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The Melbourne ACL Rehabilitation Guide Story

20 Jun 2018
Randall Cooper
I had landed my dream job. After years of networking, working with developments teams, and even moving up to the mountains for three winters in a row in Australia, I finally got to work with our national skiing and snowboarding teams.

The year was 2002, and Australia was riding high on a successful Salt Lake City Winter Olympics with our first ever winter Olympic gold medals to Steven Bradbury and Alisa Camplin. It was a great time to be involved in winter sport in Australia, and I was charged with the responsibility of looking after the medical side of our flagship program – the aerial skiing program.

The aerial skiing program at the time was star studded. Jacqui Cooper had won the 1999 World Championship and was favourite to win at Salt Lake, however she ruptured her ACL/MCL 5 days before the final (ACL rehab No. 1). Alisa Camplin was the reigning Olympic Champion and was gunning to continue her success, and an up and coming 20 year-old Lydia Lassila had just placed 8th at Salt Lake City and was touted as the next big thing. She was – she won gold at Vancouver 2010.

There were also a bunch of highly talented ex-gymnasts who had come into the program, so the next 4 years leading up to the Turin Winter Olympics was supposed to be magic carpet ride with visions of having 2 or 3 athletes on the Olympic podium in 2006. It didn’t go that way.

Over the next 3 years every single member of the World Cup and Development team blew her ACL, bar one athlete. It was 8 out of 9 out, and a few of them did it twice.

At the time I was doing my Masters by Research at La Trobe University investigating different approaches to ACL rehabilitation. I was across the ACL rehabilitation literature and I was clearly in the thick of it clinically. I kept searching for evidence on the factors used to determine return to sport, but there was very little.

A 2011 Barber-Westin & Noyes systematic review summed up the state of play at the time;

  • 40% of studies used no criteria
  • 32% of studies used time post op only
  • 15% of studies used time post op and subjective criteria, and
  • Only 13% used some form of objective criteria (isokinetic dynamometry, thigh circumference, general knee examination, hop tests and validated questionnaires).

Despite 1000’s of papers on ACL management, RTS wasn’t even a topic at the time.

I knew I had to get objective about returning these athletes back to sport, so I put together my own protocol. The Melbourne Return to Sport Score was born.

The protocol consisted of three parts;

  • Part A – Clinical Examination (25 marks)
  • Part B – Subjective Evaluation (25 marks)
  • Part C – Functional Testing (50 marks)

We felt the protocol was useful for the athletes, and getting a score out of 100 was a powerful motivator for everyone involved.

I had worked with Melbourne Orthopaedic Surgeon Hayden Morris on the protocol, and after the 2006 Winter Olympics we agreed that I would run all of his patients through the RTS protocol at the end of their rehabilitation. A few other surgeons also joined in, and between 2006 and 2012 I probably ran 200-250 tests every year. I got a good feel for things.

The protocol morphed over those years – some tests came and went, and I kept an eye on evolving assessments and evidence in the literature. I shared the protocol with many of my sports-medical colleagues in sport here in Australia, and after a while the protocol started to get a ‘name’. 

In 2013 I published the protocol as an e-book. For those of you who have used it, please accept my gratitude. Coming from both a research and clinical background, I was very aware of keeping the battery of tests evidence-based, but clinically applicable. No isokinetic dynamometry or 3D motion analysis in the lab was included to keep it “real”.

It’s been great to see RTS criteria following ACL reconstruction evolve over the past 5 years or so. It’s a topic that’s received much attention at both a clinical and academic level, and our collective knowledge has grown considerably since Barber-Westin and Noyes’ wake up call.

So, as a result, it’s time to update the (now) Melbourne ACL Rehabilitation Guide 2.0. I’ve been very privileged to be joined by sports physiotherapist Mick Hughes to co-author this edition of the protocol. Mick has done an outstanding job in recent years collating clinically relevant information on the management of ACL injuries, and disseminating that evidence in an honest and useable way. He knows his stuff, practice what he preaches, and has been an amazing resource to ensure this latest edition is current, relevant, and practical.

Here’s what’s new in the 2018 Melbourne ACL Rehabilitation Guide:

  • A Pre-Op Phase. Recent research has suggested that people who attain full range of motion, good quadriceps and hamstring strength, and minimal swelling prior to surgery have better outcomes than those who don’t up to 2 years post op. Baseline data is also collected at this time which is used later in the protocol.
  • Supplementary Assessments. For those serious athletes and practitioners that want to do everything possible in each phase, a number of supplementary assessments have been listed for Phases 2 & 3.
  • Inclusion of New Assessments. Classic assessments such as the single hop test remain, however there are new hop tests, new balance tests, new strength measures and new subjective questionnaires included in Phases 3 & 4 of the protocol.
  • Testing in a Fatigued State. Most RTS has been conducted when athletes are fresh, however research has shown limb symmetry indices can become abnormal in a fatigued state. In this new protocol, a fatigued-state protocol has been included in the RTS assessment and algorithm.
  • General Fitness Testing. How do you know if the athlete has regained full pre-injury fitness? Using objective data of course. We include two sports-specific fitness tests that are compared to baseline results to help make an accurate decision on RTS.

 

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You can also check out my ACL Masterclass with Mick Hughes at Learn.Physio, or download your copy of the Melbourne ACL Rehabilitation Guide 2.0 here.




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