ACL Deficient Copers

[pbarrettcoleman]

Hey Everyone:

Had an evaluation this week for a 32 yo male with chief complaint of left knee instability that was rare and only happened with higher level activities (basketball, running on very uneven ground). He reported a skiing incident in 2013 where after getting airborne he landed awkwardly and his knee sustained a valgus force as he landed and then crashed. His knee swelled up and it was painful, however it got better on his own and he didn’t have any problems with ADL. He has had about 4-5 episodes of it giving way since 2013, but they all involve the aformentioned activities. He didn’t do any PT or rehab.

During the objective exam, he presented with increased hyperextension on L (R was 5-10 degrees while L was 10-15), (+) Lachman’s and Anterior Drawer (much more anterior movement compared to other side), and (+) Valgus Stress test for increased laxity on affected knee. For functional testing he was able to do a 3 hop test and a 6m hop test with almost no difference between the two legs (there was some quality difference when on affected leg – increased forward lean, landing was more unstable with increased valgus and pronation).

He had an MRI but did not have the results yet. I told him how some people can cope without an ACL and that I thought it was worthwhile investigating that option given the fact that he’s never done therapy and how well he’s doing overall. We had a good follow up session where we started to work on knee motor control, hip strength, and jump training to get him back to his higher level goals.

When he went to get his results, the MRI showed an ACL deficiency and then the surgeon told him to stop doing PT. He called back and cancelled the rest of his appointments on Friday.

So I have a few questions for you guys:
– I am going to call him back to discuss exactly what happened. Do you guys have research and information on outcomes for non-copers and associated health risks? I didn’t take the message from him, but it sounded like the surgeon wanted him to stop doing PT because it was “dangerous.”
– Have you rehabed copers before, and if so, what were your interventions and thoughts of how to go about it?
– Third, did I correctly identify this person as a coper?

[Eric Magrum]

Great case with great discussion points; and a poorly informed Ortho making patient decisions.

This is the paper for your library; and the group doing the most influential research on this topic.

Have a read and discuss your clinical decision making; and points to discuss with this and future patients; and possibly this MD.

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[helenrshep]

Such a good case, Barrett! I’ve had one patient that was a “coper” (fully torn ACL per imaging, no surgery) and he did great. He was athletic pre and post injury and able to do all the things he wanted to do. I definitely think it’s worth calling him and the surgeon to discuss… I don’t have good research articles but read in a MedBridge post that ACLR patients are actually more likely to develop earlier onset OA than those that don’t have surgery.

I think based on your case, your idea to go with motor control exercises is great. It seems like his only “symptoms” are with really high level activities so doing similar things in PT to challenge his stability and proprioception would likely be the best route. I also think it sounds like you identified him correctly based on the attached article. How was his single leg stance? I also attached another article that talks about non-surgical treatment for NON copers so it seems like a call is definitely warranted.

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[awilson12]

I would agree that this guy seems to be a coper. He has been living with this for at least 7 years now and has had less than one episode a year only with higher level activities. Just out of curiosity, why did he decide to come to PT now after all this time?

Recently listened to a Clinical Edge podcast talking exactly about this. Some main points from the speaker that I took away:
– in some European countries there is a push for a trial of rehab for individuals before considering surgery 1) b/c outcomes for surgery are going to be much better with prehab and 2) b/c this may identify those who are able to cope and avoid surgery. Based off of empirical evidence mostly it seemed that this has been pretty successful for those who go through both op and non-op courses. So, in your case Barrett, either way it seems an initial trial of PT is the place to start (and likely the solution).
– his education for all ACL patients was the increased risk for OA progression with ACL-R and helping them to make an informed decision knowing this (however, admittedly don’t personally know the research on knee health down the line for op vs non-op)

I have not personally rehabbed a coper, but it makes sense to me that it is going to be a similar progression and focus as post ACL-R. For this guy, you skip the initial phase of controlling swelling, working on ROM, etc. and get to jump to focusing on higher level NMR and quad strengthening. I think coming at it from the mindset that he is lacking passive restraint so he needs increased strength and control to make up for this is helpful to guide exercise prescription.

[Taylor Blattenberger]

To the points about OA following ACL tear vs ACL-R: I could not find anything that directly compared rates of OA between copers and non-copers, but it seems that both populations experience an increase in knee OA risk. I think it’s more accurate to say that having the surgery would not decrease his risk.

I would not see the need for this guy to be pushed towards surgical intervention at this point. I think about the giant step backwards he would take for a minimum of 6 months following surgery. I think it is absolutely worth addressing whatever strength and motor control deficits that are there and seeing where he is in 5-8 weeks.

As far as what to work on, I agree with everyone that closed chain motor control, especially in task would be most beneficial. I am curious what his quad strength in isolation is given his side to side quality differences with hop testing. I would check this and prioritize a deficit here.

Mind blowing he was deterred from PT. I would love to hear the rationale (or lack there of).

[awilson12]

Barrett- curious to see how your conversation went with this patient when you called him back?

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