Episode 3: ACL injury management options with Keiran Richardson
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In this episode we delve deep into the best options for people who have recently ruptured their ACL with Kieran Richardson. Keiran is a specialist musculoskeletal physiotherapist who has a Master's in Clinical Physiotherapy from Curtin University, and is founder of Global Sports Physiotherapy, a consultancy company of academics, researchers and educators offering formal mentoring second opinions for complex patient presentations. Kieran has a special interest in evidence based non-surgical management of the anterior cruciate ligament.
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Bevan Colless
Welcome back to the Knee Gurus. I'm your host Bevan Colless, founder of Asia physio and the Knee gurus. On today's episode, our guest is Kieran Richardson, a specialist musculoskeletal physiotherapist who has a Master's in Clinical Physiotherapy from Curtin University, one of the world's leading physiotherapy schools in Perth, Western Australia. Kieran also consults in several physiotherapy practices in Perth, as well as nationally and internationally. Kieran is Director of Global Sports Physiotherapy, a consultancy company of academics, researchers and educators offering formal mentoring second opinions for complex patient presentations. Professional Development for physiotherapists, health professionals and athletes. Kieran has a special interest in evidence based non-surgical management of musculoskeletal conditions, especially the anterior cruciate ligament. I'm excited to have Kieran on today is he's at the forefront of this rapidly developing field of conservative management of ACL injuries and ACL healing. I'm sure you'll find this episode really useful and interesting, especially if you've recently sustained an ACL rupture and making some decisions on how you might manage it. Kieran, thanks very much for coming on the show.
Keiran Richardson
It's good to be talking with you. Bevan. . Nice. And I'm sure we're in the we're in the same time zone.
Bevan Colless
I think we're one hour in front of you. I'm in Japan, so pretty close.
Can you tell us a little bit more about yourself?
Keiran Richardson
I you said, at the start, I run a consultancy company of academic clinicians and researchers. And it's something I do full time. And working as a specialist physio myself, I do still work with patients probably about a day a week. And I do a mix of face to face and online consultations, a lot of acute knee injuries and pain. And we train physiotherapists and healthcare professionals, we run professional development to mentor them, that we do locally where I am in Perth, Western Australia. But then we also do it nationally and internationally as well through platforms like Zoom and Skype. And it's been very popular since COVID. We also run second opinions with patients, which is something I do every day, often with other physios present, virtually, which can be helpful. We find given the way the world's going, it's good to have these different options. I to be able to use telehealth and virtual consultations has been cool.
Bevan Colless
So, you see patients from all around the world, how do they find you?
Keiran Richardson
Some of them will just have read articles that I've posted online through my websites. Others have found me through social media forums, or posts that I've put on say Instagram or LinkedIn, Facebook. Others have been through videos I’ve put out there. And they get me through my websites, I'll wake up and see that they've booked in and it's kind of cool.
Bevan Colless
It’s such an exciting time, in particularly an ACL management, because, despite this growing body of research that's pointing towards this shift towards more conservative management and less surgery, there's still not a lot of people talking about conservative ACL management. And as , the operation rates continue to increase. And I think in Australia it’s at all-time highs.
For people that know me, I've always been a little bit of a contrarian. And I've spent a large part of my career being the first contact practitioner for patients who've ruptured their ACL, because we work in the ski fields here in Japan, and people are isolated, and an ACL tear is a very common ski injury. So, we're in the privileged position to see these patients very soon after they've done their ACL. So, I've spent most of my career having these conversations with people that have just ruptured their ACL. So it's an area that, that I've obviously been drawn to and even more so now that, that that message we're providing our patients has changed a little bit. So, it was kind of a natural fit for me, but how did you get involved in in ACL management to such an extent?
Keiran Richardson
So, it was probably around eight years ago now, when I was going through my specialist training, and I had these two contrasting cases that forced me to look into the research legit And it was one patient, first of all, who'd had about five knee surgeries following an ACL injury. And she came in and saw me on a four wheeled walker. And she was just in complete agony. And she was frustrated and disillusioned, with the whole process. And we did get her going. We got her rehabilitated, it took about 18 months, but it had been a four-year journey for her. And then I had this other patient roughly at the same time, who tore her ACL and meniscus. And she was adamant to not have surgery, because her friends had had knee surgeries, and it hadn't worked out for them. So, she was just committed to non-surgical from the get-go. And that just forced me to go okay, well, this is the first time I've done this. What should I do? So, I spoke to some mentors, I spoke to some researchers, both surgeon and physio researchers. And then I presented the evidence to her, we went through her options and started rehab. And she got back to field hockey in about four months. And so, from there, I've just continued to investigate the literature and the research, and , hit by the fact that there's a lot of people that are getting surgeries that they don't need. And not to say that surgery is never an option. But I think for many people doing rehabilitation and exercise can be a lifelong solution. So now I've overseen 1000s of ACL cases. Now, either myself personally, or through other physios and through forums that I'm a part of, and a lot of people can have success with this approach. So, it's exciting.
Bevan Colless
It is. I recently went through your Global Specialist Physiotherapy ICL training module, and I found it really interesting. So for the listeners that aren't aware, Karen's developed this training resource called the Global Specialist Physiotherapy, it's an online course with lectures and presentations, run by Kieran that include around six hours of lectures and discussion to it's mostly I think, targeted to health professionals.
Keiran Richardson
that workshop is mainly for healthcare professionals, although I have had patients to use it and I think just to give them some background literature and, , give, give them an insight into what their rehabilitation can look like, I have got courses specifically for patients that are much more, , simplified layman's terms. As I said I do see patients but largely, I'm an educator, and presenter. So, I love doing both. And I think, to have the option there online, so they don't have to use me all the time. It's probably a smarter use of my time.
Bevan Colless
And you could reach so many more people than then you can just do your one-on-one consults.
Keiran Richardson
Yes, exactly. Right.
Bevan Colless
The one that I did had a number of different courses, a two hour lecture on the history of ACL management, research base for non-operative versus operative ACL management. There was another lecture on the risks and benefits of operative versus non operative ACL management, early-stage management, and physical examination. And the last one was an ACL non-operative strengthening program. So as I was going through, it all started to think patients have become so much more educated in this day and age, and people seem to have a pretty high health awareness. And there's so much more information out there that, , why not? Why wouldn't a patient sign up for those and most of the things they could probably understand?
Keiran Richardson
and I think it's not something that they should be doing on their own. I think it is good to connect with a healthcare professional and after your injury, so you're not just flying solo, so to speak, I think you should, you should have a sounding board and someone who's experienced and trained in this method. And it's just not having that blind spot cover just in case there's something you've missed or something you've misinterpreted, because you don't want to be reckless, whether you're going about a rehabilitation post the injuries, either non surgically or surgically. It is something that must be very controlled and deliberate.
Bevan Colless
It really needs to be shared decision making, and people get as much information as they can before making that decision. So, they're reaching the right conclusion for them, , and there's never one solution that's right for everybody and every person's situation is different.
Keiran Richardson
this is right.
Bevan Colless
As we were alluding to earlier, there seems to be this disparity between where the evidence is pointing and the current practice in ACL management being that there seems to be more evidence suggesting that more that probably less people need operations than are currently having them. But in practice, more and more people are getting operation and that what do you think this is? Why is there this disparity?
Keiran Richardson
Look, there's that's a really good question. And there's, heaps of reasons why, which, I don't want to launch into a lecture. But the surgical techniques were invented in the early 1900s. But they've really been propagated in the last 50 years, and the healthcare models in typical westernized societies, who would fast track people towards a surgical opinion in surgery. And to fund that, as opposed to opting for rehabilitation or having that the option of rehabilitation as a standalone treatment first. And the whole media thing, where players, after they injured themselves, will be operated on within a day or two. And then if someone's doing a similar sport at an amateur level, they would have this belief that they need to then go into, getting a surgical consult and having the surgery as soon as possible to follow cultural trends. So, then you have a large cultural element associated with that. And then some of the messaging around what the surgery does, and its promises can also be, implicit within that, or explicit within that, that you're getting a new ACL, this is a one-way ticket back to sport. That kind of language can prejudice a patient towards that. From a research point of view, we've got very low level of evidence, and then we've got high quality evidence, and the most high-quality evidence hasn't really shown great outcomes either way or superior outcomes for surgery over just doing physio and exercise. And so that's given people that are trained and experienced in, rehab, the opportunity to present this as an option, which I think is very exciting for patients and can be good could be really good news for governments, if they took it on board. And it could be a massive cost savings. And, we can redirect funds towards this, and help to tighten up our healthcare budgets, because the spending is a bit out of control in that, which is a whole other topic. So, I think that it's an awesome opportunity for the physiotherapy profession, and for exercise physiology and sports medicine. And it's not to say we're taking a scorched earth approach, and no one ever needs surgery again. But it's probably that the models kind of upside down wrong, where it's almost like people should go through physio, first at least for three to six months. And then if they want, if they desire the surgery, or their knee keeps buckling, then they can decide upon that. But we haven't really seen that those pathways established yet.
Bevan Colless
The media is an interesting one. Because the only time you tend to hear about ACL injuries in the media is with elite athletes and with professional players who've just done their knee. And the question is always “Is it an ACL yes or no, oh, it's an ACL, ah OK he's off for an operation. He's going to be out for nine to 12 months. And now isn't that terrible, and this kind of heavy feeling in the conversation around this injury? And people see that and just assume, well, that's what happens. You do your ACL, you get an operation, you're out for 12 months. That it’s a devastating injury. And that's just the way it is.
Keiran Richardson
And that's, that's all a part of the whole sensationalism, you see in media across different topics. But certainly, it's considered almost this life threatening injury, which is what it is, but then you have international classifications that would describe the injury as a joint sprain. And so it's far less disconcerting when you hear it described as you've sprained your joint as opposed to this is 12 months of your life gone now or that assumption. And so, I think the reframing of it. And it's not to say that we're making light of the injury because it's obviously painful. And either way surgically or non surgically, you have to do the rehabilitation. But I think when we as therapists, we can present it in a calm manner, and help the patients go through their options in a really safe way and a great way without hysteria, I think that makes it much, much easier to make a logical and smart decision, as opposed to acting on emotion.
Bevan Colless
So for patients who may have had an ACL rupture, and they're considering their options, what are the factors that that you think they should consider when they're making their decision about whether to go the surgical route or whether to do delayed surgery or whether to just put all their chips in not having the operation? What are the variables that that are going to help them to decide one way or the other?
Keiran Richardson
I mean, , again, that's a that's a very good question. And we could probably spend the next hour I don't know how long the actual podcast is meant to go for. But, but we could spend the next hour talking about that. But look, I think it is an elective surgery. So it is something you can decide to do or decide not to do. And I've heard surgeons say the same thing. So that's, that's important to know. And it's not something you, you shouldn't be rushing into it. I heard on this podcast, the other day that, , we're not going to rush into buy a house or rushing to buy a car, you'd ask lots of questions, and you would consider your options and look at other look at other sources. And I think it's the same, it should be the same with healthcare and with our own body. But a lot of patients aren't really trained to think that way. They kind of almost by default trust healthcare professionals and what they're told, and they don't they don’t systematically question which you're taught when you go through tertiary health science degrees, and post tertiary degree to doctorate degrees and such. So I really encourage, if a patient seeing me, I encourage them to write out a list of questions they want answered, and they can, , spend might, I might spend the majority of my first initial consultation with them going through that. And I think that's arguably more valuable than anything physical, that I might do for them. Or even exercises the education and having it set in your mind what the research shows? And what does this mean for my specific knee injury and what my goals are, and how long it's going to take, these are the sorts of things patients should be asking, and what does the research say for my specific case, these sorts of things is what I encourage patients to ask.
Bevan Colless
And what questions do you find they're asking, can I play sport again? How long is it going to be until I can run again?
Keiran Richardson
So, it's those sorts of questions, though, is non-surgical right for me? What do I do about a meniscus tear? If I've got one? As you said, How long is it going to be for return to sport? Should I should I cancel my surgery? These are the sorts of things that people are asking me. I think we should be comfortable answering those questions if you're suitably qualified, and experienced. And I think it's, really cathartic process for the patients to go through that. And I think it's probably one of the best features, I think of what we call the shared decision-making model the patient comes with what their thoughts, beliefs, expectations are, as the as the clinician or healthcare professional, we come with the same, and then we try to meet them somewhere in the middle and help to take them on their journey.
Bevan Colless
I think a lot of people are just conditioned to having the decision made for them thinking “Oh, well, I'm, I'm paying the doctor for his opinion, so I'm just going to do what the doctor tells me and then, same for the physio, but because of the hierarchical nature of the healthcare system is it ends up with them sitting in a in a knee surgeons clinic, saying ‘What should I do doc, should I operate or not?’ Rather than collating information and coming to their own decision?
Keiran Richardson
Yes and there's a lot of kids shows that have Doc McStuffins, for example, the doctor is the one that's always in charge. And obviously, we must respect that inter-professionally, it's a team approach. And I think patients are getting more comfortable doing that, going through and asking questions of the doctor, not just taking stuff on face value. And, because these are big decisions with risks and benefits wherever you go. And so, I think that's a very key thing to get out of today's podcast, is we want patients to know they have options, and you're allowed to ask questions, without feeling guilty or, not being able to do that. I had a case recently where a patient was shut down, she was almost rushed out the door. And she was charged 330 euros for a 15-minute consultation. And she was rushed out the door. And she was like, very teary, teary afterwards. And I don't think that's how healthcare should be, we can be a lot better than that.
Bevan Colless
So, someone has just ruptured their ACL. And they're excited to try the non-operative route, at least that, or at least, do the minimum of, say, 12 weeks strong, supervised evidence based rehab before making a final decision whether to operate or not, what does that management look like from when they have an ACL through, through that 12 week barrier, and then if they're doing well, through to return to sport.
Keiran Richardson
Ye, look at basically you have a sore and swollen knee, having just injured it, sometimes it's difficult to put weight on it. And so, a lot of the treatments and exercises that therapist would do early would be to help to ease that pain and swelling and improve the movement in your knee. And then we would hope to try and get you putting equal weight on it, and then starting to just move more normally getting increased mobility in weight bearing, walking more normally, and then obviously getting stronger. And then the harder we tend to go and the more as the patient's pain settles, then we tend to, we tend to up the ante with respect to exercises. So, we would put more load onto the one leg and make it much challenging building some balance work. And it's, it's quite a nice process. And I think it gets quite fun for the patients and they can really see the benefit, the amount of work you put in tends to relate to how quick you get better. And, I think having early supervision from the therapist is really helpful. So we tend to see the patients more initially, and then I spaced them outside fortnightly over that over that 12 weeks. And I think it's a nice, it's nice to see it's and it's quite exciting to see the patients do an exercise program. And then they feel better afterwards.
Bevan Colless
Yes, it's super rewarding. And we see that in our clinics. And in ski fields, we'll have a patient who's just ruptured their ACL, they'll be carried in or brought in virtually non weight bearing carried in, popped onto the table and you do the assessment, check the Ottawa Knee Rules, make sure there's no fracture and, and you get a pretty good idea that it's an ACL from the history, and the physical examination And so once you are pretty clear that it's a vanilla ACL, you can get that person who was carried in often walking out and almost without a limp, just by taken through that process, okay, you've ruptured your ACL, but it's only a ligament inside the knee, the actual knee joint itself is still reasonably stable and able to take some of your weight. So, let's just try putting a little bit of weight on it. And it's, it's amazing how you can turn people around just in one hour just by giving that message to trust the knee and, that it's stronger than you think. That's kind of a common mantra for us. And it's really rewarding to see that progression.
Keiran Richardson
Yes, absolutely. And I think, how patients think about their knee can determine how they move and their outcomes. So I really agree with what you're saying, I think, we want to take a very positive approach initially and but still balanced, I don't want to turn them into non-surgical. But I think I think when the patient's so overtly scared and worried about using their leg, then there are some studies that talk about you're actually more likely to be unstable. So, the more you can strengthen it sooner, the more you can get back to more normal movement and trusting it, the likelihood of a positive outcome is and so I think you I think you'd be bang on with that in terms of obviously we want to help to settle the pain down but then getting your head wrapped and trusting your knee and thinking about it properly.
Bevan Colless
So how about returning to sport in the pathways before getting to patients back to doing sport even at a decent level? Non operatively, verse operatively?9oIf they do well, non-operative, do you think they can return to sport faster than if they have the operation?
Keiran Richardson
Most definitely. So, the first point is the Swedish guidelines, which I don't believe have been translated to English, but I've spoken to Swedish researchers, and they have said that it's three to six months, for non-surgical management with return to sport, my experience is probably closer to six months, like I really pull people back and I am very conservative with it, I certainly don't rush people. Surgery would be nine to 12 months typically and shouldn't really be any sooner than nine months. So it's a similar process, once you've built the strength up, then you start building dynamic strength and jumping and hopping on it. And then, gradually returning to, training over a period, and then testing it with psychological tests that people trust their knee, as well as physical tests of strength and dynamic balance. Then it becomes a graded approach, and then you still check in with the patients once they've returned to sport. And you encourage them to continue with exercises after. But, and there's always a but if we're going for non-surgical, there's always an option for surgery down the track, if it's things aren't working out.
The other option, which we haven't spoken about is what they call becoming an adapter, which is basically if you injured your knee, say in skiing or some pivoting task. But you're not confident you don't want to go back to that cutting or change of direction type activity, you can just take on more straight-line activities, and probably are at less risk of injuring your knee in the future. And so, I think that's quite a wise approach and probably not spoken about enough. I think there's some patients that, I did a professional athlete review for a fairly famous club here in Australia. And there have been multiple knee surgeries. And there's a strong argument that you could see another one happening. And so that was part of the conversation that you need to consider, the best predictor of future is past if you've had the same injury, we're doing the same thing again, where do we see this going? And so, I think some patients, it is smarter to probably not go back to that. And so that probably needs to be spoken about, as well, as a part of the conversation in some patients.
Bevan Colless
For sure you don't want to catastrophize the injury. But you also don't want to de-emphasize the importance of it. Because we do know that, unfortunately, once you've done your ACL, you are at a higher risk of osteoarthritis, and there's a decent chance you may not return to your same pre injury level of function.
Keiran Richardson
You're exactly right and I think the in the past 10 years, there's been some very rigorous research that's spoken specifically about ACL reconstruction and around half the patients don't get back to their pre injury level and one positive on the osteoarthritis thing, you are at an increased risk of osteoarthritis, but you might not necessarily get pain. So we're talking radiographic arthritis, on an x ray but you might not necessarily get pain. So sometimes when I tell patients that that can be, a little tick of hope for them.
Bevan Colless
It’s just striking that balance that tends to be us as physios, we want to have all our patients achieve all their goals, and tend to push more activity whereas the GPs, Sports Doc's and knee surgeons, a little bit more conservative. So , it's always tough to find that right balance, but that's our jobs, to make sure the patients is trusting the knee and overcoming their injury without doing further damage to it.
Keiran Richardson
Yes, exactly.
Bevan Colless
So just on the topic of surgeons, most people that do their ACL at some stage are probably going to find themselves at a GP and then get an MRI and then they'll end up having a consultation with a with a knee surgeon and generally most people will choose a knee surgeon because their friend went to it all they hear that the surgeon is the knee surgeon for their local elite sporting clubs. How do you recommend your patients to choose their surgeon?
Keiran Richardson
If they are set on seeing a surgeon, then that's obviously something that they can do. And I always encourage people to get multiple opinions, not just mine, they don't have to stick with me. I think they should get more than one opinion. I particularly like someone who's done some research in this topic, and has experience, obviously. So, I think that's, that's a good way of thinking through it. You want to go in with that list of questions that I mentioned before, and don't feel rushed or pressured. There's no rush for these types of injuries. It's something that that you can always decide to do at a protracted time point. So that's, that's my main my main advice is seek multiple opinions and ask lots of questions.
Bevan Colless
It is a little bit of a sensitive area with this growing body of evidence, questioning the need for so many knee reconstructions. What, what's been the reception to your take on ACL rupture management inter-professionally?
Keiran Richardson
I would say on the whole very positive, I've had majority positive feedback, particularly within the physiotherapy profession, within sports medicine and surgical, also pretty positive. You do have some naysayers on social media, keyboard warriors, as we would call them, it doesn't really bother me too much now. We don't want to come across as just saying that nonsurgical is the fix for everybody. But equally, but we must be able to admit that most of the systems and health care models are set up for surgery. And we have to acknowledge that. And so I think the heat needs to be equally applied in both directions. So, I think as long as what we're presenting to patients is balanced. And we're giving them all options and we're not forcing them. I've had very, very good discussions with surgeons, and very good discussions with sports doctors, in fact, where I am here in Perth, we have like a little crew of myself, a sports doctor and surgeon and we manage these patients like this, where it's very collaborative, it's not, that we're not trying to force the patients one way or the other. And if the patients ultimately choose surgical or non-surgical, it's like we sleep at night. And I think, I think in an ideal world, that's how it should be. It might take a few years for that to become the norm.
Bevan Colless
And what is it like? What's the typical patient experience? Like now for someone that's got that's done their ACL? Do you feel like the most of them are given all the options, delayed surgery, surgery or conservative? Or do you feel like most patient’s experience is “Well you've ruptured ACL? When should we book you for your operation?”
Keiran Richardson
I mean, it'd be good to hear your thoughts and what you've found. But I would say in most cases, if they've gone down the traditional medical model, they'll be told they need surgery, and there's not really much of a shared decision. So, I like the concept of a shared decision, but I just don't necessarily think it's happening. As high quality as it should be, and as early as it should be. So, I would say most patients are told that surgery is best, surgery is a gold standard, but I have seen a bit of a shift personally, and I’m inundated, seeing patients personally and so as I said at the start, as we were discussing, I'm probably more interested in training healthcare professionals, whether your surgeon sports doctor, or physiotherapists strength and conditioning expert. I'm more interested in that interprofessional communication. Because I want to see that shift because I'm yet to see a patient, really regret waiting, going through the options, but I've seen quite a lot of patients regret having early surgery. And so, I really want to get that message across. And I think that it is exciting. And it's, challenging in a sense, because you do get some people that are committed to early surgery, so then you do have a difference of opinion. And that can be what it is.
Bevan Colless
So, with our patient with our clinics, we're having these conversations about ACL management, surgical management options often before they've seen any other health care professional. So we're in a really lucky position that we're having these conversations with patients, every day in winter, well in an pre-COVID Winter anyway. And you can see their face, when you start to talk about non operative management, they're often surprised, “What is that possible? Is that a thing?” So hopefully, this podcast and all the great work you're doing is getting this information out there so that people can realize that there's more options to choose from.
Keiran Richardson
Definitely. And I think that's it, it's just about, it's almost like bringing balance to the Force, like Star Wars, we're just trying to bring a balance to the conversation. And I think that it makes a lot of sense. The way that we would manage any injury, if you're a physiotherapist would be with this kind of approach, you kind of have tiers, you would go through starting with, with your physio first, you've always got the option of medication or injections if you need it, and then you've got surgery at the end if you need that. And I think the healthcare models are shifting towards that, because it's quite cost effective. And then you kind of streamline the people that really need surgery, and I think it will be the way of the future. It's just a case of how quickly it will happen.
Bevan Colless
So last week, we were speaking with, as we've coined her ‘Rockstar ACL researcher’, Stephanie, Filbay, and one of the things that she cautioned against when it came to making the decision making is, if anyone's just telling you one side of the story, so that is: you definitely need an ACL operation, you need an ACL to live your life. Be cautious of that advice. But on the other end of the spectrum, we've got to make sure that we're not saying, ‘Well, the ACL is not important. It's just a little injury, and don't worry about surgery, just get on with it’. So how do you make sure you don't fall into that trap? Or have you had any people suggest that you've gone too far off kilter the other way?
Keiran Richardson
I think you're exactly bang on with that, we have to take a balanced approach to it. Physios have to admit defeat, if the patient has continued buckling of their knee, or they've got a large meniscus tear on scan, and they can't bend the knee, or they get Jack-knife phenomenon, and they just get stuck, for periods of time, and thein it just straightens all of a sudden, they need to consider surgery, if they've gone through rehab, and it's not working. Equally, if we've seen a patient who's going really well with rehab, for a younger patient, or wanting to return to pivoting, we've organized a follow up scan, there's MRI, evidence of healing of the ACL, we need to admit that and this patient becomes less of a candidate for surgery. And so, I think it is this balance. And absolutely, we have to be objective about it and not be emotionally attached to the outcome. And that's where I place myself. And I think, I think it's you can sleep very well at night using that approach. And it's not to say that surgery is never an option, or that every single patient needs rehab alone, but we need to have all those options presented to them in that tiered way. And I've had, I've had very good success with that approach.
Bevan Colless
With our patients, we often say the three most important factors are, the level of stability, which king. ‘Is your knee buckling, is it giving way, or does it feel wobbly underneath you? Second is your age, people that are over 40 are probably less likely to have the operation and third is your future sporting goals. So if you really want to perform at a high level, in a sport that involves contact or cutting or jumping, then you might be more in the operative basket. How much weight do you put on that ffeature? Sporting goals as a deciding factor, do you feel like it doesn't really matter? Because if your knee’s stable and not buckling then you can play at a high level and you can achieve any sporting goals you want? Or do you feel like somebody who wants to play sport at a high level, then that's probably more points in the operative side of the ledger?
Keiran Richardson
I think it depends what research we're using to justify our opinion on that? I would say, I would say we can't, you couldn't give a homogenous or a one size fits all. To return to jumping, cutting, pivoting, you need reconstruction, I would say that that's not true. And I don't think that's an even an evidence-based angle. But you're going to start to stack up those factors, like you were saying, if you've got a very unstable knee and weight bearing, and you're not confident to trust your knee, and you're playing at a very high level, and you've done a very good level of rehab, for three to six months, then you probably are at risk of potentially injuring your knee if you go about that, you becoming the case that if you want to go for sport, surgery is the next the next best option. So, but to say that, to say that, to get back to pivoting sport, you're at a better odds of having reconstruction, I would say show me the evidence, I'd say show me the research. And, I think I think it's probably you go back to the podcast of the best studies. And the research is where it's very balanced to research surgeons, to research physios, they talk about signs and symptoms, how does your knee feel? What do you think about it? What pain? Do you get buckling? I think those are the very simple factors That's very simply what I think it boils down to. And we can't work that out if the patient has had an early surgery if they haven't tried rehab. So it's kind of academic from there.
Bevan Colless
So just moving on, I wanted to talk a little bit about ACL healing, which has almost come out of the blue, this growth in realizing that the ACL can and does heal. When I was a student, we were taught that the ACL is an intra-capsular ligament that lives inside its own bubble, therefore, it doesn't get blood supply, and therefore it doesn't heal. And that is still, to a large extent, a common belief in healthcare professionals and in the general public, but it seems like there is this growing body of evidence that it's that it's incorrect. And the evidence is, there's not a heap out there, but what there is, suggests that, that it does heal. And I'm sure you've seen ACL healed cases in your clinic, as we have many times in our clinics over the years. Can you give us a little bit of a rundown on your opinion behind ACL healing, and maybe touch on some of the research that is out there?
Keiran Richardson
And again, it's another really good question, and could be a massive, massive conversation. Obviously, when someone injures their ACL, you've got some different strategies that you can use to treat that. So you can have surgery, or you could put the patient in a brace, or you could do exercises to strengthen and stabilize the knee. And so you could do a combination of all of that, or just two of them. And so, in the studies that have been done, there's various bracing protocols, and there's currently bracing protocols being implemented in clinical trials, with preliminary research showing very high levels of healing. The question is on the quality of the evidence, and it is low to moderate. So, of the studies that are available. There is low to moderate level evidence that says it can heal. But when we look at all of the studies grouped together, there doesn't seem to be any studies that actually say it can't. So that's, where it gets more interesting. And that healing is a broad term. So you've got healing, where you look at the MRI, and it's basically looks the same. So the person’s first MRI is fully torn, and then you do a repeat MRI, and it's actually normal, the ligament looks normal. So, I've lost count of how many times I've seen that now. And something I'm doing more readily is getting another MRI to see in not in every case but in in cases where they're potentially going to be using more pivoting type tasks. I've seen it attached to the PCL, I've seen it called a full thickness rupture then you do the follow up scan and it was that it was either a partial that was called a full thickness or one of the bundles has healed. I've seen it heal loose, I've seen it also not healed at all. And it's completely retracted. So, I think this is probably further reason to wait. And consult a healthcare professional who can talk through these options.
Bevan Colless
And how do you find that the results on if results in an MRI match up with your clinical findings and with the patients function? Do you find that they're people who've had an ACL, fully healed, say, on an MRI, also have a negative Lachman’s? And have a stable, strong knee? Or do you find that there is some disparity there?
Keiran Richardson
It’s two massive questions. Like, there's just too many different ones I've seen, I've seen, people where the ligament has felt loose, and then you do the MRI and it's healed. I've seen it feel stable. And you do the MRI, and it’s not healed. I've also seen it not heal at three months, done another one at five months, and it's healed. So, I've just I could talk case examples forever. And so, I think what’s most important is, the signs and symptoms. Like I said, but then if they're a younger patient under 18, or between 18 and 35, wanting to get back to very high level, I think you should probably see what the knee looks like after a few months.
Bevan Colless
Well we're hearing more and more about this haling study, we shouldn't talk too much about it, because it's not published yet. But the whispers on the street are that the healing rates are very high in the protocol that's been developed and tested.
Keiran Richardson
Well I think that the key with this will this study is coming, and it is going to show very high healing rates. The challenge is, there's other ways to heal a knee. Strengthening itself is one way to potentially heal. And there's different brace types that you can use. And so again, we don't want to get hooked on one method. Without having comparisons.
Bevan Colless
You talking about getting hooked on one method, I do wonder if they'll ever be a general consensus on the ideal ACL healing protocol. And if you've ruptured your ACL, these are steps that you can do that you need to go through to maximize the chance of ACL healing. I think there's probably too many variables for that there'd be one set one, but who knows? It's a long way away off, if it is going to happen,
Keiran Richardson
I think, well It's, it's a long way away. And I think it can get better for sure. There's a large study from this year, the first, the first and largest study looking at ACL healing. And they suggested that when it tears more towards the top of when the fall, these are full thickness ruptures, when it tears more towards the top of the ligament, it's got a greater chance of healing. Now, I've actually seen ones where it's healed in the middle heal just as well. And so, it's I think, in a lot of these coming trials, those patients where it's got the potential to be healed in the middle would be removed and have a surgery. So, we would have never known. So, I think I think it is going to be hard. And there's all sorts of pressurizing factors to challenge that.
Bevan Colless
Well, I think what we can say with a reasonable level of confidence now is the ACL can heal. And we should try and give it the chance to heal,
Keiran Richardson
I think I think it to say that every single case heals is absolutely wrong. To say that it could heal is correct. And I think if you are getting more confidence to tell patients that it can. And I think if we're deliberately not telling the patients that it could heal, I think that's wrong. We need to be suggesting that it has potential to heal, because it looks silly, if in five to 10 years, we have multiple high quality studies that can heal and all the while, we've been saying it either ignoring that it could or just saying that it can't I think we need to move we need to be really analyzing that and with vigor, questioning that and then presenting that that information to patients?
Bevan Colless
And to find out what the healing rates are. As we move forward, it seems like that'd be surprisingly high. And so one of the common reasons people give for doing an ACL is the ability to perform at a really high level. Is the thought that you can't do that without an ACL because you won't have that same control over your knee to perform at a high level in twisting and cutting and jumping. But I noticed in your Global Specialist Physiotherapy course you mentioned that quite a lot of elite athletes who ruptured their ACL and have been able to play at elite level. There was the basketball DeJuane Blair had two ACL deficient knees and played in the NBA.
Keiran Richardson
So you have obviously that I mean, there's case examples at the elite level of ACLs actually healing and confirmed on scan and the players have gone back this cases where it hasn't healed. And they've been able to function given their, their muscle stability and strengthening. And so, you do get, both of those, and then you get the ones where it’s obviously calm and then it buckles, and they may opt for surgery. But really, at the elite level, it's almost it's almost one size fits all surgery, these people, these athletes are getting surgery within a few days often. So I think it's going to be although there is there is case examples, of an English Premier League guy who got back in a few weeks. And, there was hope that that might shift the discussion, but at the elite level, there's all sorts of factors, contracts and media pressure, and, in sporting culture, the players don't have, they're not necessarily getting the best evidence based treatments anyway.
Bevan Colless
It seems like there's this culture if an elite athlete wants to try conservative management, that the current practice is not to tell anyone you've done your ACL. So, you heard, I think the NRL player Peter Wallace wasn't until he retired that they said, oh, well, look, he's played the last two years without an ACL. And I think in rugby, Dan Carter, one of the best rugby players ever ruptured his ACL and kind of kept quiet.
Keiran Richardson
Yes. I was at a National Symposium for ACL in 2017. And there was a sports physician who was up on stage and one of his players who was fairly famous, he said, Oh, he had a full thickness tear, but he was about to get married. And he was towards the end of his career. So, we just didn't tell anybody. And his knee felt pretty stable. So we just went with it. And he played his last two years without an ACL, but we didn't tell the media. So it's like, that was completely off the record. While it was a large conference, there was quite a few 100 people there. But these sorts of stories don't necessarily hit mainstream, but I think if a few people hear us, their ACL heels, or they're very successful, long term, it'll completely shifted the challenges. They're not to shift it so much that we think that, the weekend warriors can do it on their own. It's, as I said, at the very start, it has to be controlled and measured.
Bevan Colless
So just changing tact of the conversation a little bit, I want to talk about the psychological aspects of ACL injuries, which we all know is a huge part of any rehabilitation, really, in getting people to get their head around having an injury and how they're best going to chart their pathway of getting back to sport. How do you manage that psychological side of ACL injuries with your patients?
Keiran Richardson
I mean, huge topic and a multiplicity are many variables that you need to consider, person's age, what level they're at, the motivation to perform, adherence levels, trust in the process, stress, anxiety, depression, all these things to factor in. And so, we have to screen for that initially, past medical history past psychological history. So, all these things are part of how I would approach someone as they as they're going into rehab and progressing through and looking at return to sports all have to be considered as we're going through, it's not like you just have to consider the physical status of someone's knee, we have to consider the psychology. And so, in my master's degree that was a key part of managing pain and injury, is that the psychology is so predictive of someone's long term outcome. And so, when I'm going through and rehabilitating it's absolutely something I consider, pretty much every session. And trying to forecast that for the patient as well. And whether we can treat that and consider it.
Bevan Colless
One of the things Stephanie Filbay was suggesting was that perhaps you could consider referring onto a sports psychologist, which is not something I don't think I've ever done, but have you ever done that?
Keiran Richardson
I think I can count on one hand, the number of patients that I've needed to do that. There's a couple from memory where they were just ruminating, and they were thinking about their knee 24/7. And I think when it's getting that much, and they literally can't stop thinking about. And these are patients who have had failed surgery, and they're wanting to try and go non-surgical, graft deficient, which is possible, but it's, it's an intense journey, arguably harder than the first time non-surgical. So, I think absolutely, that's an option to consider sports psychology and get across that. But I wouldn't be doing it with every patient.
Bevan Colless
And we already talked a little bit before about our job, being to certain extent to de-catastrophize the injury, but also make sure the person doesn't get further injuries to the knee. So it's just finding that balance, and one of the other concepts that has become more popular recently, certainly a term that I've come across a lot more in the last five years, is this, this delineation of copers Vs non-copers. And then the adapters, which you spoke about earlier. Could you run us through this delineation? Do you consider when you're consulting a patient, this person's a coper on a non-coper?
Keiran Richardson
Not really, not based on the traditional algorithms? These algorithms were invented 20 years ago. And they were very patho-anatomical. ‘Have you got a meniscus tear?’ Well, you probably need surgery, ‘Have you got an MCL tear?’, you probably need surgery. It was very geared towards surgery and the setup of it, I think that it didn't really factor in psychology. And I think that was, obviously now looking back retrospectively, a big mess. So I think a lot of what we've discussed today is probably more looking at the patient as a person considering all the factors, what their goals are, it's no rush, you've got your options there. As opposed to, can we predict who's going to do well or not? I think it would be impossible to predict. And so, I don't think based on very good studies, we can't really predict who's going to do well or not. And so we have to this is why we have to give them these options.
Bevan Colless
So I thought, it's not so helpful to throw a label on someone as a non-coper, because obviously, it's our job to make everyone become a coper or an adapter. We don't want anyone to be a non-coper.
Keiran Richardson
And using that same algorithms, we had people who were deemed or branded a non-copers at six months, but then you give them another six months and they become a coper. So, I think it's a bit too restrictive in its rules, the coper, the non-coper research, but I probably don't tend to use it so much, personally.
Bevan Colless
It's not something that you would ever say to a patient. So just summing up it's been a great discussion, just for anyone who's listening who might have an ACL deficient knee or have ruptured their ACL in the last few weeks, what would be a couple of just simple tips and advice for those people on how to manage their injury?
Keiran Richardson
Look, I would say that the first thing is just not to panic. And don't jump on to Facebook surgery support groups straightaway, because they can be quite catastrophic. And certainly not evidence-based and kind of promote fear and worry. And it's normally the real negative outcomes anyway. So, I would plug in with a good health care professional, who you are confident is going to be balanced in presenting all your different options and is happy to answer your questions. And I would start off with a period of rehabilitation, as we discussed and, just believe that your knee can get better. And you've got hope there's good studies that show it can. And so, I think those are some simple things.
Bevan Colless
Terrific, I think people will find that really, really helpful. So many different points of view and factors to consider that it's easy for them to get overwhelmed and go into panic mode. Thanks very much for your time Keiran. I've really enjoyed that discussion. I hope our listeners have found it really helpful and it'll give a little bit more options for people that are considering what to do with their ACL injury.
Keiran Richardson
Awesome. It was great to chat to you, Bevan.
