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[Case Studies] Rehabbing an ACL rupture non-surgically with Dr Kieran Richardson

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In this episode with Dr Kieran Richardson, we explore an interesting case study on a real patient of his - a patient who ruptured her ACL and her recovery process with non-surgical management. We cover:

  • The role and importance of knee flexion in recovery from ACL rupture
  • Bracing and weight-bearing in conservative management
  • Telehealth objective assessment
  • Education and advice during rehabilitation
  • Treatment plan and the three phases involved

This episode is closely tied to Kieran’s case study he did with us. With case studies, you can see how top clinicians manage real-world cases and apply their strategies to get better results with your patients.

👉🏻 Watch Kieran’s case study here with our 7-day free trial:
https://physio.network/casestudy-richardson

Dr. Kieran is a Specialist Physiotherapist and the Director of Global Specialist Physiotherapy, a consultancy company providing Professional Development, Formal Mentoring and Non-surgical opinions for patients. Kieran and his team of academics, expert clinicians and researchers consult to multiple clinics, health care professionals and patients in Perth, Western Australia, and well as nationally and internationally via online platforms. You can find out more information about his Global services through: globalspecialistphysio.com

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is @sarah.yule from Physio Network

SPEAKER_03:

On today's episode with Kieran Richardson, we discuss a case of a professional athlete who tore her ACL and succeeded with non-operative rehabilitation. Kieran is a specialist musculoskeletal physiotherapist who has a special interest in ACL tear non-surgical management and runs national workshops and lectures on this topic. He has formally mentored many healthcare professionals for over 13 years, consulting to a number of private practices, offering a second opinion, as well as providing professional development lectures He also works as a sessional academic on the postgraduate master's program at Curtin University. Kieran has done a case study with PhysioNetwork on this case where you can dive a lot deeper into this area than we were able to do in today's episode. You can click the link in the show notes to watch Kieran's case study with a seven-day free trial. You're going to love this episode as you can get a glimpse into how Kieran's teachings can have a profound role in your clinical reasoning. I'm Sarah Yule. And this is Case Studies. Welcome to the PhysioNetwork Case Study podcast, Kieran. Thanks so much for joining us.

SPEAKER_01:

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

SPEAKER_03:

Fabulous. Well, we'll launch straight into it. We're talking all things ACL today, so I might trouble you to kick us off with a bit of an overview of the case you've got for us today. Yeah,

SPEAKER_02:

look, this is a pretty exciting case. We've shared it online in various platforms. But if you want to follow this particular patient, she's given her consent. Her name's Corbin Harvey. You can follow her on Instagram at C-O-R-B-A-N-H-A-R-V-E-Y. And it's a story of someone who injured the ACL. Playing sport, professional athlete, this one, she wasn't too keen on going into aggressive non-weight-bearing fixed flexion at 90 degrees, a la the cross protocol, and she didn't really want a reconstruction. We used a modified approach with her, and we had multiple follow-up images, which ultimately showed an intact ACL. She's returned to play or to fight, has won fights. And yeah, so I think her story is one that we need to be getting out there because I think there's a large cohort of patients that fit her criteria. And yeah, I think it's from a physiotherapy and clinician point of view, we can reason through these cases quite nicely.

SPEAKER_03:

Fantastic. And I think as is going to be relevant in these case studies podcasts, it's that concept of we don't learn from experience, we learn from reflecting on the experience. So Go back to the very beginning, if that's okay, right back to her subjective history.

SPEAKER_02:

Yeah, so going through her history, look, she was basically sparring in November 22. She had an incident where her knee gave way, which is the classic symptom, that sign often in patients will have a knee that swells up, they'll feel pain straight away. She had an MRI shortly after, which confirmed a full thickness rupture. As is the place in Australia, a lot of the time, she went and then saw a surgeon and And the surgeon, unfortunately, in essence, hemmed her in and said, look, your only option is surgery. This is going to take a year. She almost felt bullied in a way that she didn't get presented the options to her. And by chance, we were able to connect online over telehealth. And I presented to her a classic shared decision making. process. So I went through her options. Again, I don't think any physio in the world is anti-surgery, but it's more just with these reconstructions that it should be a delayed optional reconstruction that there's an elective, it is an elective surgery. So the patients can elect to have it or like not to have it. And so we went through that in the subjective and fortunately for her as well, her knee hadn't given way since the incident. Then I saw her two weeks post. And so it was appropriate for me to get her into some kind of a stabilization protocol. So there's a few ways we can do this, but one that I've settled on is a restricted extension where the patients have an extension block at negative 30 degrees, but they can flex their knee as much as they want and they can be weight-bearing as tolerated. They don't have to be on anticoagulants and they just really have to avoid pivot shift moments. So that was a large part of the discussion. And from her point of view, she also had a competition coming up the following year, which was last year in May. She was very keen on participating in that. That's always a tough one because you have to go through the risks with the patients. This ACL may not heal. You may not be competent to fight. Again, we laid that all out as a part of the discussion in our initial consult. Really from there, she was keen for us to have a look at her knee, so we then went on to the physical exam over telehealth.

SPEAKER_03:

And I think, Will, I'm very curious as to the physical exam over telehealth, but just touching back on that negative 30 degrees, what is your justification around that both clinically and then to her? Yeah.

SPEAKER_02:

When you've seen enough of these ACLs, which I've done thousands now, you'll see the patients almost homogeneously come in with a flexed deformity. So then it will be flexed. There's a few reasons for that that are purported in the research. That's that the hamstrings are co-contracting to try to prevent their shin coming forward. It's almost a reflexive action of the body, a fear avoidant pattern, if you will. So I tend to roll with that as in I see it as a part of the body's natural response. Also, there's a few studies that have suggested that having the knee in a degree of flexion can improve the likelihood of healing. So there's a French study that actually uses negative 30 specifically. That's Delin from 2012. And they have pretty high healing rates. Like we're talking 80, 85% healing, particularly when the ligament is within the condyles. So it's not flipped outside of the condyles, which hers hadn't. And so that's part of my reason. There's also some Japanese studies from the early 2000s that suggests an extension block as well as some Swiss studies where they have the shin put into an anterior-posterior position, so almost a reverse lockman's. And so that's part of how I settled on it and have been suggesting to patients, especially if they don't want to be in non-weight-bearing for an extended period of time, And a lot of surgeons are actually open to it too, because in their mind, it fits their stabilization protocol. If someone's got an ACL and they want to get the MCL to heal, if there's a concomitant MCL, they'll put them in a negative 30 blocks. So that's the research reasons, but also the clinical reasons why I do it.

SPEAKER_03:

Fantastic. Hopefully your patient also was happy with that as well, not having to take Clexane and non-surgical.

SPEAKER_02:

Yeah, I think so. So with that, obviously, if they're going to be in greater than sort of 30, 40 degrees, the risk of a DVT. Because once they're getting into past 30, 40 degrees, their foot will come off the ground essentially, or they'll just be on toe weight bearing. And so they're not going to have a normal lymphatic system drain engine. So their risk of DVT does increase. There's still a risk of DVT with this kind of approach that I'm advocating for, but it's far less than post-stop or with like a cross protocol. Again, we can talk to the research, but without a comparison arm, we really don't know what the cross protocol degree of flexion is doing. So, hopefully in future studies, we can look into that. But yeah, I find a lot of patients are happy to sit with us. It's kind of like a middle ground and allows them to get back to work and allows them to get around, drive and still function and stabilize their knee. And also take the whole non-surgical process seriously because A lot of patients with the non-surgical approach feel really good really quickly. They'll start to feel like, hey, I can take over the world, but maybe their knee could be unstable. And so having the brace there as a reminder, I think is really good. That's another reason why I like to employ it if we can catch the patients early like we did with Corbin.

SPEAKER_03:

Yeah, great point. And sorry, how early was it that you were seeing her?

SPEAKER_02:

So I first consulted her essentially two weeks to the day after injury and So she had actually already, but in the physical exam when I looked at her, she couldn't straighten her knee fully, which is commonplace. As I see these patients almost always, they'll struggle to get their extension back. Unfortunately, a lot of patients, especially overseas, but also in Australia, if they've seen a physio who's pre-having them in air quotes, they will be starting to work on extension range. And so if they're starting to If they want to consult to us, we almost have to go against that or then counsel the therapist that maybe we want to hold back on getting this range full early, especially into extension. That can be an additional challenge.

SPEAKER_03:

For sure. Well, I think we've got plenty to get to with treatment, but I'm very curious, how did you go with the objective treatment or the objective assessment on telehealth?

SPEAKER_02:

I think before COVID, I really hadn't done too many of these. I would just maybe once in a blue moon, a few times a year, I would do telehealth or video. Skype consult, I actually used to do a lot more of. But when COVID kicked off and a lot of elective waitlists burgeoned out, it became natural that patients were just reaching out. It's more normal, I think, for us as a society to do video calls. And so, since that time, I've I'm probably doing 15 to 20 a week. And so it's quite normal to do a physical exam. But the first time you do it, it's a bit weird. But really all the same things that you would do in person, you would do over video. So you're looking at the knee from front, back, side. You get the patient to do some functional tasks. You can get them into non-weight bearing, looking at their range of motion. You can get them to do some repeated functional strength tests. You can do some muscle length tests. You can even get them to self-palpate. and self-mobilize their kneecap, which is what I do. And oftentimes your city patients will have patellofemoral symptoms. And so they might be pinning that on the ACL. They'll say, oh, that's my ACL. But then when you get them to do repeated self-mobilization of their kneecap, their range of motion can improve and their pain can go away. So it's all the same principles that we would use in person you can actually use on telehealth. And there's actually some studies from Melbourne you may have read recently that show that some patients are even more satisfied with telehealth, which is quite interesting. So in my mind... We don't have to ditch face-to-face, and I think there's always going to be a place for both. But in the physical exam, you're really wanting to affirm a lot of the stuff that you've concluded in the, or hopefully concluded in the subjective, which is what we did with Corbyn.

SPEAKER_03:

Fantastic. So she's come in, she's within a couple of weeks of ACL rupture. You've done your objective. She's described... a moment where she's obviously ruptured her ACL, but as you mentioned, no mentions of unstable moments since. What did your treatment plan look like from that point?

SPEAKER_02:

Yeah, great question. So look, really what I like to do if the patients are able to consult with me early or one of my team early is I like to get them in the brace for six weeks. So I like to restrict their extension for six weeks minimum. And then I will have, after six weeks, we'll get them into unrestricted flexion extension, ideally with the brace still on. Some patients are completely over it. After the first six weeks, they're like, they're done. They're wearing it to bed. And other than really for exercise, if they can take it off and showering, they just, they want to ditch it. But I prefer them to keep it on, especially when they're from six weeks, if they're walking around outside. And also just the advice of not twisting too much on their knee, avoiding uneven surfaces, certainly no drunken dancing, which can be commonplace in Australia, hopping, change of direction. These are the kind of things that they need to be avoiding. And I tend to lay out, Sarah, the treatment plan in three phases. So, you'll have phase one is trying to heal this ACL and then do a repeat image and either do some kind of physical test via telehealth. So, you can do a Levis test over a roller, so you can sort of do a quasi-anterior-posterior ligament test in long sitting. Or if they're seeing a local PT, they can see someone who can, a local physio, they can do ligament tests. Or even if they're due to see a surgeon, the surgeon can do the ligament tests as well. And hopefully that all corroborates with, on scan, subjectively, the patients are feeling great. And then physically, if we do ligament tests, it's feeling stable. And then we basically move them into phase two, which is strength and conditioning program. We want to bulletproof this knee. And then really we would be looking at return to play in the phase three and prevention, which as you would know that a lot of these injuries can be prevented and a lot of the injuries recur and there's a risk of recurrence. So at least the patients I see, a lot of them when they first have it happen prior to that have done no strength and conditioning. So it's really a fresh canvas. So you can crank these patients up heavy with rehab and prevention exercises. And a lot of the times I've had patients, they'll say to me, look, I actually feel honestly stronger than I did previously. I feel like in a weird way, I'm actually better off having had the injury. Philosophically, you wouldn't have wanted it to happen, but they end up in a better place. So it can be a silver lining, I think.

SPEAKER_00:

Ever wished you could see how experts treat real patients of theirs? With Case Studies by PhysioNetwork, now you can. It's amazing how sometimes those

SPEAKER_03:

sorts of injuries do seem to be the catalyst for reinvention of what their S&C looks like, doesn't it?

SPEAKER_02:

Yeah, I think so. And so Look, I would say almost all of the cases I see, including some elite athletes, I'm privileged in second opinion where you're looking at the previous rehab program, and if you've done any of this, you're looking for basically blind spots and seeing where it's being missed. The classic thing I see is that the functional strength and conditioning is insufficient, especially single leg, and particularly female. We can really crank it up heavy, hard, and there's new research which is affirming that the harder and heavier we go, the better. I'm pretty open and honest with the patients. And sometimes I'll call it out early. I said, look, I think this previous exercise program was too easy. Or if I'm seeing them early on and I've already started seeing another physio and I'm liaising with the physio, I'll really want to set the expectation that the patient's going to have to commit to an intense program.

SPEAKER_03:

Just on that, in terms of heavy and hard, are you talking in the realms of like 80% 1RM?

SPEAKER_02:

That's a massive topic. But specifically, you would be looking at minimum, ideally three to four days a week in that phase two of lower limb individualized single leg strengthening. So we've got functional strengthening, but then also isolated muscle groups. I mean, you said 80%, I think so, but ideally you would be wanting to get as close to, if not better than the other side. Considering the other side, as we know, gets weaker, that also has to be taken into account. A lot of these recent strength and conditioning principles, you're looking for high RPE. So you're wanting the patients to intensely work out and then you want their sets and rep range to be around that five reps and they don't have a lot left to give in the tank. The problem is sometimes Sarah, the physios, if I'm looking at a case on second opinion, they might be doing those principles too early. So absolutely you want the patient to have a quiet knee. You don't want them in pain when they're in phase two. So I do want them to get to that phase two, but if it's like 12 weeks, 16 weeks, 20 weeks in phase one, that's fine. But eventually we will need to get them. I mean, obviously depending on their goals, but yeah, this is ideally where I think we need to take the cases.

SPEAKER_03:

That's a fantastic point. And as you say, the S&C side of things can be a whole episode on its own. But on what you said before with a quiet knee, what sort of discussions do you have with your patients about self-monitoring as they're progressing through their S&C program?

SPEAKER_02:

One of the risks of doing non-surgical, obviously it applies to surgery as well, but one of the absolute risks is the risk of infusion, which is something that happened with Corbyn actually, that on her follow-up MRI at three months, her ACL was looking wicked. It looked like it was in alignment. It was a gold standard heel, as perfect as we could get at three months. But she also had additional bone bruise, like her bone bruise looked worse than the first MRI. And she had, unbeknownst to us, started doing a bit of jogging a week before her MRI. So I like to say the patients don't go rogue because sometimes they can.

SPEAKER_03:

No choosing your own adventure.

SPEAKER_02:

No choosing your own adventure. They can almost be like an unbridled horse. So yeah, you need to keep the reins on them a bit. And so that's why I like the research talks about regular check-ins, like really every two weeks. But particularly this whole concept of an effusion. So an effusion or... stress response, bone bruise. This probably happens about 1% to 2% of cases. And so, yeah, this is something that happened with Corbin. And in fact, I had another case yesterday. Same deal happened. Another physio started working with one of my clients, and he'd started doing some plyometrics. And that was just on the end of phase one, and it was too soon. And the patient's on follow-up MRI. ACL looks okay, but the bone bruise hasn't settled. So it's a low percentage chance, but it is something you need to be monitoring from a patient point of view. It'll normally manifest in swelling in the front of the knee, a low-grade ache, mild effusion. Maybe it will get warm. And sometimes they'll lose range. So they may, typically by 12 weeks, they've got almost full range. So from six to 12 weeks, you're looking to get their range of motion better. But they may just have a reduction in range. They realize that they can't sit back onto their heels. They may have gained full extension, but then they lose that again. So those would be the things I'd be looking out for.

SPEAKER_03:

That's fantastic. It's a really nice program that offers a nice in-between. So, in your thoughts, what went well, what didn't go well? What can we learn from it?

SPEAKER_02:

Look, it's a bit of a cherry pick study because you can't ever promise the patient 100%, but it went well because it highlights a lot of what we're seeing now in research literature, but also it has been revealed that There's studies from the mid-90s and subsequently multiple cohort studies since then showing that ACL has a high capacity to heal. It was a good example of what's possible without necessarily involving a lot of medical intervention, whether it be blood thinners, whether it be surgical intervention, injectables, she didn't need any medication, that kind of thing. Imaging was obviously key. I think it shows what's possible with a physio-led approach. And so I think There is a large cohort of patients that can do very well with a physio-led approach. And then you'll see it in healthcare systems. So there's a large movement towards physios triaging these kind of cases. And I think really we have a role in that, both in the public sector and private sector, working within the multidisciplinary team. So I think Corbyn's example is what's possible. Another positive was I was able to plug her in with a local physio, Michael Ingle, who's an advanced scope physio. And he was able to do a lot of the work on the ground. And we had intermittent check-ins as well. And we collaborated on that case. So that was cool too. I think to get that virtual support as well as in-person for the patients. The patients love it. They like getting a bit of a team around them, I think. And then obviously returning to play and successfully long-term is unreal. That's what you want. It probably couldn't have gotten any better from that point of view. It possibly could have been a bit better if we'd been clearer on the risks if she bolted, if the horse bolted too soon, which you can see. It's a bit of a cross talk, like maybe we haven't ultimately communicated as well as we thought or the patient misinterpreted it. And I think these things can happen. So that probably could have been a bit tighter. Hopefully in the future, we can have, and I'm finding this more and more, we call them, in Australia, we call them surgeon heroes, but basically they're surgeons who actively advocate and both in person and online for physiotherapy input and non-surgical. So, I think in future, it would have been good to potentially see that patient before. And so, we could, if they're due to see a surgeon, give them a heads up and say, look, this is what we're thinking. And hopefully, we can be on the same page. And yeah, we're probably never going to agree on everything, but at least we can find common ground. So, maybe if we'd have been able to see Colton earlier, that would have been ideal. But yeah, Other than that, I think it really does show how non-surgical management, from a research point of view, we're talking at least 50% of these patients, up to 75% of these patients can do very well with a rehabilitation alone approach, which I think is pretty exciting.

SPEAKER_03:

That's very exciting. And I think those are some fantastic takeaways. And just to touch on your point, I think patients love a multidisciplinary team, but I also believe as clinicians, we can all benefit from the growth that a multidisciplinary approach creates. does offer as well.

SPEAKER_02:

I think so. Yeah, I think so. And probably what's happened with me personally is I've found like-minded professionals extra professionally. So I've kind of found a team of sports doctors and surgeons I know that agree with us, not on everything again. And I think it's probably silly to think that we'll always get along perfectly, but we want to advance this topic forward and identify the cases who truly need surgery, who truly are for not surgery in a way we don't know and we can agree together on that. And I think the patients, they love that team approach. They want that and I think they need it.

SPEAKER_03:

Absolutely. Well, thank you so much for your wisdom today, Kieran. I think many of us can learn and apply that to our next ACL that walks through the door.

SPEAKER_02:

That's great, Sarah. It's great to share these cases and I hope it's beneficial to the clinicians as well.