Is Surgery Necessary for an ACL Tear? New Findings in ACL Management

By Andy Parsons, PT, DPT, OCS

In 2016, A cochrane systematic review compared conservative management after ACL tear to ACL reconstruction (ACLR).1 The review concluded that ACLR did not show superior outcomes compared to conservative management up to five years after the initial injury.1,2 Prior practice standards indicated ACLR based on age and activity level; younger patients generally had ACLR, and older individuals might forego the procedure. This could be the beginning of a paradigm shift for management of ACL lesions because some active individuals seem to perform well with conservative care alone.

Copers and Non-copers

The new paradigm is based on a subset of individuals with an ACL deficient knee that “cope” without the inherent ligamentous stability of the ACL. The “coper” group likely gets their knee stability “dynamically” from the muscle groups surrounding the knee as neuromuscular activation patterns change to provide stability to the ACL deficient knee. Non-copers do not function well without the passive restraints of the ACL, and surgery would be indicated in this group.

Once a Coper Always a Coper?

The literature is still trying to answer many questions regarding the feasibility of conservative management in this population. Even though we might be able to classify a patient as a coper or non-coper, there is no guarantee that the individual will remain in one discrete group.

In the primary study of conservatively managed ACL ruptures, 39% opted for ACLR by two years and 51% opted for surgery by five years due to knee instability (these groups were randomized and diagnostically selected for surgical or conservative care). However, in another study, 70% of subjects initially classified as non-copers were functioning well without ACLR at one year following non-operative treatment.3

A Shift Towards a New Paradigm?

Proposed criteria for classifying patients as a coper:3

• Hop test of >80% for timed 6m hop test comparing contralaterally

• KOS-ADLS score >80%

• Global rating of function >80

• No more than one episode of knee giving way since injury

A new version of management would include early referral to PT after ACL tear with treatment for about 10 weeks. During that time, the medical team would attempt to classify the patient as a coper or non-coper. Ultimately, If the patient does need ACLR, he/she would potentially improve post-surgical outcome by completing “prehab”.

 

Risks

Interesting, OA rates are actually higher in subjects that had surgery than those who did not.1 There was no difference in rates of meniscus surgery between the ACLR group and the conservative care at five years.2The biggest risk in the “coper” group is opting for ACLR at a later date.

Disclaimer

Non-operative management of highly active individuals remains controversial. The science is “young” on this question. The conservative treatment findings are based on one RCT. Further replication study needs to be completed before we can confirm if a group of “copers” really exist and what complications might arise with opting out of ACLR. Admittedly, Monk et al. describe the current evidence as weak that finds no difference between conservative management and ACLR. The ability to prospectively identify individuals as true copers or non-copers is fairly poor currently.3 One could argue there is significant waste of time, resources and thus potential harm to the patient if incorrect categorization occurs.

The Future of ACL Management

We may be in the middle of a paradigm shift in which a subgroup of active people with ACL ruptures can be managed as effectively with conservative care as they can with ACL reconstruction. Consistently identifying this subgroup is proving problematic, however.3 Categorization is likely fluid and an individual can move groups after initial categorization. Depending on patient goals, a trial of conservative care for the ACL deficient may be warranted.1-4

References

1. Monk, A. Paul, et al. “Surgical versus conservative interventions for treating anterior cruciate ligament injuries.” The Cochrane Library (2016).

2. Frobell, Richard B., et al. “Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial.” Bmj 346 (2013): f232.

3. Moksnes, Håvard, Lynn Snyder-Mackler, and May Arna Risberg. “Individuals with an anterior cruciate ligament-deficient knee classified as noncopers may be candidates for nonsurgical rehabilitation.” journal of orthopaedic & sports physical therapy 38.10 (2008): 586-595.

4. Snyder-Mackler, Lynn, and May Arna Risberg. “Who needs ACL surgery? An open question.” (2011): 706-707.

Myth Busting - Running and Joint Health

The common popular opinion is running is bad for your knees and hips.  A recent systematic review from JOSPT shows the is opposite may be true.  This large observational studies shows lower rates of OA in recreational runners.

Reference:
Alentorn-Geli, Eduard, et al. "The Association of Recreational and Competitive Running With Hip and Knee Osteoarthritis: A Systematic Review and Meta-analysis." journal of orthopaedic & sports physical therapy 0 (2017): 1-36. 

Are Ankle Sprains the "Common Cold" of Musculoskeletal Injuries?

The following article was written for Medbridge- an online, video based continuing education based company.

The inversion ankle sprain is one of the most common musculoskeletal injuries, with an incidence of 7.2/1000 people age 15 to 19.1 People participating in basketball, football, and soccer are at particularly high risk for an ankle sprain. The ankle sprain has been reported to account for up to 34% of all sport-related injuries.2

Ankle Instability

Likely due to the common nature of these injuries, the common vernacular in response to this injury is, “you’re fine; just walk it off.” Because of the common “laissez-faire” attitude related to lateral ankle sprains, they have been likened to the common cold which is the most prominent example of a self-limiting medical condition. Despite this popular belief, ankle sprains can potentially lead to serious long-term disability and dysfunction. Chronic ankle instability and injury are common sequelae following just one sprain.

In fact, people who do not perform ankle proprioceptive/balance exercises after a sprain are more likely to develop ankle instability.3 The reinjury rate following the first-time sprain ranges from 17-73%.3 High-risk sports like basketball report the highest rates of reinjury. Up to 33% of patients have pain or instability at one year and 25% are still experiencing problems at three years post sprain.4

Effective Interventions

As therapists, we have an opportunity to make sure this population receives the care they need to maximize return to prior activity/sport and prevent long-term disability and instability.

Clinicians should address impairments in strength, joint mobility, and proprioception to reduce chronic instability. Specifically, balance/proprioceptive training with sport-specific activity training should be a focus in order to limit recurrence of ankle sprains. Therapists should recognize that patients who fail to use external lace-up supports (especially in high-risk sports) are at higher risk for a lateral ankle sprain.5,6 Therapists should maximize optimal dorsiflexion to decrease ankle sprain and chronic instability.3

Here’s an example of a dynamic proprioceptive activity from the MedBridge Home Exercise library:

And, here is an example of a self talocrural mobilization to increase dorsiflexion:

Advocates for Proper Care

There is a common perception among the public and many medical providers that sprains are self limiting.  Ankle reinjury and disability rates suggest this is not the case.  Therapists are positioned to advocate for proper intervention like balance/proprioception training to limit recurrence and disability related to lateral ankle sprain.

References

1. Waterman, Brian R., et al. "Epidemiology of ankle sprain at the United States Military Academy." The American journal of sports medicine 38.4 (2010): 797-803.

2. Fong, Daniel Tik-Pui, et al. "A systematic review on ankle injury and ankle sprain in sports." Sports medicine 37.1 (2007): 73-94.

3. Martin, Robroy L., et al. "Ankle stability and movement coordination impairments: ankle ligament sprains." Journal of Orthopaedic & Sports Physical Therapy (2013).

4. van Rijn, Rogier M., et al. "What is the clinical course of acute ankle sprains? A systematic literature review." The American journal of medicine 121.4 (2008): 324-331.

5. Aaltonen, Sari, et al. "Prevention of sports injuries: systematic review of randomized controlled trials." Archives of internal medicine 167.15 (2007): 1585-1592.

6. Dizon, Janine Margarita R., and Josephine Joy B. Reyes. "A systematic review on the effectiveness of external ankle supports in the prevention of inversion ankle sprains among elite and recreational players." Journal of science and medicine in sport 13.3 (2010): 309-317.

CSM 2017 - The Highlights

The Journey

by: Andy Parsons, PT, DPT, OCS

No rest for the wicked. My 8:05 PM EST flight was delayed and my touch down in Texas was about 1230 EST but my head didn't touch down to the pillow until 2am.  I woke from the dead at 5am ready to go. After all, this is #APTACSM folks. Go big or go home... everything is bigger in Texas... ***Please continue other random cliches in your head***
 

The Sessions

Integrating A “PT First” Approach in Emerging Healthcare Models

This session focused predominantly on an ATI group led by Charles Thigpen and Thomas Denninger in Greenville, SC that has changed the route of delivery for LBP and neck pain. 70% of the caseload was direct access the 1st year. They were able to show 45-60% reductions in disability and reduced costs for care routed through PT.

The take home:  It's a slow process that has been ongoing for 6 years. Don't expect change overnight. Interdiscipline collaboration is needed. 

Learning from each other: Sports and Neurology Sections Discuss Motor Learning

• Remember sports/ortho PTs do more than strength and ROM. Everybody has a nervous system!

• Motor learning = repetition matters...A LOT. intrinsic learning > extrinsic learner. Talk less, let the patient learn more.

• "Talk less, listen more" get pt's input on success of the motor task to encourage intrinsic learning.

Talking Points: An Oxford-Style Debate on Dry Needling

This one was PACKED.  Online presence? Yep… the #NeedleorNot hashtag was #1 in my tailored trends at one point.

@MarkMilligan @Kvenere @Dr_Ridge_DPT & Kali Aucoin, DPT had a cordial yet subtly heated debate about the merits or lack there of regarding dry needling. I have to admit, I learned something from both sides. The Women's Health section will be posting the video of the whole session.  I recommend you watch and decide for yourself. I will post the link here when it goes live.  Here are a couple #NeedleOrNot highlights.

Best Treatment Approach for Subacromial Impingement syndrome

The diagnosis itself is evolving and the simple definition by morphology of the hooked acromion process has lost ground. A multifactorial cause is a likely cause; intrinsic tendon pathology near the articular surface of the GH joint is one new suspect. Chad Cook reminded us that many of our special tests don't perform well in isolation. His biggest pet peeve test...

Chad also noted the path of delivery of care matters in terms of type of care delivered for SIS and many MSK disorders.  Overall, conservative exercise management of SIS performed as well as surgery in this population.

Pain is pain: Treat the patient NOT the label

Adriaan Louw gave a spirited lecture about the state of pain and many chronic conditions.  He postulated that these chronic conditions are the same variations of each other (I.e Fibromyalgia, chronic fatigue syndrome, complex regional pain syndrome, chronic lime disease, etc.)  Regardless of label, persistent pain can be treated with the same 4 pillars:

1. paced neuroscience education of pain

2. aerobic exercise

3. sleep hygiene

4. patient goal setting.

(R)evolution: PTs in Prevention and Population Health

Innovations from @MikeEisenhart (Eisenstat for those of you in attendance...HA) @ChrisHinzePT @SunsOpeningBand

• PTs absolutely have a role in population health. We are often stuck at the individual level of care, but if we think more broadly we can help so many more. Community design is one are we can have a voice. Contact your city planners and advocated for

• In the end, do you want to constantly be saving people from drowning in the water, or do you want to be part of the solution, and put up a guardrail to keep people from falling into the water in the first place?

Innovations in Health Reform: Practice Redesign in a Health System

@EricRobertson and his colleagues presented a model for decreasing variability, improving outcomes, and optimizing rehab services at Kaiser Permanente.  Ultimately, Eric pointed out the sub-optimal care costs the system more. Keys:

• Rehab services needs to be the key drivers in managing change within the system not other physician groups.

• Front line clinicians should be involved in task forces to drive clinical pathways and implementation of guidelines.

• Our group has been working on a similar undertaking at ProMedica Total Rehab. Read the associated PT in Motion article click >>>>HERE<<<< (must be an APTA Member)

Twitter: #APTACM

Was is just me or was this the best twitter presence for #APTACSM ?  The highlights:

This is just a tiny sample.  Go check out the #APTACSM hashtag for yourself.  I’m still digging through the knowledge...

The Sites

Finally, here a few of the sites I was able to soak in while in San Antonio.

Riverwalk

Mission Concepcion

The Alamo

La Villita

Pioneer Flour Mills

Tower of the Americas

In the end, #APTACSM will cause much reflection... 

Case Study in Cervical Imaging: The Canadian C-Spine Rule

By Andy Parsons, PT, DPT

The following article was written for Medbridge- an online, video based continuing education based company.

Over the last two months, you’ve treated Jean for weakness associated with MS and radiating low back pain. Today, she presents with a new issue. Over the weekend she fell twice, striking her head and neck against the wall. She now complains of neck pain.

Prior to the falls, she experienced diffuse chronic pain, including some neck pain. Currently, she has numbness down her right upper extremity as well. You note that she is rotating her neck approximately 60 degrees bilaterally but the motion is guarded. Her midline c-spine is tender to palpation.

What’s a clinician to do? Do you refer Jean to imaging due to the neck pain? She’s had numerous falls before and a history of chronic neck pain. Will you be wasting your physician colleague’s time and resources? Or, is this a potentially serious situation that requires imaging?

Using the Canadian C-Spine Rule

There is a well-studied clinical prediction rule (CPR) that can help you make this determination.1,2,3,4 The Canadian C-spine Rule helps you decide if imaging is needed in cases of neck trauma. The sensitivity of the Canadian C-spine Rule is reported between 95% and 100%.1,2 This means the CPR is almost 100% accurate in ruling out pathology if the rule is negative. That’s one powerful screening tool for your toolkit!

The rule is broken down into three sections. Jean must pass all three sections in order to defer imaging. Per the rule, Jean has paresthesias in the upper extremity that are worse since the fall, tenderness at mid c-spine, and possible dangerous mechanism; therefore, you would refer the patient for radiography of the c-spine.

Precautions for Implementation

The c-spine rule has gone through several steps of research validation, but it has been studied exclusively in the emergency department. Therefore, applying this rule in an outpatient setting may be considered outside of the rule’s validated use. Mindful application of this clinical prediction rule can still inform clinical decision making.

Expanding Your Toolkit

The Canadian C-spine Rule provides some additional insight and aids your clinical decision making. It’s quick, easy, and improves patient safety for radiography referrals.3,4 Add it to your references and use it when you get a case like Jean.

References

1. Stiell, Ian G., et al. “The Canadian C-spine rule for radiography in alert and stable trauma patients.” Jama 286.15 (2001): 1841-1848.

2. Stiell, Ian G., et al. “The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma.” New England Journal of Medicine 349.26 (2003): 2510-2518.

3. Bandiera, Glen, et al. “The Canadian C-spine rule performs better than unstructured physician judgment.” Annals of emergency medicine 42.3 (2003): 395-402. http://dx.doi.org/10.1016/S0196-0644(03)00422-0

4. Stiell, Ian G., et al. “Multicenter prospective validation of the Canadian C-Spine Rule.” Academic Emergency Medicine 9.5 (2002): 359.

**  This information is not intended to replace the advice of a physician/ physical therapist. Andy Parsons, PT, DPT disclaims any liability for the decisions you make based on this information.

Exercise Prescription: The KISS Method

By Andy Parsons, PT, DPT

Over the last year, I have been thinking critically about how I prescribe exercises in the clinic. As a new grad, I focused on making exercise prescription unique and functional. After all, the PT profession did go through the "functional exercise" revolution around the new millennium. You know, each exercise that we prescribe must mimic that functional activity that our client needs to perform to get back to full function.  Well, maybe... that is, if the exercise doesn't get too elaborate for it's own good.

After all, Isn't the best exercise the one that get's done?

I'm not throwing function completely out the window, but I now balance that thought with another main principle - the KISS method  

KISS: Keep It Simple Stupid.

Yep, Keep It Simple Stupid. The "scientific" saying first introduced to me by my high school freshmen biology teacher. Okay, seriously though, my rationale is based in some science. We do know HEP performance quality is improved with 2 exercises prescribed 8 (1).  Meaning increased exercise number likely decreases quality of exercise performed. I'm also reminded of a recent study that indicated one simple abduction exercise was as effective for RTC tendinopathy as "standard care" (2).   Also, if your "functional exercise" is still taking multiple verbal cues and tactile cues for quality after a few sessions, it is NOT getting done right a home either(3).  How can we expect to maximize adherence if the client needs two weeks to learn the exercise correctly? For many of us, most of our clients are not pitchers trying to return to the mound, or hitters trying to get back to the volleyball court; they might just want to be able to reach overhead to put the dishes away.  Keep in mind prior function and prior history of exercise as it relates to the complexity of the program you're prescribing exercise (4). 

An Example of K.I.S.S.:

Anybody ever used this isometric exercise?  Yeah... me too... many times.
 

The patient holds his/her elbow at his side taking one large step sideways and back to create and shoulder external rotation isometric. This is often performed in four directions, creating moving isometrics for flexion, extension, IR, and ER.

Compare it to the good ol' isometric vs the wall

The wall isometric isn't as "functional" as the reactive or stepping isometric, but does that make it worse? I used to prescribe the stepping isometric to every shoulder patient, that wasn't ready for isotonics, but now I only occasionally do. Why? Barriers to adherence limit this exercise:

1. It requires equipment that you have to provide or the patient has to buy

2. The equipment must be set up each time and available

3. If the elbow is tucked too tightly to the side of the body, load through the shoulder is mitigated

4. Steeper learning curve and reduced self efficacy (3)

Now I go with the standard isometric. The only equipment needed for adherence is a wall, and let's face it, most people a one "lying around"...

I never thought I'd be thinking about my eccentric, freshman biology teacher on a daily basis... Keep It Simple Stupid

References

1. Henry, Kristin D., Cherie Rosemond, and Lynn B. Eckert. "Effect of number of home exercises on compliance and performance in adults over 65 years of age." Physical Therapy 79.3 (1999): 270-277.

2. Littlewood, Chris, et al. "A self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy: A randomised controlled trial (the SELF study)."Clinical rehabilitation (2015): 0269215515593784.

3. McLean, Sionnadh Mairi, et al. "Interventions for enhancing adherence with physiotherapy: a systematic review." Manual therapy 15.6 (2010): 514-521.

4. Der Ananian, Cheryl, et al. "Factors associated with exercise participation in adults with arthritis." J Aging Phys Act 16.2 (2008): 125-143.

Images:

Flickr Via Ben Russel "Teacher"

Thank you MedBridge for permitting use of the isometric images.

**  This information is not intended to replace the advice of a physician/ physical therapist. Andy Parsons, PT, DPT disclaims any liability for the decisions you make based on this information.