ACL Pearls of Wisdom

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December 16, 2017

Skiing

ACL Injuries Skiing

On Friday the 15th of November, I had the pleasure of attending an ACL symposium hosted by the La Trobe University Sports and Exercise Medicine Research Centre in Melbourne. There were a number of excellent keynote speakers covering topics such as current ACL injury data, Injury prevention programmes and their effectiveness, Surgical techniques for ACL reconstruction, conservative management Vs surgical management, when to operate as well as return to sport testing and criteria.

Some nice take home points were the following:

1) Rehabilitation must be goal and criteria driven instead of time based. The practitioner must work with the patient closely to ensure that each program is tailored to the individual. There is no recipe!
2) Return to sport testing must be specific to the needs of that athlete and their sport. It should also include an element of unpredictability and ideally be performed in a fatigued state to better re-enact the conditions the athlete will encounter when returning back to sport
3) ACL prevention programmes reduce the risk of ACL injury by up to 50%. Thus, rather than deciding who gets the program, perhaps we should be taking the stance that EVRYONE gets the vaccine (program)
4) Our younger patients are at greater risk of re-rupture. We need to have a good think about when we return these patients back to sport and should we be considering holding these athletes off on return to sport for longer (ie 18-24 months).

The below is a short summary from a few Keynote speakers:

Tim Whitehead

Tim is a surgeon who works at Ortho sports Victoria. The main take home points from his presentation where that ACL tunnel position has gone 360 degrees and we are now back to where we were decades ago after failure of the vertical notch position and the LARS Allografts
– Old tunnel position was vertical. This would cause tibial notch impingement and a lack of control of tibial rotation. Unfortunately, this has led to a lot of tunnel widening over the years and graft failure.
– Now surgeons are back to close to where they were placing the femoral tunnel decades ago and this is more antero/medial.
– Quadriceps tendon grafts are becoming increasingly more popular with 93% rating outcomes as good-excellent at 2 years and 63% returning to a pre injury level of sport
– Currently 4 bundle Hamstring grafts are showing a 88% good-excellent rating at 2 years yet have a higher return to pre-injury sport rates at 80%.
– Watch out for lateral extra articular tenodesis as these may become more popular.

Adam Culvenor

Knee Benefits

Knee Benefits From Weight Loss

Adam is a physiotherapist and PHD who has a special interest in ACL reconstruction, Patellofemoral pain and knee osteoarthritis.
Adam presented on the statistics behind surgery success and what the data says on when to operate and when to stick to conservative rehabilitation.
– The main take home messages of his presentation were if you are functionally unstable and have concurrent meniscal damage then we should be considering surgery earlier in these patients.
– This is because for every month of being ACL deficient with a meniscal tear your risk of a increasing or new meniscal tear goes up 0.4% each month and your risk of cartilage lesion goes up 0.6%.
– Poor vertical hop testing at the end of a conservative trial of rehabilitation is an indicator that they may need to the go onto surgery
– A patient’s outcomes at the end of 2-5 years predicts of lifelong function
– It is important to ensure repeated functional testing is done to ensure patient engagement and motivation.
– 23% of ACLR fail in those < the age of 23.
– After 9 months’ post ACL reconstruction, the risk of re-injury decreases by 51% each month.
– Another interesting fact regarding Osteoarthritis is regarding weight loss with recent studies showing that in those who are overweight, for every 10% loss in weight, this equates to a 50% improvement in function and symptoms

Randall Cooper

RTS Testing

Knee Return To Sports Testing

Randall is a sports physiotherapist who has a special interest in the knee and ACL rehabilitation.
Randall spoke in depth regarding return to sport protocols and testing. He voiced his concern of how our current return to play criteria does not consider the patient who is an unpredictable sporting environment or the athlete who is in a fatigued state, thus we are likely cutting ourselves short here and maybe we need to consider pushing athletes further with this.
– Ideas for where we need to go with this is
o Incorporating a vestibular component to balance testing. For example, when does an athlete ever have to stand in tandem stance with their eyes closed on firm ground in a quiet room? Do we need to add in head and arm movements, external perturbations, distraction etc? And do we need to be testing people in a fatigued state?
o Finally we need to make this return to sport testing very much sport specific for that patient.

Rod Whitley
Rod is a specialist sports physiotherapist who currently reside in Doha, Qatar working at Aspetar. The main take home points from his presentation were focused on increased rates of re-injury past ACL repair and focussed on compliance to rehabilitation programs.
– There is a 5X increased result/ decreased risk of re-injury when the athlete complies with the rehabilitation program.
– Thus you can write the best program or advise on the best rehabilitation yet if the patient does not understand this or does not perform this with consistency or quality then it becomes useless.

Brooke Patterson

Brooke is a physiotherapist and a PHD student at La Trobe University. She has and is passionate about primary and secondary prevention strategies in grassroots AFL.
She spoke on rates of ACL injuries and recurrent Injuries and ways we can incorporate injury prevention programmes as a local club level. Her main points were as follows:
– 147% increase in ACL injuries in 10-14 year old boys in the last decade.
– We need to start involving other support staff in educating and enforcing coaches who have the most contact with the athletes at a recreational sporting level.
– Coaches learn best via informal learning. Only 2% are aware of current literature surrounding injury prevention, thus consider this when implementing injury prevention strategies at a local level.

Alana Antcliff

Alana is a physiotherapist at Netball Australia with the Diamonds. She spoke on mechanisms of ACL injuries and netball specific rehabilitation programmes.
– Main Mechanism of ACL injury in netball is non-contact.
– Common themes include: single leg land, athlete looking in another direction to where they are landing, increased trunk sway/angulation, leg external rotation, trunk rotation.
– Within netball, programs focus on soft feet, neuromuscular control, balance.
– Progressions would include predicted change of direction unpredicted  inc out BOS  Defender involved

Holly Lipson has a special interest in treating knee injuries, forged from her work with the Olympic Winter Institute and personal love of skiing and surfing.