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294 | The Collateral Damage Consideration of Going Nonoperative in ACL Rehab · The ACL Athlete Podcast

• 0:18
  SPEAKER_00: Welcome everyone to the ACL Athlete Podcast.
• 0:22
  SPEAKER_00: This is the podcast where we talk about everything related to the ACL, whether that's the injury itself, the rehab process, return to sport, and more.
• 0:31
  SPEAKER_00: I'm your host, Dr.
• 0:32
  SPEAKER_00: Robbie Patel, performance physical therapist and coach.
• 0:36
  SPEAKER_00: Between myself and fellow guests and experts, you'll learn through the lens of the patient, the healthcare professional, and the coach.
• 0:43
  SPEAKER_00: The goal of this podcast is to equip you, the athlete, with the education to make the best informed decision about your care and your ACL journey.
• 0:54
  SPEAKER_00: Thanks for joining.
• 0:55
  SPEAKER_00: Now let's dive into today's episode.
• 1:00
  SPEAKER_00: What is up, team, and welcome back to another episode on the ACL Athlete Podcast.
• 1:06
  SPEAKER_00: So I had an athlete a while back who went non-operative and they were crushing it with strong knee, strong quads, all around were doing great.
• 1:17
  SPEAKER_00: No giving way, doing everything right.
• 1:19
  SPEAKER_00: But then one day they were walking across a pull deck.
• 1:23
  SPEAKER_00: You know, the pull deck can be wet.
• 1:25
  SPEAKER_00: They slip, knee gives out.
• 1:28
  SPEAKER_00: Now here's the thing if that same slip happens to someone with an intact ACL, in a lot of cases the knee, you know, it might be able to catch itself.
• 1:40
  SPEAKER_00: Maybe if there is an injury, then it's the ACL, and maybe you get some meniscus and MCL, but it's not as aggressive.
• 1:48
  SPEAKER_00: There's a restraint there doing its job without you noticing that it's doing it, right?
• 1:53
  SPEAKER_00: But this athlete didn't have that, they didn't have that seat belt, they didn't have the ACL there to help protect them.
• 2:01
  SPEAKER_00: And so instead of, you know, that scare or what had been an ACL injury, they walked away with a pretty torn meniscus MCL tear fully and some cartilage damage on top of it.
• 2:15
  SPEAKER_00: And so today I want to talk to you about something I don't think we talk about enough with ACL rehab and people, especially who are considering the non-operative route.
• 2:26
  SPEAKER_00: So people land on non-operative for a bunch of reasons, different reasons that can exist.
• 2:32
  SPEAKER_00: And I want to name a few before we get into it because it's not just one path that people take.
• 2:38
  SPEAKER_00: Sometimes it's decided the day of injury, it could be because of your age, the season of life you are in.
• 2:45
  SPEAKER_00: You think about someone who's 15 years old versus someone who's 55.
• 2:49
  SPEAKER_00: And then you think about what sport actually demands of needing the knees themselves, what your healthcare situation and insurance and coverage looks like, whether you're in a universal healthcare system, or whether you are more insurance-based, for example, you might have to wait a long time.
• 3:08
  SPEAKER_00: Or you might be able to get into surgery next week based on the availability and your insurance.
• 3:13
  SPEAKER_00: But that is something that will influence people's decisions.
• 3:17
  SPEAKER_00: Also, what is your deductible, for example?
• 3:20
  SPEAKER_00: There's some people who are like, I don't want to pay$10,000 to have my ACL surgery.
• 3:25
  SPEAKER_00: They're like, I don't want to be in that debt.
• 3:26
  SPEAKER_00: And so therefore they're like, let me try this without, right?
• 3:29
  SPEAKER_00: And then those other things will factor in, like seasonal life, their goals, their age, all those things.
• 3:35
  SPEAKER_00: The country you're in will influence this.
• 3:37
  SPEAKER_00: Sometimes it's the information you found online.
• 3:40
  SPEAKER_00: Maybe it's people claiming they got back to sport without reconstruction, or that the ACL heals on its own.
• 3:46
  SPEAKER_00: Um, and I'm gonna use heal in quotes because the jury is still out here.
• 3:51
  SPEAKER_00: And it is something that you may read on a forum, you may see someone talk about it.
• 3:56
  SPEAKER_00: There are certain professionals who push more non-operative than others, and so it just depends on the information that you're getting in, plus all these other factors, and many I still haven't named.
• 4:08
  SPEAKER_00: But these are things that will influence that decision making.
• 4:11
  SPEAKER_00: And sometimes it's not even decided until later.
• 4:15
  SPEAKER_00: You know, maybe you plan to have surgery, your prehab's going great, the knee feels super solid, and you start thinking, maybe I'll just see how this plays out.
• 4:24
  SPEAKER_00: I've had ACLers land on non-operative from every one of those directions.
• 4:29
  SPEAKER_00: Everything I named here, we have had ACLers come through this path where they have had surgery set, they are not in a place to be able to do it, whether it's the season of life, maybe it is the sports that they are playing that they're like, I don't really need my ACL as much.
• 4:46
  SPEAKER_00: And they tore their ACL doing something else.
• 4:48
  SPEAKER_00: Like, let's say they tore their ACL skiing, but then all they want to do is hike or maybe just go on walks, you know?
• 4:55
  SPEAKER_00: So there are some considerations around this that isn't just let's go have surgery.
• 5:00
  SPEAKER_00: And then you think about just some of these situations where people might not have good coverage, or there are doctors that are in network, or they might have to wait a long time.
• 5:10
  SPEAKER_00: And we've had people in other countries who are waiting to get surgery, they are doing prehab with us in the process, and they're like, My knee feels pretty good.
• 5:18
  SPEAKER_00: And I'm like, I don't know if I need this surgery.
• 5:21
  SPEAKER_00: So then they cancel the surgery and they go to Don Op, right?
• 5:24
  SPEAKER_00: And so this is all things that can play into this, but there's no wrong way to walk through this door because it is wherever you're coming from, the question underneath all of it is essentially the same, right?
• 5:39
  SPEAKER_00: And that's the thing that I want to talk through today, and I want to be clear about what this episode is not.
• 5:45
  SPEAKER_00: It's not me making the case for surgery over rehab or rehab over surgery.
• 5:51
  SPEAKER_00: I've had ACLers succeed non-operatively.
• 5:54
  SPEAKER_00: I've got people on my roster doing it right now and with our team.
• 5:58
  SPEAKER_00: And there are people who obviously go the surgical route and do incredible as well.
• 6:02
  SPEAKER_00: There is not going to be a perfect situation for each person that is just set go operative or go non-operative.
• 6:10
  SPEAKER_00: And it can vary very much, especially as time goes on, and as many different factors can influence this as well.
• 6:17
  SPEAKER_00: What today actually is the difference between making basically a bet on this, that's what non-operative is to some degree, is kind of taking a gamble or a bet a little bit and being informed about that, and then potentially getting blindsided by that bet.
• 6:35
  SPEAKER_00: Those are, you know, just two very different experiences, even when the outcome ends up looking the same on paper.
• 6:42
  SPEAKER_00: And I think that's something that's really important here is that the end result could look the same, but in terms of going non-operative, there can be something that can happen as a byproduct of this, and you get blindsided.
• 6:58
  SPEAKER_00: And some ACLers adapt to life without an ACL.
• 7:02
  SPEAKER_00: We call those people copers, some don't, no matter what they do, and they end up needing surgery anyway.
• 7:08
  SPEAKER_00: We call those basically non-copers.
• 7:11
  SPEAKER_00: And so this is published in the research, Fitzgerald, Axe, Lynn Snyder Mackler, big ACL giant in the research world.
• 7:19
  SPEAKER_00: There's screening tools for this that date back to even the 2000s, looking at strength testing, hop testing, you know, a real framework for sorting people into who might be a coper and who can get away with not having surgery and who isn't.
• 7:33
  SPEAKER_00: And I'm not here to talk through any of the ACL healing related literature here today.
• 7:38
  SPEAKER_00: This is more so of if you tear your ACL, it's something that I want to talk through of like, you know, how can we sort this out a little bit, but more so what is the potential collateral damage of this that we need to be aware of?
• 7:52
  SPEAKER_00: And the thing with this is that the classification itself isn't fixed.
• 7:56
  SPEAKER_00: The research since then has shown some people who test out as a good candidate early on shift categories later after training changes, what their knee can actually handle.
• 8:07
  SPEAKER_00: So we have a real tool, we just don't have this like crystal ball necessarily to be able to predict, and we can guarantee like, okay, this is the route you're gonna take on day one.
• 8:17
  SPEAKER_00: And instability episodes is gonna be a big part of this because if you have more than one instability episode, then that is going to categorize you into typically the non-COPRA route.
• 8:27
  SPEAKER_00: Again, it's just gonna really vary depending on the person, situation, but they have screening tools that are helpful to make better decisions around this.
• 8:38
  SPEAKER_00: But here is what I think gets missed.
• 8:40
  SPEAKER_00: People treat this decision like it's just about whether the knee feels stable.
• 8:45
  SPEAKER_00: Does it hold up, yes or no?
• 8:47
  SPEAKER_00: But your ACL is never just something for stability, it's also a mechanical restraint, if you will.
• 8:55
  SPEAKER_00: So it's your knee's seat belt, and when it goes, the C belt goes with it too, right?
• 9:02
  SPEAKER_00: It's something that is going to help architecturally and structurally hold things in place, and it's also going to influence the stress of other things that is going to get impact on the joint.
• 9:13
  SPEAKER_00: So the risk isn't really about the time.
• 9:17
  SPEAKER_00: It's not that waiting longer without an ACL slowly builds up damage in the background.
• 9:22
  SPEAKER_00: That's not really the concern here because there's research to show that delayed surgery is not increasing a risk of arthritis.
• 9:29
  SPEAKER_00: Now, if you go and do a bunch of stupid stuff and you keep subluxing and the knee gives out, then yeah, you might tear up some stuff in the joint and that could increase your risk for osteoarthritis down the road.
• 9:40
  SPEAKER_00: But with that said, the risk shows up more so in like specific moments, is my point to share today.
• 9:47
  SPEAKER_00: It's the giving way episodes itself.
• 9:49
  SPEAKER_00: That's the actual event where that collateral damage happens, not you know, the weeks or months that pass that you don't have the ACL.
• 9:58
  SPEAKER_00: And that's what exactly happened on this pull deck scenario with this athlete.
• 10:02
  SPEAKER_00: That one moment she slipped, the ACL wasn't there to take or help with the load.
• 10:07
  SPEAKER_00: And so then therefore, the meniscus, the MCL, and the cartilage took a hit instead.
• 10:13
  SPEAKER_00: And I'll be honest with you, we can't always predict who has, you know, one clean giving away episode and walks away fine, versus you know, who has that same exact moment and ends up with the real damage from the injury.
• 10:28
  SPEAKER_00: But understanding that the moment itself just gonna carry the risk more, not because of time, but because of that ACL not being there.
• 10:39
  SPEAKER_00: And so I think that's one case that we just need to consider for this.
• 10:43
  SPEAKER_00: And the range here is that some ACLers never have another giving away moment or episode after the injury that happens.
• 10:53
  SPEAKER_00: Some have small ones here or there, and some have them repeatedly.
• 10:57
  SPEAKER_00: Sometimes the knee flares up and settles down in a day or two, and sometimes it lingers a lot longer than that.
• 11:04
  SPEAKER_00: There's no clean line that really tells you in advance the type of non-operative route you're gonna have.
• 11:10
  SPEAKER_00: And a lot of it is going to be due to a lot of these factors of you know, the injury itself, how is the knee responding, how is your instability, how many episodes do you have?
• 11:21
  SPEAKER_00: And those things are going to really all influence a lot of you know the potential route you might have for non-operative.
• 11:28
  SPEAKER_00: And obviously, if you have more instability episodes, then yeah, it is going to yield you going to have surgery more likely than not.
• 11:36
  SPEAKER_00: And I would advise that.
• 11:37
  SPEAKER_00: But if you're in this kind of category of, you know, maybe it's hard to get the surgery, or you have to delay or wait, or you don't have the resources, or you really want to try it non-operatively, or you know, the goal is whatever factors that I'd shared with you, then it is also fair to potentially trial this for the right person.
• 11:57
  SPEAKER_00: So I'm not sitting here saying everyone needs to go non-operative because there are many people I don't think that need to go non-operative.
• 12:04
  SPEAKER_00: And there's the screening information that I shared for being able to know whether that is a viable thing or not.
• 14:15
  SPEAKER_00: So if you're navigating this decision right now or you're already a few months into trying non-operative, here are three questions that I'd want you to sit with.
• 14:26
  SPEAKER_00: If I have a giving away episode, is my plan to treat it as just kind of noise or uh just like, you know, that's a repetition that I'm gonna count here?
• 14:36
  SPEAKER_00: Or is it as new information that changes the conversation with what you're gonna do?
• 14:41
  SPEAKER_00: Number two is am I actually at peace with the version of this where I still end up having surgery later?
• 14:48
  SPEAKER_00: Not hoping I avoid it entirely, but actually at peace with it as a real possibility.
• 14:54
  SPEAKER_00: And then number three is what's the one goal that's a non-negotiable for me?
• 14:59
  SPEAKER_00: And does a bad giving way episode put that goal at more risk than I'm actually willing to accept?
• 15:06
  SPEAKER_00: Those questions won't necessarily stop, you know, a slip on a wet pull deck from happening.
• 15:13
  SPEAKER_00: Nothing will in reality because you don't have that ACL there.
• 15:17
  SPEAKER_00: What they'll do is make sure you already know how you're going to respond before you're standing in that moment instead of figuring it out for the first time while it's happening to you.
• 15:27
  SPEAKER_00: And if you're a clinician or coach listening to this, this isn't something you explain once at the start of care and move on from.
• 15:35
  SPEAKER_00: This is the informed consent conversation you're having on an ongoing basis, not a box you check, just at the very first visit.
• 15:43
  SPEAKER_00: It's something that I think is very important.
• 15:45
  SPEAKER_00: Test for it, plan for it, plan for what a giving away episode actually triggers in your process.
• 15:51
  SPEAKER_00: Guide that conversation before it happens, not after you're doing the damage control on the back end.
• 15:58
  SPEAKER_00: And this is something we have a conversation with anyone who wants to navigate the non-operative path.
• 16:04
  SPEAKER_00: And I am very honest with them about what this path can potentially lead to.
• 16:10
  SPEAKER_00: And again, there are people who have been very successful at this, and there's also people who have also had challenges with this in terms of getting there, but then once they get to the dynamic things, it's more challenging and they get more giving way episodes, and it ends up being this intersection of their goals as well.
• 16:29
  SPEAKER_00: So then they end up having the surgery, and so this is where it is really hard to determine who those are, and we have to collect data points along the way during their prehab or rehab process to be able to get there.
• 16:42
  SPEAKER_00: And I'm not gonna necessarily sugarcoat this in either direction.
• 16:48
  SPEAKER_00: In the best trial we actually have on this, the canon trial, patients were randomized to either early surgery or rehab first with the option of delayed surgery.
• 16:57
  SPEAKER_00: In the rehab first group, 39% ended up having surgery within two years.
• 17:02
  SPEAKER_00: By five years, that number was 51%.
• 17:05
  SPEAKER_00: So about half the people who tried rehab first still ended up having surgery eventually.
• 17:09
  SPEAKER_00: That's not necessarily a failure rate in this situation, it's just a little bit of the odds, and this is from a pretty respected trial.
• 17:20
  SPEAKER_00: And more people are successfully going non-operative than five years ago.
• 17:24
  SPEAKER_00: The ACLers I've seen carry real regret about this path, almost never regret trying it.
• 17:30
  SPEAKER_00: What they regret is not knowing what they were actually risking when they made that call.
• 17:35
  SPEAKER_00: That's the only thing that I wanted to make sure we tackle today that I think was really important is just understanding the collateral damage of if you do not have that ACL there and you choose to go non-operative, then there could either be a situation that unfolds, like the pull deck, where you could potentially create more damage in the knee.
• 17:57
  SPEAKER_00: But then there is also the situation where the knee gives out as you start to do harder things, and then that could also lead to something in the knee where that takes the blunt of the load, right?
• 18:09
  SPEAKER_00: And it's not me scaring you away from doing non-operative.
• 18:13
  SPEAKER_00: Again, I think there are many people who also have had surgery who should have gone non-operative or should have trialed it at least.
• 18:21
  SPEAKER_00: But in most situations, people are going to be pushed to surgery, especially if they're seeing an orthopedic surgeon.
• 18:28
  SPEAKER_00: It's just a natural case, and there's still this A plus B equals C, you tear your ACL, you have surgery, you're on the road to recovery.
• 18:37
  SPEAKER_00: I think depending on exposures and training of surgeons and maybe different parts of the world, there has been a bit better understanding, and maybe some surgeons are considering this a little bit better in conversations of being able to share this information.
• 18:53
  SPEAKER_00: But I think it's also important to not sugarcoat it because sometimes people are like, Yeah, I'm gonna go non-operative, I'm gonna do great.
• 19:01
  SPEAKER_00: And they're not warned about this collateral damage.
• 19:04
  SPEAKER_00: And I think it's unfair to them.
• 19:07
  SPEAKER_00: And I think if they know this, then you know, you kind of lay out everything on the table and allow the person to make the best informed decision for the journey ahead of them.
• 19:17
  SPEAKER_00: And at that point, you can't necessarily be mad if you choose to go that journey.
• 19:23
  SPEAKER_00: And let's say you are this person on the pool deck.
• 19:25
  SPEAKER_00: Guess what?
• 19:27
  SPEAKER_00: They knew what that path looked like and they accepted that.
• 19:31
  SPEAKER_00: And yeah, they ended up going on to have surgery because of that collateral damage.
• 19:35
  SPEAKER_00: But the thing is, is that had they never gone on that pool deck, they could have gone years, maybe the rest of their lives without having the ACL reconstruction.
• 19:43
  SPEAKER_00: But that is also just the nature of life because accidents happen.
• 19:47
  SPEAKER_00: But it's also important to just understand the risk, reward, and the trade-offs of what non-operative can potentially present with.
• 19:56
  SPEAKER_00: And I think that that needs to be discussed for anyone who is choosing not to have surgery and to also have a plan A, plan B, plan C, and being able to understand what that looks like and to navigate that appropriately based on your specific context of your life, your goals, your particular knee, and the path that you want to take, right?
• 20:23
  SPEAKER_00: And so I hope that this helps you guys in terms of potentially making a decision if you're maybe on the fence and you're trying to weigh the pros and cons of this.
• 20:34
  SPEAKER_00: And it's something that I get a lot of times, especially for my athletes who are, let's say they're in their 40s, 50s, and 60s, and they're like, I don't know if I really want to go through a surgery.
• 20:46
  SPEAKER_00: There are these goals that I have, but they're not as aggressive as you know, the 15-year-old who's trying to get back to soccer to play at the next level, or you know, the 23-year-old that's still trying to go ski a million miles a minute.
• 20:59
  SPEAKER_00: Like, people have different goals, and so then therefore that can influence their decision.
• 21:05
  SPEAKER_00: And I think that is something that's really important in this is that there's not just one way to do it, but even with having ACL reconstruction, people need to know the pros and cons, just like any graph choice you make, the pros and cons to it.
• 21:19
  SPEAKER_00: You need to be educated on knowing, okay, if you're getting a quad graft, you're gonna expect a delay in quad recovery, maybe some donor side discomfort, maybe some extension challenges, just like the differences with patellar tendon or getting a hamstring or getting an allograph, right?
• 21:37
  SPEAKER_00: All these are decisions that need to be made in this process, and the non-operative is no different.
• 21:43
  SPEAKER_00: So I think equipping you guys with this, understanding it, making informed decisions.
• 21:49
  SPEAKER_00: So then that way you're three months down the road, six months down the road, and you're like, no one told me about this, and I never thought about this.
• 21:56
  SPEAKER_00: You're like, I'm just gonna give it a shot, but then you're like, I don't want to be dealing with this later, or you're like, I don't want to necessarily do more damage to my knee, especially based on my goals, or I just don't love that risk.
• 22:10
  SPEAKER_00: But as long as that's laid out, then you can feel at peace knowing you took this path.
• 22:16
  SPEAKER_00: And let's say that the seatbelt's not there and you had a situation where the knee gave out and there was some collateral damage, then at least you can swallow that, knowing, like, okay, I'm gonna go have surgery.
• 22:27
  SPEAKER_00: I knew that this could be the case, but it was worth it.
• 22:30
  SPEAKER_00: I exhausted it, and I'm on the road to having surgery and recover from there.
• 22:35
  SPEAKER_00: So I hope that this is helpful.
• 22:37
  SPEAKER_00: If you guys have any questions at all, you know I'm here to help.
• 22:41
  SPEAKER_00: Um, I'd love to hear your opinions if you have any about what I shared today.
• 22:46
  SPEAKER_00: Otherwise, I will catch you in the next episode.
• 22:48
  SPEAKER_00: This is your host, Robbie Patel, signing off.