We wish to provide a response to the APA’s endorsement of the Australian Orthopaedic Association and the Australian Knee Society’s consensus position statement on the topic of anterior cruciate ligament (ACL) injuries.

This was featured in the InMotion article ‘ACL injury consensus position statement and guideline for physios’ published in October 2022, here.

We would like to raise two issues related to the statement:

a) the divergence between the APA’s position and evidence-based management recommendations for ACL injury and

b) its implications for the physiotherapist’s role in the management of ACL injuries.

The Australian Orthopaedic Association and Australian Knee Society’s position statement was developed through a Delphi process involving discussion between surgeons only.

The position statement does not contain references and there is no declaration of conflict of interest. There was no involvement of multidisciplinary expertise, including no input from physiotherapists.

In contrast to the Delphi technique used by the Australian Orthopaedic Association and the Australian Knee Society, the recent multidisciplinary ‘OPTIKNEE’ consensus statement published in the British Journal of Sports Medicine recommends that ‘in most cases, treatment of an ACL tear should start with education and exercise-based rehabilitation (not surgery)’ (Whittaker et al 2022).

Michael Ingle.

This aligns with a living systematic review and meta-analysis that recommends exercise-based rehabilitation as the first-line treatment in most cases, informed by clinical trial evidence (Saueressig et al 2022).

The Australian Orthopaedic Association and Australian Knee Society’s consensus position statement also states that all ACL injuries need to be managed by a medical practitioner.

To quote the InMotion article, ‘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.’

ACL injuries are therefore placed outside the remit of physiotherapist expertise, for which there is no valid argument.

Of course, in the interest of risk mitigation we agree that physiotherapists must recognise their own professional boundaries and skill set for any acute injury and refer on when appropriate, whether to medical or non-medical expertise.

The article raises the case of a young person who unfortunately sustained a second injury after returning to sport.

While the facts about this case are not detailed, a single case of re-injury on return to sport cannot be used to guide the management of patients with ACL injury. Repeat injuries are a known risk after ACL injury irrespective of treatment strategy.

Approximately one in three young patients experiences an ACL graft rupture after ACL reconstruction, which is associated with injury to the meniscus in many cases (Webster & Feller 2016).

The insinuation that surgical reconstruction is superior to rehabilitation for long-term knee health is not supported by current evidence, which suggests higher rates of osteoarthritis in the long term with surgical reconstruction (Webster & Hewett 2022, Ferrero et al 2023).

Additionally, a systematic review led by orthopaedic surgeons concluded that there is insufficient evidence to support the belief that ACL surgery protects the knee against new meniscal tears (Ekås et al 2020).

We invite the APA and the national groups to reconsider their support for this guideline.

We encourage the APA to invite the Australian Orthopaedic Association and the Australian Knee Society to form a nonpartisan group to develop guidelines on the operative and non-operative management of ACL injuries that are informed by evidence.

Co-signed and drafted by Professor Evangelos Pappas, Associate Dean (Education), University of Wollongong; Dr Stephanie Filbay APAM, NHMRC Emerging Leadership Fellow, University of Melbourne; Associate Professor Christian Barton APAM, postdoctoral research fellow, La Trobe University; Dr Kieran Richardson FACP, Specialist Musculoskeletal Physiotherapist (as awarded by the Australian College of Physiotherapists in 2016), Global Specialist Physiotherapy; and Abby Aitchison APAM, owner, AA Physiotherapy and Sports Injury Clinic, Murwillumbah.

>>Michael Ingle APAM MACP is an APA Musculoskeletal Physiotherapist. Michael combines private practice at Carina Central Physiotherapy with an advanced musculoskeletal physiotherapist role at the Royal Brisbane and Women’s Hospital.

Reply

The shared decision-making model of the Australian Orthopaedic Association and Australian Knee Society’s consensus statement has widespread backing and protects both patients and practitioners, writes immediate past chair of the APA Sports and Exercise group John Fitzgerald.

Thank you to the authors for their opinions. The main author has previously written and asked the APA Sports and Exercise group to reconsider its support for this guideline. The Sports and Exercise group considered the letter and unanimously rejected its suggestions. The author was advised of this decision.

The APA position statement was generated to assist with reported confusion within the physiotherapy community about the optimal treatment of ACL injuries. Some social media activity within Australia has strongly advocated for non-surgical treatment and physiotherapy management alone.

The APA Sports and Exercise group worked with and jointly involved the Australian Orthopaedic Association and the Australian Knee Society in the development of our guideline as they were also developing their own consensus statement.

We aim to continue these established channels of communication as evidence evolves over future years.

The Australian Orthopaedic Association and Australian Knee Society consensus statement generated and agreed on by 200 Australian orthopaedic surgeons in 2021 shows that there is now consideration of surgical and non-surgical options.

Of note in this document is the fifth point. This states that ‘The decision to proceed with either Delayed Optional ACLR or Early Acute ACLR should be made in conjunction with and under the supervision of an orthopaedic surgeon’.

John Fitzgerald.

The fact that this statement now exists needs to be considered carefully by the authors and by any physiotherapist teaching management of ACL injuries.

An Australian Orthopaedic Association spokesperson who was asked for a response to the authors stated that due to the existence of this consensus statement, if any physiotherapist chooses not to involve an orthopaedic surgeon for an opinion, they need to be ready to deal with any future medico-legal consequences.

These physiotherapists are advised to discuss their approach with their indemnity insurer.

The APA guidelines recommend MRI and appropriate radiology investigations with certain presentations.

The authors do not wish to involve medical practitioners in the management of knee injuries but this is incongruous with the fact that physiotherapists are currently unable to refer for Medicare-rebated radiology of knees and are also unable to refer directly to specialists.

At its heart, the APA Sports and Exercise guideline is advocating a shared decision-making model.

As stated, it is a guideline, so it is up to the individual physiotherapist to recognise their own professional boundaries.

The APA’s primary concern is patient wellbeing and the protection of our profession—not professional competition or self-interest.

In her Final Word column in the August 2023 issue of InMotion, titled ‘Thinking about risk is best practice’, APA CEO Anja Nikolic wrote, ‘Insurance houses are seeing increases in the frequency and quantum of insurance settlements.

'They are mitigating their exposure through a number of avenues. There will be a stronger focus on a clinician’s scope of practice, with likely rejection of claims where there is evidence that the clinician was working outside of their scope.’

The APA IGNITE 2023 conference in Brisbane this October will feature speakers discussing knee injury management. We encourage you to register and to keep informed on this topic.

>> APA Sports Physiotherapist John Fitzgerald APAM MACP is the CEO and Practice Principal of Active Rehabilitation Physiotherapy in Brisbane. John’s main area of clinical focus has been the management of knee patients, with a particular emphasis on ACL injuries, and he has 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.