160. ACL injuries with Zoe Russell

You're listening to the Physio Edge podcast episode 160 with David Pope. Hey, and welcome back to the Physio Edge podcast. I'm your host, David Pope, Australian Sports and Musculoskeletal Physio, and on the Physio Edge podcast, I talk to the leaders in musculoskeletal and sports injuries and get their expertise and their practical insights into how to assess and treat all the musculoskeletal and sports injuries that you'll see in a clinic as a health professional. So in this podcast, we're going to be talking all about ACL injuries. Now, it's one of those injuries that happen really commonly, especially throughout the football season, the ski season, you're going to see a lot of these in your clinic. And how do you go about picking up when your patient has an ACL injury, as opposed to another acute knee injury, like an MCL injury, tele dislocation, or any of the other acute knee injuries that might see in your clinic. And then, once you've picked it up, how do you go about making sure you've done a really thorough assessment to identify all the injuries and to make sure you've really nailed it with your ACL assessment? And then what do you do with that assessment information? Should your patient have conservative management? Should they have conservative management plus surgery? Should they have immediate surgery or delayed surgery? How do you go about making those decisions with your patient? And all that's covered in today's podcast with Zoe Russell. Now, Zoe's a specialist sports physiotherapist based in Queensland, in Australia. Zoe works at the Queensland Academy of Sport with a range of athletes, and she's got a lot of experience treating acute and ongoing knee injuries in the highest level athletes. She also works as an educator and presenter here at Clinical Edge, and she does a fantastic job of sharing her practical insights in the podcast today, and also in her presentations with Clinical Edge. So, lots of great stuff in today's podcast. And when we recorded this podcast, Zoe had a bit of a cold, so you'll notice her voice goes in and out. But there's lots of great info. If you stick with it, you'll really enjoy the podcast. We've got a couple of resources to go along with it. Now, we've summed up a lot of the key information from the podcast in your podcast handouts, which are infographics. So, if you'd like to get early access to the infographics that sum up those key points from today's podcast, head on over to the podcast page at clinicaledge.co/podcast160 and you can get your early access to those infographics now. We've got a couple of other great resources for you as well. You can get access to a free video series on Achilles tendon opathy with Tom Goom, and Tom will take you through how to assess and treat your Achilles tendon pain patients. And the other resource we've got for you is your Clinical Edge membership. Now, in Clinical Edge membership, we've got presentations from a team of expert presenters, including Zoe Russell and the rest of the Clinical Edge team who are really experienced physios and are really passionate about sharing their experience and helping you to know exactly what to do with your patients when you've got them in. And in their presentations, they share how to go about accurately assessing your patients that come in, whether they've got neck pain, headaches, low back pain, lateral elbow tendon opathy, ankle injuries, whatever pain and injury that your patient comes in with got fantastic presentations that cover those areas. So, jump on over, get your free trial membership over at Clinical Edge.co/free trial and start improving your results with all your Musculoskeletal and Sports injury patients now. And now it's time to dive into this podcast with Zoe Russell. So, hi and welcome to this podcast with Zoe Russell and myself, David Pope, from Clinical Edge. Today, we're really looking forward to diving into ACL injuries. So, you're going to have patients that come in with ACL injuries and/or suspected ACL injuries. So, you want to know, how do you go about assessing your patients to identify those? How can you go about treating them or managing them? Are you patient suitable for conservative or surgical management? And how do you help to guide your patients and explain the process to them? So, we're really looking forward to diving into that today. And we're going to be doing that with Zoe Russell, who is a specialist sports physiotherapist based in Queensland here in Australia. And she's got a lot of experience treating sports injuries and ACLs and lots of other sports injuries. And she's also one of the senior presenters on the Clinical Edge education and presentation team. Welcome, Zoe. Hey, Dave. Thanks for having me. Great to have you join us. There's a lot of debate on social media and all over the place about who's suitable for ACL injuries and what sort of treatment we should be providing. When you've got an ACL injury patient coming in, what are some of the main challenges you face first up when you have that sort of patient? Yeah. And I think we can even go back a step, Dave, where a lot of us do work sideline with teams as well. I think one thing that often happens in football and the refs like, oh, get him off the field as quick as possible. If you give me 30 seconds, I'll be able to assess, make a decision about whether we're structuring this person off the field or whether we can walk them off. And that's a really good time that we can assess the injury in that first five minutes because person gets the opportunity to get a little bit of pain, get that protective muscle spasm of the hamstrings, if sometimes can make it a little bit harder with some of that clinical hands-on tests when you're in that particular situation, keeping your head asking for a little bit of time because taking the time to assess it there can be quite useful clinically. My background, I used to play a lot of netball and the number of times I'd get a message on a Sunday morning from someone who had injured their knee, had gone to emergency on Saturday night and they'd been diagnosed with either a patellar dislocation and you asked them a couple of questions about, well, what actually happened and you start to get a little bit suspicious that we might have a different type of instability. I think that's something that we really sometimes have to overcome. We get patients that walk in and go, I've dislocated my patellar, we need to make sure that we are really clear and clinical and get a great understanding of what was the actual mechanism, what actually happened, was it a non-contact change of direction or a non-contact landing? Sometimes in the footy codes, a less common mechanism that we think of is that they get bumped in the air and then they land into a bit of hyper extension. If someone links in often, if it looks like a duck, quite like a duck, it is a duck, but making sure that we are robust with our questioning around what actually happened because we've got to remember that patellar instability is also a differential for someone that comes in with an unstable knee and I think we have to make sure we always do our due diligence and make sure that we exclude one or the other. Sometimes these people are in a lot of pain, they've got restricted motion, there's a lot of swelling and sometimes our clinical tests, whether it's one day, two days or a week after injury, that delayed presentation, that gives a chance for the swelling to get in there particularly, the person hasn't had ideal management, which can sometimes also make our physical tests a little bit less sensitive and I think having subjective criteria as well as your objective criteria, we can use that to really formulate a picture and increase or decrease our clinical suspicion and so I think the simple tip is always make sure you test the other knee, I think that's what something that is often overlooked, we've got to get in and deal with that knee but how do we know what the other side feels like and also making sure that we think about how we're going to prioritise and organise our clinical test battery because if you have someone who's got an unstable knee and you jump in straight away to stability tests, you're probably going to aggravate them and then you're going to get very little useful information from some of your other clinical tests and so that's where things like practising your handling on different knees and working out different ways that you can use your body to address a different size knee, I'm quite sport, I've got really big hands so if someone is a little bit bigger, I can usually get away with it but I did some teaching earlier this year where we were talking about how to assess the knee and that's something particularly female physios talk about is sometimes having some inability to handle so I think making sure you're always practising that as well not just when someone is actually injured. Some really great outline of the sort of challenges you're facing when you're assessing a patient that comes in that might have had some sort of knee injury over the week and trying to identify that and you mentioned there some of the subjective and objective criteria so what sort of subjective criteria will help you identify? So do you want to talk to us a little bit about some of those and the mechanism of injury and pain patterns that sort of thing that people might present with? Yeah so I think understanding where their pain is so a lot of people who I've seen that have been misdiagnosed initially report a lot of posterior lateral knee pain and that's something to be aware of because of that kissing type mechanism and that bony contact so a lot of them complain of I've got posterior lateral knee pain I can't be my ACL because I think that's in the front so I think getting an understanding of where the pain is the mechanism of injury so what happened but also then what has happened since then we get the mechanism exactly what happened but then were you able to wait there straight away some of those things that we typically ask without auto or knee rules could you wait there straight away where is the tenderness? Did it feel unstable? Did you hear any sounds but also then what has happened in that time frame since the injury? Did it swell straight away or did it swell up later on so that'll give us some criteria sometimes ACLs and our osteocondral lesions that it happened acutely they'll swell immediately whereas say a municipal injury will tend to swell a little bit later if they do have instability what we want to get an understanding of is that instability related to either pain inhibition or the swelling so you can ask some questions about when your knee is unstable what actually happens do you feel something and then it feels unstable so we call that I feel something and nothing really happens it just feels unstable and I can catch it versus the person that has that frank instability which is nothing really happens and they might just say, I was just turning in the kitchen and all of a sudden I was on the floor, there was no warning and then I couldn't control my knee. And so that second one is a little bit more sort of symptomatic of instability as a result of major ligament disruption, also knowing what have they done, what's been helping, what hasn't been helping. And then looking at how it's functioning with walking, daily activities, the typical subjective questions we ask about our 24 hour behaviour and that sort of stuff, to help inform these sort of questions start to help us realise, is this someone that might be able to go down a non-surgical or someone that needs early referral for surgical or orthopedic opinion, because we're trying to get a clear picture about the co-committing injuries that might be associated with this particular injury and this person. - You mentioned there's some really great points. So the patient might have postural lateral knee pain, that might be one of the symptoms that they're experiencing with and they're not even suspecting an ACL, because that's not where they think that the ACL is. And they might have that swelling immediately, as opposed to which could be ACL or osteocondyl you mentioned, as opposed to your meniscus, which is more likely to have that sort of delayed onset of swelling. So that was some really great points. And then you mentioned there just looking at there, 24 hour behaviour and the types of instability as well. So all really good points. So let's have a little bit of a chat about them. So you're suspecting from that history, they had that immediate swelling, they had that mechanism of injury that might make you think that they've got an ACL. Is there any other sort of questions that you're really interested in at this point in time before you move on to the air objective? - Yeah, Dave. So definitely you want to understand some of your special regional questions. So things like, is it clicking, is it clunking? I think locking's a really clear good one. Or the literature that we have in ACL management does discuss the Bucket Handle Municipal Legion or a Legion that creates a locked knee is something that does require urgent referral on the care. So that's I think a really key critical question on top of the other questions that we've already asked. - Let's just say they haven't got that locking, but they have got that presentation that you've described there. We are suspecting that's an ACL injury. Tell us a little bit about the objective you're going to go through. You mentioned, if they've got an unstable knee, not diving straight into your stability test because they could stir them up and make it a bit harder to get the rest of your results. So tell us a little bit about how you might structure your objective to get some clear results there. - This is always a good one for debate. So if I'm suspicious about someone's from an internal derangement perspective, I'll assess them on the bed before I do any functional activity. Obviously you can see from the waiting room. You can see how they get out of a chair. You can see how they choose to walk. So you get a lot of valuable information there. And I think sometimes that's really useful because if you ask someone to go and walk, what they'll do is they'll try and change their walking to the way that you want them to walk. So use that time from the waiting room to your treatment bed or your treatment room to help you. Then I think the biggest thing is with someone with an acute knee is to make sure they're comfortable. So that might often mean that there's a rolled towel or a bolster underneath any. And I start with simple things like their swelling tests because you can do them quite gently and sensitively with broad strokes to get a bit of an appreciation. Then using their, I actually support their legs, I support under the hamstring, under the calf and then move their knee through flexion extension. So I can see what they're comfortable doing. We can get appreciation of any sounds, clicks, pops and they also feel safe 'cause they've got that reinforcement. Then if I'm looking at some of the special regional tests, I will try and do these really gently. So my handling tends to be really close to the joint line for valgus and barris stress testing just so that they feel safe and making sure that you support the rest of the way to their leg and that way you can just gently move. And I know a lot of the tests that describe as a real jerking type movement, but you actually can just feel the play and then just put a little bit of an extra pressure at the end so that you can get some good information without yanking as such on the person's leg. If they've got enough range of motion, I'll definitely then progress into lockermons, anterior draw and if possible, I'll go into a pivot shift with some of our ligamenters testing. But I think it's always important that you make sure you assess what's the posterior cruciate ligament compared to the other side, what's a posterior lateral corner looking like as well just so that you've got a full picture. And obviously, before I do some of those testing, I've already tested my differential of patellar instability in those when we did swelling testing, using your handling to be support the lateral side, support the medial side and just give that hands-on contact that will increase the patient's safety and that you're in control of the movements you're doing. And then you mentioned that when you're testing their patellar stability, tell us a little bit about how you might assess that wallery in this position. Usually with them supported on the towel, I don't see too many ACLs coming that can straighten their knee straight away. But what we do is generally have a feel of the patellar femoral glides after the range of motion, have a little bit of a look at how it looks like it's tracking with those movements. And then I just basically do a simple patellar apprehension test where you actually stabilize, literally, and just apply the glide and I do it medial and laterally just so that you can feel. And the person will tell you, obviously, you're always looking at the person's face as well because quite often that will give you your earliest indication before their mouth actually tells you, "Hey, I don't like that." And then you can do it with a little bit of movement as well where you hold that glide and get them just to try and actively bend them straight in their leg to see if they're comfortable doing that as well. So let's just say you've assessed the movement through flexion extension with that support. You've checked out their patellar stability. You've looked at some of their other tests with your Lockmans and your PCL. PCL seems to be fine. Postural lateral corner seems to be OK. Didn't have any patellar instability. We're thinking that we've got an ACL injury going on here because you've felt some laxity compared to the other side. What's your next step within that assessment? Obviously, then I'm looking at things like trying to help hate the joint line, see what that feels like. Then I might move into my municipal tests, just depending on the range of motion and appropriate to the patients' concern. If we've looked at our ligament instability, I might look at some just some functional things like bridging. Can they do it single leg? Can they do it double leg? Then moving into things like, can they get up safely from the bed, sit to stand sort of stuff? And then if someone's early on after injury, they'll usually have some dating payments as well. And I think that's somewhere where then we know what we're doing if we're addressing swelling. We're looking to get an appreciation if they can be stable with some daily activities, things like getting out of chairs. Are they stable when they walk and can they turn around looking at those functional things? Then I would sometimes put some gate training into that. So if there is something that we see, can we change it? So that we can get their gate working well early? And that's where I then start to progress into and might start just turning to a little bit more of treatment. And then to help them with any of those generally ADL impairments or functional impairments, that they'll need to be able to do it home when they leave their rooms. So you've now had a look at their function and you looked at how they're going to cope when they go home and you've looked at the meniscus and some of those other strength testing like bridging. You're now thinking that they can cope, they can walk. When do you start to describe that they have an ACL injury? I try to structure subjective, objective treatments. So the first thing I would do is sit them down and we talk through their findings. And basically if I think they've got some concern that they might have a deficient ACL in this particular case, I'll talk to them about that. I'll also talk to them about why it is a problem. So it's a primary stabilizer of the knee and we do have secondary stabilisers. And from there I will then start to talk through where they are at compared to where they want to be with their goals from the subjective consultations, their age, their sports, what they want to get back to, what's their performance plan looking like? So they might have something that they might have trials for an event in a month or it might be that they've come to a period where there's a bit of rest period and their structure of how this looks in terms of their competition, their sport might be a bit different. And then from there I start to talk about the options they've got for management. 99% of people that come to see me will usually be, I'll be the first person I've seen, which is good. We've got that opportunity to affect that conversation really well. And I think it's important to list that surgery is not the only option, but also that people have the option of having non-surgical management, non-surgical management, plus the option of a delayed procedure surgically if they were unable to regain their stability or early surgery. And then I talk about how their physical symptoms and signs from the clinical examination puts them into a category, one of those categories that would maybe mean that we need to go to one of those as our priority. So if I've got someone that comes in with a lock to knee and they've got a bucket handle medical lesion is on one of our suspicions, I would suggest that we do need to get imaging quite quickly and we would start to get the ball rolling on an orthopedic review based on that. Whereas if I've got someone who's come in, it appears to be very isolated injury, we might have ranged at imaging to be done to confirm that suspicion, but I would say like given on your clinical science, you'd fit in this non-surgical category and this would be where I would start with you. and I talk a lot about the talk. online in terms of we start our rehab today. Something I see a lot is people will go away, get their scan and someone will tell them, oh you don't need any more physio because you need surgery to fix the problem or search. There's so much that can be done immediately after the injury, swelling management, range of motion management, muscle strength, coordination and getting their walking and their moving back on track. I think it's really important and it doesn't matter which category that person falls into. I like to really try and prioritize, you've got different goals, different stages throughout your recovery but the goals we need to do are get rid of the swelling, get your range of motion, get your muscles working regardless of those three options that you've got the management. How do you describe that to patients? You mentioned that you're telling them that this is in these early phases that regardless of whether they're having surgery or not that you're looking to improve their swelling and improve their range of movement. Is there any other tips that can help to get patient by and at this stage when they're thinking, oh yeah that's all fine, Dan, if I'm going to need surgery. Anything else that gets that by and? I think it's things like using ice and compressions up to show them that if we get rid of that their functioning improves and their pain improves. I think simple things like that work really effectively and I think they're often overlooked. We're all often ready to go to the sexy stuff like the surgery but ice, compression socks. Some people have a lot more people have access to those recovery boots and things like that can be quite useful as well but if you show them if you change the swelling and functioning improves that gets a lot of pain. Things like changing their walking with the walking drills that you can do early on, that's very powerful. So if you can look at the walk and say oh it might be just look that knee up a little bit more so sometimes some little many high-need walking can help their walking pattern and if you can change their walking and if there's someone else with them like a family member or a loved one that can go wow that looks different that increases a lot of buying in as well, particularly that early phase. You said there that you're looking at those three different treatment options you're looking at immediate surgical management, particularly if they've got some sort of bucket handle tear where they're it's locked and they're not getting any movement. You're shooting them off for some imaging and then a surgical opinion fairly quickly. You've then got your option for immediate surgery or delayed surgery and then your non-surgical management, I suppose that's really full. So then within those categories the patients are always going to be like what do I need? What's going to be the best thing for me? So how do you go about stepping that through with the patient? Yes so you've got to relate it back to each individual patient so I just always a factor. So I'm in my mid-30s now, I play netball and if I did an ACL now I'd be biased towards going down a non-surgical pathway and for a number of reasons. I'm not playing at a level anymore, I'm happy to not continue to play at that high level. I'm prepared, I've got the time, I've got no competition commitments. So the type of things we're looking at is the age of the athlete, their particular sport. So looking at whether they're wanting to do level one, level two or level three type activities, they are generally things. Level one are your change of direction, your rapid change of direction, twisting turning, type sports. So your football coach and netball is that type of activities. Your level two is the things where your exposure is not as high but there's still a dynamic demand and then your level three things are more your straight line activities going for a walk, going for a job, something that is a little bit lower risk to actually sustaining, to requiring that three-dimensional stability of the knee. So that's a factor. The cocombing injuries that exist are a factor as well. So for an isolated ACL, I'm not necessarily rushing them off to surgery, depending on some of those other factors, but if someone does have a lot knee, it's quite often that they will need an earlier surgical management and we don't want to miss them. Similarly, we don't want to miss any school root tears as well because they would benefit greatly from early surgical management. So it's being aware about those things that lower our threshold to progress to seeing an orthopod early, just being aware of the person's competition goals. You might go, you haven't got enough time to have a surgical procedure but you've got enough time to do a really well-structured non-surgical rehabilitation program and you might go down that pathway but then how that person responds to that will change as well. So a perfect example is I treat her. She's now 60 but she did her ACL as a 50-year-old and she didn't matter what she did. She was unable to dynamically stabilize her knee. She was collapsing multiple times a day with just daily activities around the house and so she then continued with her non-surgical plan. She moved on to going back and having a chat to the surgeon that she saw initially based on her physical function. She was just having, I think it was one day she had about 12 instability episodes in a day and after a period of sort of 8 to 10 weeks she was still really quite struggling and that wasn't changing. So we bumped her on early because the literature suggests that we should be giving these people at least 12 weeks to see if they can achieve that which is why we have that delayed surgical category where you've got that option to try the rehab and then if you're not meeting those goals and expectations and you're using your outcome measures. So things like number of episodes of instability, swelling, function, someone can't function in their daily activities that's when you might go, we've committed to this plan but you're starting to show me signs that it's not a green with you and I might make that call to send you back to the orthopod. So you mentioned their different levels of sport and you mentioned their age and their goals, all different factors that can help to impact the decision making and whether they're most suitable for some of those activities. If they're say a younger athlete then they're looking they might have be somewhere in that level one say. So they're an elite athlete, they're playing at a higher level, they've got competitions that they want to get back to and they've got high sporting demands, might be netball, basketball, something like that where they do have some large demands on their knees. So in that level one, how do you talk to your patient about their treatment options and what's best for them? Yeah, I think it's an interesting question Dave because if we look at the literature, particularly the non-surgical management, the activity levels of those people, they were on the Tegna scale, nine or a ten and the ones that did well with non-surgical management really didn't get much higher than I think a four or a five in that study. So we're talking about activities of daily living versus playing elite level sport. So at the moment we don't have a lot of research that shows elite athletes can get back to their elite level without a surgical reconstruction. Certainly if they're younger, what we're seeing is that the plan would be to continue to give these people an ACL reconstruction, particularly if they're in one of those sports that requires a lot of change direction and pivoting and that type of activity. And I think that at this point in time is still probably the way that things will continue to progress at the moment until we get more evidence. Yeah. And normal time frames without sort of going, all right, it's likely that you're going to need surgery to get back to that higher level of sport. For those people are we looking at immediate surgery or delayed 12 weeks down the track or how do you tend to guide them as far as time frames if they have the option to get surgery immediately or or delayed? I think best practice would indicate that giving these people an opportunity to do their rehabilitation, calm the knee down and get that happy knee, so to speak. So no joint effusion, good range and good co-contraction strength. I don't think practically that's still what happens. A couple of surgeons that I work with, if I said to let it to them and say, look, I think this person will do well, can we have some time? They'll give them four to six weeks to do a little bit of that, but it's still not probably what's practically done. Convention links people are still getting that reconstruction within the first two to three weeks, whereas what the evidence is suggesting that if we could give these people a bit of a longer time, and I think that comes down to when you're in that young elite athlete sort of expectation, there's media, there's societal pressures. Most people that have done an ACL on a Saturday have three or four opinions from parents, friends who are meeting well, but are just murking the waters about what to do, and so all those expectations are set up really quite early, and it does make it hard to change that mindset, but I don't think we do it consistently at a management level either at a medical level. Yeah, okay, that makes sense. So for those level one athletes and the ones that have got high demands from their sport and looking to get back to a higher level, then surgery sounds like it's one of the options it's more likely to get them there if that's their goals. And you mentioned there as well if they got their bucket hand or tear or something like a mini-school locking of the knee, then they're a candidate for early surgery. Are there any other people that are more likely to require an ACL or that you're more likely to send them down that path and refer them to a specialist? So someone who's got multi-ligament involvement or posterior lateral corner, or people that have got severe functional impairments in terms of instability, would be the other two categories that I would recommend and a quick return to an orthopod. What about your level two athlete? So you're looking at patients and you mentioned the yourself, say you're 35 or mid-30 something around there, you're playing sport at a reasonable level, but maybe not at that elite level anymore, then what's the normal decision making process? Is it dependent on once again the other injuries that they have, whether that's to of the meniscus and other ligaments, or are there any other factors and where they have periods of instability. How do you tend to guide those patients? What did you say to them? I tend to have a conversation about always trying to the least invasive option because I've had seen a guy recently who had a ACL injury a very long time ago and has had no issues without any rehab but was just mucking around and had an instability episode and it wasn't affecting his work or his life. He was just playing basketball with his son and had his first episode of instability from his initial injury that was 20 years ago. So we did have some imaging available to us and he didn't have any other COVID injuries. He was in his early 40s and we gave him some advice around you would be an excellent candidate for having a period of rehabilitation and then discussing whether you would have a surgical reconstruction. Now he unfortunately didn't take that advice because he felt he needed to have the ligament repaired to have it fixed and so he was one of those ones that he didn't really like. Body heard so he self-selected away from physio and the irony is he was looking to go through the public health system which would have given us a fantastic opportunity to do that rehab and then reassess functional outcomes and I think the key is always making sure you've got a list of functional tests that you are measuring and re-measuring. To give some guidance about whether this person is coping or not coping as such and even though the literature suggests to give these people 12 weeks I think at any point you're really thinking this person's not doing well or this person's not coping it's okay to refer them on and get that and have that opinion and have that discussion. I think so much with ACLs is about educating the patient and having that shared decision making model between ourselves, the patient and the orthopedic specialist or sports doctor or GP, it's a group decision it's not one person, not one person is an island in this case and that's something we are seeing a really good transition in our management that there is so much more collaboration about the decision making with these for people. Do you have any examples of patients where you might be looking at seeing whether they're going to cope or not cope without an ACL to help with that decision making process? Yeah absolutely I treated a girl probably about 10 years ago now and at that time she was like I've seen an orthopod he wants me to do non-surgical rehabilitation because he doesn't think I'll need surgery and she was the type of patient we see that sort of early 30s recreationally active playing a bit of netball. When you do that you do it the same way you would assess people at different points upon their rehabilitation journey following the surgeries. Is there any silent? Is there any swelling? Is there quads bolt coming back? Have they got full range of motion? Then you might look at your endurance testing so things like making sure they've got glue, hamstring, calf, quad strength, what's that core strength like? What's that functional performance on things like single leg squat? Then you might look to start to progress into more of your neuromuscular testing so things like why balance? Modified best type testing and then you'll start to progress on as they really have progresses on you'll start to progress them onto things like hop testing and obviously at this stage you're basically on top of what their stability is feeling like, what their function is like day-to-day but as their rehabilitation progresses you'll pick testing that's appropriate to that stage and you can test people on that test battery. There's a few articles out there now I think Riddham's written an article that's a Melbourne ACL rehab guide that gives you some testing options that you can do and it's the same as the person who's having non-surgical rehab as a person that has had a surgery we need to be testing these outcomes we need to be looking at their goose we need to be looking at their ACL RSI which is that psychological readiness to return a sport measure and it actually doesn't change what you do it's just you need to make sure that you're getting good information across multiple domains to making form decisions and then include that whether it's all the pod sports doctor patient GP and everyone's included in that decision-making process. When you're describing this to your patients and you're saying here's what we want to improve into patients like I'm not gonna cope anyway I don't have an ACL and they're thinking that there's not really point waiting around 12 weeks or whatever to see how they cope with it. How do you tend to describe that process or the benefits of waiting 12 weeks to see how they go? Yeah so I think the first thing to remind the patient is that they've got a really angry knee usually it's swollen it's sore it's hot it doesn't bend and I think we need to remind people that the surgery is a second insult to that bone they've had that contact of the bone the ligaments rupture there's a lot of that inflammatory soup sitting in that knee and then we're coming in and we've got an angry knee and we're basically then drilling into the bone and creating more trauma. One thing I've seen a lot recently and I don't know if it's just where I work particularly is a lot of orthopods are now prescribing anti-inflammatories postoperatively to manage that response so in my mind they're acknowledging that it does create an inflammatory response on top of an already inflamed knee and so I talk that through with patients and one way of thinking about it is if you roll your ankle what happens if you keep rolling it the inflammation continues to get worse get sore you get increased loss of function and so I try and use different examples usually try and pick an injury that they've had before just to relate it back to something that they've experienced and I'll say we don't have to worry about the time frame is such sometimes it will be more about giving them that goal of getting the silent knee so no swelling good range and good strength and good function with daily activities and going away from that time frame because if you say 12 weeks people go old geez that's a quarter of a year whereas if we go you've just got to get a silent knee then they can go I can do that because I've got the tools I've got my eyes I've got my compression I've got my exercises I've got my things to avoid as well so you're helping to calm that knee down and then within throughout that rehab you're what are some of your your goals that you're looking always at you help to progress them through their rehab yeah so we just set goals based on whether it's sometimes that ball is a really good with okay you can go and shoot when you can do this and this or you might be able to do some passing drills try and relate it back to their sport in particular but also basically just setting up some people work really well if they can see everything some people work really well if they can see just the first phase I just call it phases this phase is going to do this this is what we need at the end of it and give them goals that they can control so things like range of motion swelling irritability pain they might be things that we're looking to get down early then we might look at okay we want to get a strength measure so it might be oh we want you to be able to do a one RM spot if we've got some data that they've had before that might be something that we can use as a goal so trying to give them tangible things rather than just give them a random timeframe of four six or twelve weeks you mentioned they use some criteria but you might say all right when you hit some criteria then you're allowed to do some shooting what are some examples of some of the criteria you might set there for them when it comes especially let's just say it's the early phases you're looking at you mentioned there's some of the goals of reducing their pain reducing the swelling and calming it all down so what might be some of the goals you might set for them within this phase so basically first of all our first one is making sure that there needs not more soil at the end of the day than it is at the start a little tip you can do is they can grab a piece of ribbon a piece of string wrapped around center of their knee go about their day and retest it before they get into bed at night so for that way you know that what they're doing with their icing and that might be enough to negate what they're doing on their feet and obviously the rehab program that you've prescribed so I think that's a really good start obviously they're picking activities so we want to get your range of motion so that we can get you either whether it's cycling or walking because a lot of people do want to start doing some form of exercise that is maybe a little bit more cardio vascular so looking at things like that and also then looking at some functional things if your knees not swollen we can start you doing some balance work and then if they're going really well with that balance work we might go we're going to put a skill that's related to your sport so that might be throwing a ball off a rebound earth we might be practicing some handballing it might be if it's a football athlete they might be able to kick a football against the wall while they're working on their balance so giving them options of how we can bring it back into their sport as quick as possible you're often working through these things when they're in that first phase then what might be some goals within your next phase of your treatment your next phase is making sure they've continued to have good range of motion and no swelling with more endurance type activities so it might be things like being able to do a lunge being able to do a squat that might be your second phase just getting the endurance the quality of movement starting some of your proprioceptive drills they would be the goals I'd be looking for in that second phase then in that third phase starting to get into some of those strength target goals and if you've got preseason data that's really useful that's around the time that people start wanting to be able to run so that's always a good target to aim for and I think if you're really clear and consistent with your messaging about you need can't be getting swollen you have to be able to have adequate strength and be able to hit those toes before we can do the running that's always something that really motivates people a lot because I think they see running as a big step in that return to sport continuum and I think if you look at some of the research that's a big milestone that's sort of your first milestone is getting it moving after the injury but that's the next big milestone that the patients put a lot of influence on because because they feel like when they get to that's when it's going to start opening up, then getting back to their sport or their activity. You mentioned there before they're moving into that running that you're looking for, that's more in that third phase. And what are some of the strength tests that you might be looking at to indicate that they're going to be ready to potentially trial running? There's a million things you can do isn't there? You know, you could look at endurance tests. So there's lots of ways to measure that. You can measure it using weights, you can measure it using RPE. You can use it measuring just numbers and reps. I like to have some 1 RM data, whether that's a leg press comes down to what's available in your clinic and what's available to your patients. So you can do things like single leg bridge tests. You can do single leg squat tests to look at their muscular control. So is there a line that good? You can look at even little things like where you get them drop off a step and see how they land. Then you can do drop land and then get them to add another jump. And that can be then double leg progress to single leg so that you can start to see how that person's able to land and move, then explode up off the ground. But then also use the muscle strength that they've got so that when they get into running, they're not going to start moving and changing their mechanics. When you do get them, you might not get to see them do that run as such. So those type of testing. And so with these three phases, I'm imagining that it's similar when you're looking at your conservative management. So you're looking at some of those athletes going yet, all right, potentially conservative management, you might be good candidate for conservative management rather than surgical management. Is that similar to the approach that you're taking when it comes to patients that are also going, let's do a conservative management program and see how you're going and then consider surgery later on. Is there a similar sort of approach or parallel approach between those two? Yeah, absolutely. I think the first point, I think we need to stop calling it conservative. I think we need to either call it non-surgical or rehabilitation because conservative person on conservative really makes it sound like it's inferior. So I think if we can change that language, I think that's really important. And it's really empowering as a physio to see patients who take that on and then feed that back to the community that they're involved in. I think the process is the same. You're looking to test things. You're looking to make sure the person's adequate at them and then progress them on. We don't still have a test battery that if you do all these and they do really well, they're very unlikely to re-inja or re-rupture whether they go non-surgical or surgical. But I think if you can get some good information and try and get good information across multiple domains, I think that's the best case to progress things on. And that's certainly where we're seeing the time frames are going out of the window a little bit now as well because of that. I think I try not to really talk about time frames with someone unless where there are is appears really inconsistent with where we would expect someone to be. And like we're worried about something is not going according to plan. And we would be referring them back to see someone. Okay. So when patients are asking you how long it's going to take until I can get back to Nepal or back to tennis or whatever it might be. And they're looking for time frames and you're going, we can't really work on a time frame basis, how do you describe their patients or have that conversation? It's a good question because we always get asked it. I generally say to people, you can get back to sport when you're ready to get back to sport. And I say, obviously, you're here of people getting back at somewhere between nine to 12 months. I think understanding some of the literature around re-injury rates. The thing was Brooke Patterson and Julian fella did a review of people under the age of 20 and their re-injury rates. And they found that people that returned the under 18 and returned in less than 12 months were more likely to have a secondary injury. And so I think using some of that data suggests gives them a bit of an expectation. So I've said to someone once at your age, if you returned before nine months, you have a significantly greater risk of re-injuring. And that's why we're going to use the criteria and not get too worried about the time. I set people in expectation is that this is the surgical populations that we should be having conversations about them returning to some sort of modified training somewhere between nine and 12 months and building into their return to sport from there. Just depending on their sport, their injury, the nature of their repair as well. You know, you get people that have meniscus injury that then is stitched up. So the first six weeks of their re had they spent in a brace. So they get significant deterioration of some of their quadriceps bulk and some of their walking patterns and that. So if we tell them 12 months that we might undershoot them as well. And so I think you can give them a basic gauge of this is where I expect you to be at these time points. But I always reinforce that the functional tests guide our progress or regress. And that makes sense. And so we're talking there about the surgical candidates, so people that have had surgery and then their recovery. What about the patients that are going with a non surgical route and they're looking for, okay, I've injured my ACL, I want to get back to a recreational level of sport and I want to see how I go. How do you guide them in the same way? Can I go back? How long are we going to tell them a team that I'm off for? Exactly the same way, but usually you'd expect somewhere between 12 and 16 weeks. But once again, I always use those criteria. Sometimes you'll get people that they test all their physical criteria really well. And then you do the ACL RSI tool and their confidence to return to sports about 50%. And that's when you can have a conversation. And I have had conversations with even all four pods where I said, this person is doing really well. And they've been surgical and non surgical. But their confidence measure is quite low. I'd like to have a bit more time and build in some drills and activities that are structured play of that sport to see if we can enhance that before we return them back to sport because we would like it over about that sort of 90% if we can. Yeah, on that RSI. And you can look at other measures of that sort of stuff. You've got tampers, you've got trust indexes. You can use, look at different tools to see if someone's comfortable or confident or anxious about their return to sport as well. It doesn't have to be just one tool, but you don't want to give everyone every tool either that becomes quite arduous for the patient. And then I want to briefly just touch on the types of graphs that patients are getting. There's been a bit of movement between and different surgeons to have favorites. And now, obviously, if the patient's gone to see a surgeon, they're going to have their favorite type. So it's not often something that we can influence or whatever. But it's good to have a bit of an idea about what's out there. What are the popular choices in the pros and cons? Do you want to give us a bit of a brief outline of where that space is at the moment? Yeah. So I think, obviously, the two best known ones are the hamstring and the patellar tendon. I've seen a few perineals and I think there are still a few people that are getting the last graph around certainly not where I work in sort of Brisbane. But I think historically, what's happened is it's just gone round in circles. We were all doing patellar tendon graphs. Then it was all hamstring graphs. I think now we're seeing a little bit more of a discerning approach. So horses for courses with the patients, a couple of the young football athletes that I've seen their surgeons have gone back to patellar tendon graphs because that will help preserve the hamstring strength. And when you speak to some of the orthopods, they feel that most of the couple of them I've had conversations with say, look, we tell people that they probably don't have any deficits. But the concern is that they're probably still a little bit of a deficit in that having even a long term. And so I think that's they're trying now to match the graph to the person. And I think that's at the moment, that's the best case we've got at the moment. And that talks about their past history. Have they had enter any pain in the past and things like that become part of that discussion? Have they had a significant hamstring history? That type of thing because I think that's really important. If they've got multiple hamstring injuries, then I don't know that taking the hamstring out to repair their knee, that they have to be a significant focus on that hamstring rehabilitation. Then you question what the hamstring was like before they were injury anyway, might become part of their risk profile within the injury. So overall, we've got some really good ideas here about patients that are likely to require surgery. We looked at different time or different criteria and how you might progress patients through those phases of rehab. When we're looking at going, okay, if we want to sum up some of that non-surgical management asset approach, if you had to look at your patients go, who's likely to be good candidates for non-surgical management? Who do you think fits into that box or the is likely to cope well? If we look at the research in this space, it was generally sort of people that are a little bit older and that weren't doing those level one sports. So those high-changing direction sports was a general consensus. But I think you can also ask your patient, what do you want to get back to? And I think probably a lot of us do have some horror stories. I have one where a patient with 30s was just playing recreational sport. Just as a bit of fun, it was only offered a surgical reconstruction. And unfortunately, her recovery ended up with your DVTs. She had scar tissue buildup. She ended up having MUAs, arthroscopies and all of that. And I think when we talk about those horror cases, people go, why would you possibly do that? And I think we've just got to be a bit of aware that at the moment, there's some good emerging evidence. But it comes down to that real robust clinical decision making for the person in front of us and making sure we get that information. But also like any condition we have, if the person is not going well with a non-surgical pathway, having that exit strategy and making sure the patient knows that if things are not going the way we want, that's okay. We've got this plan to then take the next step. Beautiful one. I think that's a really nice place to wrap this up. We've talked about a lot of fantastic stuff on the board. podcast and given people a lot to think about it, you're managing all sorts of different athletes at different levels and looking at the research, what is the most appropriate and likely to go well for each patient and then helping them to make those decisions. So that's been really fantastic to get your practical insights into all that. Thank you for having me, Dave, and I think I just want to really make sure that like most of the discussion we've had today has really been about that adult population, 16, 18, plus. We've just got to be mindful that might not necessarily be the same rapidiatric and adolescent populations as well. But thank you for having me. So now tell people where can they find out more about yourself and what you're doing? Yeah, I work for the Quechza Academy Sport at the moment as well as I'm still consulting at private practising Brisbane, but you can follow me on Twitter @physiozo. Awesome. And you're a very real member of the clinic-led presentation team, you've got some great presentations coming up on communication and also on the low back pain. Yeah, we're really looking forward to exploring those. You've got a presentation on communication and helping to resolve conflict where that's with patients when they have different goals or they've got tricky, difficult patients. And so we're looking forward to sharing that one with all our clinic-ledged members and also another one on telehealth communication module. So we'll probably get you on and explore a bit about those topics on future podcasts as well. So plenty to chat about, but we are excited to have you on the clinic-ledged team and be able to share your experience with everyone that's either a member and also on the podcast as well. Thanks, Zoe. That's all right. Thank you for having me. I hope it was helpful. Indeed. You have a great day. If you've got comments or you've got questions for Zoe or for any of the clinic-ledged team, then remember to jump on over. You can post those on the Facebook page and we can answer those in the comments or on future Facebook lives. So thanks everyone and we'll catch you very soon. Thanks, Zoe. Hope you enjoyed that podcast and you've got lots of great ideas about how to assess and accurately identify your patients that have an ACL injury and what sort of treatment pathways they can go down and what they're most suited to once they have an ACL injury. Now we've got another great podcast coming up for you on ACL injuries and that's also diving even deeper into the treatment options and that's going to be talking about your conservative, your surgical and some new emerging treatments that are coming out for ACL injuries as well. So that's coming up with Claire Walsh, who's also a specialist sports physio and we're going to be diving into that real soon. So keep an eye out for that one in your podcast feed, subscribe to the podcast on your app whether it's overcast, Apple podcasts, Spotify, wherever you get this podcast, hit that subscribe button and get your free access to all the podcasts as they come out because you're not going to want to miss the next one on ACL injury treatment. All right, remember grab your resources that go along with today's podcast. You've got your infographics that cover all the key points from the podcast. You've also got your free clinic ledges membership, that's at clinicledges.co/free trial. And then you've got your Achilles tendon optic video series, that's a Tom Goom over at clinicledges.co/achilles. Now you have a great day and I'll catch you on the next physio edge podcast. See ya.