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Unknown unknowns and lessons from non-operative rehabilitation and return to play of a complete anterior cruciate ligament injury in English Premier League football
  1. Richard Weiler1,2,3,4
  1. 1 University College London Hospitals NHS Foundation Trust & UCL Institute of Sport, Exercise and Health, London, UK
  2. 2 West Ham United Football Club Training Ground, Chadwell Heath, Essex, UK
  3. 3 The FA Centre for Disability Football Research, Burton Upon Trent, UK
  4. 4 Fortius Clinic, London, UK
  1. Correspondence to Dr Richard Weiler, University College London Hospitals NHS Foundation Trust & UCL Institute of Sport, Exercise and Health, London W1T 7HA, UK; rweiler{at}

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An illustrated example

An English Premier League (EPL) footballer decides to open-mindedly try, at least initially, non-operative and non-interventional treatment of a complete anterior cruciate ligament (ACL) rupture. At 5 weeks, he feels great and fully trusts his knee, sailing with confidence through every graded progression in his evolving rehabilitation programme. He continues with rehabilitation to full training within 8 weeks of a complete ACL injury.1 Now, almost 24 months later, he is still training and playing full competitive professional football. During 22 months available for team selection, there have been no episodes of instability, no knee pain, no effusions, no soft tissue injuries and no discernible impairment on function. There was no change on clinical ligament tests either. Treatment was entirely non-surgical with no use of needles for aspiration or injection. He remains aware that he is very lucky so far, that he cannot predict what could happen in future, possibly requiring surgery, and he is aware that risk of osteoarthritis is high following ACL injury whether reconstruction has taken place or not.2–4 Before jumping to conclusions, perhaps it is worth reading the full paper at BMJ Case Reports to decide for yourself what you may have done in this situation.1

Unknown unknowns

It is unusual for elite professional athletes to choose the uncertainty of non-operative treatment for an ACL injury when the quantity of research, and the opinions and cultural norms in professional sport, are heavily influenced towards surgical reconstruction with known prognostics, known rehabilitation programmes, known risks, a known evidence base and known experiences. ACL-injured knees progress to early osteoarthritis, whether treated non-operatively or with ACL reconstruction (ACLR),2–4 and concurrent or delayed meniscal injury may be an important prognostic factor in determining longer term outcomes.4 ,5 ACL-deficient sport has real risk of undesirable long-term outcomes, future meniscus and cartilage injury, and also loss of the option of an early surgical ACLR. It is reasonable to question whether medical teams have the experience to rehabilitate an ACL-deficient and clinically unstable knee in a professional footballer, when few elite professional medical teams will have been in this position before; and, to the best of our knowledge, none have previously shared their experiences in the medical literature. ACL-deficient athletes may also suffer from medical ignorance in discussions regarding professional contract terms, insurance policies and future club signing medical assessments, until they have managed to re-establish a performance track record. There is also the ethical dilemma of whether return to pivoting sport should be a measure of success and in the athlete’s best interest following an ACL injury, regardless of whether treated non-operatively or following ACLR;2 however, informed consent, including unknown unknowns, and patient autonomy are critical ingredients in medical ethics.

What can we learn from such cases?

This case is neither unique nor special, as many athletes (but relatively very few) will have probably returned to elite professional sport following non-operative ACL treatment, and with differing degrees of success and failure. However, such stories are inquisitive when shared in peer-reviewed medical journals, rather than by rumour, whispers or media speculation, as they question dogma and norms about what is possible. One short follow-up case report does not provide any basis to determine medical care for others, is considerably biased and must also be taken for what it is—the lowest level of evidence. Yet, case reports of individualised rehabilitation programmes from high-pressured elite settings, can challenge expert opinions and norms. This demonstrates that much-maligned conclusions of RCTs, such as Frobell et al,6 ,7 comparing operative versus non-operative ACL injury treatment outcomes, may have applicability in elite sport settings, meaning that much more work needs to be done to help us identify rehabilitation copers from non-copers.

In much the same way as motoring aficionado’s follow Formula 1 cars for road car innovations, many people (and clinicians) look towards the top end of professional sport and football for the latest sports medicine treatment innovations. Unfortunately, many of these sexy treatments lack the robust testing of Formula 1 engineering, and cutting-edge rehabilitation is frequently overlooked in favour of miracle interventions with unknown risks, unknown benefits and plenty of RCT-less placebo.

A case report could also wrongly find itself drawn into this category, but the moral of this story is: evidence continues to grow that many ACL injuries can rehabilitate well without ACLR across various sports and can even cope with the high demands of professional football. Therefore, we need better research to help identify copers, improve rehabilitation programmes and develop better patient selection criteria. It would be remiss not to mention that ACL injury prevention programmes are critical to reduce the numbers of these serious injuries but, unfortunately some ACL injuries will still occur, requiring treatment option explanations, comparisons, discussions and decisions.8


At the top end of professional sport, such as EPL football, treatment pressures are at their greatest, contracts and sponsorship run into huge sums of money, and myths, strong opinions and snake oil ‘salesmen’ are found around every corner.9 An expounded case can challenge belief systems that elite athletes may somehow be different to other populations, when research limitations are often used to dismiss methodology and conclusions as being inferior, less relevant or irrelevant. Openness during clinical consultations regarding what is unknown about treatment options may help patients more than disclosing only known factors, ensure optimal care delivering shared, fully informed decisions and autonomous patient outcomes. In elite or professional sport, addressing perceptions of non-intervention, or perhaps, in the minds of others, ‘doing nothing’ but allowing nature, healing and individually tailored rehabilitation programmes to run their course, can be one of the hardest management paths for practitioners to follow and, regardless of extreme pressures, will probably remain fundamentally as cutting edge to sports medicine as healthy lifestyles are to medicine.


The author would like to thank Mathew Monte-Colombo and all current and past members of the medical team for their support, ideas, skills, experience, expertise, challenges, rehabilitation delivery, friendship, bravery, reflection and humour. And thanks also to Domhnall Macauley who unwittingly provided the provenance for the BMJ Case Report to be written, when, in April 2014, during his Keynote presentation at the IOC World Conference on prevention of injury and illness in sport, in Monaco, he recalled a discussion with a different but very experienced club doctor at a highly successful European football club who said his ‘scariest’ career moment in sports medicine was the non-operative management of an ACL injury in a professional footballer. Hopefully this situation will not be scary any more. The author also thanks Sam Church for his feedback on an early draft of this editorial.


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  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.