Anterior Cruciate Ligament (ACL) Tears
Anterior cruciate ligament (ACL) tears have always been considered devastating injuries for athletes given the amount of time and input involved in the 12-month rehabilitation process. However, there is growing high-quality evidence to support non-surgical management for ACL tears, this can lead to earlier return to sport and earlier resolution of symptoms without increasing risk of long term degenerative arthritis.
Throughout the last 60 years many athletes have conservatively managed ACL tears and returned to high level sport. These numbers have been slowly decreasing despite no better evidence for surgery compared to conservative management. In high quality trials comparing ACL reconstruction with conservative management, including physiotherapy and exercise based rehabilitation, there has been no significant differences found between the groups. Furthermore, early surgical intervention has been shown to significantly increase inflammation and prolong pain compared to initial conservative management.
There are many myths and assumptions made about ACL tears which sometimes suggest surgery is the only option. As mentioned above, the concern that patients cannot return to high level sport following an ACL tear is not true. Also, many people are of the opinion that unlike ankle ligaments, the ACL cannot heal itself, however there is emerging evidence the ACL can re-attach and heal. Knee instability is another area of misinformation, despite the increase in joint laxity with ligament injuries, functional stability is often preserved, due to patients’ muscle strength, motor control and co-ordination adequately compensating for this loss of ligament integrity.
Once an ACL tear has been diagnosed, discussing management options is essential. It is logical (and supported by evidence) that patients should commence conservative management early, including physiotherapy, education and exercises. This early management follows a similar process to post-operative protocols but due to the fact there is no graft, recovery times should be shorter. After the initial phase of recovery, physical strengthening and goals based return to activity including sport are important. Poor physical performance predicts worse long term outcomes.
Rehabilitation following ACL surgery generally takes at least one year, this is in part due to the changes that occur at the graft. Even after this lengthy rehabilitation process, many athletes who return to high level sports end up re-rupturing their ACL. Interestingly, many patients are encouraged to undergo conservative management while they await surgery, in groups of patients like this who never end up undergoing surgery, MRIs and CT scans showed a complete healing of the ACL at 2 and 3 years allowing them to return to sport.
The growing evidence for conservative management of ACL tears suggests there needs to be a big shift in the way we view this injury. For a long time, surgery has been considered the only option, however with high re-rupture rates and slow recovery times it makes sense to shift toward conservative management. Our Physiotherapists can guide you through a comprehensive rehabilitation programs and help you make the right decisions regarding your best management options.
Larsson S , Struglics A, Lohmander L, Frobell R. (2017) Surgical reconstruction of ruptured anterior cruciate ligament prolongs trauma-induced increase of inflammatory cytokines in synovial fluid: an exploratory analysis in the KANON trial. Osteoarthritis and Cartilage 25 1443e1451
Nordenvall R, Bahmanyar S, Adami J, Mattila V, Tsai L. (2014) Cruciate Ligament Reconstruction and Risk of Knee Osteoarthritis: The Association between Cruciate Ligament Injury and Post-Traumatic Osteoarthritis. A Population Based Nationwide Study in Sweden, 1987– 2009. Knee Osteoarthritis after Cruciate Ligament Injury August 2014 | Volume 9 | Issue 8 | e104681
Filbay S, Roos E, R Frobell, Roemer F, Ranstam J, Lohmander S. (2016) Delaying ACL reconstruction and treating with exercise therapy alone may alter prognostic factors for 5-year outcome: an exploratory analysis of the KANON trial. British Journal of Sports Med 0:1–9
Smith T, Postle K , Penny F , McNamara I, Mann C. (2014) Is reconstruction the best management strategy for anterior cruciate ligament rupture? A systematic review and meta-analysis comparing anterior cruciate ligament reconstruction versus non-operative treatment. The Knee 21 462–470.
As a Physiotherapist Francis enjoys treating a wide range of musculoskeletal conditions and is particularly passionate about getting athletes back to match fitness following sporting injuries. Francis also takes hydrotherapy classes once a week Bayswater Waves, helping clients with symptom relief, rehabilitation and injury management in the pool.
Low Back Pain (LBP) and Cognitive Functional Therapy (CFT)
WHAT IS COGNITIVE FUNCTIONAL THERAPY (CFT)?
CFT provides a patient centered targeted approach to management of LBP based on a thorough examination. This classification based management approach for LBP considers many domains including: lower back movement and postures, psychological factors, social factors, workplace factors, comorbidities (e.g. diabetes, obesity), pain processing mechanisms: influenced by genetics and life experiences, sleep and lifestyle factors and their relative contributions to an individual’s LBP. CFT challenges thoughts and behaviours in a functionally specific and graduated manner.
It differs from Cognitive Behavioural Therapy (CBT) as changes in beliefs, thoughts and emotions can be realized by the patient when they experience an improvement in symptoms as they move which may challenge previous beliefs, experiences and knowledge about their condition. In a recent study CFT when compared with a manual therapy and exercise group showed clinically and statistically significant large effect sizes across multiple dimensions. The group receiving CFT was 3x less likely to take time off work in the 12 months following treatment1.
As physiotherapists, in a practical sense, it means we are considering both mechanical and non-mechanical aspects of a person’s disorder. By managing patients in this way we are helping them better understand their pain and to move and function in a way that does not perpetuate their pain. By involving the patients in the problem solving and goal setting the longer term prognosis is improved. Essentially this puts patients back in the “driving seat” for directing the course of their rehabilitation and Sarah and I are both excited about the results we are seeing implementing our improved skills so far….
Low back pain (LBP) is very common and is currently the leading cause of disability worldwide3. Only a very small proportion of people with LBP have serious pathology, such as vertebral fracture, cancer, infection or underlying inflammatory disorder, causing their pain2. Unfortunately using a scan to help diagnose LBP is not reliable because MRI abnormalities are as common in those with LBP as in those without. A common recommendation across all high quality LBP guidelines is routine imaging is discouraged unless serious pathology or specific disease is suspected e.g. if surgery is being considered or there has been a limited response to conservative care. There is no evidence that routine imaging improves LBP outcomes. Over time there has been a significant increase in LBP expenditure without any change in associated levels of disability.
Key positive messages supported by current best evidence regarding LBP include:
- The causes of LBP are rarely serious
- LBP has a good prognosis
- Stay active and resume normal activity as soon as reasonable
- Bed rest is specifically not advised
- The back is a strong structure
- Pain does not equal harm
Key management principles for LBP include:
- Diagnosing LBP via thorough questioning and physical examination
- Limited use of imaging
- Advice about what’s contributing to LBP and an understanding of what’s contributing to the pain experience
- Strategies to self-manage pain including physical activity
- Treatment and exercise specific to the problem
- Medication when required but not as the primary management
The key message here is the clear majority of people with LBP, including leg pain (sciatica), will have a good outcome with evidence based, non-surgical care. Cognitive Functional Therapy is an emerging approach to deliver high quality care considering the complexity of factors that can be relevant to a patient’s lower back condition. At Central Bassendean Physiotherapy we pride ourselves on our accurate diagnosis and evidence based, contemporary management of LBP. We are happy to have a further discussion on the material presented here.
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- Vibe Fersum, K, O’Sullivan P, Skouen J, et al. Efficacy of classification based cognitive functional therapy in patients with non-specific chronic low back pain- A randomised control trial. Eur J Pain 2013;17;916-28
- Almeda M, Saragiotto B, Richards B, et al. Primary care management of non-specific low back pain: key messages from recent clinical guidelines. Med J Aust 2018;208(6):272-275.
- Clark S, Horton R. Low back pain: a major global challenge. The Lancet 2018;391(10137):2302.