David Pope: Hi, Clare, how are you?

Clare Walsh: I'm good, thanks David. How are you?

David Pope: Yeah, great. Thanks for coming on the show. I'm really looking forward to talking all about ACLs and the different types of management of ACL injuries with you today. I know you've got tons of experience, so thanks for coming on and yeah, really looking forward to chatting to you.

Clare Walsh: Yeah, actually I'm really looking forward to chatting to you about it as well. It's a favourite topic of mine having worked in sport for such a long time and I've seen a lot of ACL injuries and other serious knee injuries, so yeah, it's great to get on here and talk to you about it.

David Pope: Yeah, for sure. Awesome. You're working in Sydney at one of the large sports clinics there. Do you see a lot of ACLs in your practice?

Clare Walsh: Yep, so I work in a multidisciplinary sports medicine centre, so we have a bunch of sports doctors and orthopedic surgeons, and then we have also a sports physio clinic with about seven physios and we also have some other allied health dietitian, podiatrist, that kind of stuff as well, and we've got a big X-ray department as well, which is really helpful.

David Pope: Yeah, for sure. Do you see a lot of ACLs during the regular work week?

Clare Walsh: We do. It certainly depends on the season. So throughout winter, we see a huge number because of all the winter sports such as the football codes are a really big source of knee injuries, but also with the skiing as well, so a lot of skiing injuries that's probably where we get most of our ACL injuries is through the change of direction sports and through skiing.

One day, we had about eight ACL injuries came in before lunch. At a time when a lot of people were skiing. So yeah, we do, we see a lot of ACL injuries and they're all managed differently depending on, I think, each patient has different goals and aspirations and things that they need to do. So depending on what suits them, we might choose the type of ACL injury management that suits the patient and we will offer them different options.

David Pope: That's what I really want to explore with you, the different types of options that are available to patients, how physios out there can help explore those different options with their patients and help them identify what's going to be the best one for that particular patient. And sometimes it can be lots of different opinions, strong opinions about what are the best types of treatment options.

But when you're working in a clinic you've got access to the latest when it comes to, working with sports medicine practitioners, physios sports doctors, orthopedic surgeons, and you're really probably have not a vested interest in which option is chosen, but more after what's the best option for that patient. So I thought you'd be great to have on because as someone who's seen a lot of, ACL injuries on the coal face and has a lot of exposure to the different approaches and the latest stuff. So what are the normal sort of pathways when we think of ACL injuries, the treatment options for your patients that are coming in?

Treatment options following ACL injury

Clare Walsh: Currently there are three main treatment options for ACLs, and certainly early ACL reconstruction is something that particularly in Australia has been probably the most common treatment pathway. So that would involve having an ACL reconstruction within the first couple of months of the injury.

And patients can have a choice of grafts, they can have a patellar tendon graft, or a hamstring graft, a quadriceps tendon graft, not as common, but has become a little bit more common recently. Or they can also have an allograft. And one of the really important things about choosing this management, is that another very important part of having surgery is the rehabilitation that follows the surgery.

So then the second treatment pathway would be to have rehabilitation first, or some people would call that prehabilitation, with the option of having a delayed ACL reconstruction. With this choice this can be great because we do know that some people may not have aspirations to go back to high levels of sport or change of direction sport. So they can choose rehabilitation and then depending on the stability of their knee, if they have great stability, they don't have any episodes of giving way and they can participate in their daily activities. And the sports that they enjoy, then they may not go on to have an ACL reconstruction, although others who don't do so well with the rehabilitation and have ongoing instability, or they might have other reasons that they feel that surgery's better for them, they can go on and have that ACL reconstruction.

And then thirdly, we have non operative rehabilitation that may involve just doing some strengthening some neuromuscular control exercises, balance progressing to plyometrics, whatever the patient needs to achieve. But we do know that there are a certain number of ACLs that spontaneously heal.

So this is where the Cross bracing protocol comes in. So there is an option to go into a brace a range of motion brace that is locked at 90 degrees within a couple of weeks of the injury to try and facilitate healing of the ACL. And this is a much newer concept.

Where I work, I actually work with Dr. Tom Cross and it was he and his father that pioneered this research. So that is another option that we offer to patients that come into our clinic. And I also know that there are other physios and some other doctors that are also offering this. There is a doctor in New Zealand that's doing it and certainly around Australia. But probably most of the patients that go through the Cross bracing protocol would come through our clinic at The Stadium.

Early vs late surgery

David Pope: Looking at those different pathways, early surgical option. That used to be a really popular option, didn't it? It used to be the one that, most patients would go down. Well, I I did when I had my ACL. It was like you've just done your ACL, let's get you in for surgery in a couple of weeks.

And that was the pathway. Are people when they are opting for an ACL reco, tending to go more straight in for the reco pretty early, or are they mostly opting for some prehab and seeing how that goes first? Or if they are going down that surgical pathway, what's the most more common trajectory?

Clare Walsh: I think that early surgery is still very common. And surgery in Australia is very good as well. We have some really fantastic surgeons. So it is still a good option for the right patient. However, I think there are more and more patients who are either learning from other patients or they're reading in the media about patients that have undergone non operative management.

And I think most people at their heart would like to avoid surgery if it's possible. And I think that it's something that just needs to be discussed with the patients. I think it's probably, the last five years, patients are now understanding that there is another option besides surgery. However, I do believe that it really is an individual thing, and it's all about the risk profile of that patient, and what is their risk, that they're going to have an unstable knee, and therefore cause further injury to their knee if they have a frank instability episode, and end up with, chondral damage or another meniscal tear, etc. To answer your question about, I think we do see still mostly ACL reconstructions, but I think that percentage is starting to drop in Australia.

David Pope: Yeah, and more patients opting for a delayed ACL reco, or are they mostly getting them early on? What are you finding there?

Clare Walsh: Most patients, I think, are opting for delayed. Interestingly, the surgeons are often telling them to do some Sometimes it's as short as six weeks. Maybe six weeks is still an early reconstruction. But lot of patients are really willing to give it time. One of the things I say to a patient that comes into me with an ACL tear is that surgery isn't urgent.

They don't have to have it that following week. They don't have to make a decision, on that day. So as long as they know that it's not urgent, they can then, look at all their options, talk to their family, talk to the doctor that's, that's seen them, sports doctor that we might refer them to.

And they can actually work out what is best for them, but I think more and more people are opting to actually wait and do some really good rehab and then see what suits them in terms of their options for surgery or no surgery.

David Pope: And I want to talk to you a little bit more as we get through the podcast about the sort of conversation and how you describe those treatment options to people and whether they're wanting to go down a early ACL reco, delay that ,looking at your non operative management or, it's some bracing protocols.

I really want to explore how you go and take patients through that sort of discussion process. Before we get there, I want to talk about, dive into some of those options a little bit more and maybe if we start comparing some of the treatment results that come the different pathways that people can go down.

Do we have any sort of indications about options and what's going to be the best from the research side of things? Clare Walsh: I think if we look at the KANON trial, which is probably the best known randomised clinical trial that was published in 2010. So it was the first clinical trial that compared operative or early ACLR to delayed ACLR. And the great thing about the KANON trial was that it actually looked at young participants who played up to quite a high level of sport including Level 1 sports such as, pivoting and changing direction sports.

The KANON trial now has two year follow up, five year follow up and they've just published this year their 11 year follow up. So we've got a really good idea of comparing the two groups. Now, overall there was 130 patients, I think, that went into this trial that were randomly allocated to those two groups, which was early ACLR or delayed ACLR.

So the patients were aged between 18 and 35, so they were young. And that was one of the great things about this trial. So they found that at the two and five year follow up, and even through to the eleven year follow up, that there wasn't any difference in outcomes, and they used the four subscales of the KOOS to measure their outcomes and looked at quality of life in particular, ongoing pain, function, level of sport that they returned to.

They found there was no difference between the patients that had an ACL reconstruction, either early or delayed, and those that didn't have an ACL reconstruction, that just did rehab alone. The patients that had a delayed reconstruction, had it for reasons that they had ongoing instability, or they had beliefs around the fact they felt that they needed to have surgery to stabilise their knee.

In terms of further injury to the knee, so meniscal damage, there was no difference between the groups whether they'd had an ACL reconstruction or not or whether they had non operative management, which is interesting because you think that having reconstruction will stabilise the knee better, but still they can have further injury to the knee, even if they've had a reconstruction.

So the study out of the KANON trial that was published the lead author was Stephanie Filbay, just recently. She looked at spontaneous healing of ACLs. So of that initial group of 130 patients, 30 of them didn't have a knee reconstruction. And out of those 30, about, just over 50 percent of them showed that they'd had a spontaneous heal on their MRI.

The interesting thing is, you wonder then, if those that had the early ACLR, how many of those would have had a spontaneous heal? So I think that is something interesting to contemplate and if we educate our patients to know that the ACL can heal I think that's where the real shift in thinking has been and I think this is also what has led to a lot of interest now in the Cross bracing protocol because the Cross bracing protocol is a type of non operative management, and what we're looking to do, certainly led by Tom Cross in our clinic, is to see if we can facilitate the healing of the ACL by placing the knee at 90 degrees in a brace, in a range of motion brace.

And if they do a 12-week protocol, which is the standard protocol that has been published as a case series, then they're looking at four weeks of locked at 90 degrees to facilitate that healing by just by bringing the ends of the ACL together. David Pope: That's a really awesome summary of some of the research around it and the results here, and spontaneous healing is an interesting thing because it's, like you said, it's it sounds like that's more of a recent development that realised that it can actually heal and that's where this Cross bracing protocol started to develop. What was the sort of origins did Tom and Merv start to see these results and think maybe there's a way we can encourage this? Or how did that sort of develop? Clare Walsh: So what happened was nine years ago, there was a patient that came into our clinic, a young girl who was a netball player and she was really distressed, she had ruptured her ACL a few days before, and she was absolutely adamant that she didn't want to have surgery. And at the time Tom Cross's dad, Merv Cross, who's a really well known orthopedic surgeon in Australia, he actually overheard this conversation because he was in the clinic having physio treatment on his own, total knee replacement at the time.

And so he thought about this and thought what's another option besides surgery? And he thought, for this girl, why don't we try putting it in a brace, and again, getting the ends of the ACL a bit closer together to see if they heal. Now this young girl, fortuitously, she actually had quite a good result.

So over the next kind of, 12 to 18 months, occasionally, they started to put more patients in a brace just to see. And it was only those that really had some very good reason that they didn't want to have surgery and the first eight patients or so actually did really well. So Tom and his dad decided to make this into more of a case series. And then they published a paper. It was published in the British Journal of Sports Medicine. So we're fast forwarding now from nine years ago up to 2021. And they had braced 80 patients by 2021. So the case series starts from 2016 and goes through to 2021, and in that time they braced 80 patients and all of the patients were braced for 12 weeks with the four weeks at 90. And then the brace was gradually released after that. Out to by eight weeks, they can fully weight bear. By 10 weeks, the brace is at 0 degrees. And so their last two weeks they're just really wearing the brace for for protection, a little bit of extra protection. They have an MRI at 12 weeks, and then they have another MRI six months after that.

So this case series looked at the MRI results after t he patients had been in the brace for the 12 weeks. And what they found was that 90 percent of the participants had some form of healing of the ACL.

So 50% of those were graded as a very good heal where there was good thickness of the ligament and good continuity. And then the other 40% had some healing, but there was some thinning in part of the tissue or there was some elongation of the ligament. So the grading systems outlined in the paper, and it's called the ACL osteoarthritis score or the ACLOAS.

Interestingly, also in the paper, couple of other outcomes they looked at were the Lysholm score, which is self reported knee function, and then the knee related quality of life score. And what they found was that the participants with the better heal on the three months reported the better knee function and the better quality of life, so that was another interesting finding.

David Pope: So he overheard someone and they were really not wanting to have an ACL reco and he was starting to think about options. Popped in a brace and then got some good healing. So he carried it on with other patients and started a trial. That's Clare Walsh: fantastic.

So the Cross bracing protocol was born, really from that. I'll just point out, I'm actually not a researcher. So we have the research was led by Stephanie Filbay through Melbourne University. And she was brought on to help with this research, so that we could get it published.

So that Dr. Cross could get it published. She did a great job. It's a case series, so it's not the highest level of evidence. And it's really only the beginning of what we feel is another option for patients who have had an ACL. It's not to replace surgery and it's not to replace other non operative management if a patient chooses it, but it's a way to facilitate healing and over the coming years we'll see whether the results continue to be equivocal to somebody that's had surgery and it can be a sound option.

David Pope: Looking at it, the original study was a 12-week program or the original program that Merv Design was putting in the brace for 12 weeks. Is that still the main protocol that you're following there when people are going into and using this Cross bracing protocol? Clare Walsh: Actually, the early patients were braced, I think, for less than that. I think it was actually around eight weeks. It varied a little bit because they were just making it up as they went along initially. But then they established just from what they felt would work the best, they established a 12-week protocol. And the 12-week protocol started in 2016, I think, whereas just this young girl was actually a bit prior to that. So from 2016 to 2021, it was a 12-week protocol, and now we have different options. So for some patients that may not be suited to 12 weeks in a brace, there are varying reasons why they may or may not be. And so patients can now choose a six, eight, or 12-week protocol. But those that were involved in the research, the case series, were all 12 week. David Pope: Yeah, okay. Why would someone go, Oh, I want the 12-week over the 6 week? You look at it and you go that's a shorter time in a brace. Are there differing results when you compare the 6, 8 or 12 week program? Or are we looking at risks if people are more likely to go out and do things that are putting it under strain? Or how does that time period tend to vary? Clare Walsh: If they do a 6 or an 8 week protocol, they still have their MRI at 12 weeks, so they're always MRI'd at the same time point. And at this stage, there hasn't been shown to be a really big difference in that 12-week outcome. The reason for choosing the shorter bracing time may be just certainly with younger patients, so if they're adolescents, the shorter time frame is more manageable. And those that also have really minimally injured ACLs, so, they might have an ACL that's still, they've got only a small amount of separation between the stumps. So we're looking at a mid substance tear with only minimal separation and the ligament's still sitting comfortably in the notch. So if they've got a very minimally injured ACL, then they may be well suited to just a shorter protocol. And I think that's just really like a work in progress. Eventually, we'd love to know what is the minimum amount of time that somebody can be braced for the maximum result of their ACL healing. And that's still a work in progress. David Pope: Yeah. a bit of a trial and error, I think, in these early stages where you're testing these things, isn't it? Clare Walsh: Yeah, one of the things that's interesting that we've found just in the last year or so, is that patients who are recreational skiers tend to have the more minimally injured ACLs. So they're actually quite well suited to the protocol. And the elite skiers, tend to have more, more trauma. So they tend to have more femoral avulsions or really big tears where the ends of the ligament fall out of the notch. And players, playing change of direction sport. As well, particularly if it's a contact injury, they may have a really, highly injured ACL that's not so suited to the bracing. But it's interesting to see that certain subgroups of sports can actually be more suited to bracing because they don't injure their ACL as severely as other sports. David Pope: Okay, now's probably a good chance to talk about who is suitable . So you mentioned there that the ends of the ACL are still in the notch. It sounds like MRI is a big part of, helping to make that decision, but maybe if we talk about some of the criteria that you use when you're going through and then we can talk about some of that testing that you might do too . Clare Walsh: So this is a really important part. So the first thing is the MRI factors. So all the patients have to undergo an MRI. The injury needs to be seen by Dr. Cross or one of the other doctors, or by one of us, certainly within the first 3 weeks, 2 weeks preferably, but within the first 3 weeks. Dr Cross doesn't offer the bracing to patients who, come in 3 months after their ACL injury because it doesn't work. So it has to be, certainly within the first 3 weeks is ideal, 2 weeks is probably better. So once they've had their MRI. The type of tear that they've got is discussed with the patient and Dr. Cross and the patient's family, and if it's one of the more minimal injuries or minimal to moderate, then they're still offered the option of surgical intervention, they're offered the option of just doing some rehabilitation with the option of a delayed ACLR, or they're offered the option of going into a brace for 12 weeks, 8 weeks, or 6 weeks. And they will need to undergo some prophylactic therapy to avoid a blood clot, so some anticoagulants. So that's also discussed with them. Anybody with a history of a DVT would not be offered bracing because it's potentially dangerous for obvious reasons. So that's the early process. Now, obviously when we're treating somebody with an ACL, we're not just treating an ACL, we're treating a whole person. So there are patient factors that are taken into consideration. And those patient factors include things like, if it's their left or right knee, so if it's the left knee, they can still drive. If it's the right knee, they can't drive, unless they drive a manual, then obviously both doesn't matter if it's left or right, really. But considering most people drive an automatic, having a left knee injury means that they're more likely to take the brace on. So we actually brace a lot of left knee ACLs, and not as many right knee ACLs. So that, if driving's important for their lifestyle, because they've got kids, or for their work, then that is a consideration. The other thing to consider is concomitant injuries. So if they have an MCL tear or a meniscal tear, they can also heal in the brace. However, if they've got a severely injured meniscus, like a bucket handle tear, then they would be sent to surgery because we wouldn't put somebody with a bucket handle tear in a brace. They need to see a surgeon for that. The other factors that are considered are things like, if they've got a history of a lot of patellofemoral pain or patellofemoral osteoarthritis, because we're considering putting them in a brace at 90 degrees for up to 4 weeks, and so this can exacerbate that condition and having pain we think can actually even affect the healing at this stage. Other things like anxiety. If somebody's got a lot of anxiety, if they feel that they're, they don't have much home support. Some people live by themselves and getting around on crutches, if they've got a lot of stairs, they may not be able to work if they're a manual labourer. So there are all these lifestyle considerations that have to be discussed with the patient. Psychological factors, anxiety and depression are also probably something that needs to be considered with patients who are going to be braced for any extended period of time. So the MRI factors are important, the timing factors of when the injury has occurred, and then we've got the psychosocial side of it, the factors that are important as well for these patients to make a shared decision making. It's a shared decision making process between Dr. Cross and the patient, and that will sometimes also involve their family and involve us as their physio. David Pope: So you've got all those factors about the actual person that are involved and where they've got that history of DVT, which side it is, so that it's impacting their driving, where they've got those other injuries, where they've got a history of patellofemoral pain and anxiety, and then coming back to the MRI findings as well, so you said, you're looking to get an early MRI to identify the extent of the tear of that ACL and whether it's sitting in a notch and then those tears are graded, is that right? So you grade those injuries, are there any sort of, if people are looking at it without having a grading system at hand, what are the general things you're looking for in an MRI that indicate that they could potentially be suitable for that? Clare Walsh: The grading of the ACL injury is actually very specific. At the current time, Dr Cross and his colleagues, some really experienced radiologists they've become experts in looking at the index injury on MRI and looking at how severely injured the ACL is to see whether or not it is going to have a chance to heal well in the brace. And essentially what they're looking for, so if they've got a mid substance tear, then the less distance between the two stumps the better. As long as part of the ligament hasn't started to involute. So what tends to happen after two or three weeks is if you've got a mid substance tear and you've got only a little bit of distance between the two ends of the stump, then part of that ligament can fall away and some of it will fall outside the intercondylar notch, so therefore when the knee is put at 90 degrees, the ends of the ligament may not be in a very good position for healing. The other thing they look at is the injury to the femoral attachment of the ACL. If there's a large femoral avulsion or a large amount of the ligament that's come away from the femoral attachment, then they're also not very suitable to healing in a brace. So, I would probably advise that any physios or doctors not to assess the suitability on the MRI themselves, because this is quite early stage research and it's taken Dr. Cross and his team, a good eight or nine years to figure this out. So they have the expertise to look at the MRI and decide whether or not this type of ACL heal will do well with the bracing. And of course they're also looking at other things like the psychological suitability and, the social appropriateness for undertaking this treatment. I would encourage any physios or other doctors out there to actually get a better idea, rather than just doing it themselves, maybe to refer to Dr. Cross or one of the other doctors that's, really experienced in looking at those MRIs. David Pope: Yeah, and we'll talk about that later on, about how people can, if they're not based in Sydney, how they can actually go about, offering this potential treatment option for patients as well. And tell us a little bit about the downsides. I think it's always important to think about what the potential negative outcomes are for patients. What are some of those? You mentioned before DVTs is a potential downside. Is that something, obviously you put the people on anticoagulants? Anything else in previous history of DVT you mentioned as well as something that you look for that you wouldn't put them in a brace? Clare Walsh: The anticoagulant therapy, they have they're given that up until 8 weeks, because usually by 8 weeks they're weight bearing. So once they start walking, then they don't need to have it anymore. So if they're on one of the shorter protocols, again, they don't need to be on that for such a long time. The downsides of the bracing there are definitely a few, certainly, that risk of DVT, but the other things are stiffness, so they can come out of that brace really stiff and without gaining their full extension. Having said that, the way we work with the patients the amount of reduced extension at the end of 12 weeks has, we do see that with patients, but pretty much within a few weeks after they come out of the brace, they're back to full extension. We haven't had very many that have had ongoing problems with that. Then there's also the muscle wasting and there's also bone health. So those things, when you're non weight bearing in a brace for an extended period of time, they're probably the three main things. So it's stiffness, muscle wasting and bone health. And they're problems that we mitigate by putting them through a rehabilitation program that's been designed specifically for those patients that have been through the bracing protocol. And if you read the research, so the research covered patients up until 2021, and that was the first 80 patients. But since then, Dr. Cross has probably braced another, or some of his colleagues have braced another 300 patients. And so it's the ongoing problems that we see, that have made us progress the rehabilitation protocol, so we now offer them a basic rehabilitation and a more advanced rehabilitation depending on the patient, and that's actually how we mitigate some of those problems like the muscle wasting and the bone health and the stiffness is through that rehab protocol. David Pope: When you're looking at potential outcomes , it sounds like you've got a good way of addressing your bone health and your muscle wasting and you're addressing those throughout the protocol. They're not just locked into 90 and not using that leg, but you're looking to keep some muscle bulk or strength going through that and also that bone health. So we'll have a chat about that in a bit. As far as non healing, what are the sort of, rates that you're seeing? You've had a lot of patients coming through. Are there many patients you're seeing that's just been unsuccessful for you being in that brace for 8 weeks, 12 weeks, whatever it might be? Clare Walsh: There are some that don't get a great heal. I'm unsure of what the exact percentage of that is, I would have to probably check back with Tom Cross about that. But having said that, sometimes when a patient goes through their initial consultation and they're making a decision about going into the brace, the majority of people that choose it don't have health insurance. So they can't afford surgery. So they may have a tear that may heal, but it might not be the best type of tear for facilitating healing. And therefore that can be a factor why they don't heal in the end. But the patient's told that from the beginning. If they've got a really minimally injured ACL, They have a very high chance of healing. And the case series did have 90 percent of some kind of heal, and 50 percent of those had a very good heal. The more recent statistics, I think because we've got better at choosing who goes into the brace, I think are continuing to improve. So we'll see less with poor healing and more so that have achieving a good heal at the end of 12 weeks or however long they're, they've been wearing the brace for. So I don't know the exact percentage but it's certainly very positive. David Pope: How do they go, being in a brace for 6, 8, 12 weeks is quite a long time to be in a brace for. And you mentioned there about driving, it obviously impacts driving and people with stairs that type of thing. But how do people go if they're in a brace for that longer period? Clare Walsh: When the patient's braced by our team or some, there are other physios out there who are now become experienced, so they might go back to their own physio for bracing. But we tell them that the first week is the hardest. And we're very upfront about that. They're given a two page troubleshooting tips. So that actually helps them navigate things like showering, things like getting around on crutches. Some of them choose to have a scooter, which is really helpful, a knee scooter. And others can choose an iWalk. If anyone out there hasn't seen what an iWalk is, you should Google it, because if you see it, it's a pretty groovy contraption. So some of the patients will use that. So it's a way to enable them to actually weight bear while their knee's at 90 degrees. They can actually walk around on it. So using a scooter or an iWalk is helpful, but a lot of patients just use crutches, which again, just depends on their lifestyle, what they have to navigate around the house and to get to work, et cetera. So it's the first weeks that are really the hardest. Then we have some patients who actually cruise through the rest of the protocol. They just go really well, they don't have much pain, they're in the gym really regularly and we encourage the patients to, to be in the gym. If they've been doing gym before their injury, we encourage them to keep going from the first week. And we tell them what they can do and what they can't do. We take them through how to use the machines with their knee locked at 90. And they love that. We find that's really helpful keeping them exercising as much as they would like. Patients can also swim in the brace. We usually encourage them to get a second brace, just so that one brace can dry out while they put the other brace on. We've had quite a few patients that have swum. So encouraging them to exercise is probably one of the main ways we help them cope with being in that brace. Other patients just really struggle with it. There have been some patients that within 3 or 4 weeks have taken the brace off and just said they can't do it and they don't want to go through it anymore. And that's okay, if they decide to do that, that's absolutely fine. They still have a 12-week MRI, and interestingly, some of them have shown that they've healed even if they haven't continued through the bracing protocol. Again, we know that ACL has that capacity to heal. To be honest, I'm surprised that not more patients have chosen to rip that brace off and after a few weeks and not do it, but it's actually only really a few patients have done that. So the majority of people tend to cope quite well, particularly if they've got some support. From us and, people around them. David Pope: That iWalk looks like an interesting device. You've got the brace on and then you're knee's bent at 90 degrees and you've got an extension coming down to the ground so you're almost walking and stepping forward on it. That looks like it'd make things a little bit easier. Clare Walsh: That's actually what it looks like when you first see it. It looks like, and then you realise, oh, actually there's a leg.. David Pope: Yeah. Clare Walsh: To that at 90 degrees, so.. David Pope: Bent up and hidden behind them. While we're talking about the bracing and getting about, you mentioned there that they're in 90 degrees initially. How long are they kept in 90 degrees for at the moment? Clare Walsh: So for the 12-week protocol, they're kept at 90 degrees for four weeks. Then they come out to 60, so they're 60 to 90 after four weeks. Then depending on the brace they use, I'll talk about the different braces shortly as well. They go either to 45 degrees or 40 degrees, and then to 30, 20, 10, and then to zero. They're at zero by 10 weeks. David Pope: Yeah, so 10 weeks, they're at zero. So you're gradually progressing them out because I think that 90 degrees would be probably one of the most intimidating angles to be at where you're right out and can't weight bear at all really on that foot. It's getting in the way a lot more. Clare Walsh: Yes. It is. David Pope: Then you mentioned there before about people that are choosing this protocol often don't have insurance. When people are choosing an option, is it because they don't want to have an ACL reco, or in this option are they choosing it because they think that this is actually a better option for them to avoid surgery, or what's that sort of decision making like for people? Clare Walsh: I think a lot of people that want to explore non operative management, and not everybody, some people just don't want to have surgery, but they have to be, they have to understand why surgery might be important for them as well. So if they're going to have an unstable knee. then maybe surgery is the best option for them. But I think it's just so that it's a financial decision. If they don't have private health cover, and they have an appropriate tear type that may heal, in a brace or spontaneously, then they can be offered this protocol. If they don't have private health cover, and they've got a really highly injured ACL, then they still are recommended to have surgery, but what they might do is they might try the brace or they might just go for a non operative rehabilitation program, so with or without bracing, and then they might sign up for private health cover because that can kick in 12 months later. So it's just that there will be a 12 month delay and then it gives them the option at 12 months if they want to go on and have an ACL reconstruction. So I guess there is one group where it's a strong financial consideration, and then there's another group who might have had a good friend or, a brother or sister that's had a reconstruction that hasn't gone well, and therefore they don't want to have a reconstruction themselves. So it's not such a money thing, it's actually just their own belief system is that it's not for them. David Pope: And you also wonder about other countries that maybe don't have the same access to private health care, maybe the UK or somewhere where you might be in the NHS but you might not be able to access ACL reco for maybe it's a couple of years or maybe it's, further down the track and once again I suppose that could be a private health insurance thing as well where there's potential for it to help a lot of those people that might be otherwise struggling without an ACL and struggling to get back to sport or yeah, might have some better outcomes. Clare Walsh: Yes, I think that's true, I think certainly the NHS system is one that might take this up because people are on, a waiting list sometimes for quite a long time before they can have surgery and and so this could be another option for them with the option for a delayed ACLR if they need it. David Pope: We've talked there about some of the downsides and it might be good to have a little bit of a chat about re rupture . So as people are coming out of the brace and they're, moving further down the track, what's the return to sport time periods look like? Are we still looking, are we looking at a shorter return to sport time frame than having an ACLR or what's the time frames like? Clare Walsh: I think originally it was a little bit shorter but now I think the recommendation is return to sport should be around 12 months. It depends on the type of sport that they're playing, of course, certainly, the earliest that we get patients to run is about four weeks out of the brace that patients can return to running, but we have criteria, so at 12 weeks. When they have their MRI, they will also go through a series of tests with us, the physios looking at muscle strength using dynamometry looking at just, thigh circumference, functional tests such as single leg balance and squatting, et cetera. We use a Tampa scale, the short form, so a TSK-11, so we give them that to complete at 12 weeks as well. And then that will help to inform the rehab, obviously orientated around their goals, but for example, if they haven't got full range of motion so they don't have full extension, that will be a priority to work on. And a lot of the patients are coming out at 12 weeks, doing really well in this testing, so we will progress them towards running if that's one of their goals. And anywhere between that four to six months post their injury, they'll be back running again. So not too dissimilar from an ACL reconstruction. A lot of the surgeons now are recommending the younger ACL reconstructed patients not to go back to sport to 18 months because of the high rate of re rupture. So they're also in addition to, the traditional reconstruction using a lateral loop to augment the the ACL reconstruction and improve the stability. So this tends to slow down the initial part of ACL rehabilitation, if they've had surgery with a lateral loop. So the timeframes are quite similar, although there are probably less early issues with pain, from 12-week out of the brace when you compare that to someone who's 12 weeks post surgery. In terms of return to sport, it's probably just a little bit quicker at this stage than having surgery. But we're also a little bit cautious because we don't really know if someone's had a spontaneous heal or healing in a brace. Some of them will choose to have a further MRI, but that's not compulsory, it's not really part of the research at this stage, but certainly if we progress to a clinical trial, there'll be further MRIs to look at the quality of the ligament after 12 weeks and then 6 months later, 12 months later, 2 years, etc. And then we'll know how robust the ligament is, but it also it depends on how much stability the patient has got through their rehabilitation program. So I think that the important part of it is good rehabilitation, whether it's surgery or whether it's non-surgical management, is probably one of the really key important things.

David Pope: You mentioned about 90% having some heal and 50 percent having a good heal. You might not have the research right now to back it up, still early days, but are you seeing many in the way of, re ruptures or people that are going on to have, ACL recos after completing the protocol? Clare Walsh: Yep. There certainly is re ruptures. Most of those re ruptures occur for patients that have gone back to level one sports. So the pivoting sports. At this stage, I'm unsure of anyone who's re ruptured skiing, but I could be wrong if something more recent has happened, but certainly the ones that have re ruptured have occurred either during contact injury or pivoting in a level one sport. The re rupture rate is around 14 percent at this point in time. That's as far as we've got with the statistics. That was reported in the research project, the case series, but we do believe that it still sits around that number currently. It's less than the re rupture rate for surgery, but again we just don't have the long term data to say what it's going to be if we look at two years, we're not really 100 percent sure. And the other thing I think is that with ACL reconstruction, the statistics show that only less than 60 percent of patients go back to their pre injury level of sport. So a lot of patients activity modify, whether they have an ACL reconstruction or whether they go through non operative management with or without a brace. And we do see that with our bracing patients, some of them say, oh, I'm not going to go back to netball, they've had a pretty good heal. They're just going to do some, continue their rehab and take up triathlon or something like that. And that's, quite acceptable and that's a really sound goal to have. That happens whether they have a reconstruction or whether they don't. I think it's a big part of coping with having an ACL injury is what you do afterwards. David Pope: That gives us some really good ideas. Do you have any sort of patient examples that you can talk us through about their presentation, how you talk them through the options and some of the outcomes of the different treatment pathways there? Clare Walsh: Yep, so in our clinic, Dr. Cross does all the initial consultations, so he will spend up to an hour and a half with the patients going through all the options. I'll give you a good case example of two patients that I saw at the time of them having their ACL injury. So the first patient is Amy, and she's a 29 year old female, and she injured her ACL skiing.. At the same time I saw another patient of mine who I'd seen previously for knee injuries, but he did his left ACL, they were both left ACLs, he did his ACL playing soccer. He's 39 years old his name's Mark. Mark had actually ruptured his right ACL 15 years previously and had surgery, and he had gone back to play soccer, not for the full 15 years, on and off he'd played soccer for, at least a cumulative 5 or 6 years. Family things had got in the way not to do with his knee, but he'd had a really good result and a solid 5 years plus of returning to soccer. And just the other thing with Amy, she was keen to avoid surgery and the reason for her was because one of her friends had surgery and said to her, oh, my knee's never really been the same since I had the surgery. So Amy had a little bit of a different set of beliefs around surgery than Mark had. They both had tears that were really suitable to be braced. Particularly Mark, he had a very minimally injured ACL, so he could have done really well with the bracing. So he was quite happy to consider it. Amy considered it, Amy decided to, she had very good support at home. She was a very positive person, so she decided that she wanted to do the 12-week protocol. Now Mark decided that he wanted to go and speak to his surgeon that did his first knee. And he subsequently decided to have surgery. So he did two months of rehabilitation and then had an ACL reconstruction. And that was absolutely fine, that was his decision, he discussed it with his family. He has two really young kids, they're 10 and 8 years old, so he just felt being in a brace was going to be problematic. And because he'd had a good result with surgery previously, he thought that's the option for me. So the interesting thing about these two was that I would probably say that Amy had very few issues. She breezed through the bracing protocol. She was a fantastic patient. She did all her rehab. She went to the gym, she did everything. Mark was the same. He did all his rehab to the letter. He was really wanting to get back to soccer so he did everything possible. So at the 11 month mark, I did both of their part of their return to sport testing, or, on the way to their return to sport testing. Mark was nine months post his ACLR because he had two months to prehab, so eleven months post his injury, and Amy was the same. And so she'd been out of the brace for 8 months. And what I found when we did the muscle strength tests, we did the balance tests we did, all the functional hopping tests, triple Crossover hop tests. Every test they did, they performed outstandingly. They also underwent another TSK11, they did ACL -RSI, so the Return to Sport Index, which examines fear around returning to sport. They both got in the high 80s for that, which was probably for where they were about, right? We'd love them to get in the 90s, but 80s is pretty good for that period. So essentially their outcomes were the same. They did their injury at the same period of time. Amy at 11 months, she was going to travel in Europe for 3 months. She wasn't planning on going back to skiing for another 6 months, so she had a little bit more time and she's returning to a level 2 sport, so not a level 1 sport. Whereas Mark, he was returning to a level 1 sport and he is actually going to go back to play next month now, which will be 13 months since his reconstruction. So I guess what I'm pointing out with these two cases is that both of them came into our clinic with ACL injuries. They were both very suited to non operative management. One of them chose surgery. One of them chose Cross bracing protocol. And after 11 months, they both did exceptionally well. And both of them said to me, Clare, I am so happy with my outcome. Mark was so happy with his surgery. Amy was so happy with her non surgical management with a brace, with a Cross bracing protocol. And so it shows us that as physios there are actually different things suit different patients and we have to really be able to take into consideration what those patients needs are, what their beliefs are, what's going to suit their lifestyle, what their return to sport plan looks like. And that's what I think that the crux of this is. David Pope: And it's a great example of a patient centered decision making where they're deciding what's actually suitable for them and not pushing them down a pathway because someone thinks it's more suitable or you've got the right type of tear so you really need to get into a brace or whatever it might be. But sort of their understanding of decisions, figuring out what's right as part of the, with their medical team and moving forward that way. Clare Walsh: Yes, and I think that, as physios we often have a bias. I think there are some people that think that every patient that comes into our clinic is put in a brace, and that's quite to the contrary, a published case series of 80 patients is not the highest level of evidence. What we really believe is that it's a great starting point. It's a great starting point for hopefully some randomised controlled trials that are starting to hopefully will be underway, but they're only in preliminary talks at the moment. But yeah, it's a great starting point and hopefully something that we can offer to more patients in the future as an alternative to having surgery. David Pope: Are there many patients that get offered non surgical rehab without being braced? So they're going, yeah, I don't want to be braced, but I don't want to have surgery either. When does that come into the equation? Clare Walsh: Yep, absolutely. So patients who might, again, financial could be an issue for them, so if they don't have private health cover, but there could be lifestyle reasons that they don't want to go into a brace. That could be just because they, because of their work, because of, other reasons they don't have much support. that being in a brace would be really difficult for them. So they have the option of just doing rehabilitation and then possibly having a reconstruction down the track if they need it and, they might save up for it or they might get private health insurance in the meantime and then go on to have surgery. But they're offered that non operative management with a really robust high quality rehabilitation program. And then it's all about stability for them. So it depends on, over the months during the testing, if they have any instability in their knee, then they may, at that point in time, be suggested to see a surgeon. And if they do well, then they'll just return to whatever sport they feel that they can functionally cope with their ACL deficient knee. David Pope: You're using those sort of criteria and testing to see what their knee stability is like as they're, going through some training drills, you're doing some testing to see if they are up to, and their knee up to returning to training and sport fully. Clare Walsh: Yeah, 100%. So I have had a patient who did, for that exact reason, undergo non operative management. She didn't have private health insurance and she was, determined again. She worked really hard through her rehab. She went to the gym. She returned to running. When I got her doing, hopping and plyometrics and stuff, she started to slow down a little bit, like she'd come back into physio and she'd go, Oh, I haven't really been doing as much hopping as you'd given me or I've been running and running's fine. And then it got to a point where she said to me that she was thinking about returning to netball. So she's probably about nine months post her injury. And I feel that she had given non operative management a pretty good go. But when we did her testing, her strength was good. Even her quad strength was pretty good. It was up, it wasn't quite 90%. I think it was around 88 or 89%, but her functional hopping test, she failed miserably like, particularly Crossover hop and, side to side hopping, she couldn't do it. And I had to really sit down with her and say she'd been stuck at this point where she couldn't progress to change of direction because her knee couldn't cope with it. So she was encouraged to seek a surgical opinion at least or consider not going back to netball and just continuing to do some running. So she actually did end up having a knee reconstruction. And she's done really well with that. She's, I think she's only about six months post op now so there are cases where rehabilitation alone can work really well, but it may if you've got instability, then surgery's a better option for you. David Pope: Perfect. And I want to get you back in talking about, that return to training, return to play testing and, the details of that. So we're going to dive into that, I think on a future episode, that'd be really interesting to explore. Cause it sounds like there's some really good indicators there about maybe why she was unable to, do as much of that in her rehab is what, you might've liked. And if it was limited by that knee stability, that's going to be a bit of a limiting factor there. Clare Walsh: That's right. Yeah, no, I'd be very happy to talk about some of that stuff . David Pope: I just want to wrap this up, just have a little bit of a discussion about how you talk to the patients about their options. So you've got a patient that comes in with a likely ACL tear, you do some testing and tell us about how that process goes and that discussion you have with them about their treatment options and how you describe it to them. Clare Walsh: If the patient has come to us first as a physio, so they haven't already been seen by one of the sports physicians or by Dr Cross, what we do is we consider the patient's age and their level of sport and what their goals are and we sit down with them and we say, look there are different treatment options now for ACL, having a reconstruction is still probably the most popular pathway that patients go down, but that the surgery is not urgent, so they do have time to think about this, and that it's a great idea just to work on their knee, reducing the swelling, getting back to normal gait, starting to do some basic strengthening exercises. And then through that process we can see whether their knee is unstable, if they're having episodes of giving away, and if we think that they need an early knee reconstruction because of that, or because they're going to go back to a very high level of sport, then we, I would probably say to them, they would at least want to get a surgical opinion on that. But if they want to explore non surgical options, then they would go through the rehab program. We still, tell them that it will take time. It will take a good six to nine months. Some patients can get back to sport as quickly as six months, but I find nine, nine months is more common for patients that have non operative rehabilitation. Just because it takes them that long to really get over the injury, get the muscle strength, get back to running and then get back to obviously the other, if it's power, plyometrics, agility, etc. And also too, to get their head around what it means for them to go back to sport, to address their fears as well. So I think it takes about that long. And then we also tell them that if they want to try and facilitate healing of the ACL. That we have a novel bracing protocol and then we would send them straight through to Dr. Cross to discuss that option with them and they can learn more about that with him and have their MRI looked at and then it's basically a shared decision making process between Dr. Cross and the patient the discussions we've had with the patient and then discussing it with their family as well. So that's pretty much how it goes really. If physios refer into If they're interested in referring into the Cross bracing protocol. we recommend that they refer directly to Dr. Cross at The Stadium clinic by ringing his rooms and his receptionists are fantastic. So they'll actually tell the patient or the physio exactly what they need to do. They'll tick a couple of boxes, they'll make sure it's not, three months since their injury or, if they've already had an MRI, they'll find out where they've had it. So they can fast track that appointment to see Dr. Cross to see whether they're an appropriate patient or not. David Pope: Yeah, that's great to hear that they can still get access. So you're not in Sydney, they're based somewhere else, but they can get like a telehealth consult. Clare Walsh: Dr. Cross does a lot of telehealth consults and we've had physios who work in the ski fields in Japan who've come down to Sydney to actually sit in with Dr. Cross and, sit in with physio and see what we do as well and we also run a practical workshop to teach physios what to do, which Tom is also part of that educating them on what to do if they have an acute, a patient with an acute ACL tear. So there's lots of opportunities out there for physios to learn more about it and to refer patients in if they're interested and if they think it's appropriate for their patient. David Pope: Physios might be going, okay, maybe I can just, put people in a brace, that type of thing. So what's the sort of guidance there? Clare Walsh: Yeah, David, that's such an important question important comment really, because there are physios and other clinicians out there who we know are putting patients in a brace just based on reading the research project and that's not a great thing to do at all. It can be quite dangerous if they're bracing somebody. With a history of DVT if they haven't assessed that properly, if they don't have medical intervention that can put them on anticoagulant, if they don't know how to manage a patient that's in a brace at 90 degrees. That includes, certainly taking them through the very basic or more advanced exercises that they need to do in those first few weeks to mitigate the issues that they can have down the track. So we really discourage physios from just doing this bracing protocol on their own if they're not educated in what to do. So they need some medical management and obviously Tom Cross at The Stadium is the best person to involve in that or he can recommend other sports doctors that can help them navigate the protocol on the medical side. David Pope: Anything else that you want to cover before we wrap up this discussion on ACL management and the bracing protocol? Clare Walsh: Probably only one thing, because I know a lot of physios do ask us this, is what's the type of brace that we use? And any, you can use any range of motion brace. So we started out using an Ossur range of motion brace, but you can use a Breg or a DonJoy. Quite often the patients will come already in a brace, particularly if they've come from the ski fields, they tend to brace them quite quickly. So they might just use the brace that they've come in with. However, back in around 2020, I think it was, Bauerfeind, they designed a brace particularly for patients going through the brace protocol. It's called a SecuTec Genu. It's a beautiful brace, it's really light which makes it really amenable, to patients who are going to be wearing it for a long period of time and that's our brace of choice. So we give the patients the choice, and you just show them the brace and it looks a lot lighter and a lot more comfortable. But it is very expensive. So it's 700 dollars as opposed to using a range of motion brace, which is 200 dollars. So we let the patients choose, but we certainly offer them what we call the Rolls Royce of braces, which is the Bauerfeind. David Pope: Yep, they've got lots to choose from there. Any other key points that you want people to take away? Clare Walsh: They're the main key points, I would say. I think it's an exciting area and as a physio who's seen a lot of ACLs for many years, I've seen surgery go super well, I've seen it not go so well, I've had some hesitations around putting people in a brace for 12 weeks, when I have patients that do so well and are so grateful for the fact that they've, had some healing of their ACL without having to have surgery. I think that this is a really exciting area and a great option, but certainly we need a lot more ongoing research and data to look at the outcomes. David Pope: Definitely. Yeah, for sure. All right. That's great, Clare. Lots of great stuff within that podcast. It is an interesting area to look at all the different options and to go, okay, we've got some new emerging things that hold some potential promise for specific patients. And overall, do you reckon, if you had to put a wild, stab in the dark about, you look at the number of patients come through with an ACL, rupture. What sort of percentage of patients do you think end up getting a brace as opposed to other types of rehab? Clare Walsh: Okay, so in our clinic, about 40 percent of patients that come through would go into a brace. And 60%, a high number of that 60 percent would go to surgery. Or a smaller percentage would have rehabilitation without the brace. Now one thing I will say is that patients particularly referred into our clinic are already interested in bracing because they know that's where to come. So that means that it's probably slightly higher in our clinic because they've already come with that idea in mind that they want to explore the bracing protocol. It's about 40 to 60 do bracing as opposed to 60 percent surgery or other non surgical management. David Pope: And when it comes to like your 6, 8, 12-week sort of timeframes, it sounds like it's still not totally clear which, is having, if the outcomes are changing, but how many people are opting for the 6 versus the 8 or the 12 sort of protocols? Clare Walsh: Interestingly, a lot of patients still opt for 12. Most are still opting for 12. They do have the opportunity to not be in the brace for as long, but I think they're, the reasoning behind that is because they feel like they want the best chance of the best heal. And because we don't know with the shorter bracing protocols as yet they're mostly choosing the 12 week. And, yeah, fewer are choosing six and eight weeks at this point in time. But down the track that might change.

David Pope: That's awesome, Clare. So much great information in this podcast. You're with the Clinical Edge team. You're one of our senior educators and presenters, and it's awesome to have you on the team with your level of experience and knowledge and being able to share that with Clinical Edge members. And it gives us the, also the ability to record more of these podcasts with yourself and be able to share that with a wider audience as well. But besides on the Clinical Edge website, where else could people find out more about what you're going on and also the Cross bracing protocol? Clare Walsh: Probably the best place to contact me is through my email at work, which is Clare, and there's no I in my name, C L A R E, because I'm Irish, not French at stadiumsportsphysio.com.au. I'm very happy for people to email me if they want more information about that. I also have a Facebook, Clare Walsh Physio Facebook page, and I am on Twitter. I think my handle is @clarwalshphysio, without the E on Clare. But I think, yeah, email or Facebook is absolutely fine. Yeah, happy to receive any queries or anyone wants to touch base about this subject. David Pope: Awesome. And if you mentioned there, Dr. Tom Cross, so people can contact him . Clare Walsh: Yeah, The Stadium Clinic, that's where they would get in touch with him if they were interested in directing a patient to him or if they were a patient that wanted to, that had an ACL rupture. We've actually had a lot of physios who've ruptured their ACLs that have come through and done the bracing protocol themselves actually. David Pope: Oh, excellent. Clare Walsh: Yeah. David Pope: And you've also got some education programs for physios that want to take patients through this as well, I think. Is that right? Clare Walsh: Yeah, so we've run one workshop and we've got our second workshop coming up . That involves Tom Cross giving his talk about the research and about the grading of the tears, all of that kind of stuff, on the medical side, and then there's four of us physios who are then presenting pretty much a practical hands on workshop putting on the brace, getting on the leg press, doing all the stuff that we get our patients to do while they're in the brace in the gym and and troubleshooting taking someone through 12 weeks of bracing. Yeah, the first one was really successful, so hopefully the second one will be as well. That's run through The Stadium sports physio clinic. So that would be where to contact us if they wanted to participate in that. David Pope: Alright thanks Clare and really been fun to have you on the show and, have a chat to you about ACLs, so uh, thanks again and we'll look forward to catching you on another episode. We can chat more about ACLs and some of the rehab and lots of other topics as well around sports injuries. Clare Walsh: Thanks so much, David. Thanks for having me. Appreciate it.