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.
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.
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From Cucumbers To Kindles
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You’ve Got Questions? We’ve Got Answers!
Q: Where do I get cucumber extract?
A: You can buy it from BulkSupplements.com (who, despite their name, start at 100g packs)
Alternatively: you want it as a topical ointment (for skin health) rather than as a dietary supplement (for bone and joint health), you can extract it yourself! No, it’s not “just juice cucumbers”, but it’s also not too tricky.
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Genetic Risk Factors For Long COVID
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Some people, after getting COVID, go on to have Long COVID. There are various contributing factors to this, including:
- Lifestyle factors that impact general disease-proneness
- Immune-specific factors such as being immunocompromised already
- Genetic factors
We looked at some modifiable factors to improve one’s disease-resistance, yesterday:
And we’ve taken a more big-picture look previously:
Beyond Supplements: The Real Immune-Boosters!
Along with some more systemic issues:
Why Some People Get Sick More (And How To Not Be One Of Them)
But, for when the “don’t get COVID” ship has sailed, one of the big remaining deciding factors with regard to whether one gets Long COVID or not, is genetic
The Long COVID Genes
For those with their 23andMe genetic data to hand…
❝Study findings revealed that three specific genetic loci, HLA-DQA1–HLA-DQB1, ABO, and BPTF–KPAN2–C17orf58, and three phenotypes were at significantly heightened risk, highlighting high-priority populations for interventions against this poorly understood disease.❞
For those who don’t, then first: you might consider getting that! Here’s why:
Genetic Testing: Health Benefits & Methods
But also, all is not lost meanwhile:
The same study also found that individuals with genetic predispositions to chronic fatigue, depression, and fibromyalgia, as well as other phenotypes such as autoimmune conditions and cardiometabolic conditions, are at significantly higher risk of long-COVID than individuals without these conditions.
Good news, bad news
Another finding was that women and non-smokers were more likely to get Long COVID, than men and smokers, respectively.
Does that mean that those things are protective against Long COVID, which would be very counterintuitive in the case of smoking?
Well, yes and no; it depends on whether you count “less likely to get Long COVID because of being more likely to just die” as protective against Long COVID.
(Incidentally, estrogen is moderately immune-enhancing, while testosterone is moderately immune-suppressing, so the sex thing was not too surprising. It’s also at least contributory to why women get more autoimmune disorders, while men get more respiratory infections such as colds and the like)
Want to know more?
You can read the paper itself, here:
*GWAS = Genome-Wide Association Study
Take care!
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Getting Flexible, Starting As An Adult: How Long Does It Really Take?
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Aleks Brzezinska didn’t start stretching until she was 21, and here’s what she found:
We’ll not stretch the truth
A lot of stretching programs will claim “do the splits in 30 days” or similar, and while this may occasionally be true, usually it’ll take longer.
Brzezinska started stretching seriously when she was 21, and made significant flexibility gains between the ages of 21 and 23 with consistent practice. Since then, she’s just maintained her flexibility.
There are facts that affect progress significantly, such as:
- Anatomy: body structure, age, and joint flexibility do influence flexibility; starting younger and/or having hypermobile joints does make it easier.
- Consistency: regular practice (2–3 times a week) is crucial, but avoid overdoing it, especially when sore.
- Lifestyle: weightlifting, running, and similar activities can tighten muscles, making flexibility harder to achieve.
- Hydration: staying hydrated is important for muscle flexibility.
She also recommends incorporating a variety of different stretching types, rather than just one method, for example passive stretching, active stretching, Proprioceptive Neuromuscular Facilitation (PNF) stretching, and mobility work.
For more on each of these, enjoy:
Click Here If The Embedded Video Doesn’t Load Automatically!
Want to learn more?
You might also like:
Jasmine McDonald’s Ballet Stretching Routine
Take care!
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Pine Nuts vs Pecans – Which is Healthier?
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Our Verdict
When comparing pine nuts to pecans, we picked the pine nuts.
Why?
Both have their merits!
In terms of macros, pine nuts have more protein while pecans have more fiber. They’re about equal on fats, although pine nuts have more polyunsaturated fat and pecans have more monounsaturated fat, of which, both are healthy. They’re also about equal on carbs. So really it comes down to the subjective choice between prioritizing protein and prioritizing fiber. On principle, we pick fiber, which gives the win to pecans, but your preference in this regard may differ; prioritizing the protein would give the win to pine nuts.
In the category of vitamins, pine nuts have more of vitamins B2, B3, B9, E, K, and choline, while pecans have more of vitamins A, B1, B5, B6, and C. Thus, a 6:5 marginal win for pine nuts.
Looking at the minerals, pine nuts have more copper, iron, magnesium, manganese, phosphorus, potassium, and zinc, while pecans have more calcium and selenium. An easy win for pine nuts this time.
Adding up the sections makes for a win for pine nuts, but of course, enjoy either or (preferably) both; diversity is good!
Want to learn more?
You might like to read:
Why You Should Diversify Your Nuts
Enjoy!
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How Beneficial Is MCT Oil, Really?
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Often derived from coconuts (though it doesn’t have to be), medium-chain triglycerides (MCTs) are trendy… But does the science back the hype?
First, the principle
MCTs are commonly enjoyed because unlike short- or long-chain fatty acids, they can be quickly broken down and either immediately converted quickly and easily into energy, or turned into ketones in the case of a surplus (in the case of true excess, however, it’ll simply be stored as fat).
Most of that involves the liver, so for anyone who wants a refresher on liver health:
How To Unfatty A Fatty Liver ← notwithstanding the title, this is also important knowledge even if your liver is healthy now—if you’d like it to stay healthy, anyway!
You can also read about the ins and outs of glycogen metabolism and the body’s energy-based metabolic processes in general (including the body’s energy processes that go on in the liver), here:
From Apples to Bees, and High-Fructose Cs: Which Sugars Are Healthier, And Which Are Just The Same?
If the liver turns the MCTs into ketones, those ketones will then be used for energy if there is insufficient glucose available (as the body will always use glucose from the blood first, if available, before moving to alternative energy sources such as ketones and/or fat reserves.)
Thus, many people look to ketones as a solution for having enough energy to function while on a very low-carb diet such as the ketogenic diet:
Ketogenic Diet: Burning Fat Or Burning Out?
…which as you’ll recall, does work for short-term weight loss, but brings long-term health risks, so should not be undertaken for long periods of time.
So, does MCT Oil help?
With regard to weight loss, the research is weak and mixed:
- Weak, because often the methodology was shoddy, often there are many factors not controlled-for, and often the sample sizes were small (and also, RCTs by their very nature tend to be quite short-term (often 6, 8, or 12 weeks), whereas heavy reliance on ketones from MCTs may fall into the same long-term problems as the ketogenic diet in general).
- Mixed, because the results varied widely (probably because of the aforementioned problems).
Rather than pick at individual studies, let’s look at this review and meta-analysis of 13 studies, with a combined sample size of 749 people (so you can imagine how small the individual RCTs were):
❝Compared with LCTs, MCTs decreased body weight (-0.51 kg [95% CI-0.80 to -0.23 kg]; P<0.001; I(2)=35%); waist circumference (-1.46 cm [95% CI -2.04 to -0.87 cm]; P<0.001; I(2)=0%), hip circumference (-0.79 cm [95% CI -1.27 to -0.30 cm]; P=0.002; I(2)=0%), total body fat (standard mean difference -0.39 [95% CI -0.57 to -0.22]; P<0.001; I(2)=0%), total subcutaneous fat (standard mean difference -0.46 [95% CI -0.64 to -0.27]; P<0.001; I(2)=20%), and visceral fat (standard mean difference -0.55 [95% CI -0.75 to -0.34]; P<0.001; I(2)=0%).
No differences were seen in blood lipid levels.
Many trials lacked sufficient information for a complete quality assessment, and commercial bias was detected.❞
So, if we’re going to take those numbers at face value, that means a net weight loss, over the course of the trial period, was…
*drumroll*
0.51kg (that’s about 1 lb).
To put that into perspective, if you did nothing else but pee 1 cup of urine before getting weighed, you’d register as having lost 0.25kg (or about ½ lb) by virtue of the bathroom trip alone.
Here’s the paper:
What about cholesterol and heart health?
With regard to cholesterol, MCT oil is touted as improving blood lipids, which means lowering LDL and increasing HDL (within a safe range, anyway).
You’ll remember that the above review concluded “No differences were seen in blood lipid levels”.
It may again be a case of individual studies cancelling each other out. For example…
This study found that it improved lipids in 40 young women as part of a calorie-controlled interventional diet:
This study found that it worsened lipids in 17 young men, worse even than taking an equivalent amount of sunflower oil:
In short, it’s a gamble.
It may be good for insulin sensitivity, though
This one seems to be specific to people with type 2 diabetes. The paper heading says it all, but we include the link in case you want to know the details (the short version is, it improved insulin sensitivity in diabetic subjects only (not others), and didn’t affect anything else that was measured:
The sample size was small (20 people total, of whom 10 had diabetes), and the next study was with 40 people, this time moderately overweight and all with type 2 diabetes:
Want to try some?
We don’t sell it, but here for your convenience is an example product on Amazon 😎
Enjoy!
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Mythbusting Cookware Materials
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In Wednesday’s newsletter, we asked you what kind of cookware you mostly use, and got the above-depicted, below-described, set of responses:
- About 45% said stainless steel
- About 21% said cast iron
- About 15% said non-stick (e.g. Teflon)
- About 9% said enamel
- About 6% said aluminum
- And 1 person selected “something else”, but then commented to the contrary, writing “I use all of the above”
So, what does the science say about these options?
Stainless steel cookware is safe: True or False?
True! Assuming good quality and normal use, anyway. There really isn’t a lot to say about this, because it’s very unexciting. So long as it is what it is labelled as: there’s nothing coating it, nothing comes out of it unless you go to extremes*, and it’s easy to clean.
*If you cook for long durations at very high temperatures, it can leach nickel and chromium into food. What this means in practical terms: if you are using stainless steel to do deep-frying, then maybe stop that, and also consider going easy on deep-frying in general anyway, because obviously deep-frying is unhealthy for other reasons.
Per normal use, however: pretty much the only way (good quality) stainless steel cookware will harm you is if you touch it while it’s hot, or if it falls off a shelf onto your head.
That said, do watch out for cheap stainless steel cookware that can contain a lot of impurities, including heavy metals. Since you probably don’t have a mass spectrometer and/or chemistry lab at home to check for those impurities, your best guard here is simply to buy from a reputable brand with credible certifications.
Ceramic cookware is safe: True or False?
True… Most of the time! Ceramic pans usually have metal parts and a ceramic cooking surface coated with a very thin layer of silicon. Those metal parts will be as safe as the metals used, so if that’s stainless steel, you’re just as safe as the above. As for the silicon, it is famously inert and body-safe (which is why it’s used in body implants).
However: ceramic cookware that doesn’t have an obvious metal part and is marketed as being pure ceramic, will generally be sealed with some kind of glaze that can leach heavy metals contaminants into the food; here’s an example:
Lead toxicity from glazed ceramic cookware
Copper cookware is safe: True or False?
False! This is one we forgot to mention in the poll, as one doesn’t see a lot of it nowadays. The copper from copper pans can leach into food. Now, of course copper is an important mineral that we must get from our diet, but the amount of copper that that can leach into food from copper pans is far too much, and can induce copper toxicity.
In addition, copper cookware has been found to be, on average, highly contaminated with lead:
Non-stick cookware contaminates the food with microplastics: True or False?
True! If we were to discuss all the common non-stick contaminants here, this email would no longer fit (there’s a size limit before it gets clipped by most email services).
Suffice it to say: the non-stick coating, polytetrafluoroethylene, is itself a PFAS, that is to say, part of the category of chemicals considered environmental pollutants, and associated with a long list of health issues in humans (wherein the level of PFAS in our bloodstream is associated with higher incidence of many illnesses):
You may have noticed, of course, that the “non-stick” coating doesn’t stick very well to the pan, either, and will tend to come off over time, even if used carefully.
Also, any kind of wet cooking (e.g. saucepans, skillets, rice cooker inserts) will leach PFAS into the food. In contrast, a non-stick baking tray lined with baking paper (thus: a barrier between the tray and your food) is really not such an issue.
We wrote about PFAS before, so if you’d like a more readable pop-science article than the scientific paper above, then check out:
PFAS Exposure & Cancer: The Numbers Are High
Aluminum cookware contaminates the food with aluminum: True or False?
True! But not usually in sufficient quantities to induce aluminum toxicity, unless you are aluminum pans Georg who eats half a gram of aluminum per day, who is a statistical outlier and should not be counted.
That’s a silly example, but an actual number; the dose required for aluminum toxicity in blood is 100mg/L, and you have about 5 liters of blood.
Unless you are on kidney dialysis (because 95% of aluminum is excreted by the kidneys, and kidney dialysis solution can itself contain aluminum), you will excrete aluminum a lot faster than you can possibly absorb it from cookware. On the other hand, you can get too much of it from it being a permitted additive in foods and medications, for example if you are taking antacids they often have a lot of aluminum oxide in them—but that is outside the scope of today’s article.
However, aluminum may not be the real problem in aluminum pans:
❝In addition, aluminum (3.2 ± 0.25 to 4.64 ± 0.20 g/kg) and copper cookware (2.90 ± 0.12 g/kg) were highly contaminated with lead.
The time and pH-dependent study revealed that leaching of metals (Al, Pb, Ni, Cr, Cd, Cu, and Fe, etc.) into food was predominantly from anodized and non-anodized aluminum cookware.
More metal leaching was observed from new aluminum cookware compared to old. Acidic food was found to cause more metals to leach during cooking.❞
~ the same paper we cited when talking about copper
Cast iron cookware contaminates the food with iron: True or False?
True, but unlike with the other metals discussed, this is purely a positive, and indeed, it’s even recommended as a good way to fortify one’s diet with iron:
The only notable counterpoint we could find for this is if you have hemochromatosis, a disorder in which the body is too good at absorbing iron and holding onto it.
Thinking of getting some new cookware?
Here are some example products of high-quality safe materials on Amazon, but of course feel free to shop around:
Stainless Steel | Ceramic* | Cast Iron
*it says “non-stick” in the description, but don’t worry, it’s ceramic, not Teflon etc, and is safe
Bonus: rice cooker with stainless steel inner pot
Take care!
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