Anterior Cruciate Ligament Repair (ACLR)

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Part 1 – My Story

January 1996; I was 20 years old and in my final year at The University Of Central Lancashire in England. I was in the Uni Badminton team, played squash, was a member of the Taekwondo club and trained in two local gyms most days of the week. I’d been physically active and involved in sports since before I reached double-digits.

The first incident was a poorly timed side-kick against a heavy kick bag which jarred my knee. The second incident was playing indoor football (soccer) for the first time in years and my knee “popping” and giving way; I collapsed in a heap and took myself off but thought nothing of it as there had been zero pain. The third and final incident was taking a jumping backwards leap on to my left leg to hit an overhead backhand.

You know that feeling of twisting the leg of a hot freshly roasted chicken? – the sensation of the joint rotating and dislocating – it felt like that, mixed with the immediate blow of excruciating pain. After the pain subsided I dragged myself off the court and that was the end of all my sports for several years. My active life as it was stopped at that point.

I saw a GP at the University health centre soon after the court incident. She performed what I now know to be called an anterior-drawer test. It’s used to see if the shin-bone moves forward of the knee. It shouldn’t, but if the anterior cruciate ligament (ACL) has ruptured, it usually does. I don’t know if it did or not, but the Dr told me I’d strained it and that I should cycle to strengthen my quads. I did as I was told. I remember trying to do turning kicks and my knee continuing to give way and feel unstable, so that quickly stopped. I didn’t know what had happened and never thought to get any further help. I’d never seen a Physio before and don’t recall one ever being mentioned.

Fast forward to 1999 and I’d had the shits with it for so long that I ended up having an MRI. There was no ACL. Surgery was an option but I opted not to have it done. I don’t really recall why, but I think it was because I wasn’t playing any sport and it wasn’t stopping me from doing what I wanted, which was train in the gym. I was training in the gym without issue, I could snowboard no problem, and both racquet sports were slowly starting to creep back into the picture again.

Fast forward to 2009. I’m back at Uni again and in a class about biomechanics. A well respected local Sports Physio is taking the class and my ACL-deficient knee is used as an example to demonstrate comical knee laxity. The Physio tells me that the excess laxity is going to cause arthritis and that I’d be wise to have it repaired to delay the inevitable; the last thing I want is an early knee replacement. I respected him and trusted what I was told and quickly went ahead with a surgical consultation. I had elective surgery early 2010 with a hamstring graft. The surgeon, Dr Chris Vertullo, is exceptional. I’d been fortunate to observe him in surgery as a Physio student and his meticulous attention to detail, wall full of fancy-looking certificates, and remarkably confident George Clooney demeanour and appearance all had me feeling like I was in the hands of an Orthopaedic god. My MRI showed absolutely *zero* signs of change in the cartilage from the preceding 14 years of laxity, despite me putting a *lot* of mechanical stress through the joint in the gym. I had a ‘go heavy or go home’ attitude to training. Dr Vertullo even used my images at an international conference to illustrate the point that ACL deficient knees can do just fine.

My first placement as a Physio student was in the Orthopaedic ward I found myself sitting in after surgery. My clinical educator was a lovely guy and I knew a lot of the staff there. I was told to stay in bed, but I didn’t. I’d taught plenty of people how to use crutches and stairs after knee surgery, and now it was my turn to shine! I hopped round to the team room with a big smile on my face to say hello. Apparently, I wasn’t a good patient.

At one point, I was sitting in bed with a splint on my leg; the Physio had left a bag of ice near my feet; not a smart place for it… I didn’t consider the effect on my hamstring (the one which had just had a big portion surgically removed) if I were to rapidly fold myself toward my toes to grab the bag, which is what I did. I quickly recoiled with the sensation of it feeling like it was ripping apart.

I was back in class a few days later with instructions to keep the brace on for 10 days (or thereabouts). In class, I took the splint off straight away and spent most of my time in sitting trying to get the knee to bent to 90 degrees, which it comfortably did within the week. In week two I was still using the crutches but the splint had gone. I also ventured back into the gym to get on a stationary bike and cross-trainer. The cross-trainer felt fine as that didn’t need much bend and it felt good to be able to put some load through it in a controlled way; plain old walking felt less controlled. The first time on the bike wasn’t comfortable at all, even with the seat up high. Back then I hadn’t heard the phrase “push into pain, not through it”. I never felt like I was being silly or irresponsible and nothing I ever did felt ‘painful’, after all, cyclic bending and straightening without load is a pretty reasonable way to improve bending.

At two weeks (from memory), the crutches had gone and I was walking relatively normally again. What was bothering me, which nobody had told me about, was the huge lump I had in the middle of my hamstring! I booked an appointment with Dr Vertullo so he could fill me in. I had the rehab protocol which Dr Vertullo and the Sports Physio from Uni had jointly written and I knew full well that I was way ahead of where I was ‘supposed’ to be. I recall his look of surprise when I ‘walked’ into his office. When I flexed my knee to 90 degrees in standing asking “what’s this?” his response was “you shouldn’t be able to do that”. I was thinking, yeah, I know, now tell me why the heck I have a big hole and lump in my leg?!

It feels pretty much the same now as it did then. I don’t recall seeing Dr Vertullo again after that visit. He suggested that I should see a Physio and recommended Brad Beer. I first met Brad in early 2006 soon after he’d graduated and was opening his first practice, My Back’s Physio in Surfers Paradise. I’d heard about him in 2005 when I was teaching because he was regularly massaging the owners of the company I worked for. I briefly worked for Brad as a Massage Therapist at My Back’s and again in 2012 at Back in Motion as a new-grad Physio.

I’d never seen anyone post-ACL repair/reconstruction, but we’d been through it at Uni and I felt I knew enough about tissue repair, exercise and returning to activities over 9-12 months. I couldn’t see any benefit in seeing Brad, or anyone else. I was active, but I wasn’t returning to sport; I just wanted to get back in the gym and I was already there. I wasn’t stupid enough to being doing deadlifts and heavy leg presses; how was Brad going to help me? I certainly wasn’t going to pay someone to rub my leg.

From memory, I hurt myself four times throughout my rehab. The first was the ice bag incident in the hospital bed. The second was putting my jocks on one morning; I couldn’t bend my knee enough and got the elastic caught on a toe and nearly fell over. A third was catching the bottom of my shoe on a big plastic cover over some cables at the Gold Coast marathon my wife was running in. I can’t remember the fourth but remember there were four incidents because I was keeping track. Each of the four incidents were out of my control; unforeseeable accidents. They were things which otherwise wouldn’t have been an issue. They were memorable (apart from No.4 obviously) because each one felt like my hamstring tearing in two.

I don’t have, and never have had, any issues with my hamstring or knee in terms of function or symptoms. For a long time I was a bit bothered by fluid around my knee cap. Dr Vertullo said it would take about a year and as if by clockwork, disappeared at 12 months.

Last year I saw evidence in the literature that an ACL repair does not change the likelihood of developing arthritis. I hadn’t needed to have the surgery after all. I’d exposed myself to unnecessary risk, having elective surgery which has now turned out to be unhelpful, at least as far as the reason for having it was concerned. It had cost the healthcare system thousands of dollars. It had been recommended by an experienced Sports-titled Physiotherapist and happily conducted by a prominent knee surgeon. Late last year while observing another Orthopaedic surgeon in theatre at the same hospital, I was chatting with him about my ACLR and he very quickly interjected with something along the lines of “there’s no evidence that’s helpful”.

I have no idea what my knee would be like if I had not elected to have surgery. I will never know the effect on the likelihood of developing arthritis later in life. Functionally, I don’t know if I’m any better off now that I have a new ACL. I don’t know the effect of having lost a large piece of one hamstring; objectively at least it measures as relatively equal, certainly within what would be considered ok.

The next logical question might be, “So what’s the role of Physiotherapy?”

That would be a good question! As normal, the answer is “It depends”.

What we do know is that anything we may do passively, cannot stimulate or induce the necessary changes in tissue to alter their mechanical properties following damage or disuse. It is biologically implausible for that to happen. That means passive techniques are next to useless for functional rehabilitation.  Dr Eyal Lederman’s process approach here addresses that.

Somewhere at home I have the discharge letter that Dr Vertullo wrote to my Physiotherapy program coordinators. I’d had the surgery in a mid-semester week-long break and was expected back in class first thing Monday morning. One of his comments was something along the lines of “a good clinician doesn’t treat himself”. I understand that, but to this day I’m still unsure what ‘treatment’ I may have received from Brad, or anyone else, that would have been physiologically helpful. What we (should) do as Physiotherapists, which has efficacy, is to educate patients about the risks and progress their physical activity appropriate to the individual’s goals and in line with the surgeon’s protocol. Just because *I* didn’t follow Dr Vertullo’s protocol with my own knee doesn’t mean I disregard the cardinal rule with someone else – the first rule of ortho club: don’t mess with the surgeon.

A dentist wouldn’t work on his or her own teeth. A surgeon would not operate on themselves, but in my onion, a Physio familiar with and comfortable with an ACLR protocol should be perfectly capable of self-directing their own loading progressions – it really isn’t rocket science! One of the reasons why it’s important for Jo-public to have some input from a Physiotherapist is to protect them from themselves! We wouldn’t expect Jo-public to know anything about the physical and physiological affect of the surgical procedure, biomechanics and loading responses which would be helpful or harmful, timeframes of adaptation, specific exercises etc.

Similarly, a pharmacist may need to see a GP to confirm a diagnosis of a medical condition. If it requires a course of medication, they would likely know the appropriate dosing, titration, symptoms and pharmacokinetics and pharmacodynamics to self-manage that without risk or any further guidance from the GP/PCP.

I didn’t feel that I needed someone else to tell me what I already knew, or to check that I was on track. On a recent podcast on PT Inquest, host Erik Meira suggested that more and more rehab protocols will likely become patient-led in terms of “do what you feel comfortable with”. I agree. If something doesn’t feel comfortable i.e. it’s painful, then it’s probably unhelpful to continue doing whatever is that’s causing the pain.

The human body is designed with a pretty effective in-built alarm system. Over the weekend I took my 18-month old daughter onto her first bouncy-castle. It had a ladder and a slide inside, which we climbed up together. For some daft reason, I ended going down the slide head-first on my chest, behind Rosie, holding on to her hips. I hadn’t thought that through at all. As I tried to slow the pair of us down with my forearms, I experienced searing pain as the sticky rubber burnt a layer of skin clean off. Reaching towards that ice pack in my hospital bed, my alarm system went off loud and clear like a punch in the face. There were other times, like getting on the stationary bike for the first time, when the alarm went off, but not as loudly – a reminder to proceed with caution.

Accidents do happen. If risks are known and understood, then I see no reason why Jo-public would ‘need’ to see a Physio on a regular basis. We know how enthusiastically many patients follow the post-surgical protocols they’ve been given (rarely). Often things ‘feel’ ok, long before tissues have healed. While I was finishing this, I popped into a coffee shop and passed a woman on the way in who was wearing an arm sling. She was holding the arm out of the sling holding a coffee! “do what you feel comfortable with”.

Physiotherapists have a valuable contribution in rehabilitation, but in my experience there are many instances when we’re over-utilised.

To be Cont.

Anterior Cruciate Ligament Repair (ACLR)

Part 2 – The Three Phases of Rehab

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