0:03

On today's episode with Kieran Richardson,

0:05

we discuss a case of a professional

0:07

athlete who tore her ACL and succeeded

0:10

with non-operative rehabilitation. Kieran

0:12

is a specialist musculoskeletal physiotherapist

0:15

who has a special interest in ACL

0:17

tear non-surgical management and

0:19

runs national workshops and lectures on

0:22

this topic. He has formally mentored

0:24

many healthcare professionals for over 13

0:26

years, consulting to a number of private

0:28

practices, offering a second opinion, as

0:31

well as providing professional development lectures

0:33

He also

0:35

works as a sessional academic on the postgraduate

0:38

master's program at Curtin University.

0:41

Kieran has done a case study with PhysioNetwork

0:43

on this case where you can dive a lot

0:45

deeper into this area than we were

0:47

able to do in today's episode. You can

0:49

click the link in the show notes to watch

0:52

Kieran's case study with a seven-day free

0:54

trial. You're going to love this episode

0:56

as you can get a glimpse into how Kieran's

0:58

teachings can have a profound role in

1:00

your clinical reasoning. I'm Sarah

1:03

Yule. And this is Case Studies. Welcome

1:08

to the PhysioNetwork Case Study

1:11

podcast, Kieran. Thanks so much for joining

1:13

us.

1:14

Thanks for having us on again, Sarah. It's great

1:16

to be here.

1:17

Fabulous. Well, we'll launch straight

1:19

into it. We're talking all things ACL

1:22

today, so I might trouble you

1:24

to kick us off with a

1:26

bit of an overview of the case you've got for

1:29

us today. Yeah,

1:30

look, this is a pretty exciting case. We've

1:32

shared it online in various platforms.

1:35

But if you want to follow this particular

1:37

patient, she's given her consent. Her name's Corbin

1:40

Harvey. You can follow her on Instagram at C-O-R-B-A-N-H-A-R-V-E-Y.

1:45

And it's a story of someone who injured

1:48

the ACL. Playing sport, professional athlete,

1:50

this one, she wasn't too keen

1:53

on going into aggressive non-weight-bearing

1:55

fixed flexion at 90 degrees, a la

1:57

the cross protocol, and she didn't really

2:00

want a reconstruction. We

2:02

used a modified approach with her, and we

2:04

had multiple follow-up images, which ultimately

2:07

showed an intact ACL. She's

2:10

returned to play or to

2:12

fight, has won fights. And

2:14

yeah, so I think her story is one that we

2:17

need to be getting out there because I think there's a large

2:19

cohort of patients that fit her

2:21

criteria. And yeah, I think

2:23

it's from a physiotherapy and clinician

2:26

point of view, we can reason through these cases quite

2:28

nicely.

2:29

Fantastic. And I think as is

2:32

going to be relevant in these case studies podcasts,

2:35

it's that concept of we don't learn from experience,

2:37

we learn from reflecting on the experience.

2:40

So Go back to the very beginning,

2:42

if that's okay, right back to her subjective

2:45

history.

2:46

Yeah, so going through her history, look, she

2:48

was basically sparring in November

2:51

22. She had an

2:53

incident where her knee gave way, which is the classic

2:56

symptom, that sign often in patients will

2:58

have a knee that swells up, they'll feel pain straight away.

3:01

She had an MRI shortly after,

3:03

which confirmed a full thickness rupture.

3:05

As is the place in Australia,

3:08

a lot of the time, she went and then saw a surgeon

3:10

and And the surgeon, unfortunately,

3:13

in essence, hemmed her in and said, look, your

3:15

only option is surgery. This is going to take

3:17

a year. She almost felt bullied in

3:19

a way that she didn't get

3:21

presented the options to her. And

3:24

by chance, we were

3:26

able to connect online over telehealth. And

3:29

I presented to her a classic

3:31

shared decision making. process. So I went

3:33

through her options. Again, I don't think

3:35

any physio in the world is anti-surgery,

3:38

but it's more just with these reconstructions

3:40

that it should be a delayed optional

3:43

reconstruction that there's an elective, it is

3:45

an elective surgery. So the patients can elect to have

3:47

it or like not to have it. And so we went through

3:49

that in the subjective and fortunately

3:51

for her as well, her knee hadn't given way

3:54

since the incident. Then I saw her two weeks post.

3:56

And so it was appropriate

3:59

for me to get her into some kind of a

4:01

stabilization protocol. So there's a

4:03

few ways we can do this, but one that I've settled

4:06

on is a restricted extension where

4:08

the patients have an extension block

4:10

at negative 30 degrees, but they can flex

4:13

their knee as much as they want and they can be weight-bearing

4:15

as tolerated. They don't have to be on anticoagulants

4:18

and they just really have to avoid pivot shift moments.

4:20

So that was a large part of the discussion. And

4:23

from her point of view, she also

4:25

had a competition coming up

4:27

the following year, which was last year in May. She

4:30

was very keen on participating in that.

4:33

That's always a tough one because you have

4:35

to go through the risks with the patients. This ACL

4:37

may not heal. You may not be competent

4:39

to fight. Again, we laid

4:41

that all out as a part of the discussion

4:43

in our initial consult. Really

4:47

from there, she was keen for us to have a look at her knee,

4:49

so we then went on to the physical exam over

4:51

telehealth.

4:52

And I think, Will, I'm very curious

4:54

as to the physical exam over telehealth,

4:57

but just touching back on that negative

4:59

30 degrees, what is your

5:02

justification around that both clinically

5:04

and then to her? Yeah.

5:07

When you've seen enough of these ACLs, which

5:09

I've done thousands now, you'll see

5:11

the patients almost homogeneously

5:14

come in with a flexed deformity. So then

5:16

it will be flexed. There's a few

5:18

reasons for that that are purported in the research.

5:21

That's that the hamstrings are co-contracting

5:23

to try to prevent their shin coming

5:26

forward. It's almost a reflexive action

5:28

of the body, a fear avoidant pattern,

5:30

if you will. So I tend

5:33

to roll with that as in I

5:35

see it as a part of the body's natural response. Also,

5:38

there's a few studies that have suggested that

5:40

having the knee in a degree of flexion can

5:42

improve the likelihood of healing. So there's a

5:45

French study that actually uses negative

5:47

30 specifically. That's

5:49

Delin from 2012. And they have pretty

5:51

high healing rates. Like we're talking 80, 85% healing,

5:54

particularly when the ligament is within

5:57

the condyles. So it's not flipped

5:59

outside of the condyles, which hers hadn't. And

6:01

so that's part of my

6:03

reason. There's also some Japanese studies from the early

6:05

2000s that suggests an extension block

6:08

as well as some Swiss studies where they have the

6:10

shin put into an anterior-posterior

6:13

position, so almost a reverse lockman's. And so

6:15

that's part of how I settled on it and

6:18

have been suggesting to patients, especially

6:20

if they don't want to be in non-weight-bearing for

6:22

an extended period of time, And a lot

6:24

of surgeons are actually open to it too, because in

6:27

their mind, it fits their stabilization

6:29

protocol. If someone's got an ACL and they want to get the MCL

6:32

to heal, if there's a concomitant MCL, they'll

6:34

put them in a negative 30 blocks. So that's the

6:36

research reasons, but also the clinical reasons why

6:39

I do it.

6:39

Fantastic. Hopefully your patient

6:41

also was happy with that as

6:44

well, not having to take Clexane and non-surgical.

6:47

Yeah, I think so. So with that,

6:50

obviously, if they're going to be in greater

6:52

than sort of 30, 40 degrees,

6:54

the risk of a DVT. Because once they're getting

6:56

into past 30, 40 degrees, their

6:59

foot will come off the ground essentially,

7:01

or they'll just be on toe weight bearing. And so

7:03

they're not going to have a normal lymphatic system

7:05

drain engine. So their risk of DVT does

7:08

increase. There's still a risk of DVT

7:10

with this kind of approach that I'm advocating

7:12

for, but it's far less

7:15

than post-stop or with like

7:17

a cross protocol. Again, we

7:19

can talk to the research, but without

7:21

a comparison arm, we really don't know what

7:24

the cross protocol degree of flexion is doing.

7:26

So, hopefully in future studies, we can look into that.

7:29

But yeah, I find a lot of patients are happy

7:31

to sit with us. It's kind of like a middle ground and

7:33

allows them to get back to work and allows

7:35

them to get around, drive and

7:37

still function and stabilize their

7:39

knee. And also take the whole

7:42

non-surgical process seriously because

7:44

A lot of patients with the non-surgical approach

7:47

feel really good really quickly. They'll start

7:49

to feel like, hey, I can take over the

7:51

world, but maybe their knee could be

7:53

unstable. And so having the brace there

7:55

as a reminder, I think is really good. That's

7:58

another reason why I like to employ it if we

8:00

can catch the patients early like we did with Corbin.

8:02

Yeah, great point. And sorry, how

8:05

early was it that you were seeing her?

8:07

So I first consulted her

8:09

essentially two weeks to the day after injury

8:12

and So she had actually already, but

8:15

in the physical exam when I looked at her, she couldn't straighten

8:17

her knee fully, which is commonplace. As I

8:19

see these patients almost always, they'll struggle

8:22

to get their extension back. Unfortunately,

8:24

a lot of patients, especially

8:26

overseas, but also in Australia, if they've seen

8:29

a physio who's pre-having them in

8:31

air quotes, they will be starting to work on extension

8:34

range. And so if they're starting

8:36

to If they want to consult to us, we

8:38

almost have to go against that or then counsel

8:40

the therapist that maybe we want to hold back

8:43

on getting this range full early,

8:45

especially into extension. That can be

8:47

an additional challenge.

8:49

For sure. Well, I think we've got

8:51

plenty to get to with treatment, but

8:53

I'm very curious, how did you go with the objective

8:56

treatment or the objective assessment on

8:58

telehealth?

8:59

I think before COVID, I really

9:01

hadn't done too many of these. I would just

9:04

maybe once in a blue moon, a few times a

9:06

year, I would do telehealth or video. Skype

9:09

consult, I actually used to do a lot more of. But

9:11

when COVID kicked off and a lot

9:13

of elective waitlists burgeoned out,

9:16

it became natural that patients were

9:18

just reaching out. It's more

9:20

normal, I think, for us as a society to do

9:22

video calls. And so, since

9:24

that time, I've I'm probably doing 15 to 20

9:26

a week. And so it's quite normal to do a physical

9:29

exam. But the first time you do it, it's a bit weird.

9:31

But really all the same things that you would

9:33

do in person, you would do over video.

9:35

So you're looking at the knee from front, back,

9:38

side. You get the patient to do some functional tasks.

9:40

You can get them into non-weight bearing, looking at their range

9:42

of motion. You can get them to do some repeated

9:45

functional strength tests. You can do some

9:47

muscle length tests. You can even get them to

9:49

self-palpate. and self-mobilize their

9:51

kneecap, which is what I do. And oftentimes

9:53

your city patients will have patellofemoral symptoms.

9:56

And so they might be pinning that on the ACL.

9:58

They'll say, oh, that's my ACL. But then when you get them to

10:00

do repeated self-mobilization of their kneecap,

10:03

their range of motion can improve and their pain can go away.

10:05

So it's all the same principles that we

10:07

would use in person you can actually use

10:09

on telehealth. And there's actually some studies from Melbourne

10:11

you may have read recently that show that

10:13

some patients are even more satisfied with telehealth,

10:16

which is quite interesting. So in

10:18

my mind... We don't have to ditch

10:20

face-to-face, and I think there's always going to be a place for

10:22

both. But in the physical exam,

10:25

you're really wanting to affirm a lot of the stuff that

10:27

you've concluded in the, or

10:29

hopefully concluded in the subjective, which is what we

10:32

did with Corbyn.

10:33

Fantastic. So she's

10:35

come in, she's within a couple of weeks of

10:38

ACL rupture. You've done your

10:40

objective. She's described... a

10:43

moment where she's obviously

10:45

ruptured her ACL, but as you mentioned, no

10:47

mentions of unstable moments since.

10:50

What did your treatment plan look

10:52

like from that point?

10:55

Yeah, great question. So look,

10:58

really what I like to do if

11:00

the patients are able to consult with me

11:02

early or one of my team early is

11:05

I like to get them in the brace for six

11:07

weeks. So I like to restrict their extension for six

11:09

weeks minimum. And then

11:12

I will have, after six weeks, we'll

11:15

get them into unrestricted flexion

11:17

extension, ideally with the brace still

11:19

on. Some patients are completely over

11:22

it. After the first six weeks, they're like, they're

11:24

done. They're wearing it to bed. And other than

11:26

really for exercise, if they can take it off

11:28

and showering, they just, they want to ditch it. But

11:31

I prefer them to keep it on, especially when they're

11:33

from six weeks, if they're walking around outside.

11:35

And also just the advice of

11:38

not twisting too much on their knee, avoiding

11:40

uneven surfaces, certainly

11:43

no drunken dancing, which can be commonplace

11:45

in Australia, hopping, change of direction.

11:47

These are the kind of things that they need to be avoiding. And

11:50

I tend to lay out, Sarah,

11:52

the treatment plan in three phases. So,

11:55

you'll have phase one is

11:57

trying to heal this ACL and then

11:59

do a repeat image and

12:01

either do some kind of physical

12:04

test via telehealth. So, you can do

12:06

a Levis test over a roller,

12:09

so you can sort of do a quasi-anterior-posterior

12:12

ligament test in long sitting.

12:14

Or if they're seeing a local PT, they can see

12:16

someone who can, a local physio,

12:19

they can do ligament tests. Or even if they're due

12:21

to see a surgeon, the surgeon can do the ligament tests as well.

12:23

And hopefully that all corroborates with, on

12:26

scan, subjectively, the patients

12:28

are feeling great. And then physically,

12:30

if we do ligament tests, it's feeling stable.

12:33

And then we basically move them into phase two,

12:35

which is strength and conditioning program. We

12:37

want to bulletproof this knee. And then really

12:40

we would be looking at return to play

12:42

in the phase three and prevention, which

12:45

as you would know that a lot of these

12:47

injuries can be prevented and

12:50

a lot of the injuries recur and there's

12:52

a risk of recurrence. So at

12:54

least the patients I see, a lot of them

12:56

when they first have it happen prior

12:59

to that have done no strength and conditioning. So

13:01

it's really a fresh canvas. So you can crank

13:03

these patients up heavy with rehab and

13:05

prevention exercises. And a lot

13:08

of the times I've had patients, they'll say to me, look, I actually

13:10

feel honestly stronger than I did previously.

13:12

I feel like in a weird way, I'm

13:14

actually better off having had the injury.

13:17

Philosophically, you wouldn't have wanted it to happen,

13:19

but they end up in a better place. So it can

13:21

be a silver lining, I think.

13:23

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13:26

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13:28

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13:30

It's amazing

13:36

how sometimes

13:38

those

13:48

sorts

13:51

of injuries do seem to be the catalyst for

13:53

reinvention of what their S&C

13:56

looks like, doesn't it?

13:58

Yeah, I think so. And so Look, I

14:00

would say almost all of the cases

14:02

I see, including some elite athletes, I'm

14:04

privileged in second opinion where you're looking

14:06

at the previous rehab program, and if you've

14:09

done any of this, you're looking for basically

14:11

blind spots and seeing where it's being missed.

14:14

The classic thing I see is that the functional strength

14:16

and conditioning is insufficient, especially single leg,

14:18

and particularly female. We

14:21

can really crank it up heavy,

14:23

hard, and there's new research which is affirming

14:25

that the harder and heavier we go, the better.

14:28

I'm pretty open and honest with the patients. And

14:31

sometimes I'll call it out early. I said, look, I think this

14:34

previous exercise program was too easy. Or

14:36

if I'm seeing them early on and

14:38

I've already started seeing another physio and I'm liaising

14:40

with the physio, I'll really want to

14:43

set the expectation that the patient's going to have to commit

14:45

to an intense program.

14:47

Just on that, in terms of heavy

14:49

and hard, are you talking in the realms of

14:52

like 80% 1RM?

14:55

That's a massive topic. But specifically,

14:59

you would be looking at minimum,

15:01

ideally three to four days a week in that phase two

15:04

of lower limb individualized

15:07

single leg strengthening. So

15:09

we've got functional strengthening, but then also isolated

15:12

muscle groups. I mean, you said 80%,

15:15

I think so, but ideally you would

15:17

be wanting to get as close to, if not

15:19

better than the other side. Considering the other

15:21

side, as we know, gets weaker, that

15:23

also has to be taken into account. A

15:25

lot of these recent strength and conditioning principles, you're

15:27

looking for high RPE.

15:30

So you're wanting the patients to intensely

15:32

work out and then you want their sets

15:35

and rep range to be around

15:37

that five reps and they don't have a lot

15:39

left to give in the tank. The problem

15:41

is sometimes Sarah, the physios,

15:44

if I'm looking at a case on second opinion,

15:46

they might be doing those principles too

15:48

early. So absolutely you want the

15:50

patient to have a quiet knee. You don't want them in

15:52

pain when they're in phase two. So

15:54

I do want them to get to

15:56

that phase two, but if it's like 12

15:59

weeks, 16 weeks, 20 weeks in phase

16:01

one, that's fine. But eventually

16:03

we will need to get them. I mean, obviously depending

16:06

on their goals, but yeah, this

16:08

is ideally where I think we need to take the

16:10

cases.

16:11

That's a fantastic point. And as you say, the S&C

16:14

side of things can be a whole episode

16:16

on its own. But on what you said before

16:19

with a quiet knee, what

16:21

sort of discussions do you have with your patients

16:23

about self-monitoring as they're progressing

16:26

through their S&C program?

16:28

One of the risks of doing non-surgical, obviously

16:30

it applies to surgery as well, but one

16:33

of the absolute risks is the risk of infusion, which

16:36

is something that happened with Corbyn actually,

16:38

that on her follow-up MRI at three months,

16:40

her ACL was looking wicked. It

16:42

looked like it was in alignment. It was

16:44

a gold standard heel,

16:47

as perfect as we could get at three months.

16:49

But she also had additional

16:52

bone bruise, like her bone bruise looked worse than

16:54

the first MRI. And she had,

16:56

unbeknownst to us, started doing a bit of

16:58

jogging a week before her MRI. So

17:01

I like to say the patients don't go rogue

17:03

because sometimes they can.

17:04

No choosing your own adventure.

17:06

No choosing your own adventure. They

17:08

can almost be like an unbridled horse. So

17:11

yeah, you need to keep

17:13

the reins on them a bit. And so that's why I like

17:16

the research talks about regular check-ins, like really

17:19

every two weeks. But particularly this whole

17:21

concept of an effusion. So

17:23

an effusion or... stress

17:26

response, bone bruise. This

17:28

probably happens about 1% to 2% of cases. And

17:31

so, yeah, this is something that happened with Corbin.

17:33

And in fact, I had another case yesterday. Same deal

17:35

happened. Another physio started working

17:38

with one of my clients, and he'd started doing some plyometrics.

17:40

And that was just on the end of phase one, and it

17:42

was too soon. And the patient's on

17:44

follow-up MRI. ACL looks okay,

17:47

but the bone bruise hasn't settled. So it's

17:49

a low percentage chance, but it is something you need

17:51

to be monitoring from a patient point of view. It'll

17:53

normally manifest in swelling in the

17:55

front of the knee, a low-grade ache, mild

17:58

effusion. Maybe it will get warm. And

18:00

sometimes they'll lose range. So they

18:02

may, typically by 12 weeks, they've

18:05

got almost full range. So from six to

18:07

12 weeks, you're looking to get their range of motion better.

18:09

But they may just have a reduction

18:12

in range. They realize that they can't

18:14

sit back onto their heels. They may have gained

18:16

full extension, but then they lose that

18:18

again. So those would be the things I'd be looking out for.

18:21

That's fantastic. It's a really nice

18:24

program that offers a nice in-between.

18:26

So, in your thoughts, what

18:28

went well, what didn't go well? What can

18:30

we learn from it?

18:33

Look, it's a bit of a cherry pick

18:35

study because you can't ever

18:37

promise the patient 100%, but it

18:40

went well because it highlights

18:42

a lot of what we're seeing now in research literature,

18:45

but also it has been revealed

18:47

that There's studies from the mid-90s

18:49

and subsequently multiple cohort

18:52

studies since then showing that ACL has a high capacity

18:54

to heal. It was a good

18:56

example of what's possible without

18:59

necessarily involving a lot of medical intervention,

19:02

whether it be blood thinners, whether

19:04

it be surgical intervention, injectables,

19:07

she didn't need any medication, that kind of thing.

19:09

Imaging was obviously key. I think it shows

19:11

what's possible with a physio-led approach. And

19:14

so I think There is a large cohort

19:16

of patients that can do very well with a physio-led

19:18

approach. And then you'll see it in healthcare

19:21

systems. So there's a large movement

19:24

towards physios triaging these kind

19:26

of cases. And I think really we have a role

19:28

in that, both in the public sector and

19:30

private sector, working within the multidisciplinary

19:33

team. So I think Corbyn's example

19:36

is what's possible. Another

19:38

positive was I was able to plug her in with

19:41

a local physio, Michael

19:43

Ingle, who's an advanced scope physio. And

19:45

he was able to do a lot of the work on the ground.

19:47

And we had intermittent check-ins as well.

19:50

And we collaborated on that case. So that was cool

19:52

too. I think to get that virtual

19:54

support as well as in-person for

19:57

the patients. The patients love it. They like getting

19:59

a bit of a team around them, I think. And then obviously

20:01

returning to play and successfully long-term

20:04

is unreal. That's what you want. It

20:06

probably couldn't have gotten any better from that point of view. It

20:08

possibly could have been a bit better if we'd

20:10

been clearer on the

20:13

risks if she bolted, if

20:15

the horse bolted too soon, which

20:18

you can see. It's a bit of a cross

20:20

talk, like maybe we haven't ultimately

20:22

communicated as well as we thought or the patient

20:24

misinterpreted it. And I think these things can happen.

20:27

So that probably could have been a bit tighter. Hopefully

20:30

in the future, we can have, and

20:32

I'm finding this more and more, we

20:34

call them, in Australia, we call them surgeon heroes,

20:38

but basically they're surgeons who actively

20:40

advocate and both in person and online

20:43

for physiotherapy input and non-surgical.

20:46

So, I think in future,

20:48

it would have been good to potentially see that patient

20:50

before. And so, we could,

20:53

if they're due to see a surgeon, give them a heads

20:55

up and say, look, this is what we're thinking. And

20:57

hopefully, we can be on the same page. And

21:00

yeah, we're probably never going to agree on everything, but at

21:03

least we can find common ground. So, maybe

21:05

if we'd have been able to see Colton earlier, that

21:07

would have been ideal. But yeah, Other than that,

21:10

I think it really does show how

21:12

non-surgical management, from a research

21:14

point of view, we're talking at least 50% of these patients,

21:16

up to 75% of these patients can

21:18

do very well with a rehabilitation

21:21

alone approach, which I think is pretty

21:23

exciting.

21:24

That's very exciting. And I think those are some

21:26

fantastic takeaways. And just to touch

21:29

on your point, I think patients love

21:31

a multidisciplinary team, but I also believe

21:33

as clinicians, we can all benefit from

21:36

the growth that a multidisciplinary approach

21:38

creates. does offer as well.

21:41

I think so. Yeah, I think so. And probably

21:43

what's happened with me personally is I've

21:46

found like-minded professionals

21:50

extra professionally. So I've kind

21:52

of found a team of sports doctors and surgeons

21:55

I know that agree with us, not

21:57

on everything again. And I think it's probably silly

21:59

to think that we'll always get along perfectly,

22:02

but we want to advance this topic

22:04

forward and identify the cases

22:06

who truly need surgery, who truly

22:08

are for not surgery in a way we don't know and we can agree

22:11

together on that. And I think the patients, they

22:13

love that team approach. They want that

22:15

and I think they need it.

22:16

Absolutely. Well, thank you so much

22:18

for your wisdom today, Kieran. I think many

22:21

of us can learn and apply that to our

22:23

next ACL that walks through the door.

22:25

That's great, Sarah. It's great to share these cases

22:27

and I hope it's beneficial to the clinicians

22:29

as well.