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David Pope: Hi and welcome to this podcast with Zoe Russell and myself, David Pope from Clinical Edge. Today, we're really looking forward to diving into ACL injuries. So you're going to have patients that come in with ACL injuries and or suspected ACL injuries. So you want to know how do you go about assessing your patients to identify those.

How can you go about treating them or managing them? Are your patients suitable for conservative or surgical management? And how do you help to guide your patients and explain the process to them? So we're really looking forward to diving into that today. And we're going to be doing that with Zoe Russell, who is a specialist sports physiotherapist based in Queensland, here in Australia. And she's got a lot of experience treating sports injuries and ACLs and lots of other sports injuries. And she's also one of the senior presenters on the Clinical Edge education and presentation team. So welcome Zoe.

Zoe Russell: Hey Dave. Thanks for having me.

David Pope: Great to have you join us. There's a lot of debate on social media and all over the place about, who's suitable for ACL injuries and what sort of treatment we should be providing.

When you've got an ACL injury patient coming in, what are some of the main challenges you face first up when you have that sort of patient?

Zoe Russell: Yeah. And I think we can even go back a step, Dave, where a lot of us do work sideline with teams as well.

So I think one thing that often happens in football and the refs like, I'll get him off the field as quick as possible. If you give me 30 seconds, I'll be able to assess, make a decision about whether we're stretchering this person off the field or whether we can walk them off. And that's a really good time that we can assess the injury, in that first five minutes because person gets the opportunity to get a little bit of pain, get that protective muscle spasm of the hamstrings, it sometimes can make it a little bit harder with some of our clinical hands on tests. When you're in that particular situation keeping your head, asking for a little bit of time because taking the time to assess it there can be quite useful clinically.

My background, I used to play a lot of netball and a number of times I'd get a message on a Sunday morning from someone who had injured their knee, had gone to emergency on Saturday night, and they'd been diagnosed with either a patellar dislocation, and you ask them a couple of questions about what actually happened, and you start to get a little bit suspicious that we might have a different type of instability.

I think that's something that we really sometimes have to overcome. We get patients that walk in, they go, Oh, I've dislocated my patella. We need to make sure that we are really clear and clinical and get a great understanding of what was the actual mechanism? What actually happened?

Was it a non contact change of direction or a non contact landing sometimes in the footy codes, a less common mechanism that we think of is that they get bumped in the air and then they land into a bit of hyper extension. If someone limps in, often if it looks like a duck, quacks like a duck, it is a duck, but making sure that we are robust with our questioning around what actually happened, because we've got to remember that patellar instability is also a differential for someone that comes in with an unstable knee.

And I think we have to make sure we always do our due diligence and make sure that we exclude one or the other.

Sometimes these people are in a lot of pain. They've got restricted motion.

There's a lot of swelling and sometimes our clinical tests, whether it's one day, two days or a week after injury, that delayed presentation, that gives a chance for the swelling to get in there, particularly the person hasn't had ideal management, which can sometimes also make our tests a little bit less sensitive.

And I think having, subjective criteria as well as your objective criteria, we can use that to really formulate a picture and increase or decrease our clinical suspicion. And so I think a simple tip is always make sure you test the other knee. I think that's what something that is often overlooked.

We go, Oh, we've got to get in and deal with that knee, but how do we know what the other side feels like? And also making sure that we think about how are we going to prioritise and organise that clinical test battery? Because if you have someone who's got an unstable knee and you jump in straight away to stability tests, you're probably going to aggravate them. And then you're going to get very little useful information from some of your other clinical tests. And so that's where things like practicing your handling on different knees and working out different ways that you can use your body to address a different size knee. I'm quite sport. I've got really big hands. So if someone is a little bit bigger, I can usually get away with it. But I did some teaching earlier this year where we were talking about how to assess the knee. And that's something particularly female physios talk about is sometimes having some inability to handle.

So I think, making sure you're always practicing that as well. Not just when someone is actually injured.

David Pope: Some really great outline of the sort of challenges you're facing when you're assessing a patient that comes in that might've had, some sort of knee injury over the weekend, trying to identify that.

And you mentioned there some of the subjective and objective criteria. So what sort of subjective criteria will help you identify it? So you want to talk to us a little bit about some of those and the mechanism of injury pain patterns, that sort of thing that people might present with.

Zoe Russell: Yeah. So I think understanding where their pain is. So a lot of people who I've seen with ACL injuries that have been misdiagnosed, initially report a lot of posterior lateral knee pain because of that kissing type mechanism from bony contact. So a lot of them complain of posterior lateral knee pain. It can't be my ACL cause they think that's in the front. So I think getting an understanding of where the pain is, the mechanism of injury. So what happened, but also then what has happened since then? We get the mechanism exactly what happened, but then were you able to weight bear straight away?

Some of those things that we typically ask with our Ottawa knee rules. Could you weight bear straight away? Where is the tenderness? Did it feel unstable? Did you hear any sounds? But also then what has happened in that timeframe since the injury? Did it swell straight away or did it swell up later on?

So that will give us some criteria. Sometimes ACLs and our osteochondral lesions that happen acutely will swell immediately, whereas a meniscal injury will tend to swell later. If they do have instability, what we want to get an understanding of, is that instability related to either pain inhibition or the swelling?

So you can ask some questions about when your knee is unstable, what actually happens? Do you feel something and then it feels unstable? So we call that, I feel something. And nothing really happens. It just feels unstable and I can catch it versus the person that has that frank instability, which is nothing really happens.

And they might just say, Oh, I was just turning in the kitchen and all of a sudden I was on the floor. There was no warning and then I couldn't control my knee. And so that second one is a little bit more sort of symptomatic of instability as a result of major ligament disruption.

Also knowing what have they done, what's been helping, what hasn't been helping and then looking at how it's functioning with walking, daily activities, the typical subjective questions we ask about our 24-hour behavior and that sort of stuff to help inform these sort of questions start to help us realise, is this someone that might be able to go down a non surgical or someone that needs early referral for surgical or orthopedic opinion? Because we're trying to get a clear picture about the concomitant injuries that might be associated with this particular injury in this person.

David Pope: You mentioned there's some really great points. So the patient might have posterolateral knee pain. That might be one of their symptoms that they're experiencing where they're not even suspecting an ACL because that's not where they think that the ACL is and they might have that swelling immediately as opposed to which could be ACL or osteochondral you mentioned, as opposed to meniscus, which is, more likely to have that sort of delayed onset of swelling. So that was some really great points. And then, you mentioned they're looking at their 24-hour behavior and the types of instability as well.

So all really good points. So let's have a little bit of a chat about them. So you're suspecting from that history, they had that, immediate swelling. They had that, mechanism of injury that might make you think that they've got an ACL. Are there any other sort of questions that you're really interested in at this point in time before you move on to their objective?

Zoe Russell: Yeah, Dave. So definitely you want to understand some of your special regional questions. So things like, is it clicking? Is it clunking? I think locking's a really clear, good one. All the literature that we have in ACL management does discuss that a bucket handle meniscal lesion or a lesion that creates a locked knee is something that does require urgent referral on for care.

So that's, I think, a really key critical question on top of the other questions that we've already asked.

David Pope: Let's just say they haven't got that locking. But they have got that presentation that you've described there, where you're suspecting that it's an ACL injury. Tell us a little bit about the objective you're going to go through. You mentioned if they've got an unstable knee, not diving straight into your stability test because that could stir them up and make a bit harder to get the rest of your results.

So tell us a little bit about how you might structure your objective to get some clear results there.

Zoe Russell: This is always a good one for debate. So if I'm suspicious about someone's from an internal derangement perspective, I'll assess them on the bed before I do any functional activity. Obviously you can see from the waiting room, you can see how they get out of a chair.

You can see how they choose to walk. So you get a lot of valuable information there. And I think sometimes that's really useful because if you ask someone to go and walk, what they'll do is they'll try and change their walking to the way that you want them to walk. So use that time from the waiting room to your treatment bed or your treatment to room help you.

Then I think the biggest thing is with someone with an acute knee is to make sure they're comfortable. So that might often mean that there's a rolled towel or a balls underneath their knee. And I start with simple things like their swelling tests because you can do them quite gently and sensitively with broad strokes to get a bit of an appreciation.

Then using their, I actually support their legs, I support under the hamstring, under the calf and let them move their knee through flexion extension. So I can see what they're comfortable doing. We can get appreciation of any sounds, clicks, pops, and they also feel safe because they've got that reinforcement.

Then if I'm looking at some of the special regional tests, I will try and do these really gently. So my handling tends to be really close to the joint line for valgus and varus stress testing so they feel safe and making sure that you support the rest of the way to their leg. And that way you can just gently move.

And I know a lot of the tests are described as a real jerking type movement, but you actually can just feel the play and then just put a little bit of an extra pressure at the end so that you can get some good information without. yanking as such on the person's leg. If they've got enough range of motion, I'll definitely then progress into Lachman's anterior drawer.

And if possible, I'll go into a pivot shift with some of our ligamentous testing. But I think it's always important that you make sure you assess what's the posterior cruciate ligament compared to the other side. What's the posterior lateral corner looking like as well? Just so that you've got a full picture.

And obviously before I do some of those testing, I've already test my differential of patellar instability in those when we did swelling testing, using your handling to be, support the lateral side, support the medial side and just give that hands on contact that will increase the patient's safety and that you're in control of the movements that you're doing.

David Pope: And then you mentioned that when you're testing their patellar stability, tell us a little bit about how you might assess that while they're in this position.

Zoe Russell: Usually with them supported on the towel. I don't see too many ACLs that come in that can straighten their knee straight away.

But what we do is generally have a feel of the patellofemoral glides after the range of motion. Have a little bit of a look at how it looks like it's tracking with those movements. And then I just basically do a simple patellar apprehension test where you actually stabilise laterally and just apply the glide.

And I do it medially and laterally. Just so that you can feel and the person will tell you, obviously, you're always looking at the person's face as well, because quite often that will give you your earliest indication before their mouth actually tells you, hey, I don't like that. And then you can do it with a little bit of movement as well, where you hold that glide and get them just to try and actively bend and straighten their leg to see if they're comfortable doing that as well.

David Pope: So let's just say, you've assessed their movement through flexion extension with that support. You've checked out their patellar stability. You've looked at some of their other tests your Lachman's and your PCL .

PCL seems to be fine. Posterolateral corner seems to be okay. Didn't have any patellar instability We're thinking that we've got an ACL injury going on here because you felt some laxity compared to the other side. What's your next step within that assessment?

Zoe Russell: Obviously then I'm looking at things like trying to palpate the joint line, see what that feels like. Then I might move into my meniscal tests, just depending on the range of motion and appropriate to the patient's concern.

If we've looked at our ligamentous instability, I might look at some, just some functional things like bridging. Can they do it single leg? Can they do it double leg then moving them into things like, can they get up safely from the bed, sit to stand sort of stuff. And then, if someone's early on after injury, they'll usually have some gait impairments as well.

And I think that's somewhere where then we know what we doing if we're addressing the swelling, we're looking to get an appreciation if they can be stable with some daily activities, things like getting out of chairs. Are they stable when they walk and can they turn around looking at those functional things?

Then I would sometimes put some gait training into that. So if there is something that we see, can we change it so that we can get their gait working well early? And that's where I'd then start to progress into and might start to turn into a little bit more of treatment .

And then to help them with any of those, generally ADL impairments or functional impairments that they'll need to be able to do at home when they leave their rooms.

David Pope: So you've now had to look at their function, and you looked at how they're going to cope when they go home. And you've looked at meniscus and some of those other strength testing, like bridging . You're now thinking that, they can cope, they can walk.

When do you start to describe that they have an ACL injury?

Zoe Russell: I try to structure subjective, objective treatment. So the first thing I would do is sit them down and we talk through their findings. And basically if I think they've got some concern that they might have a deficient ACL in this particular case.

I'll talk to them about that. I'll also talk to them about why it is a problem. So it's a primary stabiliser of the knee and we do have secondary stabilisers. And from there, I will then start to talk through, where they are at compared to where they want to be with their goals from the subjective consultation.

Their age, their sports, what they want to get back to, what's their performance plan looking like. So they might have something that they might have trials for an event in a month, or it might be that they've come to a period where there's a bit of rest period and that, their structure of how this looks in terms of their competition, their sport might be a bit different.

And then from there, I start to talk about the options they've got for management. 99% of people that come to see me will usually be, I'll be the first person they've seen, which is good. We've got that opportunity to affect that conversation really well. And I think it's important to list that surgery is not the only option.

But also that people have the option of having non surgical management. Non surgical management, plus the option of a delayed procedure surgically if they were unable to regain their stability or early surgery. And then I talk about how their physical symptoms and signs from the clinical examination puts them into a category, one of those categories that would maybe mean that we need to go to one of those as our priority.

So if I've got someone that comes in with a locked knee and they've got a bucket handle meniscal lesion is on one of our suspicions, I would suggest that we do need to get imaging quite quickly, and we would start to get the ball rolling on an orthopedic review based on that. Whereas if I've got someone who's come in, it appears to be very isolated injury.

We might arrange some imaging to be done to confirm that suspicion. But I would say, look, given on your clinical science, you'd fit in this non surgical category. And this would be where I would start with you. And I talk a lot about the timeline in terms of we start our rehab today. Something I see a lot is people will go away, get their scan and someone will tell them, Oh, you don't need any more physio cause you need surgery to fix the problem .

as such. There's so much that can be done immediately after the injury. Swelling management, range of motion management. Muscle strength coordination and getting their walking and then moving back on track.

I think it's really important and it doesn't matter which category that person falls into. So I like to really try and prioritise, like you've got different goals at different stages throughout your recovery, but the goals we need to do are get rid of the swelling, get your range of motion get your muscles working, regardless of those three options that you've got for management.

David Pope: How do you describe that to patients? So you mentioned that you're telling them that this is in these early phases that regardless of whether they're having surgery or not, that you're looking to improve their swelling, you're looking to improve their range of movement.

Is there any other tips that can help to get patient buy in at this stage when they're thinking, Oh yeah, that's all fine and dandy, but I'm going to need surgery. Anything else that gets that buy in?

Zoe Russell: I think things like using ice and compression sock to show them that if we get rid of that, their function improves and their pain improves.

I think simple things like that work really effectively. And I think they're often overlooked. We're all often ready to go to the sexy stuff like the surgery, but ice, compression socks. Some people have a lot more people have access to those recovery boots and things like that can be quite useful as well.

But if you show them, if you change the swelling, their function improves. That gets a lot of buy in. Things like changing their walking with the walking drills that you can do early on. That's very powerful. So if you can look at the walk and say, oh, it might be just lift that knee up a little bit more.

So sometimes some little mini high knee walking can help their walking pattern. And if you can change their walking, and if there's someone else with them, like a family member or a loved one that can go, wow, that looks different, that increases a lot of buy in as well, particularly in that early phase.

David Pope: You said there that you're looking at those three different treatment options. You're looking at immediate surgical management, particularly if they've got some sort of bucket handle tear where they're it's locked and they're not getting any movement.

You're shooting them off for some imaging and then a surgical opinion fairly quickly. You've then got your option for immediate surgery or delayed surgery and then your non surgical management. I suppose that's really full. So then within those categories, the patient's always going to be, what do I need? What's going to be the best thing for me. So how do you go about stepping that through with the patient?

Zoe Russell: Yeah, so you've got to relate it back to each individual patient. So age is always a factor.

If, so I'm in my mid thirties now, I play netball. And if I did an ACL now, I'd be biased towards going down a non surgical pathway. And for a number of reasons. I'm not playing at an elite level anymore. I'm happy to not continue to play at that high level. I'm prepared. I've got the time.

I've got no competition commitments. So the type of things we're looking at is the age of the athlete, their particular sport. So looking at whether they're wanting to do level one, level two or level three type activities. They are generally things, level one are your change of direction your rapid change of direction, twisting, turning type sports.

So your football codes, your net balls, that type of activities. Your level twos are things where your exposure is not as high. But there's still a dynamic demand, and then your level three things are more your straight line activities, going for a walk, going for a job, something that is a little bit lower risk to actually sustaining, to requiring that three dimensional stability of the knee.

So that's a factor. The concomitant injuries that exist are a factor as well. So for an isolated ACL, I'm not necessarily rushing them off to surgery depending on some of those other factors, but if someone does have a locked knee, it's quite often that they will need an earlier surgical management and we don't want to miss them.

Similarly, we don't want to miss the meniscal root tears as well because they would benefit greatly from early surgical management. So it's being aware about those things that lower our threshold to progress to seeing an orthopod early. Just being aware of the person's competition goals.

You might go you haven't got enough time to have a surgical procedure, but you've got enough time to do a really well structured non surgical rehabilitation program, and you might go down that pathway. But then how that person responds to that will change as well. So a perfect example is I treat her, she's now 60, but she did her ACL is a 50-year-old and she didn't matter what she did. She was unable to dynamically stabilise her knee. She was collapsing multiple times a day with just daily activities around the house. And so she then didn't continue with her non surgical plan. She moved on to going back and having a chat to the surgeon that she saw initially based on her physical function. She was just having, I think it was one day, she had about 12 instability episodes in a day. And after a period of sort of eight to 10 weeks, she was still really quite struggling and that wasn't changing. So we bumped her on early because the literature suggests that we should be giving these people at least 12 weeks to see if they can achieve that.

Which is why we have that delayed surgical category where you've got that option to try the rehab and then if you're not meeting those goals and expectations and, using your outcome measures. So things like number of episodes of instability, swelling, function. If someone can't function in their daily activities, that's where you might go, we've committed to this plan, but you are starting to show me signs that it's not agreeing with you, and I might make that call to send you back to the orthopod.

David Pope: So you mentioned their different levels of sport and you mentioned there, their age and their goals, all different factors that can help to impact the decision making and whether that's most suitable for some of those activities. If they're say, a younger athlete and they're looking, they might have be somewhere in that level one, say, so they're an elite athlete. They're playing at a high level. They've got competitions that they want to get back to. And they've got high sporting demands. It might be netball, basketball, something like that where they do have some large demands on their knee. So in that level one, how do you talk to your patient about their treatment options and what's best for them?

Zoe Russell: Yeah, I think it's an interesting question, Dave, because If we look at the literature, particularly the non surgical management, the activity levels of those people, they were, on the Tegner scale nine or a 10. And the ones that did well with non surgical management really didn't get much higher than I think a four or five in that study. So we're talking about activities of daily living versus playing elite level sport. So at the moment we don't have a lot of research that shows elite athletes can get back to their elite level without a surgical reconstruction. Certainly if they're younger. What we're seeing is that the plan would be to continue to give these people an ACL reconstruction, particularly if they're in one of those sports that requires a lot of change, direction and pivoting and that type of activity.

And I think that at this point in time is still probably the way that things will continue to progress at the moment until we get more evidence. Yeah.

David Pope: And normal timeframes, with that sort of going, all right, it's likely that you're going to need surgery to get back to that high level of sport.

For those people, are we looking at immediate surgery or delayed 12 weeks down the track, or how do you tend to guide them as far as timeframes, if they have the option to get surgery immediately or delayed?

Zoe Russell: I think best practice would indicate that giving these people an opportunity to do their rehabilitation, calm the knee down and get that happy knee, so to speak.

So no joint effusion, good range and good cocontraction strength. I don't think practically that's still what happens. A couple of surgeons that I work with, if I send a letter to them and say, look, I think this person will do well, can we have some time? They'll give them four to six weeks to do a little bit of that.

But it's still not probably what's practically done conventionally, as people are still getting that reconstruction within the first two to three weeks. Whereas what the evidence is suggesting that if we could give these people a bit of a longer time and I think that comes down to when you're in that young elite athlete sort of expectation, there's media, there's societal pressures.

Most people that have done an ACL on a Saturday have three or four opinions from parents, friends, who are meaning well, but are just murky in the waters about what to do. And so all those expectations are set up really quite early and it does make it hard to change that mindset, but I don't think we do it consistently at a management level either, at a medical level.

David Pope: Yeah. Okay. That makes sense. So for those level one athletes and the ones that have got high demands from their sport and looking to get back to a high level, then, surgery sounds like it's one of the options it's more likely to get them there if that's their goals. And you mentioned there as well, if they got that bucket handle tear or something like meniscal locking of the knee, then they're a candidate for early surgery. Are there any other people that are more likely to require an ACL or that you're more likely to send them down that path and refer them for to a specialist?

Zoe Russell: So someone who's got multi ligament involvement or posterolateral corner or people that have got severe functional impairments in terms of instability would be the other two categories that I would recommend a quicker return to an orthopod.

David Pope: What about your level two athletes? So you're looking at patients, you mentioned there yourself, say you're 35 or mid thirties, something somewhere around there, you playing sport, but at a reasonable level, but maybe not at that elite level anymore.

Then what's the normal decision making process? Does it depend on once again the other injuries that they have, whether that's to the meniscus and other ligaments, or are there any other sort of factors and whether they're having periods of instability, how do you tend to guide those patients? What do you say to them?

Zoe Russell: I tend to have a conversation about always trying to the least invasive option because, I've had seen a guy recently who had a ACL injury a very long time ago and has had no issues without any rehab, but was just mucking around and had an instability episode.

And it wasn't affecting his work or his life. He was just playing basketball with his son and had his first episode of instability from his initial injury. That was 20 years ago. So we did have some imaging available to us and he didn't have any other concomitant injuries. He was in his early forties.

And we gave him some advice around, you would be an excellent candidate for having a period of rehabilitation and then discussing whether you would have a surgical reconstruction. Now, he unfortunately didn't take that advice because he felt he needed to have ligament repaired to have it fixed.

And so he was one of those ones that he didn't really like what he heard. So he self selected away from physio and, the irony is he was looking to go through the public health system, which would have given us a fantastic opportunity to do that rehab and then reassess functional outcomes. And I think the key is always making sure you've got a list of functional tests that you are measuring and remeasuring to give you some guidance about whether this person is coping or not coping as such. And even though the literature suggests give these people 12 weeks, I think if at any point you're really thinking this person's not doing well or this person's not coping, it's okay to refer them on and get that and have that opinion and have that discussion. I think so much with ACLs is about educating the patient and having that shared decision making model between ourselves, the patient and the orthopedic specialist or sports doctor or GP.

It's a group decision. It's not one person. Not one person is an island in this case, and that's something we are seeing a really good transition in our management that there is so much more collaboration about the decision making with these for people.

David Pope: Do you have any examples of patients where you might be looking at, seeing where they're going to cope or not cope without an ACL to help with that decision making process.

Zoe Russell: Yeah, absolutely. I treated a girl probably about 10 years ago now. And at that time she was like, Oh, I've seen an orthopod. He wants me to do non surgical rehabilitation because he doesn't think I'll need surgery. And she was the type of patient we see that sort of early 30s, recreationally active, playing a bit of netball, when you do that, you do it the same way you would assess people at different points upon their rehabilitation journey following the surgery. Is their knee silent? Is there any swelling? Is there quads bulk coming back? Have they got full range of motion? Then you might look at your endurance testing.

So things like making sure they've got glute, hamstring, calf, quad strength. What's their core strength like? What's their functional performance on things like single leg squat? Then you might look to start to progress into more of your neuromuscular testing. So things like Y balance, modified BESS type testing. And then you'll start to progress on as their rehab progresses on, you'll start to progress them onto things like hop testing. And, obviously at this stage you're basically on top of, what their stability is feeling like, what their function is like day to day, but as their rehabilitation progresses, you'll pick testing that's appropriate to that stage. And you can test people on that test battery. There's a few articles out there now. I think Brindon's written an article. There's a Melbourne ACL rehab guide that gives you some testing options that you can do. And it's the same as the person who's having non surgical rehab as a person that has had a surgery.

We need to be testing these outcomes. We need to be looking at their cues. We need to be looking at their ACL-RSI, which is that psychological readiness to return to sport measure. And it actually doesn't change what you do, it's just you need to make sure that you're getting good information across multiple domains to make informed decisions and then include that, whether it's orthopods, sports doctor, patient, GP, and everyone's included in that decision making process.

David Pope: When you're describing this to your patients and you're saying, here's what we want to improve, if the patient's like, I'm not going to cope anyway, I don't have an ACL and they're thinking that there's no really point in waiting around 12 weeks or whatever to see how they cope with it. How do you tend to, describe that process or the benefits of waiting 12 weeks to see how they go?

Zoe Russell: Yeah, so I think the first thing to remind the patient is that they've got a really angry knee usually. It's swollen, it's sore, it's hot, it doesn't bend and I think we need to remind people that the surgery is a second insult to that bone.

They've had that contact of the bone, the ligaments ruptured, there's a lot of that inflammatory soup sitting in that knee and then we come in and we've got an angry knee and we're basically then drilling into the bone and creating more trauma. One thing I've seen a lot recently, and I don't know if it's just where I work particularly is a lot of orthopods are now prescribing anti inflammatories post operatively to manage that response.

So in my mind, they're acknowledging that it does create an inflammatory response on top of an already inflamed knee. And so I talk that through with patients and, one way of thinking about it is if you roll your ankle, what happens if you keep rolling it? The inflammation continues to get worse, get sorer, you get increased loss of function.

And so I try and use different examples, usually try and pick an injury that they've had before, just to relate it back to something that they've experienced. And, I'll say, we don't have to worry about the timeframe as such sometimes, it will be more about giving them that goal of getting the silent knee, so no swelling, good range and good strength and good functioning with daily activities and going away from that timeframe, because if you say 12 weeks, people go, Oh, geez, that's a quarter of a year.

Whereas if we go you've just got to get a silent knee, then they can go I can do that because I've got the tools, I've got my ice, I've got my compression, I've got my exercises, I've got my things to avoid as well.

David Pope: So you're helping to calm that knee down and then within throughout that rehab period, what are some of your goals that you're looking at or ways that you help to, progress them through their rehab?

Zoe Russell: Yeah, so we just set goals based on whether it's sometimes netballers are really good with, okay you can go and shoot when you can do this and this or you might be able to do some passing drills and try to relate it back to their sport in particular.

But also basically just setting up. Some people work really well if they can see everything. Some people work really well if they can see just the first phase. I just call it phases. This phase is going to do this. This is what we need at the end of it and give them goals that they can control.

So things like range of motion, swelling, irritability, pain, they might be things that we're looking to get down early. Then we might look at, okay, we want to get a strength measure. So it might be, oh, we want you to be able to do a one RM squat. If we've got some data that they've had before, that might be something that we can use as a goal.

So trying to give them tangible things rather than just give them a random time frame of, four, six or 12 weeks.

David Pope: You mentioned they use some criteria, but you might say, all right, when you hit some criteria, then you're allowed to do some shooting.

What are some examples of some of the criteria you might set there for them when it comes to, especially, let's just say it's the early phases and you're looking at, you mentioned there's some of the goals of reducing their pain, reducing the swelling and calming it all down. So what might be some of the goals you might set for them within this phase?

Zoe Russell: So basically, first of all, our first one is making sure that their knee is not more swollen at the end of the day than it is at the start. A little tip you can do is they can grab a piece of ribbon, a piece of string, wrap it around the center of their knee, go about their day and retest it before they get into bed at night.

So that way you know that what they're doing with their icing and that might be enough to negate what they're doing on their feet and obviously the rehab program that you've prescribed. So I think that's a really good start. Obviously then picking activities. So we want to get your range of motion so that we can get you either, whether it's cycling or walking, because a lot of people do want to start doing some form of exercise that is maybe a little bit more cardiovascular.

So looking at things like that and also then looking at some functional things. If your knee's not swollen, we can start you doing some balance work. And then if they're going really well with that balance work, we might go we're going to put a skill that's related to your sport.

So that might be throwing a ball off a rebounder. It might be practicing some handballing. It might be, if it's a football athlete, they might be able to kick a football against the wall while they're working on their balance. So giving them options of how we can bring it back into their sport as quick as possible.

David Pope: You're often working through these things when they're in that first phase. And then what might be some goals within your next phase of your treatment?

Zoe Russell: Your next phase is making sure they've continued to have good range of motion and no swelling with more endurance type activities. So it might be things like being able to do a lunge, being able to do a squat. That might be your second phase. Just getting the endurance, the quality of movement, starting some of your proprioceptive drills.

They would be the goals I'd be looking for in that second phase. Then in that third phase, starting to get into some of those strength target goals. And if you've got pre season data, that's really useful. That's around the time that people start wanting to be able to run. So that's always a good target to aim for.

And I think if you're really clear and consistent with your messaging about your knee can't be getting swollen, you have to be able to have adequate strength and be able to hit those tights before we can do the running. That's always something that really motivates people a lot because I think they see running as a big step in that return to sport continuum.

And I think, if you look at some of the research, that's a big milestone that sort of your first milestone is getting it moving after the injury, but that's the next big milestone that the patients put a lot of influence on because they feel like when they get to that's when it's going to start opening up then getting back to their sport or their activity.

David Pope: You mentioned there before they're moving into that running that you're looking for, that's more in that third phase. And what are some of the strength tests that you might be looking at to indicate that they're going to be ready to potentially trial running?

Zoe Russell: There's a million things you can do, isn't there? You could look at endurance tests. So there's lots of ways to measure that. You can measure it using weights. You can measure it using RPE. You can use it measuring just numbers and reps. I like to have some one RM data whether that's a leg press, it comes down to what's available in your clinic and what's available to your patients.

So you can do things like single leg bridge test. You can do single leg squat test to look at their neuromuscular control. So is their alignment good? You can look at even little things like where you get them drop off a step and see how they land. Then you can do drop land and then get them to add another jump.

And that can be then double leg progress to single leg so that you can start to see how that person's able to land and move, then explode up off the ground, but then also use the muscle strength that they've got. So that when they get into running, they're not going to start limping and changing their mechanics when you do get them, you might not get to see them do that run as such. So those types of testing.

David Pope: And So with these three phases I'm imagining that it's similar when you're looking at your conservative management. So you're looking at some of those athletes are going, yeah, all right, potentially conservative management. You might be a good candidate for conservative management rather than surgical management.

Is that similar to the approach that you're taking when it comes to patients that are also going, let's do a conservative management program, see how you're going and then, consider surgery later on, is there a similar sort of approach or parallel approach between those two?

Zoe Russell: Yeah, absolutely. I think the first point I think we need to stop calling it conservative. I think we need to either call it non surgical or rehabilitation because conservative versus non conservative really makes it sound like it's inferior. So I think if we can change that language, I think that's really important.

And it's really empowering as a physio to see patients who take that on and then feed that back to the community that they're involved in. I think the process is the same. You're looking to test things. You're looking to make sure the person's adequate at them and then progress them on.

We don't still have a test battery that, oh, if you do all these and they do really well, they're very unlikely to re injure or re rupture, whether they go non surgical or surgical. But I think if you can get some good information and try and get good information across multiple domains.

I think that's the best case to progress things on. And that's certainly where we're seeing the timeframes are going out of the window a little bit now as well, because of that. I think, I try not to really talk about timeframes with someone unless where they're at is appears really inconsistent with where we would expect someone to be and like we're worried about something is not going according to plan and we would be referring them back to see someone.

David Pope: Okay. So when patients are asking you, how long is it going to take me until I can get back to netball or back to tennis or whatever it might be. And they're looking for timeframes and you're going we can't really work on a timeframe basis. How do you describe that to patients or have that conversation?

Zoe Russell: It's a good question because we always get asked it. I generally say to people, you can get back to sport when you're ready to get back to sport. And I say, obviously you'll hear of people getting back at somewhere between nine to 12 months. I think understanding some of the literature around re injury rates.

I think it was Brooke Patterson and Julian Feller did a review of people under the age of 20 and their re injury rates and they found that people that returned that were under 18 and returned in less than 12 months were more likely to have a secondary injury. And so I think using some of that data suggests gives them a bit of an expectation.

So I've said to someone once, at your age, if you return before nine months, you have a significantly greater risk of re injuring and that's why we're going to use the criteria and not get too worried about the time. I set people an expectation is that this is the surgical populations, that we should be having conversations about them. Returning to some sort of modified training somewhere between nine and 12 months and building into their return to sport from there.

Just depending on their sport, their injury, the nature of their repair as well. You get people that have meniscus injury that then is stitched up. So the first six weeks of their rehab, they spend in a brace. So they get significant deterioration of some of their quadriceps bulk and some of their walking patterns and that.

So if we tell them 12 months that we might undershoot them as well. And so I think, you can give them a basic gauge of this is where I expect you to be at these time points, but I always reinforce that the functional tests guide our progress or regress.

David Pope: And that makes sense. And so we're talking there about the surgical candidates, so people that have had surgery and then their recovery. What about the patients that are going with a non surgical route and they're looking for, okay, I've injured my ACL. I want to get back to recreational level of sport and I want to see how I go. How do you guide them when they're saying when can I go back? How long am I going to be telling my team that I'm awful?

Zoe Russell: Exact same way, but usually you expect somewhere between 12 and 16 weeks, but once again, I always use those criteria. Sometimes you'll get people that they test all their physical criteria really well.

And then you do the ACL-RSI tool, and their confidence to return to sports about 50%. And that's when you can have a conversation. And I have had conversations with even orthopods where I said, look, this person is doing really well and they've been surgical and non surgical. But their confidence measure is quite low.

I'd like to have a bit more time and building some drills and activities that are structured play of that sport to see if we can enhance that before we return them back to sport. Because we would like it over about that sort of, 90% if we can.

David Pope: Yeah. On that RSI.

Zoe Russell: And you can look at other measures of that sort of stuff. You've got Tampa's, you've got trust indexes. You can use, look at different tools to see if someone's, comfortable or confident or anxious about their return to sport as well. It doesn't have to be just one tool. But you don't want to give everyone every tool either. That becomes quite arduous for the patient.

David Pope: And then I want to briefly just touch on the types of graphs that patients are getting and there's been a bit of movement between, and different surgeons have favorites. And now obviously, if the patient's going to see a surgeon, they're going to have their favorite type. So it's not often something that we can, influence or whatever, but it's good to have a bit of an idea about what's out there. What are the popular choices and the pros and cons. Do you want to give us a bit of a brief outline of where that space is at the moment?

Zoe Russell: Yeah. So I think obviously the two best known ones are the hamstring and the patellar tendon. I've seen a few perineals and I think there are still a few people that are getting the LARS graft around certainly not where I work in sort of Brisbane, but I think historically what's happened is it's just gone around in circles. We were all doing patellar tendon grafts, then it was all hamstring grafts.

I think now we're seeing a little bit more of a discerning approach. So horses, for courses with the patients. A couple of the young football athletes that I've seen, their surgeons have gone back to patellar tendon grafts because that will help preserve the hamstring strength. And when you speak to some of the orthopods, they feel that, most a couple of them I've had conversations with say, look, we tell people that they probably don't have any deficits, but their concern is that there probably is still a little bit of a deficit in that hammy even longterm.

And so I think that's they're trying now to match the graft to the person. And I think that's at the moment, that's the best case we've got at the moment. And that talks about their past history. Have they had anterior knee pain in the past and things like that become part of that discussion.

Have they had a significant hamstring history? That type of thing, because I think that's really important. If they've got multiple hamstring injuries, then I don't know that taking the hamstring out to repair their knee, there'd be have to be a significant focus on that hamstring rehabilitation.

And you question what the hamstring was like before their injury anyway, might become part of their risk profile within the injury.

David Pope: So overall, we've got some really good ideas here about patients that are likely to require surgery. We looked at different time or different criteria and how you might progress patients through those phases of rehab when we're looking at going, okay, if we want to sum up some of that non surgical management as an approach. If you had to look at your patients go, who's likely to be good candidates for non surgical management? Who do you think fits into that box or that is likely to cope well?

Zoe Russell: If we look at the research in this space, it was generally sort of people that are a little bit older and that weren't doing those level one sports. So those high change of direction sports was the general consensus. But I think you can also ask your patient, what do you want to get back to?

And, I think probably a lot of us do have some horror stories. I have one where a patient mid thirties was just playing recreational sport just as a bit of fun was only offered a surgical reconstruction. And unfortunately her recovery ended up with DVTs. She had scar tissue buildup.

She ended up having MUAs, arthroscopies and all of that. And I think when we talk about those horror cases, people go, Oh, why would you possibly do that? And I think we've just got to be a bit aware that at the moment, there's some good emerging evidence, but it comes down to that real robust clinical decision making for the person in front of us and making sure we get that information.

But also like any condition we have, if the person is not going well with a non surgical pathway, having that exit strategy. And Making sure the patient knows that if things are not going the way we want, that's okay. We've got this plan to then take the next step.

David Pope: Beautiful. And I think that's a really nice place to wrap this up we've talked about a lot of fantastic stuff on the podcast and given people a lot to think about it. You're managing all sorts of different athletes at different levels and looking at the research what is the most appropriate and likely to go well for each patient and then helping them to make those decisions.

So that's been really fantastic to get your practical insights into all that .

Zoe Russell: Thank you for having me, Dave. And I think I just want to really make sure that like most of the discussion we've had today has really been about that adult population, 16, 18 plus.

I think, we've just got to be mindful that might not necessarily be the same for our pediatric and adolescent populations as well. Thank you for having me.

David Pope: So now tell people where can they find out more about yourself and what you're doing.

Zoe Russell: Yeah, I work for the Queensland Academy of Sport at the moment, as well as I'm still consulting at private practice in Brisbane, but you can follow me on Twitter at @physizo.

David Pope: Awesome. And you're a valuable member of the Clinical Edge presentation team. You've got some great presentations coming up on communication and also on low back pain. Yeah, we're really looking forward to exploring those. You've got a presentation on communication and helping to resolve conflict, whether that's with patients when they have different goals or you've got tricky, difficult patients.

And so we're looking forward to sharing that one with all our Clinical Edge members. And also you got another one on telehealth in the communication module. So we'll probably get you on and explore a bit about those topics on future podcasts as well. So plenty to chat about but we are excited to have you on the Clinical Edge team and be able to share your experience with everyone that's either a member and also on the podcast as well. Thanks Zoe.

Zoe Russell: That's alright. Thank you for having me. I hope it was helpful.

David Pope: Indeed. You have a great day. If you've got comments or you've got questions for Zoe for any of the Clinical Edge team, then remember to jump on over, you can post those on the Facebook page. And we can answer those in the comments or on future Facebook live.

So thanks everyone and we'll catch you very soon.