During 2020, the APA National President received a letter from the Australian Orthopaedic Association (AOA) about the contentious discussion regarding conservative versus non-conservative management of anterior cruciate ligament (ACL) injuries. 

The AOA stated that as a group it was seeing many patients who were being given advice by physiotherapists that a rehabilitation program is the best treatment for all ACL injuries. 

The letter cited an example of a young patient being cleared to return to sport by the physiotherapist and unfortunately re-injuring their knee and sustaining extra injuries, including meniscal damage. 

An orthopaedic surgeon had recommended a surgical option. 

The AOA offered to collaborate with the APA to review the education of physiotherapists in Australia with regard to this issue.

Besides the obvious litigation risks and the need to review our education, the APA President and the APA Sports and Exercise national group were concerned about the damage to the relationship between the APA and the AOA and made it a priority for this relationship to be nurtured. 

In 2021, I and the committee of the APA Sports and Exercise national group made the development of a clinical guideline one of their key strategies.

The AOA and the APA Sports and Exercise national group have each subsequently worked to develop evidence-based statements for their members.

Consistent feedback from teachers of the Levels 1 and 2 Sports Physiotherapy courses is that the skill and accuracy of objective manual assessments of the knee is a key area for improvement. 

The APA Sports and Exercise national group has taken this into consideration when rewriting the content and competency assessments of the Level 1 Sports Physiotherapy course.

MRI has allowed the identification of meniscal, chondral and other bony and ligamentous issues that need to be considered. 

We now know of the significance and urgency of meniscal root repairs, meniscal extrusions and the loss of hoop stress and tensile integrity in the meniscus, and of the importance of tibial slopes and intercondylar notch widths when considering surgical and conservative options. 

We also now know, due to the concept of isometricity, that if graft placement is not accurate to 1–2 millimetres, the ACL is not functional. 

Just because it appears that some torn ACLs may have healed, it does not mean that they are effective. 

Many of these considerations are outside the scope of training of most of our physiotherapists and illustrate why it is important to have a shared decision- making process. 

Non-operative management of ACL injuries is not without substantial risk.

Australian Knee Society and Australian Orthopaedic Association

In October 2021, the Australian Orthopaedic Association and the Australian Knee Society developed a Consensus Position Statement on Non-Operative and Operative Management in Anterior Cruciate Ligament Injury. 

The Australian Knee Society is the peak body representing clinicians and researchers in the science of knee surgery and knee conditions in Australia, with the aim of advancing the standard of Australian surgery and management of conditions of the knee joint. 

This consensus position statement deals with operative and non-operative management in ACL injury. 

The Delphi method, a systematic structured communication technique, was used to achieve consensus in a two-round process, with members of the Australian Knee Society present at the 2021 Annual Science Meeting as the expert panel. 

All statements received 80 per cent consensus or greater. 

See kneesociety.org.au/documents.html for the formal statement.

Stakeholders/consultation

 

John Fitzgerald, chair of the APA Sports and Exercise National Group

Representatives from the Australian Knee Society, the AOA, the APA and the APA Sports and Exercise national group worked together to develop the physiotherapy guideline. 

The APA Deputy General Manager, Policy and Government Relations assisted with advice. 

In April 2022, the APA Sports and Exercise national group endorsed the draft guideline: The APA Sports and Exercise Physiotherapy National Committee Guidelines for ACL Injury Management of acute knee injuries in Australia. 

As APA Sports and Exercise national group chair, I presented the guideline to the APA National Advisory Council on 22 April 2022.

Further input was subsequently received from the chairs of the APA Musculoskeletal national group, the APA Advanced Practice (including Emergency Department) national group and the APA Orthopaedic national group. 

There has also been further consultation with Fellows of the Australian College of Physiotherapists.

APA intent

This ACL injury management guideline (below) is designed to support and to mitigate risks to our physiotherapists involved in the management of ACL injuries.

The APA Sports and Exercise Physiotherapy Australia National Committee Guideline for ACL Injury Management 

The Australian Physiotherapy Association is the peak body representing physiotherapists in Australia. 

The APA Sports and Exercise Physiotherapy Australia National Committee aims to advance the management of people with acute knee injuries in Australia.

The APA Sports and Exercise national group, the APA Musculoskeletal national group, the APA Advanced Practice (including Emergency Department) national group and the APA Orthopaedic national group support the Australian Orthopaedic Association and Australian Knee Society Consensus Position Statement on Non-Operative and Operative Management in Anterior Cruciate Ligament Injury (October 2021).

This ACL injury management guideline aims to integrate current research into practical management guidelines for the non-operative and operative management of ACL injury by physiotherapists.

1.    Early clinical examinations can be misleading. MRI and appropriate radiology investigations should be strongly considered for any acute knee injury that results in:

a.    a feeling that the knee gave way, buckled or subluxed with either a contact or non-contact injury

b.    the injured athlete leaving the field of play

c.    the injured athlete hearing or feeling a pop or snap inside the knee

d.    a mechanically locked knee

e.    a paediatric athlete injury where an adequate history is difficult to obtain.

(Medicare-rebated MRIs for acute knee injury in those under 50 are available via GP referral.)

2.    Individuals with an ACL injury or any high-grade ligamentous injury, traumatic meniscal injury or traumatic chondral injury should have an urgent or semi-urgent orthopaedic review.

3.    The decision to proceed with either delayed optional anterior cruciate ligament reconstruction or early acute anterior cruciate ligament reconstruction should be made in conjunction with the patient, physiotherapist and orthopaedic surgeon or public hospital orthopaedic outpatient department. 
The final decision for management should be in the hands of the patient, who should be educated on the pros and cons of different management options, based on up-to-date clinical evidence.

The APA Sports and Exercise national group trusts that you will find this guideline useful as part of your decision-making tree.

If you are a physiotherapist who deals with knees, we encourage you to surround yourself with a team, learn from surgeons, go to theatre and, if you are lucky enough, perform examinations under anaesthetic and observe the nuances of additional pathologies associated with an ACL injury.

>> APA Sports Physiotherapist John Fitzgerald MACP is the CEO and Practice Principal of Active Rehabilitation Physiotherapy in Brisbane and the national chair of the Sports and Exercise group. John has been in clinical practice for 40 years and his main area of clinical focus has been the management of knee patients, with a particular emphasis on ACL injuries. He has seen the evolution of the management of ACL injuries and worked in partnered clinics with knee surgeons for the past 30 years. He is an adjunct associate professor at the University of Queensland and has lectured extensively on this topic and taught in the APA Sports Levels 1 and 2 courses for many years.