The power of prehab
Yorkshire Knee Clinic’s Dave Duffy explores why the next advances in knee treatment will happen away from the operating table.
Over the past five years the orthopaedic community has made great strides in reconstructing the anterior cruciate ligament (ACL). Specifically, those improvements have occurred in diagnosis and operative treatment. Whilst there are always further improvements to be made, I’d expect the big advances in ACL treatment over the next five years to focus on injury prevention and reducing the risk of re-injury.
These are areas that have traditionally not enjoyed the spotlight in the same way that operative techniques have. For every article about surgical techniques, you’ll find little on ACL treatment pre- and post-diagnosis.. You could argue the reason for the lack of prominence is that we’ve been a little slow on the uptake in the UK when it comes to injury prevention, but we’re making up for lost time now.
The Santa Monica PEP
Mind you, there’s plenty of ground to make up. As long ago as 2000, the Santa Monica Orthopaedic and Sports Medicine Research Foundation launched a genuinely revolutionary study into the effect changing training regimes could have on the incidence of ACL injuries.
In a study of 2000 college-level female soccer players, around 1,000 players were enrolled in an “alternative warm-up program focusing on injury awareness and avoidance techniques, lower extremity strength and trunk stability, flexibility, progressive plyometrics, and sports specific agilities.”
Almost 2,000 players formed a control group working to a traditional model of training.
During the season-long study, 32 members of the control group suffered ACL injuries. In the PEP group (Prevent Injury, Enhance Performance), only two did.
Since the Santa Monica study, football’s governing body, FIFA, has launched the FIFA 11+, applying a similar approach to the training of football skills in younger players. In a 2014 study, the programme was described as being “a useful and effective overall injury risk reduction program at the amateur level” although as players progressed to elite levels it was recognised that more needs to be done.
Increased benefits for women
What both these programmes tell us is that whilst ACL injuries cannot be eradicated, risks can be reduced. That’s particularly important for women, who are about 4-10 times more likely to rupture their ACL as men. That’s a result of a difference in the anatomy of the knee and of the way women’s knees tend to move inwards when landing a jump, which places them at greater risk.
At Yorkshire Knee Clinic, our knee surgeons – in common with most knee surgeons in the UK – have carried out more ACL reconstructions on men, but that’s simply a reflection of the traditional dominance of the men’s game in rugby, football etc. As the women’s game has gained in popularity over the past decade, we’ve started to see a distinct shift. Assuming the games eventually achieve parity of participation, we’ll be operating on many more women than men unless prevention measures improve.
After ACL reconstruction, knee consultants have tended to operate on a nine month rule of thumb for returning to sport. Yet there’s evidence to suggest we need to take a less generalist and more subjective approach tailored to the patient’s age, muscle strength and activity.
Recent studies have shown that if you’re under 18 and you recommence sporting activity within a year of ACL reconstruction, your risk of re-injury is significantly higher.
Once an ACL is reconstructed, no knee specialist wants to have the same patient back in the operating theatre to fix another injury to the same knee – or to the opposite one. So at Yorkshire Knee clinic, we’re working to take a more personalised, less blanket approach to returning to sport. If we can also instil injury prevention programmes in schools and clubs, then we can reduce the risks of rupture in the first place and reduce the risk of re-injury.
The power of prehab
Transforming the way clubs train and the advice knee consultants give can make a real difference to the sportsmen and women we see. Of course, knee injury isn’t exclusive to the sporting community, yet it remains the case that someone who has the motivation and muscle strength to exercise before their operation is likely to find it aids their recovery afterwards.
In the case of joint replacements, the more you’re doing before the treatment, the better the rehab afterwards. For ligament reconstructions (all other things being equal), getting into the habit of doing the right things exercise-wise can help dictate the speed of recovery and the completeness of that recovery.
If you want to find out more about what you can do to get in shape for your knee treatment, talk to the knee surgeons of Yorkshire Knee Clinic.