The Sports Physical Therapy Podcast

Nonoperative ACL Rehabilitation with Mick Hughes - Episode 16

August 23, 2022 Mike Reinold
The Sports Physical Therapy Podcast
Nonoperative ACL Rehabilitation with Mick Hughes - Episode 16
Show Notes Transcript

When it comes to ACL injuries, there is a ton of research and information on reconstruction and injury prevention, but it seems like no one ever talks about nonoperative ACL rehabilitation.

It has been shown that the ACL does have some capacity to heal and that some people may do well without having surgery.

But probably not in as many people as we would like.

In this episode, I'm joined by Mick Hughes to discuss his experience with nonoperative ACL rehabilitation, some of the factors that may decide who is the best candidate, and how to progress these people through the rehabilitation process.

 Full show notes: https://mikereinold.com/nonoperative-acl-rehabilitation-with-mick-hughes

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Introduction:

On this episode of the sports physical therapy podcast. I am joined by Mick Hughes. Make is an exercise scientist in physiotherapist in Australia that specializes in ACL injuries. We often talk a lot about ACL reconstruction. But in this episode, we're going to focus on non-operative treatment. We're going to cover a wide range of topics, including if the ACL can heal who potential candidates for non-operative treatment could be and how we could rehabilitate these people make as a ton of clinical experience this year. So it was really great chatting with him.

Mike Reinold:

Heym welcome to the podcast. I really appreciate you taking some time out in us trying to coordinate this from literally across the world to, uh, to get you on for an interview. So thanks so much for joining us.

Mick Hughes:

Pleasure, Mike always, uh, great to talk shop with. Um, some people who've got a strong passion for ACLS is what I do. So thanks for asking me to come on board. Yeah,

Mike Reinold:

Yeah, that's awesome. And you know, from somebody from afar, that's been really enjoying some of the content that you're putting out there on your website, your social media presence. Um, I I've, I've learned a ton from you over the last, you know, few years or so, and, you know, just wanna say big, thank you for, for putting that stuff out there because you know, if it wasn't for people like you that are sharing all their experience right. Then, you know, we wouldn't keep growing. So, you know, really appreciate you taking the effort to do all that.

Mick Hughes:

you. Yeah. Or, I mean, I, I, I. I'm an avid sharer of, I absolutely need to give credit to those great researchers and academics who are doing the work. Um, I'm just a, a lover of great research and trying to translate that research into clinical practice as soon as possible. So I think hopefully I've been able to bridge that gap a little bit and, and shared these, these wonderful research papers in ACL. And so, yeah, that's, um, it's been nice to be able to sort of help, help use that. Help that on social media.

Mike Reinold:

Yeah, that's great. And, and, you know, I mean, I think we, you know, we need people like yourself that can like bridge that gap, uh, that, that, that, uh, gap between, um, the clinical research and clinical implications. So meaning like, I, you know, how do I take this data and what does it do to. To change my everyday patterns that I do with people. And that's exactly what you're doing. I think that's why I'm drawn to your educational content so much and your website and your, your master classes, just because it is very research based, but clinical implications BA based. I really love it.

Mick Hughes:

Yep. Yeah, no, thanks. It's uh, yeah, hopefully I've got the balance, right? So, and hopefully I'm, I'm actually doing a, a service great service to the, to the academics who actually do the hard yards and hopefully I've interpreted their data well and applied it, um, in a, in a good way that, uh, benefiting us all. So yeah, no, I appreciate the con.

Mike Reinold:

I like it well said. So, um, so I, you know, I always, I like to ask this question because it, we, we start a podcast like this and clearly you and I have a, a topic that we want to talk about, but did you ever think, like, you know, flashback several years, did you ever think you were gonna be so heavily focused on ACLS and that it is almost like your life revolves around ACLS? It seems like now. Did, did you ever think that was gonna happen?

Mick Hughes:

No. Got I honestly thought, cause I actually really sucked at ACL rehab management early on in my career. When I reflect on my early two or three years as a clinician. I thought I knew a lot and I tried to take it on, tried to take patients on board and I thought I was doing a good job and, and probably to be fair at the time, the research, really the mountains of research and the, um, the high quality research that we now now know, you know, 10, 15 years ago probably wasn't sprinkle. Yeah. It wasn't out there in a practical sense. And. You know, how we managed return to sport especially was really time based, um, back then. And so I was just sort of doing as best as I could. And, and unfortunately, I, I know of at least probably half a dozen patients I saw under my watch that re-rupture their graphs in the first one or two years postop. Um, and, and taking that time to reflect. And obviously as the years go on and, and my experience grew and research evolved as well. Started to know that certainly criteria driven rehab is a far better way to go with, uh, especially return to training return to sport management. So, yeah, I, I, once that just started to evolve, I really started to live and breathe ACL, uh, rehab and return to sport management. And. And, and certainly try to change my clinical practice to improve it to a, a much better standard. So, yeah. Look I, yeah, 10 years ago, I didn't really think I'd be sort of here I am. Um, but I'm glad I am because I've certainly learn a lot along the way and, um, probably will continue to learn more over the next 10 years too. And my practice will evolve in 10 years, timers, uh, hopefully in a better place and even what it is now. So yeah, it's, it's, it's been a great.

Mike Reinold:

I, I can't wait to have you on the podcast again in 10 years, assuming I'm still doing this podcast in 10 years in, in us talking about how bad we thought our ACL rehab was 10 years ago. Even, even today we're saying we like it. but you know, I, I mean, T. To me that that's always the sign of, of, you know, that's how everything develops like great innovation develops. It's we have a problem and you know, you put your head down and you, you solve that problem. And I love that about, about hearing that from you is that you, you felt like you were a little bit weak maybe in ACL. So you, you put your head down and said, I'm, I'm gonna, I'm gonna dive head deep into this and become the best ACL clinician I can. And then over time, The reps and the experience that helped produce this, this new level of judgment that that only experience could take. So

Mick Hughes:

Yeah. Yeah. The other other thing that really was a catalyst was I, I was invested into a, uh, profe, a semi-professional a, uh, bunch of athletes in a, in a sporting code in here in Australia, which is a all called netball, which is a bit foreign to most of your American, uh, listeners. It basically, if you think about basketball, But without backboards and you've got seven players on a court, um, and it's very female driven sport. And the only way of moving the ball up the court is passing. You can't dribble it, you can't, you know, Dodge people, it's basically jump catch, pass, and then nothing but net swishes to, to score points. So, you know, look, it's such an intense game and I was the head physio for this group of elite athletes who were incredible, you know, female. Athletes, um, but a sport that has got notorious notoriously high rates of ACL injuries. So, you know, I basically took it upon myself to learn everything. I knew everything that I could learn about ACL injury, both injury prevention, but unfortunately we did cop a couple of ACLS with our players. Um, you know, how was I gonna rehabil rehabilitate them back to, you know, a high professional standard as well. So yeah, it there's nothing like being thrown in the deep end and being told to sink or swim. Um, it was, yeah, it was great.

Mike Reinold:

that, that sounds like a Petri dish of potential, uh, people to, uh, to, to study there. I mean, all the pivot cutting and, uh, jumping on court. That's that's crazy. So, um, Awesome. Well, when, when we talk ACL, I think the majority of times you hear people talk about ACL. We're always talking about, um, reconstruction. What do we do after return to sports? Been a huge topic the last few years, um, even injury prevention is a pretty popular topic, but one thing we very rarely hear about and people just don't talk about enough is non-operative treatment for an acute ACL tear. So you just, or your, your ACL it's almost, I, I dunno. I think the majority of people would assume. you need surgery, right? I, I think if we did a poll, I think it would be, it would be very high. So, um, you know, very curious, like why, why do you think that is? Why, why do you think people don't don't think about non-operative treatment for ACLS?

Mick Hughes:

Yeah. I think it's probably geographical in that decision. Part of that conversation is probably depends on where you live. Um, you know, and probably the different healthcare systems that you, you live in. Like if you go to parts of Europe and parts of Scandinavia, like the, the default is rehab first, um, you know, they're reconstruction rates over in parts of Europe are only 50%. Whereas here in Australia, over in the states, reco reconstruction rates are as high as 1990 5%. Um, so definitely it is a geographical. Um, problem so to speak. Um, but yeah, I think that's, that's probably largely part of that conversation and, and yeah, so I think that's probably a big part of that conversation is, you know, where you did your training, where you live, what geared towards, I think definitely here in Australia and, and I hope we're not speaking outta line to, um, you guys in America, but it's definitely a case of here in Australia is it's what we've always done. So we're going to, we're gonna keep on reconstructing. Um, cuz we know that's probably got. A safer bet, I guess, in terms of the end result, um, definitely the non rehab or the non-operative slash rehab alone path is got a lot of gray area to it, like with the outcomes. Um, you know, we don't know if, um, the person will have a successful outcome and return back to pivoting, twisting sports without an ACL. We don't know if the very well, if the risk of re-entering other parts of the knee, Um, is gonna be worse compared to a reconstruction like that. That's very debatable. Um, especially when we talk about maybe some of the recent research coming out later. Um, but yeah, look, there's, there's a lot of UN unknowns with. Rehab alone. Um, there also, that's probably counted by the fact there's only been two randomized control trials ever done. Um, prospective randomized control trials that actually set out to answer. Um, is there a better course of action for the acutely injured ACL patient, you know, early, either early rate? Fairly reconstruction or having the option for a delayed reconstruction. Um, so with all the papers and researchers published every month in ACL land, only two papers have ever, ever been published to this date that have tried to answer that question out of the hundreds of thousands of ACL papers out there. So that that's probably part of the part, part of that problem.

Mike Reinold:

we don't, we don't have subjects. Right. We don't have enough people that are going through the non-operative, uh, path to be able to do a study like that. So that makes complete sense that, of why we have that lack of, of quality research in that area. You know, it almost seems like to me, at least in the United States here with us that I, I don't wanna say it's in impatience because I, I don't know if that's kind of the right thing, but I, I feel like once a young. Tears their ACL between the athlete, the parent, the coach, the surgeon, the, the physio team. You put all those people together. Everyone just wants to get them back as fast as they can. And, and they don't, they don't want to delay. And they just, they just know that, Hey, I, you know, surgery's gonna be, you know, successful, hopefully. So, you know, instead of taking that chance and missing three years of your, of your four year high school career, you know, it's probably not, not worth it. So, um, yeah, it's,

Mick Hughes:

Yeah.

Mike Reinold:

a

Mick Hughes:

And it's definitely hard. Exactly. And I imagine it's much harder for the clinician in America because of the high school pathway systems to college and the college systems potentially through to professional contracts, you know, NFL, NBA, baseball, ice, hockey, major league soccer, all the, all the. Big big sports Australia. Definitely doesn't have probably that same elite driven pathway. Um, we we've definitely got, you know, elite sporting schools that sort of are nurseries to the professional codes here in Australia, but it's definitely not so, so geared in that way. And I, I could understand absolutely, um, that time pressure demand, um, for the high school athlete, who's probably only got one or two years to sort of prove, potentially prove to, you know, college Scouts. And then obviously college students to prove to, you know, professional Scouts like how, what their worth is and how talented they are and that kind of stuff. And, you know, a miss season potentially. Could be, could be harmful to their long term careers. So I kind of, I absolutely, um, empathize with the clinicians there and I absolutely empathize with the pediatric, you know, like the, the young patients who have injured themselves that are still skeletally immature. Like I deal largely with adults. Um, I, my clinical practice is largely geared towards the adult population who have re you know, injured their ACL as an adult. I, I very rarely see these days, any, you know, young 12, 13, 14 year old kid, and. Man that is a tough decision. You know, that's a tough conversation and it almost just doesn't get spoken about a non-operative pathway for these young kids. But yeah, look, it's, it's definitely a, a hard treatment choice, but importantly, I think that's probably the whole point of this chat ride is to, to probably, you know, raise some awareness that there is a treatment choice out there. It's just whether or not you choose to take it or not. so,

Mike Reinold:

Right. Right. Well, and, and sometimes too, I, I think what we do is we'll take the information, the data, and even those, those circumstances that we just talked about in that you would have for maybe a 16 year old athlete. And we would apply that to. 26 year old adult, that's just doing recreational sports and give them the same, you know, like clinical algorithm in our head where we say, no, just get surgery right away where maybe that's not the case. I mean, and you just, I think you spoke very well as, as to the problem and the system that we have here in the United States with getting people into college and professional sports. But when you start applying that to everybody, I think that's when we start running into trouble. So, I mean, like you said, it's, it's about awareness. Right.

Mick Hughes:

Yep. Yeah. I, the first conversation I have with anyone that's acutely walking in, you know, with a, with a suspected ACL or a confirmed ACL. You know, what, what are your goals? Where, where are we going with this? You know, where, where do you wanna be in 12 months time? Are you sort of knocking on the door of a, a scholarship program or are you being sort of earmarked as a future, you know, MVP or, you know, professional sporting player? Or are you, are you just playing sport just for kicks? um, because if you're just playing for kicks and a, been a bit of fun, Hey, let's sit on this. Let's sit on this, uh, injury that you've got for three months. Let's take a breath. Let's take the emotion out of it. Cuz that first month especially is very emotional. Um, you often make very emotional decisions when you just wanna get back to sport, but I really encourage, um, those absolutely are justified. You know, those that aren't dealing with a repairable men. Or, or fracture, um, that often need early reconstruction. Um, those that have got indications for a delayed reconstruction at the very least, I I'm having conversations with them to say, let's wait three months. Let's take, take a breath. Let's do some really good rehabilitation. um, and then let's, let's get that at three month mark and, and see, see where you're at and then see where your head space is at and see where you want to go with this. Because if you're feeling good after three months, then I, I think there's a strong argument there and not only feeling good, but feeling stable. Um, and your rehab's been really good. Um, let's continue this ride, um, and let's see where, where you go with it. Um, yeah, I might have gotta skip ahead some of the questions, but

Mike Reinold:

No, no, that's great. I mean, I mean, I like that because that's, it's, it's taking a practical approach from an emotional situation. And a lot of times I feel like we're the ones that have to help guide the people through that path. We have to help them say, let's take a deep breath. Just like you said, let's take a step back. Let's take a deep breath and let's think this through here. And, and I think. You know, sometimes we serve as almost these, these, uh, guides that have to bring people through this decision making process. Sometime I think it's important that that PTs and physios understand this. So this is important. So, um, well, so here's the, here's the big question. If we're gonna even do this, does the ACL itself even have the capacity to heal? Is that on the table or are we just hoping that their secondary stabilizers pick up what's what's the research saying? And, and by the way, You saw this on Instagram. I, I posted these, uh, these questions on Instagram last week to get some poll. And I was amazed at how many people said yes, the ACL key hail. And yes, we should be doing non op ACL. I was amazed at the majority, said that. So, uh, maybe a little selection bias between my followers, but, but what do you think can the ACL heal? What is the research

Mick Hughes:

Yeah. And. It can, and, and there, there is certainly some, um, emerging evidence, like probably the strongest research we got at the moment is just coming on the back of a rare analysis of the, the famous cannon trial, um, which probably is, you know, a foundation paper to a lot of my clinical practice. Um, so for those that aren't. Aware of the cannon trial, basically they, uh, ran, it was a perspective, uh, randomized control trial. They divided the 120 people into two groups of 61 group. 60 had, um, an early reconstruction. The other group of 60 had the option. Well, did rehab first, the option of a delayed reconstruction at. At five years post, um, entry into the trial, 50% of the delayed reconstruction group was still rehabbing alone, um, and, and had equal outcomes across the board compared to early reconstruction versus delayed reconstruction. So that that's definitely one of the foundation papers that's allowed us to sort of make some better decisions, but they actually did re-analysis of that group. Um, so at the two year mark, they went through and looked at the MRIs cause they did serial MRIs over the period of time too. And they found. 56% of the rehab alone group. So the group that I was doing well, which probably justifies why they were doing well is because 56% of them had more physiological healing of the ACL, um, tissue. So that was massive. Like, that's been a, a huge change. Like, you know, it's a huge evidence, uh, or a huge shot in the arm for the evidence that the ACL can heal. Um, it would be wonderful to know if any of those early, um, paid well, you can't find, we won't find out, but it would've been wonderful to know if any of those early reconstruction patients. Were going to be healers as well. Um, but we would never, we never found out it's probably a fair argument to say those that elected for a delayed reconstruction probably weren't healing and were having some degree of instability or symptoms, which led them down that reconstruction part. Um, so yeah, 56% of those, um, yeah, in the rehab alone group where we're healing at two years, there's also two, some probably. Uh, strong papers out there. Um, so longitudinal study, not longitudinal studies, sorry, but, um, retrospective, um, studies on, um, uh, a case series of patient. So the strength of the literature isn't there, we, we, but we have seen healing in other papers, so aha. And. Kuo was a Japanese study. Um, they, they found, um, healing, um, in, in a certain subset of ACL patients. They had over a hundred patients over a two year window and they took serial MRIs, um, from memory they had about, oh, please don't quote me on this, but it's about 40, 40%. Of their group, um, started to show healing. Um, and they found that it was kind of like a subset of ACL tears. So you imagine, I think, you know, back in the day, I used to imagine all ACL tears, basically all mid substance tears are basically exploded in the mid middle part of the ACL, but we've actually started to discover slowly over time that there's. There are subtypes of ACL tears. So you, you do get those mid substance tears that basically split and, and cut in half, but we're actually seeing the emergence of some proximal, um, almost like evulsion type tears from, um, the proximal attachment of, of the, of, of the ACL. Um, from its femoral attachment and, and they, they found in that, uh, aha. And Kawano paper that, um, the people that were more likely to heal were those proximal almost like avulsion type injuries. So the ACL itself was largely in intact, still. But it was healing either on the footprint of where it tore off or very nearby. Um, it had a couple of limitations there, um, into that paper, but it was starting to show some, um, there was another paper that showed some evidence there and there's another one by Costa PA, which showed healing in, in about 30 odd it's about 20 or 30 odd patients there as well. So it, to, to say that the ACL can't heal, um, is certainly a, a, it's a false statement. Um, We probably just don't know yet who these lucky people are. Uh, are they young? Are they old? Are they male? Are they female? Are they, you know, pivoting hard pivoting, cutting sports, you know, are they sort of more gentler, um, ACL tears, um, speaking to an orthopedic surgeon, he said the people that he's come across that have healed are more those traumatic injuries with a lot of bone bruising, um, a lot of concomitant injuries. So a large, you know, big grade, three MC tear as well. Um, so yeah, all that bleeding and all that inflammatory sort of, you know, juice in the knee is somehow later, you know, scar network between the endpoints and it's, it's created some healing potential there, so that that's certainly, um, you know, a potential there. If you see someone with a big bone bruise, a bigger fusion and he AOSIS early, you know, maybe these are the people that are lucky. Um, so yeah, we, we just don't know quite yet. I think that that's the exciting literature. I can't wait to see. Evolve over these next five or 10 years is hopefully a, a better understanding of who these lucky healers are, but I've seen many cases in my own clinical practice of these people healing. Um, and it's just, it's a really nice thing to, to see and to rehabilitate these people. Um, but yeah, I never promise it's gonna happen. And I think that's important for all the people say, look, the, the chances of this happening are probably less than 10%, maybe even less than 5%, but Hey, let's roll the dice. We're not under time pressure. Let's you know, rehab sensibly over the next three months, let's re evaluate clinically at three months, you know, Lockman pivot. If it all looks and feels better, Hey, let's get another MRI on this and see if you're in these early stages of healing. Because if, if you're healing at three months, then that naturally you should strengthen up and mature and evolve over the next, you know, 12, 12 months. So yeah, it, it can happen.

Mike Reinold:

It, it, it's pretty interesting too. And I think we, what we needed was this, right. We needed just a glimer of hope that this could happen. And then now we can dive in again and, and really research this. And I, I like how you brought up it's, you know, the different types of tears, how traumatic it was. The other types of injuries, but probably more importantly is the location of the tear and, you know, proximal, distal, mid substance, the blood supply, the healing supply of that. Um, I, you know, once we, once we identify that, let's say half of the people may have the potential of, of healing then. Great. We can now study. Maybe, how do we maximize that? Maybe it's, you know, proximal tears are better than mid substance and we can start this clinical decision making tree. I, I, I, this is the first step that we're witnessing right now. Instead of saying you have a very minimal chance. Now we say like, well, that chance may just depend on what type of tear you have and what a. Great place to be in. And we haven't even, you know, that's, you know, probably beyond the topic of today's podcast, but like the whole concept of orthobiologics and internal bracing. I mean, there's, there's, there's so there's so much future here that, um, you know, it's, it's a good niche to specialize in ACLS right now.

Mick Hughes:

Yeah. Oh, a hundred percent. It's an exciting, definitely an exciting field. And, um, yeah, I can't wait to see what the future holds.

Mike Reinold:

Yeah. Yeah. So, all right, so it can heal. We don't, we're not a hundred percent sure why, but we're starting to get some clues as to maybe why that might help a little bit. Um, let's talk about some of the research on non-operative rehabilitation. Again, you, you alluded to this, there isn't a ton out there, but there is some out there. Um, what, what have they shown in, in, in detail here? I know you kind of like glanced. Quickly, but so far, what do we know clinically that, that, that can happen with non-operative rehab? How are the outcomes in

Mick Hughes:

Yeah. So the, it probably, if we I'll probably, and I'll, I'll lean more into what, what the two best papers are. There are to, you know, talk sort of talk with and. Two, um, definitely the cannon trial and the most recent compare trial. Um, the cannon trial's got two year follow up and five year follow up. Um, their, their primary outcome measure was, uh, the COOs for, um, questionnaire. So one that's looking at, you know, knee, you know, symptoms and. Quality of life and return to sport or sports and leisure and that kind of stuff. Um, they, they also looked at radiographic OA changes, return to pre, uh, activity levels of sport. Number of meniscus surgeries performed. Um, they were probably the, the key sort of secondary measures. They also looked at, um, I guess comparatively the compare trial only sort of really focused on the I KDC questionnaire at two years, and it hasn't had five year follow up yet telling in its infancy. So, so basically there were no differences between any of the, the groups. When we looked at the cannon trial that had early ACLS delayed burst being the rehab alone, um, for any of the, the primary outcome measures, as I mentioned, or the secondary outcome measures. So we know that you. If you go down a rehab alone path, you know, at five years, you'd likely to have just as good as outcome as those that had a delayed reconstruction or an early reconstruction. But I think the important thing to note out of that is no significant difference doesn't mean return to normal. So, which is a huge, huge thing for us to understand because these people, even at five years, they all had impair. Cruise scores. So on average, their scores were still sitting on 80, but all three groups were sitting on about 80 or a touch below, which means they're still getting treatment for their knee. Um, you know, they're seeing a physio occasionally or a physical therapist, or, you know, going to their gym or, you know, rehabilitating still or seeing their GP or their doctor for symptoms. So it's still not perfect. Five years down the. Um, they're still, but the other thing was, um, by five years, 20% were still in their pre-entry levels of activity. Um, so all three groups were still, but only 20%. So you'd expect, you know, five years down the track and these upon entry of the trial too, they were all on average about 26 years of age. So they're a bit older than probably what most people would sustain an ACL injury. I think, you know, the vast majority of males are it's happening between, you know, 19. You know, 16 and to 2022, that's kind of like that age bracket, females are a bit younger, 14 to 19. So, um, you know, like five years down the track, you'd sort of still expect that you, if you had an ACL reconstruction, Um, you'd be still participating in your pre-entry levels of sport or you'd hope to be at the age of 30, 31. So by five years down the track only 20% were back into their pre-entry levels of sport. So there definitely, that's probably the strength of literature there look rehab in itself. I guess if we're sort of nuting down what that rehab looks like, look, it doesn't look any different to a really good strength and conditioning program. Um, you know, like just cause you, this is the thing that really, I guess, irritates me as a clinician and I see so much rubbish on, um, You know, social media, Instagram, YouTube, TikTok, like there's just so much distraction and so much rubbish exercise out there that people are doing. And I know it's just a very small snapshot of that person's whole entire program, but I just there's, there's just so much underloading, um, ineffective, rubbish out there that people just need really good, high quality, strength and conditioning. That's got progressive overload that in that ticks off all the bread and butter stuff, you know, squats, leg, press lunges, knee extensions, hamstring, curls, Carras, but with adequate load, you know, like 70%, one RM, 80%, one RM, progressively overloaded. Like it's not rocket science. just, just once that knee is quiet so that when the knee is settled and then it's got a little effusion, it's got full range of movement. It's got no quads lag. That knee is ready for some load, even if it's. Gen, even as gentle load three, lots of 15 kind of stuff for the first couple of weeks. But once that knee is proven, it can tolerate even a little bit of light and easy load start loading it for goodness sake. Like

Mike Reinold:

right.

Mick Hughes:

Yeah. That's that's. Um, but yeah, look, there's no fancy tricks to a really good, um, non-operative rehab, um, approach. You know, it looks very, very similar to what an ACL reconstruction rehab should look like in the early stages. Although you don't have to worry about the harvest tissue, that's the beauty of it. Just getting there and start, you know, loading this person up and getting their knees strong.

Mike Reinold:

Yeah. I mean, and it's, I mean, that to me is even more criteria based than anything else. Cuz the timelines are, have almost evaporated when you do it that way. And it's just once the knee settles down low, I think that's, that's a great way of thinking of it. Uh, but you know, like you said, that's not, uh, that's not exciting on Instagram though, right? It's not exciting to see somebody do a leg press on Instagram. That's kind of boring. Right. so, yeah. And, and

Mick Hughes:

magic happens.

Mike Reinold:

and, and you know, and, and I, that's where I feel for some of these young clinicians. Are that actually think Instagram is a place to learn, which I don't, I don't think it is. I think it's a place to kind of share and think, but maybe not be your primary learning, but like, I, I think people will just, if you were to learn basically on, on solely on Instagram, I think you would do so much fluff. That it would be, it would be ridiculous. Um, so yeah, I mean, you have to be able to see that you need to work with a good mentor, like somebody like yourself, or, you know, or go through your educational products that you sell. Right. That that's like, Hey, here's my ACL masterclass, because you need to understand that. Yes, there is some, some glitz and glamor that we put on social media sometimes, but the bread and butter is basic.

Mick Hughes:

Yep.

Mike Reinold:

you know, it's so boring. Right. And, and. You know, and I don't know what it's like in other parts of, of the world, like Australian stuff. But I know in the United States, like, right, like phys, a lot of physio clinics are just not set up to load. Right. They don't have the equipment. They're, they're just baseline stuff. You know, you have an ankle weight is your max strength at a lot of places that that's, that's challenging. And then people either don't love going to the gym. Like I know a ton of athletes that absolutely hate going to the gym, which blows my mind still, but they either don't go to the gym or they're not being told they need to go to the gym or. Or they're not being, you know, they're not giving any advice on how to navigate the gym. So man, there's, there's, there's so many potential, uh, points throughout that process where the person could accidentally fall off. And we wonder why people are so weak after surgery. We wonder why return to sports, getting more and more delayed and, and everything. It's, there's so many opportunities to have somebody drop off the face of the planet and we don't get to see'em anymore. It's it's really, it's really disappointing.

Mick Hughes:

Yep. Yep. I agree on all points and yeah, I think more, more, um, I guess the, the more clinics can look a bit more like a, um, at least a personal training training studio doesn't have to look like a gold gym or, you know, something, you know, crazy like across the gym or something like that. But the more it can start to look like at least a personal training studio, um, the, the, the better will all be, um, especially from a physiotherapy point of view.

Mike Reinold:

yeah, we, we always say at champion, one of our, our things, when we built champion was we wanted to build a gym and add PT to it. Um, we, what, you know, we see all the time, you know, you're in an office building with drop ceilings and, uh, an old PT clinic with like a high, high, low table, maybe some parallel bars and. Let's put a squat rack in the corner. right. Like, like, like, I, I don't, I just, I feel like the person's not gonna really be, be motivated to really, uh, to, to get after it. It's it's I like that make your PT clinic look like a personal training studio. I think that's a, that's a great way of thinking it and that's geez. That's for that's for every diagnosis, right? I mean, I, I, every, everybody would benefit from that. So.

Mick Hughes:

yeah,

Mike Reinold:

Awesome. So, all right. So I think we're starting to get here and I've, I've heard you talk about this a little bit here. So what, what do you think right now when, when somebody comes to you, who is the perfect candidate for non-operative care and who do you say? No, let's, let's talk about surgery actually right away. Like how do you make that decision?

Mick Hughes:

Yeah. So I probably, I mean, I always give people the choice, ultimately, like I, I think I, I still, despite the evidence really being a bit murky in regards to. The risk of worsening the knee, um, with meniscus injuries and cartilage injuries, despite, you know, a lot of orthopedic surgeons saying it will happen or experience physio, older physiotherapists saying, if this person plays basketball or football without an ACL, they're gonna rip off their cartilage and bucket handle tear their meniscus it's guarantee. Like it's not a guarantee, but there, I think there's always that risk, right. Even if it's one person like one 16 year old kid who goes back to sport, pivoting sport, that's training two or three times a week, level one, cutting pivoting, twisting sport, you know, American football, basketball, whatever sport it is like I don't sleep well at night with that kid going back to sport without an ACL look, it may not happen, but the risk of it happening is probably a little bit more, um, compared for, for that athlete. Who's got no frontal lobe. Who's got no breaks. Who's got no, yeah,

Mike Reinold:

and the implications of that secondary injury are huge. So if you, if you do have a bucket handle tear, you do have a huge bone bruise that you get because you do that. That's not just, oh, well, no big deal. Okay. Let's have surgery that could have significant implications. I think that's part of the issue.

Mick Hughes:

And to have a 16 year old kid who have that really, and, and have an irreparable, like to go from having a pretty clean, happy knee with an ACL deficiency to that knee. And then all of a sudden now having a, uh, I like a meniscus tear that the surgeon can't fix. Plus a big bone bruise. That's just adding, you know, a repeated trauma to that injury site like that that's the catalyst to, to 10 years where in 10 years time, that need does not look the same. It, and it doesn't look like anything like the other knee. And now that that kid is now 26, 27 and not looking great. Um, you know, he gets to his forties. Gets through his forties and probably needs a unique compartment, you know, replacement at least. Um, yeah. You know, like that's, that's hard, that's a hard decision and I don't like making those decision and they're, they're the people that I lean more into, you know, look, look, there are risks with surgery. They're a hundred percent risk for surgery, but I'd probably sleep better at better at night, knowing that we're getting a reconstruction, we're achieving some stability. Sure. Like you've got a 20, 30% risk of re rupturing this graft. When you go back to sport in the next year or two, you know, like

Mike Reinold:

right. Yeah.

Mick Hughes:

these are the conversations we gotta have too, right? Like you just, you can't reconstruction. Isn't perfect. Um, but if these people are unwilling to change their path and they are unwilling to change their sport and their career choices and where they want to go into the future, then I think of all the options that you lay down reconstruction is probably still the best choice for that young level one pivoting twisting sport. Um, some people may disagree with me, but that's probably where I sleep comfortably at night. Um, the, the rehab alone pathway is certainly a bit more of the older athlete. Even someone who's young, like 21, 22, but doesn't want to go down chasing that. Career that professional dream of representing their country or playing NBA or being, you know, the MVP of the super bowl or whatever it may be. So I, those people who have just got time on their side and there's no urgency for surgery, or they're not getting paid to train or play, they're the ones I'm saying, look, let's just sit on this for three months. Let's rehabilitate. Let's see where we go. Um, and let's, and look, even if you are not healed, is your knee still feeling really good? You know, like, you know, Yes, you've got an instability there, but are you able to cope or adapt, um, and modify your life without an ACL? Um, and are you willing to slow down, you know, some of those choices and if they are sort of answering all those questions, like yeah. Let's, let's rehabilitate first and, and see where you go. Cause you can always have a reconstruction later if you don't like the way the knee feels and, and, and these probably people are probably less likely to have these really significant secondary injuries. If they do feel. Unstable from time to time that, you know, their knee starts to feel a bit gross or, you know, it feels a little bit unstable from time to time. They probably aren't likely to worsen their knee significant significantly compared to that 16, 17 hard cutting pivoting athlete that, you know, has the risk of making a significant secondary injury occurred to their can secondary injuries occur.

Mike Reinold:

It, it, it makes sense. And, and as any experienced clinician will tell you I've seen it. And when you do see it, it's heartbreaking. Right. You see, you know, that young, that young girl that wasn't that bad. And, um, all of a sudden have a huge meniscus tear that is going to impact her life for forever. I mean, that's, it's terrible. And it's, it's, you know, we always talk about the risk versus reward. I, I, I think this is one. Situations, you have to also talk about the risk versus the punishment, maybe, right? it's not just the reward, but what's the punishment. If this, if this goes poorly,

Mick Hughes:

That's right. There's not a great, great way. And look, I, I was, on the other hand, I was on the other side of that as well. Like in COVID I, I was, um, managing a, a young guy. He was, well not, he wasn't that young. He was sort of late twenties, early thirties, but he was trying to rehabilitate alone. And, and just in the midst of all the, so in Melbourne, not sure if he was sort of aware of all the news, but we basically locked down the city for two years straight. Um, and you know, we had very tight restrictions on our gym use and exercise use in rehab. So I had a guy. Who I started rehab alone first before our series of lockdowns. And so he was doing some rehab at home. He just landed awkwardly with a box jump and, and Tori's bucket did a bucket handle, meniscus tear and ended up having to get a, um, he got a repair. Luckily enough, the surgeon was able to stitch her back, um, stick back down. Um, but yeah, it could have been a significantly worse outcome. So, you know, I've, I've, I've lived that experience as, as a, you know, physio, rehabbing people without. ACL. And it makes you feel awful when you hear these stories and, and I've been lucky enough to not have a significant outcome to date, um, who knows what the future will hold. But I think importantly, we always have these discussions of risks. Of what we're trying to do, you know, risks versus rewards of, you know, surgery versus non-surgery, you know, the risks of development of OA over time, the, you know, all these kind of things. We just need to have really Frank and open honest discussions, but also importantly include the orthopedic surgeon and the sports doctor and the coaches and the parents. And, and I think where people have run into problems with, um, is that they've basically shielded the patient away from the other health network. And I think it's absolutely vital. We include. Everyone, um, to the table for a really good chat about where we go with this particular patient or athlete.

Mike Reinold:

For sure makes sense. So I, I don't, I don't wanna put words in your mouth, but what I'm hearing here is we, it's almost like we have a sliding scale. Right. And for, for a bunch of different variables. So age, activity, level, uh, the type of sport, is it, uh, you know, just a straight plane sport? Is it a pivot? Cutting? Is it jumping? Is a court sport, a field sport with all these sliding scales that, you know, the more. Those scales that slide in one direction. The more you're probably probably the right decision to have ACL reconstruction. Uh, but for those people that maybe they're younger, I mean, uh, older, excuse me, maybe they're, they're older, they're less active. They're totally fine. Just saying, you know, all I wanna do is, um, you know, ride my bike and swim and, and that, those types of things, those are the people that maybe, maybe we should focus on, you know, trying some non-operative care with.

Mick Hughes:

Yeah, absolutely. Yeah. Look, I mean, and fun enough. Like, I, I, uh, had, I I've just started two weeks postop, um, reconstruction rehabbing, a 67 year old lady who, who like, so she, her ACL over 12 months ago and our rehab just, she kept on having instability. You despite having really good rehab. Um and it got to the point where she goes now, what, like. I'm always feeling like I'm gonna fall over. And I was like, fine. We've if that's the case, and we've basically exhausted all your rehab options and you're feeling this way and she's a fit 67 she's, you know, she's not a, you know, she's not a couch potato. She likes to go out and hike and swim and bike ride and do these things. I was like, well, look, if we're getting to this point all the time, And maybe reconstruction is your choice. It's not the choice for most 67 year olds, but for you, it's probably gonna have a great result for you. Um, so yeah, look it's yeah, my first ever, um, certainly oldest ACL patient

Mike Reinold:

wait, what, what what'd she do for a graph? Oh,

Mick Hughes:

uh, shared a hamstring graft and, and yeah. Autograph as well, autographed as well.

Mike Reinold:

good for her. Good for her. Yeah.

Mick Hughes:

wasn't allograph. I was suspecting it was gonna be an allograph, but yeah, no, she went autograph hamstring and yeah, she's doing well so far.

Mike Reinold:

All right. So this might be the most telling question of all here. Okay. So tomorrow, no offense. Knock on wood. You tear your ACL. What are you doing?

Mick Hughes:

me. Oh, man. Uh, I'm, I'm rehabbing for three months and, and hoping I'm gonna be heal. I'm gonna be a healer. Um, well, yeah, look, I mean, that's, that's just me, like I'm also too, I'm just a Walker. I'm a hiker, I'm a cyclist, you know, like a Cy, I've got five, you know, seven year old kid and a five year old kid and then super active yet. So I'd certainly see if I could be one of these lucky healers. Um, yeah. What about you, Mike? What would you.

Mike Reinold:

Yeah. Well, I do think you are at an advantage though, because I think you're not gonna do anything silly during that timeframe. Right. You know, I, I think, I think, you know, a little bit better and it's not that the, the other people don't, it's just, I think they're not thinking of it as much and like, oh, I didn't realize that was a pivot. Like yeah, no, that was a pivot. You can't put you can't. Just because you, you can't play tennis doesn't mean you can't play pickle ball. Right. Like, of course they're, they're, they're similar. But, um, but yeah, I, I think you would, um, I don't know. I, I think I, I think I would probably do it. I probably wouldn't be in a, a huge rush, but I think I would do it because I, I am, um, I'm one of the rare people, I think that think about the future, right? Like, I feel like everybody's just focused on today, but for me, I'm like, I, I, you know, I don't wanna, I don't wanna limit, like, as I get older, I don't wanna limit what I might do. I I, for the first time in my life, I'm starting to shift away from patella tendon and maybe think hamstring for myself though.

Mick Hughes:

Yeah, right. Yeah.

Mike Reinold:

you know what I mean? I was always a patella tendon, Gavin. I'm like, wow, my hamstring's already stink now. Maybe they're not gonna get any worse. Right.

Mick Hughes:

That's it. You're not gonna be doing any high speed running anytime soon, mate. So you might as well.

Mike Reinold:

ex exactly. So, uh, I thought, I thought that was, that was awesome. So, uh, well, so Mick, that, that was amazing. Great, great conversation. Great stuff on, on not operative. Uh, I, I think more importantly, the future is bright and this is we're only gonna get better at this. We're gonna have a higher percentage of people that heal. We're gonna have the ability to hopefully, you know, narrow that down to help them. And then heck maybe even have some cool things to help facilitate that with some orthobiologics and stuff like that. So, you know, The future's bright. I like your approach. I like your thought process of, of, of, uh, you know, given that three month timeframe, just trying to do the best we can. I, I think that was awesome.

Mick Hughes:

no, I appreciate it. Thanks for the kind words and, uh, yeah, no, it's, uh, it's nice hearing different perspectives from people all around the world too. So it's nice. Uh, yeah. Thanks for sharing your experiences too, Mike it's. Yeah.

Mike Reinold:

Yeah. I mean, and, and again, you think about it, there's, there's there's decision making process based on the, the injury. So your ligament, how does your ligament look and you as a person, what, what's your activity level? That sort of thing. But three is also like these variables, these outside variables, like, well, okay. What's, what's our timeline like, like again, you know, the American model of, of high school sports. I mean, if you don't get this done right now, you're not playing in college. Right. So, you know, there, there's so many factors that you have to put together that, that I think is, is pretty neat. So, um, so awesome stuff. Hopefully everybody enjoy that. Uh, Mick, I'd love to end with my high five, five quick questions, five quick answers from you, but it shows a lot about what your brain's thinking and what you're doing next, I think is very helpful. So, first question, what are you currently working on for yourself for your own professional development in con ed?

Mick Hughes:

I I'm luckily enough to be a, um, a director of an online education business. So I get to review all these wonderful.

Mike Reinold:

Right.

Mick Hughes:

classes. So next on my list is bone stress injuries of the low limb. Uh, it's a two hour masterclass by Dr. Stuart warden, who I think is at a university of Iowa or Indiana. I wanna say anyway, he's an Australian guy working over in the states and he's a, he's just an absolute wealth of knowledge of bone stress injuries of the low limb. So yeah, he's uh, and the next one's Eva Rouse, um, who's a prolific researcher about the knee. So, yeah. Neo osteoarthritis, um, professional education, then also two, one on lower limb bone stress injuries. So there, by the end of, uh, July, I'll have those knocked out.

Mike Reinold:

I, I love it. And, and again, it's, it's, uh, yeah. You know, having access to that is amazing. So, um, and we're, we're gonna talk about this at the end and in the show notes, but again, you know, mix website for that is learn.physio. Right? learn.physio. Did I say, yeah, that's, that's a tough URL to get good job on that. That's I'm impressed with that.

Mick Hughes:

Yeah, it's it. There's a story. There's a story I might share. Well, I'll share it with you listeners now, if you like, but it's bit of a longwinded one, basically we're giving it to for free. Um, so we got very, very lucky. I'll tell you another story, uh, for another time, but yeah, we, in a nutshell, we got that website for free. We're running with it. We're making the most of it.

Mike Reinold:

That, that that's funny. I like the pH I like the.physio, but that does, you know, in a, in the United States people don't get physio. So for our website, we're champ, cuz we're champion we're champ.pt. I had to buy that URL from the country of Portugal to, uh, that, that that's that's, that's how I got that from, because I didn't think people understood physio, but yeah, always funny with those, so. Awesome. All right. Second, second question. What's one thing that you've recently changed your mind, or even just evolved your thoughts on. Other than can the ACL heal, because I think we already talked about that, but something, something else.

Mick Hughes:

Yeah, no, it was definitely part of my big one. Um, look, my, um, definitely from an ACL rehab focus has definitely been a shift of gears to the calf muscle. Um, certainly I, I was probably a bit more focused on, you know, obviously strengthen the quad STR strengthen the harvest tissue, mostly hamstrings for us down here in Australia. But then I used to sort of spend a bucket load of time, strengthening their hips and look, I, I still focus on the hips a bit, but the calf muscle. Is an underrated beast, um, and so important for running, jumping, hopping and the amount of wasting and loss of power through that calf complex and the importance of what it does when you run and jump for the first, time's completely understated in, in new, most new grad programs and undergrad training. And I didn't really pick up on it how important it was until the last probably three years. And it's definitely shifted, shifted my gear and my focus when I rehabilitate ACL.

Mike Reinold:

Yeah. I, I think we were along the same lines with that too. And then you, you, you look back and you're like, wow, we, why weren't we focusing on that? But it was probably more that we were just, but we were just so, so focused on other things, but yeah, it's in retrospect you're like, yeah, no, that's, that's a, that's a big, that's a big, uh, muscle group, for sure. So, um, awesome. What is your favorite piece of advice that you like to give students in early career professionals?

Mick Hughes:

Yeah. Um, be patient is ultimately my mantra for a lot of things is just slow down. Take a breath. Don't try to be, you know, like from a physio perspective, a lot of new grads. I mean, myself, I used to want to, like my first two years I was. Convinced I was gonna be the head physiotherapist for, um, the national sporting code here in Australia being cricket and not just like baseball but different. Um, I, I thought I had the skill set to be the Australian head physiotherapist and I was so far wrong. I was so far off it and, and it's only now 10 years down the track that I just. Have now grown comfortable in being patient. And I encourage all sort of new grads and students that, you know, don't try to, you know, know everything in the first two years, you know, like you, what, what allows you to be a great clinician is variety of patients that you see variety of injuries that you see different sporting codes that you work with and all that time, all that stuff takes time. Um, so importantly, yeah, be patient and don't expect to be in your dream job. In your first five years out, you know, take that time to develop your skill set and, and ultimately enjoy that part of the ride, but ultimately be patient.

Mike Reinold:

Love it well said. Uh, what's coming up next for you. M.

Mick Hughes:

Uh, well, man, I've got a busy couple of months. I've got I've actually been lucky enough to work on a, uh, and co-author a paper which is being published soon. Um, so Matt buck thought. Um, who's published a lot of great ACL stuff. Um, I've sort of collaborated with him and, um, there's another few like Lee Harrington. Um, Ali Gola, uh, Francisco D Villa there's about five, five guys. We've basically all co-authored this paper on it's coming out soon. Um, early focusing really on that early stages of ACL rehab, so that that's coming out in the next month or so that's, that's exciting. Um, but yeah, I'm working with some universities here in Australia doing some education to some undergrads and postgrad students. And. Just really looking forward to learn.physio. It's moving into some pretty cool territory with some hands on interactive workshops in our Melbourne studios. So yeah. Watch this space.

Mike Reinold:

That's great. Yeah, no, I, I, I, I completely agree. And I I've checked out some of the stuff@learned.physio and again, topnotch stuff from topnotch people. I mean, you can't miss with that. Right. I mean, it's, it's, you know, very experienced people sharing that experience. And I, I don't think you could ask for anything better. So definitely great resource that, that everybody needs to check out. Um, I, what about you ick? How do we learn more about you? That's learned at physio, but like you, you also have your own online presence and stuff. What's the best place for people to learn more about you.

Mick Hughes:

Yeah. Look, I'm, I'm sort of a bit everywhere. I've got my own personal website. Um, just a landing page, which you know more about me. So it's M Hughes. Dot physio. M I C K dot H U gs.physio. Um, yep. That's my personal website, but all over Instagram. Um, I'm there, um, every day I've just actually signed up to, to, um,

Mike Reinold:

that. I saw that. Hey, what do you think? How's that going?

Mick Hughes:

yeah, it's, uh, slow and steady. Uh, once again, mick.hughes are my handles everywhere. So Facebook, Instagram, TikTok, YouTube. Jump on those social media channels and you'll find me.

Mike Reinold:

Awesome. And a, a great follow some great, uh, evidence based clinical stuff that, that that's, that's the type of people. I love to follow people with experience that, understand the research and can talk about how they use that in their own practice. I think that's, uh, that's a great combination som. Thanks again for taking time outta your busy schedule, to do this and share your knowledge with the audience. I really appreciate it and hope to see you in our future episode.

Mick Hughes:

Anytime, Mike, thanks very much for the opportunity to talk, mate.