidney beans)
      • 1 medium onion, chopped
      • 2 stalks celery, sliced
      • 1 carrot, chopped
      • ½ bulb garlic, minced (or more, if you like)
      • 1 jalapeño, chopped
      • 2 tbsp tomato paste
      • 1 tbsp chia seeds
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      • Extra virgin olive oil, for frying

      For the béchamel sauce:

      • ½ cup milk (we recommend a neutral-tasting plant milk, such as unsweetened soy, but go with your preference)
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      • 1 tsp garlic powder
      • 1 tsp dried thyme

      Method

      (we suggest you read everything at least once before doing anything)

      Note: it will be a bonus if you can use a pan that is good both for going on the hob and in the oven, such as a deep cast iron skillet, or a Dutch oven. If you don’t have something like that though, it’s fine, just use a sauté pan or similar, and then transfer to an oven dish for the oven part—we’ll mention this again when we get to it.

      1) Preheat the oven to 250℉/175℃.

      2) Heat the pan, adding some oil and then the oven; fry it for about 5 minutes, stirring often.

      3) Add the potatoes, celery, carrot, garlic, and jalapeño, stirring for another 2 minutes.

      4) Add the tomato paste, along with 1 cup water, the chia seeds, and the black pepper, and cook for a further 15 minutes, stirring occasionally as necessary.

      5) Add the cannellini beans, and cook for another 15 minutes, stirring occasionally as necessary.

      6) Blend all the ingredients for the béchamel sauce, processing it until it is smooth.

      7) If you are using an oven-safe pan, pour the béchamel sauce over the bean mixture (don’t stir it; the sauce should remain on top) and transfer it to the oven. Don’t use a lid.

      If you’re not using an oven safe pan, first transfer the bean mixture to an oven dish, then pour the béchamel sauce over the bean mixture (don’t stir it; the sauce should remain on top) and put it in the oven. Don’t use a lid.

      8) Bake for about 15 minutes, or until turning golden-brown on top.

      9) Serve! It can be enjoyed on its own, or with salad and/or rice. See also, our Tasty Versatile Rice Recipe.

      Enjoy!

      Want to learn more?

      For those interested in some of the science of what we have going on today:

      Take care!

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    • Screaming at Screens?

      10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

      I Screen, You Screen, We All Screen For…?

      Dr. Kathryn Birkenbach is a postdoctoral research fellow in the Department of Neuroscience at Columbia University, and Manager of Research at Early Medical in New York.

      Kathryn has things to tell us about kids’ neurological development, and screen time spent with electronic devices including phones, tablets, computers, and TVs.

      From the 1960s criticism of “the gogglebox” to the modern-day critiques of “iPad babies” as a watchword of parental neglect, there’s plenty people can say against screen time, but Dr. Birkenbach tells us the that the reality is more nuanced:

      Context Is Key

      On a positive note”: consistent exposure to age-appropriate educational material results in quicker language acquisition than media that’s purely for entertainment purposes, or not age-appropriate.

      Contrary to popular belief, children do not in fact learn by osmosis!

      Interaction Is Far More Valuable Than Inaction

      Kathryn advises that while adults tend to quite easily grasp things from instructional videos, the same does not go for small children.

      This means that a lot of educational programming can be beneficial to small children if and only if there is an adult with them to help translate the visual into the practical!

      There’s a story that does the rounds on the Internet: a young boy wanted to train his puppy, but didn’t know how. He asked, and was told “search for puppy training on YouTube”. His parents came back later and found him with his iPad, earnestly showing the training videos to the puppy.

      We can laugh at the child’s naïvety, knowing that’s not how it works and the puppy will not learn that way, so why make the same mistake in turn?

      ❝The phenomenon known as the “video deficit effect” can be overcome, when an on-screen guide interacts with the child or a parent is physically present and draws the child’s attention to relevant information.

      In other words, interaction with others appears to enhance the perceived salience of on-screen information, unlocking a child’s ability to learn from a medium which would otherwise offer no real-world benefit.

      Screens Can Supplement, But Can’t Replace, Live Learning & Play

      Sci-fi may show us “education pods” in which children learn all they need to from their screen… but according to our most up-to-date science, Dr. Birkenbach says, that simply would not work at all.

      Screen time without adult interactions will typically fail to provide small children any benefit.

      There is one thing it’s good at, though… attracting and keeping attention.

      Thus, even a mere background presence of a TV show in the room will tend to actively reduce the time a small child spends on other activities, including live learning and exploratory play.

      The attention-grabbing abilities of TV shows don’t stop at children, though! Adult caregivers will also tend to engage in fewer interactions with their children… and the interactions will be shorter and of lower quality.

      In Summary:

      • Young children will tend not to learn from non-interactive screen time
      • Interactive screen time, ideally with a caregiver, can be educational
      • Interactive screen time, not with a carer, can be beneficial (but a weak substitute)
        • Interactive screen time refers to shows such as Dora The Explorer, where Dora directly addresses the viewer and asks questions…But it’s reliant on the child caring to answer!
        • It can also mean interactive educational apps, provided the child does consciously interact!
        • Randomly pressing things is not conscious interaction! The key here is engaging with it intelligently and thoughtfully
      • A screen will take a child’s time and attention away from non-screen things: that’s a genuine measurable loss to their development!

      Absolute Bottom Line:

      Screens can be of benefit to small children, if and only if the material is:

      • Age-Appropriate
      • Educational
      • Interactive

      If it’s missing one of those three, it’ll be of little to no benefit, and can even harm, as it reduces the time spent on more beneficial activities.

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        10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

        At first glance, this can seem like an unscientific book—you won’t find links to studies in this one, for sure! However, if we take a look at the seven circles in question, they are:

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        Or to say the same thing in sciencey terms: how to mindfully improve integrated lifestyle factors synergistically for greater efficacy and improved health-adjusted quality-of-life years.

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      • Managing Jealousy

        10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

        Jealousy is often thought of as a young people’s affliction, but it can affect us at any age—whether we are the one being jealous, or perhaps a partner.

        And, the “green-eyed monster” can really ruin a lot of things; relationships, friendships, general happiness, physical health even (per stress and anxiety and bad sleep), and more.

        The thing is, jealousy looks like one thing, but is actually mostly another.

        Jealousy is a Scooby-Doo villain

        That is to say: we can unmask it and see what much less threatening thing is underneath. Which is usually nothing more nor less than: insecurities

        • Insecurity about losing one’s partner
        • Insecurity about not being good enough
        • Insecurity about looking bad socially

        …etc. The latter, by the way, is usually the case when one’s partner is socially considered to be giving cause for jealousy, but the primary concern is not actually relational loss or any kind of infidelity, but rather, looking like one cannot keep one’s partner’s full attention romantically/sexually. This drives a lot of people to act on jealousy for the sake of appearances, in situations where they might otherwise, if they didn’t feel like they’d be adversely judged for it, be considerably more chill.

        Thus, while monogamy certainly has its fine merits, there can also be a kind of “toxic monogamy” at hand, where a relationship becomes unhealthy because one partner is just trying to live up to social expectations of keeping the other partner in check.

        This, by the way, is something that people in polyamorous and/or open relationships typically handle quite neatly, even if a lot of the following still applies. But today, we’re making the statistically safe assumption of a monogamous relationship, and talking about that!

        How to deal with the social aspect

        If you sit down with your partner and work out in advance the acceptable parameters of your relationship, you’ll be ahead of most people already. For example…

        • What counts as cheating? Is it all and any sex acts with all and any people? If not, where’s the line?
        • What about kissing? What about touching other body parts? If there are boundaries that are important to you, talk about them. Nothing is “too obvious” because it’s astonishing how many times it will happen that later someone says (in good faith or not), “but I thought…”
        • What about being seen in various states of undress? Or seeing other people in various states of undress?
        • Is meaningless flirting between friends ok, and if so, how do we draw the line with regard to what is meaningless? And how are we defining flirting, for that matter? Talk about it and ensure you are both on the same page.
        • If a third party is possibly making moves on one of us under the guise of “just being friendly”, where and how do we draw the line between friendliness and romantic/sexual advances? What’s the difference between a lunch date with a friend and a romantic meal out for two, and how can we define the difference in a way that doesn’t rely on subjective “well I didn’t think it was romantic”?

        If all this seems like a lot of work, please bear in mind, it’s a lot more fun to cover this cheerfully as a fun couple exercise in advance, than it is to argue about it after the fact!

        See also: Boundary-Setting Beyond “No”

        How to deal with the more intrinsic insecurities

        For example, when jealousy is a sign of a partner fearing not being good enough, not measuring up, or perhaps even losing their partner.

        The key here might not shock you: communication

        Specifically, reassurance. But critically, the correct reassurance!

        A partner who is jealous will often seek the wrong reassurance, for example wanting to read their partner’s messages on their phone, or things like that. And while a natural desire when experiencing jealousy, it’s not actually helpful. Because while incriminating messages could confirm infidelity, it’s impossible to prove a negative, and if nothing incriminating is found, the jealous partner can just go on fearing the worst regardless. After all, their partner could have a burner phone somewhere, or a hidden app for cheating, or something else like that. So, no reassurance can ever be given/gained by such requests (which can also become unpleasantly controlling, which hopefully nobody wants).

        A quick note on “if you have nothing to fear, you have nothing to hide”: rhetorically that works, but practically it doesn’t.

        Writer’s example: when my late partner and I formalized our relationship, we discussed boundaries, and I expressed “so far as I am concerned, I have no secrets from you, except secrets that are not mine to share. For example, if someone has confided in me and asked that I not share it, I won’t. Aside from that, you have access-all-areas in my life; me being yours has its privileges” and this policy itself would already pre-empt any desire to read my messages.

        Now indeed, I had nothing to hide. I am by character devoted to a fault. But my friends may well sometimes have things they don’t want me to share, which made that a necessary boundary to highlight (which my partner, an absolute angel by the way and not prone to unhealthy manifestations of jealousy in any case, understood completely).

        So, it is best if the partner of a jealous person can explain the above principles as necessary, and offer the correct reassurance instead. Which could be any number of things, but for example:

        • I am yours, and nobody else has a chance
        • I fully intend to stay with you for life
        • You are the best partner I have ever had
        • Being with you makes my life so much better

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        And if your partner (or you, if it’s you who’s jealous) can express the insecurity in the format…

        “I’m afraid of _____ because _____”

        …then the “because” will allow for much more specific reassurance. We all have insecurities, we all have reasons we might fear not being good enough for our partner, or losing their affection, and the best thing we can do is choose to trust our partners at least enough to discuss those fears openly with each other.

        See also: Save Time With Better Communication ← this can avoid a lot of time-consuming arguments

        What about if the insecurity is based in something demonstrably correct?

        By this we mean, something like a prior history of cheating, or other reasons for trust issues. In such a case, the jealous partner may well have a reason for their jealousy that isn’t based on a personal insecurity.

        In our previous article about boundaries, we talked about relationships (romantic or otherwise) having a “price of entry”. In this case, you each have a “price of entry”:

        • The “price of entry” to being with the person who has previously cheated (or similar), is being able to accept that.
        • And for the person who cheated (or similar), very likely their partner will have the “price of entry” of “don’t do that again, and also meanwhile accept in good grace that I might be jittery about it”.

        And, if the betrayal of trust was something that happened between the current partners in the current relationship, most likely that was also traumatic for the person whose trust was betrayed. Many people in that situation find that trust can indeed be rebuilt, but slowly, and the pain itself may also need treatment (such as therapy and/or couples therapy specifically).

        See also: Relationships: When To Stick It Out & When To Call It Quits ← this covers both sides

        And finally, to finish on a happy note:

        Only One Kind Of Relationship Promotes Longevity This Much!

        Take care!

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        10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

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        The illustrations are clear and the explanations excellent. The book also dives into (as the title promises) the science of HIIT, and why it works the way it does to give results that can’t be achieved with other forms of exercise.

        Bottom line: if you’ve been wanting to do HIIT but have not yet found a way of doing it that suits your lifestyle, this book gives many excellent options.

        Click here to check out Science of HIIT, and level-up yours!

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