Practitioner Seed # 11: Be the Conservative Advocate!

I saw a surgeon who told me that I need surgery to fix my meniscus otherwise my knee will wear out.

So often over the years, patients will present to your clinic with this all too familiar story. They lob a pile of scans and surgical paperwork on your desk that make the lord of the rings series look like a children’s short story picture book!

I have shoulder impingement and the surgeon said the tendon was rubbing on the bone, so the bone must be removed.

While these instances are becoming less & less common, we are also seeing an explosion of ‘pop up’ rehab facilities that are attached or run under the banner of a surgical practice. Surgeons are very smart people. You don’t finish 15+ years of intensive practical and cognitively demanding training, without living in the upper echelon of human intelligence! You might surmise…….

That they are reading the writing on the wall?

 

That is, they are being proactive!

More and more evidence appears in the scientific world, supporting the effectiveness of a conservative approach in the management of MSK issues.

A recent systematic review by Skou et al (2022) has highlighted just this. They pooled 100 RCT’s and concluded that 9 out of 13 conditions for pain, 9 out of 9 for function & 11 out of 11 for Quality of life, showed no significant effect for surgical compared to a conservative approach.

Interestingly, the 4 conditions that showed a moderate effect size in improving pain with surgical intervention, were cervical disc herniations, spinal stenosis, sacro-iliac joint pain and chronic low back pain.

This indicates, that while the current narrative to avoid spinal surgery at all costs is strong, there are still some spinal patients who might achieve a reduction in pain from surgery. These are the patients that have tried multiple conservative approaches, and exhibit an absence of any major psycho-social yellow flags. However, although pain improved in these patients, function & Quality of life did not. We postulate, that these cohorts became ‘activity avoidant’  ….

 

So their pain settled, but was it the surgery or the avoidance of activity?

 

Surgical techniques such as sub -acromial decompressions, meniscal resections / repairs, Achilles repairs & even ACL reconstructive surgery, are all being challenged for their efficacy. If you merge this evidence with the potential adverse effects that surgery might produce, and the financial burden on patients – it’s not at all surprising that more and more patients are opting for a conservative approach.

 

Does your patient need a cuff repair?

 

A recent systematic review & meta- analysis by Fahy et al (2022) has highlighted that from a total of 297 subjects, there was no significant difference between surgical or exercise therapy for large rotator cuff tears (Large classified as > 5cm, 2 or more tendons, night pain, pain & weakness with abduction & Ext rotation). One of the major issues that this, and similar studies encounter, is the heterogeneity or lack of reporting when it comes to the exercise program implemented.

Consider the arbitrary nature of an exercise program……..

Comprising multiple facets

• ROM
• Strength
• Hypertrophy
• Endurance
• Muscle activation

Then combine that with the right dosage – Enough to achieve adaptation (Minimal clinically effective dose), without overdoing it.

Consider the human in front of you – Technical competence, program adherence, affinity for exercise……

Include the right education and advice at the right time………

Ensure there are no other confounding activities or factors that might interfere with the exercise effect……….

THEN…..

It’s nigh on impossible to create a standardised exercise program across a large cohort of patients!

 

It is probable that the exercise program effects might be EVEN GREATER once we have applied our individualised, patient- centred rehab approach.

 

Surely, this ACL needs a reconstruction?!

 

The landmark RCT series by Frobell & colleagues (2013) has highlighted that surgical reconstruction of the ACL is not an absolute requirement for a successful outcome. Out of 59 patients who underwent primary conservative rehab with the option for delayed reconstruction, 23 progressed to surgical reconstruction.

36 (61%) got back to full function without surgery!

At 2 & 5 year follow ups, there were no differences in the battery of patient reported outcome measures or KOOS scores.

 

Revolutionary work that has changed the landscape of how we approach ACL injuries!

For your everyday patient and amateur athletes, it makes sense to trial a conservative approach. Problems arise when you reach the elite level. Adopting a conservative approach requires a trial period- 3 months of intensive rehab.

There is also some emerging evidence from sports physician Tom Cross and colleagues in Sydney who are trialling a progressive fixed flexion bracing protocol to be adhered over 12 weeks, then rehab starts!

There is a 50/50 chance that we get to the end of the 3-4 months block and either the ACL has not healed (if applying the bracing protocol) or this patient is not a coper- subsequent instability episodes occur – & Surgical reconstruction is on the horizon! Unfortunately there is one luxury that is not afforded at the elite level, that is….. TIME!

From personal experience, we have rehabilitated 2 elite level ACL injuries conservatively on opposite sides of the same athlete…….

 

ACL INJURY 1

Presented with a hyper extension episode, laxity on lachmans testing, yet firm EF. Imaging revealed a rupture to the PL bundle, AM bundle intact.  With a criteria- based rehabilitation program & rigorous objective testing, the athlete was able to clear our RTP guidelines and returned to the elite level for 12 months prior to injuring the opposite ACL!

 

ACL INJURY 2

Mechanism was classic pivot shift: change of direction, wide step, low knee flexion angles, valgus and internal rotation. Lachmans testing revealed laxity, this time without a discernible EF.

We were more concerned with this injury than the previous!

After the shared decision- making process, the main factor that arose was the players age – he was in his twilight and feared reconstruction would mean the end. Combine this with a positive experience the previous season, conservative management was the outcome. Unfortunately on this occasion, while the player cleared his physical criteria to RTP, the lack of ACL continuity resulted in a further instability episode during a competitive match – The player retired.

 

And finally…….

 

Achilles Ruptures? Surgical v Conservative…

 

A recent systematic review and meta- analyses has highlighted a statistically significant reduction in re rupture rate in those treated surgically v conservatively (Ochen et al, 2019). Although this reached statistical significance, a difference of ONLY 1.6% raises questions of clinical relevance? Does reducing the risk of re-rupture by 1.6%, offset the potential serious adverse effects of surgery?  The answer for most of our patients will likely be NO!

Taking the conservative approach for achilles ruptures, it’s critical to be accurate with the early / acute management. Intervening early with appropriate orthotic devices to maintain the injured tendon in a shortened position, and facilitate optimal tendon healing. Failure to do this adequately can lead to the tendon healing in a lengthened position, & the patient suffering ongoing issues with function of the triceps surae complex.

 

So where are we at with Surgical v Conservative management?

Thanks to some fantastic, clinically transferrable work from our research compatriots – our position in the injury rehab world is stronger than ever!

Now, lets apply this back to the patient in front of us!

1. Ensure a shared decision- making approach – Engage all the key stakeholders, lead the process and supply all of the facts to your patient. At the end of the day, surgical v conservative is THEIR DECISION!

2. Understand when surgery is more likely to be a reasonable option – ie multiple failed conservative rehab attempts, significant joint mechanical signs, history of traumatic episodes….

3. But remember, that not all conservative rehab is equal! Some programs completed in the past might have missed the mark in terms of identifying and addressing the key driver/s of the injury.

4. When things are a little ‘Grey” Mark out a timeline for your patient. In the event that you’re not completely certain that things won’t progress to surgery, you can use language like ” We are going to give a trial of rehab, if things aren’t progressing as we would like at the 8- week mark, we will discuss other potential medical interventions”. 

More often than not, you will achieve a really great outcome for your patient with conservative management.

The better you become at your craft, the more WINS you will have!

The next step on your quest to becoming a great clinician..

Head over to our modules page and join the Foundations Learning Experience

 

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REFERENCE:

 

• Skou, S. T., Poulsen, E., Bricca, A., Dideriksen, M., Lohmander, L. S., Roos, E. M., & Juhl, C. B. (2022). Benefits and Harms of Interventions With Surgery Compared to Interventions Without Surgery for Musculoskeletal Conditions: A Systematic Review With Meta-analysis. Journal of Orthopaedic & Sports Physical Therapy, 52(6), 312-344.
• Kathryn Fahy, Rose Galvin, Jeremy Lewis, Karen Mc Creesh.(2022), Exercise as effective as surgery in improving quality of life, disability, and pain for large to massive rotator cuff tears: A systematic review & meta-analysis, Musculoskeletal Science and Practice. Volume 61.
• Frobell, R. B., Roos, H. P., Roos, E. M., Roemer, F. W., Ranstam, J., & Lohmander, L. S. (2013). Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. Bmj, 346.
• Ochen Y, Beks RB, van Heijl M, Hietbrink F, Leenen LPH, van der Velde D, Heng M, van der Meijden O, Groenwold RHH, Houwert RM. Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. BMJ. 2019 Jan 7

 

 

 

 

 

Shoulder imp

Knee meniscus

ACL

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