I wrote a blog recently called When can I return to sport after ACL surgery?. It summarised two recent articles by Grindem et al (2016) and Krytsis et al (2016) that both clearly showed a reduction in ACL re-injury risk in elite adult athletes who waited at least 9 months, and passed a battery of strength and functional tests prior to being cleared to return to sport (RTS). To reiterate the above literature; waiting at least 9 months, being within 10% of the uninjured limb on a number of different strength and hop tasks, performing an agility T-test under 11 seconds and performing sport-specific conditioning at training, significantly reduced the athlete's risk of re-injuring their ACL upon RTS.
This blog however will be a little different as I wanted to explore some worrying trends in the literature that suggest we should be more conservative with our RTS planning in our younger athletes who have had ACL reconstructive surgery – specifically those athletes under the age of 20.
I recently attended the annual Sports Medicine Australia (SMA) Conference here in Melbourne and was lucky enough to sit down and listen to some world experts in the field of sports medicine and sports physiotherapy. Two people in particular, Tim Hewett and Kate Webster, really grabbed my attention with their research and insight into the world of ACL injury.
And unfortunately that world is very bleak...
I'll cut straight to the chase.
One study they discussed showed that 30% of young people (mean age 17) who RTS following ACL reconstruction will sustain a 2nd ACL injury within 2 years (1). Of this 30%, females were 5x more likely to do so than males.
And before you say, "C'mon Mick, don't jump at shadows. This is just one study".
This research wasn't alone...
In a further review of the literature I started to find a depressing trend:
25% of subjects (n= 16, mean age 16 years) sustained a 2nd ACL injury within 12 months upon RTS following ACL surgery; with 14 (87%) being female and 12 (75%) sustaining a 2nd injury to the contra-lateral knee. The authors conclusion was that, in this cohort of young athletes, those that RTS were 15x more likely to sustain a 2nd ACL injury within 12 months (2).
29% of patients under 20 years of age (32/110) sustained a 2nd ACL injury within 3 years (3). To put this in perspective, only 8% (35/451) of the subjects aged over 20 years of age in this study sustained a 2nd ACL injury within the 3 year follow up period.
23% of subjects (13/56, mean age 16 years) sustained a 2nd ACL injury within 12 months following RTS (4).
With such a concerning trend of 2nd ACL injuries within the first 2-3 years following a RTS, it has lead some researchers, including Tim Hewett (Nagelli & Hewett, 2016) (6), to pose the question:
“Should we be waiting 2 years to allow our younger athletes (<20 years of age) to return to sport?”.
Nagelli & Hewett wrote their paper based on the current ACL literature and make some very valid points. If we are to look purely at biological and physiological healing, the research is telling us that it can take up to 2 years to achieve baseline knee health (ie. full maturation of the ACL graft, resolution of bone bruises), restoration of knee joint position sense (proprioception/balance), restoration of neuromuscular control and restoration of knee strength following ACL reconstruction.
Although Nagelli & Hewett make a very good argument to delay sport for 2 years, we are all going to have a very difficult time explaining to a 17 year old, their coach and their parents that we need to wait 2 years before we allow them to RTS. This would be an even more difficult discussion, especially if the young athlete is at a critical stage of their early sporting career and the opportunity for a professional sporting contract is on the horizon.
But what I feel often goes missing in the literature on 2nd ACL injuries are the 3 things that are critical to a successful RTS following ACL reconstruction:
1) Was the patient compliant to the ENTIRE rehab plan as set out by their physio, exercise physiologist or strength and conditioning coach?
2) Did the rehabilitation plan include a period of supervised jumping, landing, pivoting, unanticipated change of direction, unanticipated landing and sports specific conditioning?
3) Was the athlete cleared to RTS with strength tests and functional hop tests prior to stepping back on the field/court? And were these tests also passed in a fatigued state?
My gut instinct tells me that these 3 things are not frequently ticked off prior to the patient returning to sport, and I have no doubt that the absence of these 3 criteria plays a significantly role in the high rates of 2nd ACL injuries that we see in the literature.
And there was some preliminary research presented that supports my gut...
Jay Ebert and colleagues from Hollywood Functional Rehabilitation Clinic (Perth, WA) presented some nice (unpublished) data on post-op ACL rehabilitation in a community setting of non-elite athletes. They reported that of the 111 ACL reconstructed patients in their study, 9% DID NOT attend ANY supervised physiotherapy within 12 months, 45% did not attended supervised exercise after 3 months, and only 30% of patients actually performed jumping, landing and agility training as part of their rehab.
Furthermore, they also looked at the quality of rehab and it's influence on functional outcome measures (the same quads/hamstring strength and hop tests that Grindem et al & Krytsis et al used).
They found that of the 55% of patients who conducted at least 6 months of supervised rehabilitation/physiotherapy, they were all able to achieve 90% or greater limb symmetry on strength and hop tests at the 12 month follow-up mark. Furthermore those that completed supervised training longer than 6 months and/or completed high level training drills such as jumping and landing, were all close to achieving full limb symmetry between operated and non-operated limbs. This lead the authors to conclude that the higher quality of the rehabilitation, resulted in superior post-operative functional outcomes.
In conclusion, I think 2 years may be an ultra-conservative RTS timeframe for young athletes, but the evidence for biological healing is very hard to ignore. What us health professionals really need to be explaining to our young patients who wish to return to sports that involve hard landing, cutting and pivoting, are the follow key points:
Up to 30% of people under the age of 20 will go on to sustain a 2nd ACL injury within 2 years upon to RTS. We can't shy away from the statistics, and we need to try as best as we can not to allow the patient sitting in front of us to become another statistic of 2nd ACL injury!!
Surgery is only 50% of the rehabilitation plan. Surgery only restores mechanical/anatomical stability of the knee. It does not restore functional deficits of the knee; some of which may have been present prior to the primary injury (ie. dynamic knee valgus, poor trunk control, abnormal quad to hamstrings ratio).
The better the quality rehabilitation (ie. one that includes regular jump, landing, agility training), the more likely the patient will achieve post-operative limb symmetry on strength, hop and agility tests. As a result, the patient will have a significantly reduced chance of 2nd ACL injury.
The decision to allow unrestricted training and RTS should be based on an orthopedic assessment, time (at least 9 months post-op) AND a battery of strength and functional tests. The tests must include quads and hamstrings strength tests, hop tests and agility tests and the athlete must achieve at least 90% symmetry between limbs on all tests prior to RTS clearance. In my very humble opinion, we should be aiming to get close to 100% on all tests in both fresh and fatigued states.
With the very high rates of contra-lateral injuries, as much as possible, single leg rehabilitation drills need to be performed on BOTH legs.
For better functional outcomes in non-professional athletes, a supervised physiotherapy/strength and conditioning/sports-specific training plan needs to be conducted for at least 12 months prior to returning to sport.
Once back playing sport, the patient should be conducting at least 2x per week ACL injury prevention drills (ie. PEP, FIFA 11, KNEE) for the remainder of their sporting career to reduce the risk of 2nd ACL injury.
I hope you have enjoyed this summary of recent evidence. As always, please share this blog with colleagues, other health professionals, patients, coaches, parents, family and friends. The more people are on board with this evidence, I firmly believe that we will start to see declining ACL injury rates, 2nd ACL injury rates and an overall improvement in individual and team performances on the field.
1. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of Second ACL Injuries 2 Years After Primary ACL Reconstruction and Return to Sport. The American journal of sports medicine. 2014 Jul;42(7):1567-73. PubMed PMID: 24753238. Pubmed Central PMCID: PMC4205204. Epub 2014/04/23. Eng.
2. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of contralateral and ipsilateral anterior cruciate ligament (ACL) injury after primary ACL reconstruction and return to sport. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. 2012 Mar;22(2):116-21. PubMed PMID: 22343967. Pubmed Central PMCID: PMC4168893. Epub 2012/02/22. Eng.
3. Webster KE, Feller JA, Leigh WB, Richmond AK. Younger Patients Are at Increased Risk for Graft Rupture and Contralateral Injury After Anterior Cruciate Ligament Reconstruction. The American journal of sports medicine. 2014 March 1, 2014;42(3):641-7.
4. Paterno MV, Schmitt LC, Ford KR, Rauh MJ, Myer GD, Huang B, et al. Biomechanical Measures During Landing and Postural Stability Predict Second Anterior Cruciate Ligament Injury After Anterior Cruciate Ligament Reconstruction and Return to Sport. The American journal of sports medicine. 2010 08/11;38(10):1968-78. PubMed PMID: PMC4920967.
5. Wright RW, Magnussen RA, Dunn WR, Spindler KP. Ipsilateral graft and contralateral ACL rupture at five years or more following ACL reconstruction: a systematic review. J Bone Joint Surg Am. 2011 Jun 15;93(12):1159-65. PubMed PMID: 21776554. Pubmed Central PMCID: PMC3110421. Epub 2011/07/22. Eng.
6. Nagelli CV, Hewett TE. Should Return to Sport be Delayed Until 2 Years After Anterior Cruciate Ligament Reconstruction? Biological and Functional Considerations. Sports medicine (Auckland, NZ). 2016 Jul 11. PubMed PMID: 27402457. Epub 2016/07/13. Eng.
Simply put, carpal tunnel syndrome is the inflammation or entrapment of nerves within the carpal tunnel of the anterior wrist, which can cause pain and numbness. “Most of my clients see me presenting with the classic symptoms,” explains Richard Garcia, a massage therapist in private practice in Peyton, Colorado. “These symptoms include numbness and tingling in the hand, difficulty grasping or carrying objects and, sometimes, hand pain.” Some clients, too, report the pain is worse in the evening, and sleep can be interrupted.
The causes of carpal tunnel syndrome are often associated with repetitive motion, such as working at a computer all day, for example, though other factors can come into play, as well. “Carpal tunnel is most often considered a repetitive strain or overuse injury, but genetics and disease processes can contribute to the symptoms, too,” explains Mary Bennett, owner of Alleviate LLC in Bloomington, Indiana. “Excessive flexion and extension of the wrist seem to be the most popular theory as to cause of carpal tunnel syndrome. However, heredity, those with smaller carpal tunnels, diabetes and rheumatoid arthritis, to name a few, can all play a part.”
What You Need to Know
Necessary knowledge. Everyone we talked to agreed that a better-than-average understanding of anatomy and physiology was necessary when working with clients with carpal tunnel syndrome. “You must know the anatomy of the area,” Bennett explains. “There are specific structures involved; you should know what they are so you help your client and not hurt them.”
Also, according to Kanoa General, owner of Blue Turtle Healing in New York, having sound critical thinking skills is a must, as well as knowing how to apply current massage therapy techniques to help resolve the problem. “Having a strong professional relationship with a variety of health care professionals should be a given,” adds Garcia. “This gives the massage therapist the opportunity to use the health care professionals as a ‘sounding board’ to privately confirm their assessments, and it shows the health care professionals that you take your work seriously and are actively striving to improve your own knowledge.”
One other critical skill mentioned by the massage therapists we spoke with: know your own limitations. Whether you need to consult with other massage therapy colleagues or refer the client to another health care professional, understanding what you can and cannot do for the client is imperative, especially if there are additional underlying health conditions. “Don’t be afraid to reach out to colleagues or therapists who know more than you and ask for help,” General says. “Also, don’t be afraid to refer out to other health care providers.”
Assessment. Some of your clients will come to you with a diagnosis from their health care provider—and some won’t—making your initial assessment critical. “The initial assessment includes a detailed health history form and an interview,” explains Bennett. “I ask about their medications, general health issues and specific information about the carpal tunnel syndrome, such as the location of the pain and/or numbness, the initial onset and duration of symptoms, activities that exacerbate the symptoms and prior treatment.”
Along with medical history, evaluative tests like Phalen’s or Tinel’s for the wrist can be helpful in developing a comprehensive treatment plan, says General. “I also assess the pronator teres, the shoulder and cervical region for compression along the median nerve, especially if they have a history of neck or shoulder injuries or perform repetitive movements on a daily basis,” he adds.
Because these clients are going to likely need a series of massages to get real relief, reassessing how massage therapy sessions are working is also going to be important. “I assess before and after treatment and ask questions related to the clients activities of daily living,” General says. “For example, were they able to sleep at night with less pain or have they been able to lift and drink a glass of water without feeling like they were going to drop the glass.”
Garcia, too, asks general questions about the client’s condition, as well as if they are seeing any relief from their symptoms or have experienced any changes in lifestyle or stress levels, for example. “I also ask them if they feel we need to make any changes to how the massage is carried out,” he adds. “Do they want or need more or less pressure, more or less oil, as well as what stretches worked, what stretches didn’t, and if there was any discomfort or soreness afterwards.”
Communicate clearly. The same can be said of any consumer demographic you’re working with, but you need to be able to tell your clients what they can expect. First, says Bennett, develop a treatment plan yourself. “Ask yourself ‘what is my objective and how am I going to accomplish that?’” she explains.
From here, make sure you can properly explain the treatment plan to the client in a way that is easily understandable. “The client should know your plan,” she says. “They should know what to expect as far as discomfort and expected results.” Also, be sure you don’t promise results you can’t deliver. Be very clear about the benefits massage therapy will provide so your clients aren’t expecting results you might not be able to achieve.
How Massage Can Help
Techniques used. There are a variety of ways you can work with clients who have carpal tunnel syndrome. Though much of the focus may be on the wrist area, as with other problems, more than one structure may be involved. Garcia does a full-body session with a concentration on the wrist, believing that carpal tunnel is very rarely strictly a wrist problem. “My opinion is that if the client has carpal tunnel syndrome, the probability of other muscles being out of balance is approximately 100 percent,” he says.
Bennett agrees. “The arm is usually in a torsion pattern that is present in the rest of the body,” says Bennett. “Typically carpal tunnel syndrome clients will present with an internal rotation of shoulder and arm. Because the nerve that supplies the sensation in the carpal tunnel originates in the neck and shoulder area, I feel it is important to release possible ‘kinks’ along the entire nerve pathway.”
Using detailed deep tissue work that releases tension, adhesions and trigger points in the soft tissue of the shoulder, full arm and hand, Bennett works to bring the shoulder and arm out of internal rotation. General uses orthopedic massage techniques like myofascial release through stripping, compression and active engagement.
Typical session. Bennet begins by releasing the internal rotation of the shoulder, specifically the pectoral muscles and subscapularis. “Then, starting at the upper arm, down to the elbow, forearm and hand, I feel for adhesions and fibrous tissue, especially along the nerve pathways, releasing them systematically,” he says.
General typically works on clients for an hour, using heat and compression to reduce hypertonicity in the flexor muscles. “This is followed by myofascial release techniques and stretching of the muscle tissue,” he says. “The entirety of the session is not devoted to releasing the forearm but the whole arm, shoulder girdle and cervical region."
Time it takes. The number of sessions a client needs to find relief will vary of course, and most often is dependent on how severe the problem is. “I’ve had clients improve in one 60-minute session,” General says. “Others have improved in six, 60-minute sessions, after addressing primary, secondary and tertiary reasons for carpal tunnel syndrome.”
Most agree, however, that clients should see some relief after the first session. “Most clients experience some relief after the first session,” explains Bennett. “Typically it takes three to five sessions to get long-term results, sometimes more, sometimes less.”
Garcia uses deep tissue and neuromuscular therapy, saying clients usually begin to see relief almost immediately. He’s careful to temper this statement, however. “Note that relief does not mean complete resolution of symptoms,” he cautions.
One of the biggest factors concerning the time it takes for clients to find relief revolves around the time they’ve spent suffering from the symptoms. According to Bennett, the longer a person goes without treatment, the longer it takes for them to recover, generally speaking.