In the latest edition of “Mick talks with…”, I sit down with Kieran Richardson for a talk on non-operative management of ACL injuries.
For those who don’t know Kieran, he is a Specialist Musculoskeletal Physiotherapist (as awarded by the Australian College of Physiotherapists in 2016) and is the director of Global Specialist Physiotherapy, a consultancy service that provides formal mentoring, latest evidence professional development and second opinions for complex patient presentations to a number of private practices in Australia.
As all my talks, I walked away from this one better off as a clinician! I hope you enjoyed this chat as much as I did…
Mick: Hi Kieran and thanks for your time today. ACL injuries and reconstructions are on the rise worldwide - can you give us all a summary of the current trends here in Australia alone?
Kieran: Absolutely Mick. The topic of ACL tears and management trends is being reported more and more in mass media, with Australia now having the unenviable title of the highest rates of reconstruction in the world!
Firstly the injuries themselves are on the rise. There are a number of factors that cause this – the lack of implementation of prevention programs/exercises at the general population level, the type of twisting sports that Aussies tend to love and play, and the advent of sophisticated imaging techniques like MRI being more available to identify a torn ACL on scans.
Now ACL reconstruction (ACLR) procedures have also concurrently rapidly increased due to a number of reasons such as:
· General population awareness of the availability of a surgical technique that is federally and privately funded
· Sports media outlets often demonstrating borderline hysteric reactions when an athlete suffers a suspected ACL tear
· Difficulty in quick translation of the best literature to clinicians and
· A lack of up-to-date patient-friendly resources outlining current practice guidelines which suggest commencing intense, structured, supervised physiotherapy and exercise before even considering a surgical decision.
Mick: Interesting stuff! Now it may come as a surprise to some people, but there has been good evidence challenging the benefit and necessity of ACL reconstructions. What is the literature telling us about non-operative management?
Kieran: There is actually no high-quality evidence for any patient to be offered an ACL reconstruction as superior to structured, supervised physiotherapy and exercise. This forces us to rethink our assumptions based on what we may have heard through university, colleagues, friends/family and certainly through sports news reporting!
The optimum way to determine the effectiveness of various management strategies after any injury like an ACL tear is through high-quality randomised controlled trials (RCT’s), which amongst other positive elements reduce susceptibility to biases. So in 2019, the evidence-based practice rules that govern scientific culture aren’t the same as they were 40 or 50 years ago, when many of the systems to roll out these procedures were created.
Hundreds of RCT’s have compared patients having different surgical techniques for ACL tears, but the optimal trials comparing rehabilitation alone to surgery and rehabilitation haven’t provided any greater benefit to the group who undergo reconstruction.
This information may be challenging to read, but it has the capacity to rejuvenate the injury management industry and give hope to many current and future patients, which is actually such great news.
Mick: I think that will surprise many people out there Kieran! From the research published on non-operative management, is there any indication as to who may do "better" with non-operative management? Ie. Older vs younger, females v males?
Kieran: Based on really good quality data, it’s very difficult to predict, but it is likely far more psychologically driven than we would have thought 20 years ago. The KANON trial by Frobell and colleagues (the only high-quality RCT available comparing physiotherapy and surgery, to surgery alone) included a highly active, near-elite young adult group of males and females – the typical cohort that present to primary care with these injuries. There were no significant differences in lasting outcomes across multiple domains (such as pain and symptoms, quality of life, return to sport rates, osteoarthritis rates, meniscal tear and surgery rates etc.) based on age or gender.
The patients that did cross over from initial supervised exercise alone to ACLR did so as they has strong pre-existing preferences for surgery (had determined to do this before entering the trial!), they found rehabilitation “boring” and they believed surgery was necessary to return to pre-injury function.
Patients that performed well physically in terms of quads strength and hop tests were more successful in both non-operative and operative groups, highlighting the need for us to really get commitment and adherence from patients to the concept of graded, comprehensive, longstanding rehabilitation.
Wellsandt et al 2018 described the attempt to screen and identify the perfect candidates for either approach as being a “tremendous hurdle.” They suggest patients who may initially have poor dynamic knee stability can eventually improve given extended periods of time for progressive rehabilitation.