Jared Powell:
One. All right. So here we are with Karen Richardson who you you're based over in Western Australia right in Perth.
Kieran Richardson:
Yes. Yeah. I'm in the Southwest of Australia in Perth. So,
Jared Powell:
Awesome. Well thank you for for joining us east coast at a time, that opposed to, as opposed to you, I'm really pumped to have this chat. Karen, it's the hot topic at the moment. It seems to be getting hotter and hotter and hotter, hotter by the week. So I was very keen to get you on to, to get your thoughts on this, in this weird time of the coronavirus and everything. So video conferencing seems to be another hot well, so let's get into it. So give us a brief intro about yourself and then also how you came to interested in the non.
Kieran Richardson:
Yeah, so yeah, thanks for having me. So I work as a specialist, musculoskeletal physio in Perth, and we consult, I run a consultancy company of academics and researcher, clinicians, and we give second opinions to clinics in Perth and run mentoring in professional development for the physios. And so that's, I do that full time and I have my own caseload of about 10 hours a week to two, two half days where I see a lot of ACL injured patients for nonsurgical opinion. And there's some failed grafts as well in there. So people that have gone through the surgery that returned to sport it's ruptured and then I'll, I'll see them for review and, and rehab. It all started for me when I was going through my specialist, physio training, and I had two contrasting cases that really forced me to look into the literature.
Kieran Richardson:
So I had this one case and there were similar demographics. So there was this patient, she was in her thirties and she was out late one night, dancing under the influence of alcohol and she knee gave way. And then she went to an emergency department and saw a specialist who decided to operate on her the next day. And then during that operation in the the op the operation notes, it says that the hamstring graph that they'd used was contaminated. So they I put Alars graft in about, she, she really, she wasn't given any rehabilitation after. And so her knee felt sore for about a year. And then they had a follow up MRI and that showed that she developed a cyclo lesion, which meant that her knee was stiff. So she had an for that and helped a bit.
Kieran Richardson:
So she got a little bit more range inflection. And then she had a another series of scans, which showed she had developed inflammatory arthropathy within her knee mm-hmm . And so the specialist decided upon after feeling her knee at her, her Lars graft was lax. So they did a two part revision where they took out the Lars and then decided upon using a Contra later hamstring as well as that she had a hit what he felt was a poster later corner instability. So they used the Contra gracilis for a poster lateral corner reconstruction. And they did a, this revision of the knee. Unfortunately after the first stage of the revision, she developed an infection where they took bone graft from her hip after a dog jumped up onto her hip. And then, so she was then she had antibiotics, which didn't help.
Kieran Richardson:
And then, so she was in the hospital on I, an IV drip for a week. And then a couple months later she had the last part of the revision. Unfortunately, the day after that revision, they she got up after and her knee like buckled, and she did a grade two MC and near, near full thickness, pop tears. So she came in and saw me in clinic on a four wheel Walker. So this is a patient that I just saw in practice. And she was like weeping, the entire consult. And she was in, you know, a lot of pain. And so I saw her and we rehabbed her and got her eventually semi functioning in about a year and a half. And then, and then while I was seeing her, I had this other patient who had a sporting injury where she was playing field hockey, the knee gave way kind of classic ACL and mild small M MC L small municipal test, sorry.
Kieran Richardson:
She came in and said, look, whatever the scan shows, cuz she hadn't had a scan. I want to have I don't wanna have surgery cuz my friends have had surgery and it didn't work out so well. And so I looked a bit into the research and I just thought, okay, well what is the research? So, cause I was going through this, this specialist training, which is big on translating research to, to what you were doing in the clinic and this this patient, she was committed to the rehab. And then we, we just took her through based on, I guess the, the best studies that were available and she returned to sport in four months. and that was the first one that I'd done, which was about six years ago now mm-hmm and after that, I guess I just had these two contrasts and I just, it forced me to look into the literature.
Kieran Richardson:
So I would've spent, you know, hundreds of hours just reading my own papers reviews. And then I started interviewing research experts from both sides of the aisle, like Sur you know, surgeon, research experts and physio research experts. And then I just started to realize we had a problem with over servicing of this, this technique in managing not to say that no one ever needs it, but just that there was no real resources for patients to, to access early nonsurgical opinion or even just that, that nonsurgical is as a as good for many people. So that's just forced me to, to look into it more. And, and I've, I've now I now run workshops for physios as, and I've seen hundreds of patients using this, this sort of approach.
Jared Powell:
So the li so the light bulb moment was this, this two very opposite outcomes which is, which is kind of how it happens. Doesn't it, you, a light bulb moment comes with clinical practice and you see differing outcomes based on, to be honest, if you to run those two scenarios and didn't say the intervention that they had most physios would say the one who got back to sport quicker was likely the surgical one. I'm sure. So this is,
Kieran Richardson:
Yeah. And that's the thing it's just so I guess, you know, you're right, like it was guess I guess, an epiphany or a light bulb moment, like I hadn't even thought about, I just assumed I'd never thought critically about whether it was the best approach. I just assumed surgery was better and this is coming from an experienced physio. You know, I just sort of had, had assumed that the research would be quite obvious on it. And then the deeper you look into the research probably similar with what you find with the shoulder what you, what you start to see is there's this commitment to a patho anatomical approach that maybe isn't necessarily founded in good in good evidence. And then patients are told things that you know, this is a new ACL, this is a minimally invasive technique.
Kieran Richardson:
You know, this is the gold standard and there's these kind of euphemisms that they're presented with. But when you, when I just started asking the question, well, okay, well, is there actually research that shows that a, a structured exercise program is worse, is gonna make patients worse off who have an ACL tear or, you know, is there actually good science to show that doing rehab is gonna you know, be detrimental and you start thinking, okay, well, if, if the best studies aren't showing that that's true, then you know, maybe we've got a problem
Jared Powell:
Conspiracy on our hands. That's for sure. but I mean, conceptually, it makes sense, doesn't it? Yes, yes. And this is, this is a problem with path anatomy, not the problem, but this is why it's such an appealing model. Right? You, you tear something which is imperative for what we were taught, the functional stability of the knee, and I can extrapolate to the shoulder for a rotated as well. You correct that. And then you go on, as you were correct. So you can understand probably why we have sort of gone down the pathway, but here we are 50 years later, potentially, or even more, I don't know when, when did they, when was the first a surgery done?
Kieran Richardson:
So they started doing a reconstructions in the early 19 hundreds. And they did all sorts of, they've done all sorts of a reconstruction. So you've got, obviously the ones that we know now, the hamstring or bone patella, tendon bone, but they used to use the meniscus for some patients. They used to use the ITB for some patients. They they've used different animal models and there's, there's a paper after, of famous AFL player fairly famous for his 12 ACL surgeries Alex Johnson from the Sydney swans. So after he did his, yeah, he had, so he had five reconstructions and then a further seven ops cuz he developed an infection. And you'd think, you know, after maybe the first or second that they'd be thinking differently, but so there was this, there's this group now I'm pretty sure on the east coast that are advocating for kangaroo tendon to be used in human subjects, which I actually thought when I first read the article was a satirical piece mm-hmm but then I, I, the more I looked into it and the, the lead researcher says, look, the marketing is easy.
Kieran Richardson:
People are always asking us to put extra hop into their step and I thought it was a joke literally, but as a well, as a new Zealander, I thought this was a joke. Like I was like, is this a joke? You know, but it's, it's true. So there's, there's these people and you're right. Like conceptually does make sense. The problem is it it's, it's a series of logical fallacy. So whenever you take a drill and put it through someone's bone structure, it does something to the bone structure that's different to not doing it. And you know, I can, I can mention studies if, if that would help the list, but, or the viewers, but there was a paper
Jared Powell:
Might come to that in a minute. Yep.
Kieran Richardson:
So it it's BA it's basically you, when you, when they drill the tabular and femoral tunnels it softens the joint cartilage creates microfractures it punctures into the joint. So when you have an ACL injury, normally it's it's incap. But when you, when you come in with a drill into the joint, it, it changes the joint environment as well and creates more synovial inflammation. And then you're taking a, a, a tendon typically hamstring in Australia, which doesn't have a ligament it's, it's not a ligament. And so you, then you put that in to the joints. And if you look at an ACL normally on an MRI, it's, it's like the size of your thumb, but a graft is like the size of your pinky. And, and it, it never has the properties even at year follow up of a, of a ligament.
Kieran Richardson:
So hence the, the re-rupture rates are fairly high. And so conceptually yes, it does make sense. This is a new ACL, but it's not a like for like, and then you, you start to go, okay, well, what is that doing when I'm having that technique plus exercise versus just doing exercise. And so for physios, that makes sense. It's like, okay, yeah, we would just wait for a joint to settle down. We would start applying, strengthening, you know, look at motor control, deficiencies and, and what the patient psychology is like. And then are they fear, avoidant? Have they strengthened condition before? But if they're just told based on a scan, and even this week, I've had a couple of patients that because of the coronavirus, they're stopping elective surgery, but some hospitals and it's come out in the media are pushing patients through for debatably urgent surgery. And they're told, look, based on your scan, you need this, this procedure, but there's no sort of scientific evidence to say that, you know, scan alone is what we need to treat a patient.
Jared Powell:
Yeah. Wow. It's far out, it's a bit of, a bit of a dark really isn't it? When, when you go into it and it's, it's, it probably just gets deeper and deeper and deeper. Let's, let's touch on some of the, some of the evidence. So I first, I first I think came across some contrary evidence through the ACL reconstruction two or three years ago when that 20 year follow up study came out. And then it showed no difference in osteoarthritis outcomes, which was fluxed me. It was befudling. I couldn't believe it didn't make sense. Right. How can you have an unstable need? That's not wearing out quicker versus a stable. So then I being a shoulder, man, I didn't really go too deep down it, but, but that was quite interesting. So what are some, do we have good randomized control trials where we have a group of non-operative versus an operative group and we follow them
Kieran Richardson:
Through. Yeah. So probably I guess the first the first point I would say is there's that you know, you spoke about like intellectual dark or the dark web and it is actually it's, it's all, it's not a conspiracy it's it's actual fact that there was a systematic review by Kay in 2017 and there was 411 RCTs that compared surgery to surgery. Right? Yeah. But there's only one study that compares exercise to surgery and exercise, mental
Kieran Richardson:
It's mental. And so that's why Cochran in, in all of their reviews, pretty much for the last, you know, 20 years have said, there is no scientific evidence to say that people need early ACL reconstruction, and it's basically just become this healthcare system supported process. And so from an RC T point of view, the, the, the RCT is the can noon trial, which people can look up and it's got a five year follow up with a 10 year follow coming out this year, which might crash the internet. And it, it, at each point at two year follow at five year follow, and I know I can say it now they've come. The authors have come out and said, although it's not published yet, but they've said it through conferences and, and online that there is still no differences between the groups. Mm. So then across
Jared Powell:
What measures are we looking at? Structure, are we looking at functional campaign, everything,
Kieran Richardson:
Every measure, literally every measure pain symptoms, mental health quality of life return to sport outcomes. And these are in highly active, near elite. So kind of a grade amateur, the typical patients that would, would have a reconstruction 18 to 35. And so this, this is the paper that has turned everything on its head in our thinking. And you've, it was very bad written by two surgeons, two physios and they, and if you listen to Buddhi journal sports medicine and their podcast, they're just like, look, we just wanted to be open and honest. And so we started the trial and, you know, in, in the late naughts, people were coming up and patting us on the back saying, look this is a this is great to, we can finally prove that reconstruction is the superior strategy. But then the same people when the two and five year follow up results came out were not welcoming. They were openly hostile is how the research is saved because it didn't support, not only the narrative, but practice.
Jared Powell:
Yeah. Well mate questions, their whole identity world view all of the above things that we don't wanna have questioned Kirin .
Kieran Richardson:
So I'm just, don't shoot the messenger. I'm just trying, I'm, I'm trying to help people, you know,
Jared Powell:
Your fault. So, so let's talk about, so, so that's the Canon or Canon trial, correct. So when was that? So it's one year, five year, 10 year, or what are the, what are the,
Kieran Richardson:
So they did, they did a, it was, it was collated in the the, I think from early to like 2004, I think they recruited and it took quite a few years to get the subjects. And then they published the, the, the two year follow up in 2010. And that this is the first trial that's compared a, you know, not a, it could be maybe more specific in terms of the exercises it's quite general, but the other cool thing was, yes, there was a protocol that people had to the patients had to go through, but there was also, there was pragmatism in the sense that the therapists could add in exercises as they wanted, which was pretty cool. So the, the, the two year follow came out in 2010 and then the five year follow up, came out in 2013 and then they've since done a series of prognostic analyses on the, the Canun group.
Kieran Richardson:
And they've found that so there's a, there's a Australian researcher actually from Queensland, Stephanie, Phil. She did a it was like an award-winning review in editorial sorry prognostic analysis in 2017 that showed that patients that have early Rico before 10 weeks across every measure at five year follow up are prognostically worse. So this, this is sort of further reason. So I guess my key message out of today is that like any other soft tissue injury, we should just wait three to six months, give the patient their options, and then just commence strengthening and, and, and rehab like we would with anything else. And then if the patients have like a locked knee, if they have an associated meniscus tear, or if their knee continues to buckle, despite high quality strength, and then they become a surgical candidate, but if, if we don't give them the option and then if they don't complete the rehab, we kind of never know.
Jared Powell:
OK. So what, what, so, what you're saying is essentially that an ACL rupture occurs that person should then go down to mandatory three to rehabilitation regime if they were to fail that, or be, I don't like saying fail that, or be unhappy with their outcome after that. Yeah. They can choose to go in and have surgery. It shouldn't be ACL rupture surgery happens. And, but only if you really want to, you can try rehabilitation. Is that,
Kieran Richardson:
That that's a, that's a great summary. There's a, there's an emeritus professor of orthopedics. So he's, he mainly does trauma, but he is a world expert in Neo a and he Stephan low Mander. And he was a the, the senior author on the Canun trial. So Bel who I've interviewed in person, he was the physio researcher who actually was the lead. It was his PhD, but then the the senior author, Stephan Loman, I met him when he came to Perth last year and I asked him, I said, like, what do you tell patients? And he goes, I give every patient six to 12 months of physio because I can't promise as a surgeon, if I operate on them, their knee will be any better afterwards. So he takes a very you know, non-invasive approach and, and sort of like you said, the patients have to be willing to commit to it and open to the idea.
Kieran Richardson:
I wanna other point this is all assuming the ACL doesn't heal. So when we went through, based on animal models, the understanding was that the ACL has a poor capacity to heal because of its blood supply. Now there's been, since the mid nineties, there's been about 10 or 12 papers that she show, in fact, the ACL can heal particularly when we apply strengthening to it. So there was a paper which you know, you could pass onto the group or share on your socials, but it was a Japanese study in, in 2017 IARA and Kiwan, and I'd encourage you to reach out to the authors, cuz it blew my mind when I read it, but they had 102 patients who all sustained full thickness, ACL ruptures plus minus concomitant injury and 83 of the 102 healed at 12 year follow up so, so this, so this group, what makes this different is they applied strengthening to the knee. So every patient was put in a brace for three months and they started strengthening within three weeks mm-hmm okay. So,
Jared Powell:
So that, so there is, there is. Okay. So, so does, so the people who ACL has healed to, or show signs of healing, do they do better than those who, who haven't. So is the healing essential or is it a, like something good that happens potentially?
Kieran Richardson:
Yeah, I think that's, that's a good question. So for me, like I just had a lady yesterday like I see quite a few ACLS now, not so I imagine. And yeah, so I tell them, look, it's great if it heals, but it isn't essential. In fact, I don't encourage a follow up MRI. As you would know, with the shoulder research if MRI tends to increase rate of depression, focus on the injury itself you know, fear avoidance behavior increased rate towards trajectory towards surgery. So I just go on signs and symptoms if I was to boil it down. And I find the the patients that, that kind of settles their, their them down and they're not so stressed. But it, it, it's a cool, it's a very cool like myth Buster and I've had four or five in clinic and I PO I've posted them on my, my global specialist physiotherapy group where we online and it's the there's one case we had in Perth here.
Kieran Richardson:
She was a 16 year old netball, a fairly high level. She ruptured her ACL. She was booked in it three months, but fell three weeks, but fell sick. And then she went, she delayed it and her a physio had come on, my workshop kept rehabbing. Her surgeon delayed it till six weeks. Then she, she had a, her HR exam. So she canceled it again and she felt awesome. And so they did all the return to sport testing. She was fine returned to netball in nine weeks has been totally fine asymptomatic with a two year follow up. And she had a six month MRI, which showed complete healing after a full thickness rep so, so it's awesome. And it's that I think if in an ideal world, if we could kind of you know, not tell, not tell the patient the result of the scan, but, you know, depending on whether it heals or not work out some you know, system whereby we could de threaten it either way.
Kieran Richardson:
I think it could be useful to get an MRI, but it's just a great like that, that that's the sort of the healing paper is what I use with elite athletes, because they're just in a, they're in a, a, almost a whole nother ball game, like the, the, the media pressure and the you know, the pressure from the clubs and contractually there's pressure. So it it's, you see them having a selfie, you know, the next day after their injury in their surgical gown, like they're already prepped for surgery. Like it's just this kinda, you know, caricature that we see.
Jared Powell:
That's a that's a completely different conversation, isn't it? Let's, let's not get into a, the, the shortcomings of elite sport medical management anyway. Oh, so if I can summarize, I know you have to go, so yeah, a ACL ACL management or non-operative ACL management, let's just say that , there's never been any evidence to suggest that it in a randomized control trial that surgically repair ACL is superior to a non-operative, non-operatively managed ACL true.
Kieran Richardson:
That's true. You know, and I'm not saying that no one ever needs surgery like that. Definitely. I'm not saying that, but I'm just saying particularly now with the coronavirus, the elective surgeries are canceled. So what are we meant to do with these patients on the wait list? It's kind of the perfect opportunity for them to get rehabbing you know, with telehealth and, and I'm actually just did one before this. I had a, a patient in far north Queensland Wednesday, I had a patient in Southeast Queensland guy in Saudi Arabia this afternoon, next week, people all over the world. It's, it's, you know, they're kind of, well, they can't have an op, so it's almost hand of God forced to, to not, you know, so,
Jared Powell:
So you, you offer telehealth staff online. So tell us exactly what you offer here.
Kieran Richardson:
so well for, for physios that are listening, I do online courses that are you can, you can check out at global specialist, physio.com/acl. So there's courses that you can access through there. For patients, I do second opinion reviews, nonsurgical via zoom like this, or Skype. And I've found them to be very successful at, at the very least it's an education session. So they, they can be informed of their options, but a lot of the patients will go on and just, and just do, you know, E education and, and exercise with facilitated through, through me.
Jared Powell:
Excellent. And you don't, do you demonize open kinetic chain exercises for the knee? Or where, where are you at with that?
Kieran Richardson:
I'm right. I'm okay with it. I think, I think the end, the end game is always function. And so I'm really interested in you know, getting the, like, if they were, if their job was sitting down at a chair straighten their knee day, then maybe that would be one of the exercises I'd give, but I'm not like if, if the, if there's no ACL, assuming it doesn't heal, then it doesn't matter. There's no studies that say it would it's detri. So I, I just, I'm happy if people want do it, but it's not my go to exercise, I
Jared Powell:
Guess. Awesome. Right, mate. I'll I'll let you get back to saving the ACL world. M and
Kieran Richardson:
Yeah. Cool. Yeah, no worries. Yeah. It's, it's good. I love talking about it and yeah, there's, there's much more to unpack, so I'm happy to do you know, more sessions in the future, if you can. And not just start
Jared Powell:
I'll I'll take up on minute.
Kieran Richardson:
Yeah, yeah. Not just a little that's is just a little snippet.
Jared Powell:
No, totally. There's about 14 other questions I have written down that I wanna go through. We were we were handicapped by technology today, but definitely let's sit down and do something again in the mate. Cool. Mate, cheer.
