ACL Recovery Inequality: Socioeconomic Status and Injury Recuperation

by | Apr 9, 2021 | Anterior Cruciate Ligament Injury, Athletic, I. Issues, II. Roles, III. Solutions, Medical Officers, Physical Therapy / Medicine and Rehabilitation | 0 comments

A man is resting his right ACL-injured knee.

Anterior cruciate ligament (ACL) injury is commonplace amongst athletes and individuals alike, yet despite its frequency, this injury devastatingly increases morbidity and greatly impacts one’s day-to-day schedule (1). ACL injuries comprise up to 50% of ligamentous knee injuries and are exceptionally severe  due to their enduring recuperation time and process (2). Recovery from ACL injury often requires intense surgical reconstruction, including autograft from hamstrings or the patella, as well as subsequent difficulties in decreased area strength and prolonged pain in the anterior knee (3). Though ACL reconstruction and rehabilitation have improved greatly in recent years (4), external  factors beyond medical capacity additionally impact both short and long-term recuperation injury prevalence. 

While age, gender, and general athletic capacity influence the rate and severity of ACL injury, socioeconomic background has been shown to play a large role in recovery and initial injury reaction. Studies comparing ACL injury patients with varying health insurance qualities reveal that individuals in  lower socioeconomic brackets both receive treatment and fail to recuperate from injury at a slower pace than  their wealthier counterparts (5). Individuals in lower socioeconomic brackets experience barriers receiving individual orthopedic evaluation, MRI examination, and surgery. Surgical outcomes for ACL injury are worse for those who received this delayed treatment and are at higher risk for requiring further procedures and recuperation, both of which are unlikely to occur at the pace required to prevent long-lasting consequences (5, 6). Individuals receiving less frequent and immediate care also demonstrate higher rates of additional knee injuries and an overall lower likelihood of receiving adequate care (7). 

Rehabilitation following injury plays a critical role in allowing patients to return to their individual routines and for athletes to return to the field. ACL reconstruction depends  on orthopedic rehabilitation, which requires expensive medical  appointments and recuperation maintenance. Individuals in lower socioeconomic positions encounter difficulty finding eligible providers capable of enforcing necessary recuperative exercises and work. This barrier leads to overall prolonged recovery time and delay in injury management (5, 8). Lack of adequate, immediate support serves to worsen conditions and can impact individuals suffering from ACL injuries for a lifetime, creating residual health problems and impacting day-to-day function. 

Individuals with poor physical health experience both a reduced quality of life and reduced resiliency in both personal outlook and health due to prolonged, untreated pain or complications following injury (9). Those who receive reduced ACL injury rehabilitation ,including failure to undergo surgical procedures due to insurance limitations or regional inability, report decreased health quality later in life. These socioeconomic medical inequalities between high and low income brackets reflect that those in higher socioeconomic positions experience a more satisfactory recovery; research reports reveal that those in the higher quartile for economic status received surgical treatment (95%) and prolonged care, and therefore, are more likely to return to routine activities while experiencing higher quality of life in the future with reduced complications and lower pain compared to their lower quartile counterparts (< 50%) (1, 8). Overall, these findings support the need for more accessible treatment and call for the furthering of cost-efficient therapeutic options to ensure all individuals suffering from ACL injury remain capable and positive in their day-to-day lives.  

  1. Lundblad, M., Waldén, M., Magnusson, H., Karlsson, J., & Ekstrand, J. (2013). The UEFA injury study: 11-year data concerning 346 MCL injuries and time to return to play. British journal of sports medicine, 47(12), 759–762. https://doi.org/10.1136/bjsports-2013-092305
  2. Risberg MA, Lewek M, Snyder-Mackler L. A systematic review of evidence for anterior cruciate ligament rehabilitation: how much and what type? Phys Ther Sport. 2004;5:125–145. doi: 10.1016/j.ptsp.2004.02.003. 
  3. Xie, X., Liu, X., Chen, Z., Yu, Y., Peng, S., & Li, Q. (2015). A meta-analysis of bone-patellar tendon-bone autograft versus four-strand hamstring tendon autograft for anterior cruciate ligament reconstruction. The Knee, 22(2), 100–110. https://doi.org/10.1016/j.knee.2014.11.014
  4. Mahapatra, P., Horriat, S., & Anand, B. S. (2018). Anterior cruciate ligament repair – past, present and future. Journal of experimental orthopaedics, 5(1), 20. https://doi.org/10.1186/s40634-018-0136-6
  5. Patel, A. R., Sarkisova, N., Smith, R., Gupta, K., & VandenBerg, C. D. (2019). Socioeconomic status impacts outcomes following pediatric anterior cruciate ligament reconstruction. Medicine, 98(17), e15361. https://doi.org/10.1097/MD.0000000000015361
  6. Newman, J. T., Carry, P. M., Terhune, E. B., Spruiell, M., Heare, A., Mayo, M., & Vidal, A. F. (2014). Delay to Reconstruction of the Adolescent Anterior Cruciate Ligament: The Socioeconomic Impact on Treatment. Orthopaedic journal of sports medicine, 2(8), 2325967114548176. https://doi.org/10.1177/2325967114548176
  7. Williams, A. A., Mancini, N. S., Solomito, M. J., Nissen, C. W., & Milewski, M. D. (2017). Chondral Injuries and Irreparable Meniscal Tears Among Adolescents With Anterior Cruciate Ligament or Meniscal Tears Are More Common in Patients With Public Insurance. The American journal of sports medicine, 45(9), 2111–2115. https://doi.org/10.1177/0363546517707196
  8. Nordenvall, R., Marcano, A. I., Adami, J., Palme, M., Mattila, V. M., Bahmanyar, S., & Felländer-Tsai, L. (2017). The Effect of Socioeconomic Status on the Choice of Treatment for Patients With Cruciate Ligament Injuries in the Knee: A Population-Based Cohort Study. The American journal of sports medicine, 45(3), 535–540. https://doi.org/10.1177/0363546516672651
  9. Tanaka A, Shipley MJ, Welch CA, et al. Socioeconomic inequality in recovery from poor physical and mental health in mid-life and early old age: prospective Whitehall II cohort study. J Epidemiol Community Health 2018;72:309-313.

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