Limiting the risk of osteoarthritis after anterior cruciate ligament injury: are health care providers missing the opportunity to intervene?

Key points

1. 0171% of primary care sports physicians and 77% of orthopedic surgeons always discuss OA risk, compared to only 34% of physiotherapists
2. 02Discussions mostly happen at the time of initial injury management and drop off sharply thereafter
3. 03Re-injury risk is the most discussed factor; modifiable risks like weight, muscle strength, and activity levels are addressed less consistently
4. 0480% of physicians and 99% of physiotherapists agreed that physiotherapists are the most appropriate provider for OA risk discussions, creating a clear disconnect with practice
5. 05Fewer than 5% of patients with ACL injury perceive themselves to be at risk for OA, despite real-world risk estimates of approximately 50%

How it was conducted

Design

Cross-sectional electronic survey

Participants

501 Canadian health care providers: 98 primary care sports physicians, 263 physiotherapists, 140 orthopedic surgeons

Recruitment

Distributed through the Canadian Academy of Sport and Exercise Medicine, Canadian Physiotherapy Association, Royal College of Physicians and Surgeons, and Canadian Orthopaedic Association, April to December 2017

Eligibility

Practitioners treating non-elite athletes aged 16 and older with ACL tears in Canada

Primary outcome

Frequency and content of OA risk discussions with ACL-injured patients, and timing of those discussions

What they found

• 71.4% (95% CI 61.8, 79.4) of primary care sports physicians always discussed OA risk with ACL patients
• 77.1% (95% CI 69.5, 83.3) of orthopedic surgeons always discussed OA risk
• 33.8% (95% CI 28.4, 39.8) of physiotherapists always discussed OA risk; 1 PCP, 1 OS, and 24 PTs reported never discussing OA risk
• OA risk was discussed as part of initial ACL management by 79.6% (95% CI 70.3, 86.5) of PCPs, 94.1% (95% CI 88.8, 97.0) of OS, and 64.6% (95% CI 58.1, 70.7) of PTs
• Discussion dropped sharply after initial management: only 13.2% (95% CI 8.5, 20.2) of OS discussed OA risk at 3-6 months post-injury
• Concurrent joint injury (71-88%) and repeat ACL tear (63-81%) were the most common factors prompting OA risk discussion
• Knee re-injury was always discussed by 63.8% of PCPs, 62.9% of PTs, and 74.5% of OS
• Approximately 75% of all providers (range 74-79%) reported offering some advice on managing OA risk, but fewer than 17% provided specific resources
• 80.0% (95% CI 70.3, 86.5) of PCPs, 98.7% (95% CI 96.3, 99.6) of PTs, and 79.9% (95% CI 72.3, 85.8) of OS identified physiotherapists as the most appropriate provider for OA risk information

Limitations

• True response rates could not be calculated because the number of eligible practitioners in each group was unknown
• Respondents may not be representative of all providers treating ACL-injured patients in Canada or other countries
• PCP respondents were members of a sports medicine academy and likely have more sports-specific expertise than average primary care physicians
• Self-reported survey data may overestimate actual practice due to social desirability bias

Why it matters

For patients

If you have had an ACL injury, ask your physiotherapist or surgeon about your long-term OA risk and what you can do now, such as managing weight and building muscle strength, as many providers may not raise this topic on their own.

For clinicians

Physiotherapists have the greatest opportunity to counsel ACL patients about OA risk during rehabilitation, but only one in three routinely do so, highlighting a need for structured education tools and care pathways that embed this discussion.

For readers

This Canadian survey quantifies a practice gap: most patients with ACL injuries are not receiving consistent, comprehensive OA risk counselling, and closing that gap could meaningfully reduce the burden of post-traumatic knee OA.