Last weekend I was asked to present at an ACL Conference organised by the La Trobe University Sports and Exercise Medicine Research Centre (SEMRC) here in Melbourne. It was a fantastic multi-disciplinary event that covered topics such as:
- ACL injury data
- Success of injury prevention programs
- Surgical techniques used by surgeons
- Conservative management options following ACL injury
- ACL reconstruction rehab protocols
- Evidence supporting criteria-driven discharge testing prior to returning to sport
- 2nd ACL injuries in young athletes
- Athlete perspectives following ACL injury
For those that missed the event here in Melbourne, or missed some of the Facebook Live videos, you can still catch up with what was discussed by heading over to Twitter and following the thread #LatrobeACL. For those of you that aren't on Twitter, here are just a few pearls of wisdom that were shared among the presenters:
One key message to come out of #LatrobeACL was adherence to exercise. This applies to rehab, maintenance and injury prevention programs, in not just ACL injury, but all injuries that we see in the clinic.
1) Exercises need to be individualised to suit patient & their goals - You could prescribe the best gym program, but if they've never been to the gym before and unwillinging to go to the gym, you need to be flexible to how your program will be delivered to your patient.
2) Sometimes less is more - 2-3 exercises that the patient can and will do, is better than 6 exercises that don't get done at all.
3) Communication is vital - make sure that the patient knows how to do the exercise and why they are doing it. Most people have Smartphones now. Record videos or take photos of the patient doing the exercises.
This is a wonderful slide put together by Adam Culvenor (keynote speaker) showing the negative consequence of weight gain on knee loads and subsequent knee pain and function. We can sometimes get caught up trying to give sexy exercises to our patients to help with their knee pain, but for some patients, they dont need sexy quads/glutes/balance exercises. They just need to be involved in a multi-disciplinary health team, trying to help them lose weight.
Note: Since this presentation, it has since been acknowledged that the "8-fold" figure is incorrect, and it is in fact 4-fold. Regardless, it is clear that a reduction in body weight equates to improved knee health, function and quality of life.
Rod Whiteley (keynote speaker) presented twice, with one of his topics being Injury Prevention Programs. The take home message from this talk was that we can't predict confidently who will, and who won't sustain an ACL injury. So for us to decide who gets an ACL Injury Prevention Program, and who doesn't need one, is a decision fraught with danger.
At the end of the day, we know ACL Injury Prevention Programs reduce ACL injury risk by 50%, so it is not a matter of who should get the vaccine, rather the decision be made that everyone should get the vaccine.
Kate Webster presented a long list of sobering statistics highlighting the significantly higher rates of 2nd ACL injuries in young athletes (under 20 years of age). Across 6 different studies she showed, it is known that approximately 30% of athletes aged under 20 years of age will have a 2nd ACL injury; with many experiencing that 2nd injury within 12 months of returning to sport. She also presented some unpublished data from Victoria showing that 18-19 year old males here in Victoria have 2nd ACL injury rates as high as 45%.
The take home messages from this topic:
1) Consider a longer rehab period for these younger athletes, with some suggesting waiting at least 18months - 2years until return to sport.
2) Encourage consistent supervised rehabilitation for a minimum 6 months post-op that includes plyometrics, agility and landing exercises.
3) Ensure that the athlete has been cleared to return to unrestricted training and sport via a series of strength, hop and agility tests, rather than being cleared to return to sport based on time.
4) Encourage ongoing maintenance programs that include sport specific injury prevention programs.
Lastly, and following closely on from the last topic discussed, I presented an interesting ACL case study on a young elite netball player; made interesting by the fact that she sustained 2 ACL injuries within 13 months of each other. From this, I just want to highlight a few of the things I learnt along the way during this rehab case that I have summaried in the "Take Home Messages" summary slide:
1) There are non-modifiable reasons as to why ACL injuries occur, and sometimes your best efforts to maintain best practice through criteria-driven return to sport testing and maintenance of injury prevention programs still won't be enough. So don't lose sleep like I did, wondering if there was more that you could have done to prevent the 2nd injury fom occuring.
3) Do the basics well - if the patient can't competently squat their own body weight, or perform good quality single leg squats, or can't stick a single leg land with good control; why on earth would we get them to do stuff on BOSU balls or Swiss Balls?
5) Know your skillset. Lose your ego. Don't be afraid to refer on - It's important that ACL patients who are gearing up for returning to sport following a reconstruction are being prepared physically for the demands of their sport. And this means for us physios (especially those that don't have a background in exercise science or a skillset in strength & conditioning), to let go of our ACL patients and send them off to appropriately skilled exercise professionals to make sure that they are being prepared physically for the rigors of the sport. Team work during mid-late stage rehab is an absolute must for the patient and their treating health team, as the patient's goals shift from improving function towards improving physical performance.
So there you have it! A nice little snapshot of some of the conference proceedings. Of course there was much more on offer, and if you're at all interested, please head over to Twitter and follow the #LatrobeACL thread.
FYI: A fair bit of content that was delivered over the weekend is covered in my online ACL presentation which can be found by clicking on this link. For 90mins of your time, you can watch it in the comfort of your own home, and for most health professionals, you can also claim it as continuing professional development!
I hope you have enjoyed this snapshot of the weekend's proceedings, and have learnt something to help your clinical practice tomorrow!
Yours in health,