Ep 175: Measuring for success in ACL rehabilitation, with Dr Eric Hamrin Senorski

[00:00:00] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research

[00:00:10] to quality practice. I'm Claire Ardern, the editor-in-chief of the Journal of Orthopedic

[00:00:15] and Sports Physical Therapy. It's great to have you listening today.

[00:00:23] Are you looking for some guidance on what to test and how to think about using the

[00:00:27] results of clinical tests when you're designing, implementing and progressing a rehabilitation

[00:00:32] program? Well, you're in the right place. Because today, Dr Eric Hamerins-Synoski joins

[00:00:38] me to share how he blends his research training with his clinical skill set to best help athletes

[00:00:44] and active people with ACL injury. And the beauty of today's chat is that the principles

[00:00:49] apply to any program you might think about designing. So even if you don't see many

[00:00:54] people with ACL injuries, you will definitely find value in today's episode. Dr Hamerins-Synoski

[00:01:00] is an associate professor at the University of Gothenburg in Sweden and a specialist sports

[00:01:05] physiotherapist in practicing Gothenburg. At the clinic and in research, Eric focuses

[00:01:11] on sports related injuries to the lower extremities and most of his work has been on understanding

[00:01:17] the interplay of orthopedic and physical therapy data to make better rehabilitation

[00:01:22] decisions. Dr Eric Hamerins-Synoski, welcome to JOSPT Insights.

[00:01:28] Thank you so much. I'm happy to be here and try to contribute with some good discussion.

[00:01:33] You can definitely contribute because you are a clinician scientist in the absolute truest

[00:01:38] sense of the phrase. You're in the clinic, you're working with athletes of all ages

[00:01:43] and all levels each week and you are collecting loads of data from those clinical encounters.

[00:01:49] And I'm looking forward to hearing about how you use those data to help you, help the

[00:01:55] patients and athletes you're working with. I want to start by asking you what are the

[00:02:00] metrics that you pay most attention to during your ACL rehabilitation programs?

[00:02:06] Dr Hamerins-Synoski, just as you said, I am a clinician researcher so I have a very

[00:02:11] good setup where I do research and I have clinic. And what we've been very happy

[00:02:17] with in Gothenburg is that we started a local project, which we call Project ACL,

[00:02:23] which is just any patient within the area or Sweden that could come to the clinic and they

[00:02:30] could come there and they get to run through a series of structured

[00:02:33] testimus function and patient board outcomes. And this is regardless of whether you had

[00:02:38] surgery, if you don't have surgery, regardless of where you're doing your

[00:02:42] rehabilitation. And the results are shared to clinicians and the surgeon and the

[00:02:47] patient, which is really been a good thing to create compliance. It has good clinical

[00:02:53] information but maybe a bit much research. But there's also things that we look at

[00:02:58] in clinic of course, which also matters because it's really about covering the

[00:03:03] patient, the patient's injury and what are the goals and expectations that

[00:03:08] we're looking for. It's interesting that you talk about being in this very

[00:03:13] special environment and Project ACL having a very particular setup and being

[00:03:18] privileged to have the data. And I would argue that the data you're collecting

[00:03:23] and the data that are going into the Project ACL database are actually really

[00:03:27] clinically relevant data points and they are metrics that most people who

[00:03:33] are working often with people with ACL injuries, they're probably

[00:03:37] collecting. It's maybe a clinical practice environment at a scale. So tell us a

[00:03:42] bit about what are those key metrics or what are the measurements that go into

[00:03:46] Project ACL? Because I'll bet that people listening to us are going to

[00:03:51] think, oh, I'm measuring that. It's a nice reminder that even in our

[00:03:55] clinical, in our maybe individual clinical contexts, we do have a mini,

[00:04:00] almost a mini research project and that's the beauty of and underscores

[00:04:04] why it's so important to measure stuff in the clinic as our friend and

[00:04:09] colleague Professor Lynn Snyder-Macalus says, if you're not measuring,

[00:04:12] you're guessing it. That's a brilliant quote. I really like that quote.

[00:04:17] So what we do is we have certain follow ups. They're after injury or

[00:04:21] after reconstruction. We do 10 weeks after injury reconstructions. We do

[00:04:26] four months. We do eight months. We do 12 months, 18 months, 24 months

[00:04:30] and then every 50 years. And what we collect is isokinetic strength

[00:04:34] tests quadriceps hamstring strength. We start that 10 weeks, then at

[00:04:40] four months or forward, we start doing hop tests and the three hop

[00:04:44] tests that we use is the hop for distance, the vertical jump and

[00:04:48] the 30 second side hop tests, which are simple good tests. And

[00:04:53] they reflect the patient's function in a good way. Or for the test

[00:04:58] battery, we also have some patient board outcomes. So we use the

[00:05:01] COOS, we use the ACL RSI, we use the knee self efficacy scale and a

[00:05:06] few others we use this we use the tangerotivity scale to measure

[00:05:10] some kind of return to sports aspect. But the key to the

[00:05:13] project success and for clinicians is that we provide

[00:05:18] the patients and the clinicians with a protocol or a test

[00:05:22] protocol where you can see how well did you do 10 weeks? How

[00:05:26] well did you do four months? How well did you do eight months? So

[00:05:29] you can follow the progression through rehab and help guide the

[00:05:33] patient to make better or smarter decisions along the way.

[00:05:38] That's so important. And I think many of the folks listening

[00:05:42] to us today will know from talking with athletes and

[00:05:46] patients that people want to know where most people want a

[00:05:50] sense of where am I up to? Am I doing as you're expecting?

[00:05:53] How am I doing compared to other people? A lot of athletes are

[00:05:56] very competitive. So they want to know how am I doing compared

[00:05:59] to other teammates? So this is the beauty of having that bigger

[00:06:02] data set, isn't it where you can use some summary data and

[00:06:05] provide people a bit of a guide about, you know, how are they

[00:06:09] how are they doing? How is their physical function? How

[00:06:11] are their questionnaires? How are their scores doing

[00:06:13] compared to what we would typically expect? How do people

[00:06:16] respond to getting that information?

[00:06:18] Well, our perception of it is that they like it a lot.

[00:06:22] People like to know that you are your injured limb is 20%

[00:06:26] weaker than your healthy limb. And compared to statistics of

[00:06:30] all the patients in this, in this project, I'm 10% behind at

[00:06:34] this fallup. So okay, I need to get my ax together or well,

[00:06:39] you can use it as some kind of the other factors you as a

[00:06:43] clinician can use it. So given that you also have this

[00:06:46] menisco injury and had suture repair your menisco

[00:06:49] injury, it's not strange that that you're a little bit

[00:06:52] behind. But no worries, if we just give it enough time, you'll

[00:06:55] make it back.

[00:06:56] And I love that you raise the support for clinicians,

[00:07:01] particularly if you're someone who is maybe not seeing so many

[00:07:04] athletes or patients with an ACL injury might see one or two

[00:07:08] or three per year, then having that reassurance of

[00:07:12] knowing a bit of benchmarking is this person where I would

[00:07:15] expect or if it's a more unusual injury that you're much less

[00:07:20] likely to see again, having that sense of okay, this is roughly

[00:07:24] what I would expect compared to a much larger data set. I think

[00:07:27] is a really helpful way of using information. We talk a lot

[00:07:31] about using information to help us support athletes to make

[00:07:34] clinical or to make decisions for them. It's also helpful

[00:07:38] for clinicians making clinical decisions and supporting your

[00:07:41] clinical reasoning.

[00:07:43] I want to talk a little bit about how you interpret the

[00:07:46] information that's in the database, Eric. Before we get

[00:07:50] there, how many data points are in this database or how many

[00:07:54] how many athletes roughly are in this database?

[00:07:58] We have over, like I don't know the exact number, we have

[00:08:01] over 4,000 patients, recovering patients from, I think

[00:08:06] around eight years to seven years old. So it's a good

[00:08:10] data against you a lot of details.

[00:08:12] That's fantastic. And we will link to the resources, we'll

[00:08:15] link to the website and other resources as we go through the

[00:08:19] podcast and people can find those links in the show notes.

[00:08:22] Let's come back to interpreting some of the data from this

[00:08:25] wonderful database. I would really like to talk about the

[00:08:29] hop and the strength measures because I think people will

[00:08:32] remember or recognize his heaps of discussion around how do you

[00:08:36] make sense of these numbers, particularly hopping and

[00:08:39] strength testing where you're testing both limbs. And some

[00:08:43] people would argue that it's really not good to compare to

[00:08:46] the uninjured side. That's a bit of a challenge in real life

[00:08:50] clinical practice because often we don't have pre injury

[00:08:53] measures. If you're working in a team environment, you may

[00:08:56] have have the luxury, I guess, of having pre injury measures

[00:09:02] in the clinic. We typically don't. So how do you make

[00:09:05] sense of the data that you're getting, particularly with the

[00:09:08] hopping and the strength test results?

[00:09:10] We have pushed for a long while in the project. And I still do

[00:09:15] in clinic. I'll confess to that that looking for this 90%

[00:09:20] LSI landmark, but also thinking it's a 10% deviation from

[00:09:26] being symmetrical. So we're not going trying to go above

[00:09:29] 110 for logical reasons is something that we push. I know

[00:09:33] there's a discussion out there that it's not good. I think it

[00:09:37] is good, but you have to consider what is it good for? It

[00:09:40] doesn't it won't explain everything. It may not explain

[00:09:45] why certain patients go on to have a second injury. But we

[00:09:49] know there is some correlation with being more symmetrical

[00:09:53] appears to correlate quite well with the recovery of

[00:09:56] patient outcomes and moving more towards normal and looking

[00:10:00] one year a lot down the line. Well, 20 to 30 patients have

[00:10:04] recovered within that deviation from 10% from being

[00:10:09] symmetrical. So there's quite some work we can still do and

[00:10:12] trying to push our patients motivate our patients to do

[00:10:15] better. And I think given that it is a good, it's good to

[00:10:19] compare to it on the inner side, but it won't tell us the

[00:10:22] whole story. Well, there are some some different options out

[00:10:26] there. There are as you said, if you're if you're lucky

[00:10:29] enough, you have pre injury data. You may also have if you

[00:10:33] don't have that you may have pre operative data, which may be

[00:10:37] more relevant because typically see some sort of

[00:10:40] decrease in also the healthy limb after reconstruction. You

[00:10:43] can also think of maybe we should put and we've given

[00:10:47] this some effort recently that maybe we should put some

[00:10:50] effort into looking how well is your strength or your

[00:10:53] hop performance compared to your body weight. So sort of

[00:10:57] relative to your body weight, is it is it enough compared to

[00:11:00] what you're doing? The thing which I really want to

[00:11:03] highlight where I think we will find the most in recent

[00:11:07] coming years is that we're probably going to move away

[00:11:11] from just looking at point predictions, looking at what

[00:11:14] doesn't matter if you had recovered the 90% or 100%

[00:11:18] and trying to estimate everything that will happen

[00:11:21] to you during a certain amount of time after that point,

[00:11:25] even if it's a half a year or a year or two years or

[00:11:29] whatever we're talking about, series of testing and

[00:11:32] trying to understand things how they line up over time.

[00:11:36] It's like being a coach for an athlete. You don't

[00:11:39] predict their performance based on one workout they do

[00:11:41] with one point because there's so many things that

[00:11:44] can affect what you're doing that day.

[00:11:47] There's a few threads there that are really

[00:11:49] interesting and I want to pick up on a couple of

[00:11:51] them. One is you mentioned this idea of trajectories

[00:11:55] and I really like the analogy of if you're a coach,

[00:11:58] you're not evaluating the athlete's overall

[00:12:01] performance based on one session. And I think that

[00:12:04] will really resonate with clinicians for exactly

[00:12:06] the reason that you described. So having the

[00:12:09] capacity to look over time and look at the

[00:12:11] trajectory over time is really helpful. And I

[00:12:14] think again it's this sense of not relying on

[00:12:18] one individual piece of information that is why

[00:12:23] some of these data sets like your database and

[00:12:26] there are other databases we know out there,

[00:12:28] people doing similar kinds of work and making

[00:12:30] these data available is giving us as clinicians

[00:12:34] different pieces of information, different

[00:12:36] pieces of the puzzle to put together. So there

[00:12:39] are I think it's reassuring to know that

[00:12:41] there are a lot of different options out there.

[00:12:43] So you're not solely relying on comparing to

[00:12:46] the opposite side all the time. Let's talk a

[00:12:49] little bit about the risk and the reward of

[00:12:52] supporting athletes when they're returning to

[00:12:54] pivoting sports. I'm going to focus on the

[00:12:56] high-risk pivoting and cutting sports like

[00:12:59] football soccer, American football, basketball

[00:13:02] and ACL rehabilitation. What would you advise

[00:13:06] clinicians and athletes when they're thinking

[00:13:08] about this balance, this dance if you like,

[00:13:11] Eric? How risky is it to return to those

[00:13:15] pivoting sports and then what are you really

[00:13:17] looking for when you're supporting that

[00:13:19] return to sport phase? We have a few

[00:13:22] scenarios here which are difficult. We see

[00:13:25] that a lot of athletes, they don't make it

[00:13:28] back at all for some reason. And when you

[00:13:31] say a lot what proportion is that Eric?

[00:13:33] Well it depends who you ask. If we read

[00:13:36] your systematic review, it's around 50%

[00:13:40] if we ask the athlete, we followed up all

[00:13:43] the patients who underwent surgery who

[00:13:45] were pediatric or adolescents in Sweden

[00:13:48] who were in the national database for ACL

[00:13:51] and we asked them a bunch of questions

[00:13:53] about returning to sport and how well

[00:13:55] they did and so on. And the proportions

[00:13:57] from athletes who were able to return

[00:14:00] and consider themselves as being able

[00:14:03] to perform at the same level as

[00:14:05] before their injury was 10%. Wow. So

[00:14:08] that's not that many? No, one in ten.

[00:14:10] That's pretty low. Yeah, so they're back

[00:14:14] in sports but they're not where they

[00:14:16] want to be or believe they should be.

[00:14:20] And we have a lot of patients who make it

[00:14:23] back but they decide to quit maybe

[00:14:25] because they're not feeling that well

[00:14:26] or performing that well. There's also

[00:14:30] a lot of re-injuries which we see in

[00:14:31] tons of data especially in pediatric

[00:14:33] and adolescents. We really need to

[00:14:36] reconsider what we're doing and what

[00:14:39] we're trying to frame here. And I think

[00:14:43] for the athletes who are going back to

[00:14:46] risk sports, this is where it becomes

[00:14:50] challenging for clinicians because we

[00:14:52] really need to think of all the risk

[00:14:54] factors that a patient may have. Is

[00:14:57] it born in morphology? Is it the type

[00:14:59] of sport? Is it the position they're

[00:15:00] playing? Do they have persistent laxity?

[00:15:03] Do they have something else driving

[00:15:05] the risk? And then nobody can tell you

[00:15:10] or today we don't have an instrument

[00:15:12] good enough saying that your risk will

[00:15:14] be 50% but if we did what is the risk

[00:15:18] that you as a clinician would be

[00:15:19] comfortable with? That's a difficult

[00:15:22] question. It's a totally different

[00:15:24] question asking the patient what

[00:15:26] risk they would be comfortable with.

[00:15:29] That's where sort of the discussion

[00:15:31] has to start. You have to put all

[00:15:33] those risk factors on the table and

[00:15:36] somewhere we listen to the patient. We

[00:15:39] try to help them reach their goal

[00:15:42] by providing relevant and direct

[00:15:44] information and recommendations but if

[00:15:47] they want to return although I may not

[00:15:49] consider it, my approach is okay we're

[00:15:52] going to have to put up some goals

[00:15:55] depending on what you're doing and

[00:15:56] what you should be able to do

[00:15:59] within your sport. What is relevant

[00:16:01] for that sport? And I will say you're

[00:16:03] not good enough and you have to prove

[00:16:05] me wrong and I think that's a way of

[00:16:08] giving the athlete a bit more time

[00:16:11] testing the athlete in a relevant way

[00:16:14] and sort of guiding them closer to

[00:16:16] their sport and what they're doing. We

[00:16:18] have to think about what type of

[00:16:20] re-injuries are we talking about.

[00:16:22] I'm pretty sure rehab has an important

[00:16:24] role in helping non-contact

[00:16:27] ACL injuries. Certain type of

[00:16:29] contact injuries. I'm not sure they can be

[00:16:31] prevented. Research should do better in

[00:16:34] trying to be more specific. What type of

[00:16:37] re-injuries are we trying to prevent

[00:16:40] and have we actually looked at that in

[00:16:41] our data? Provide better recommendations

[00:16:44] for clinicians and petitions. Definitely

[00:16:47] and I know Dr Hager Grindem and her

[00:16:49] colleagues in Oslo have done a lot of

[00:16:52] work

[00:16:52] at trying to look beyond the ACL

[00:16:55] rupture and thinking that there are

[00:16:57] a whole lot of other possible injuries

[00:17:00] or re-injuries or trauma that can occur

[00:17:03] to that knee joint. After you go back to

[00:17:05] sport whether that's another meniscus

[00:17:07] tear,

[00:17:08] whether it's another conural injury or

[00:17:11] an ACL tear that there is as you say

[00:17:13] that there's a lot... There are plenty

[00:17:14] of other structures that are really

[00:17:16] important in the knee

[00:17:18] beyond the ACL. The ACL is an important

[00:17:20] structure and then there are others

[00:17:22] on top of that to pay attention to

[00:17:24] and I think you're right that we

[00:17:25] don't have nearly as good a sense of

[00:17:29] the overall trauma or re-injuries to

[00:17:32] the knee and the structures of the knee

[00:17:34] itself as we do. We've got a reasonably

[00:17:37] good overview of

[00:17:38] re-injuries to the ACL

[00:17:40] and we're primarily talking about

[00:17:42] re-injuries to that same knee. There's

[00:17:44] injuries to the opposite knee as you

[00:17:46] know so there is I think a lot of

[00:17:47] work

[00:17:48] still to do to help us understand

[00:17:51] what goes on, what's going on after

[00:17:53] someone gets back to these much more

[00:17:55] higher risk

[00:17:56] scenarios. So maybe someone who's

[00:17:58] listening today and thinking about a

[00:18:00] PhD in ACL, in the ACL field there's

[00:18:02] there's some ideas for you.

[00:18:05] Let's start to wrap up our chat here

[00:18:07] Eric and I cannot let you go without

[00:18:10] talking a little bit about how your

[00:18:12] approach

[00:18:13] to rehabilitation differs depending on

[00:18:16] the person. How do you tailor

[00:18:17] a rehabilitation program and your

[00:18:20] return to sport planning,

[00:18:21] your planning for

[00:18:24] injury prevents secondary and tertiary

[00:18:25] injury prevention? Depending on the

[00:18:28] personality, the characteristics, how

[00:18:30] the athlete themselves is responding

[00:18:32] and I'm sure that people will

[00:18:34] recognize there are some kind of

[00:18:35] stereotypes of patients out there. There's

[00:18:38] the person who speeds through rehab

[00:18:40] doesn't seem to really have any issues,

[00:18:42] gets through in three months and you

[00:18:43] think oh my goodness please

[00:18:45] I'm really worried about you getting

[00:18:46] back too quickly.

[00:18:48] They can't get back to the football

[00:18:49] pitch or the soccer pitch fast enough

[00:18:51] versus the person who is really

[00:18:53] apprehensive and you feel like

[00:18:56] you're constantly reassuring and trying

[00:18:58] to support this person to see that they

[00:19:00] are making progress.

[00:19:02] How do you make a rehabilitation

[00:19:04] program your return to sport planning?

[00:19:07] Truly athlete focused and athlete

[00:19:09] centered. I think an important thing

[00:19:11] when we speak about this is

[00:19:12] saying that well what we see

[00:19:16] in the literature now the evidence is

[00:19:18] probably still pretty weak but we're

[00:19:20] seeing that the athletes that are doing

[00:19:22] pretty good they feel confident, they

[00:19:24] feel strong, they are strong compared to

[00:19:26] their body weight and so on.

[00:19:28] They may be the patients who are at

[00:19:30] greater risk of having a second

[00:19:33] ACL injury quite early because things

[00:19:35] are feeling good and they probably

[00:19:38] want, they're probably very eager to

[00:19:39] go back.

[00:19:40] We as clinicians were proven wrong

[00:19:43] when we're trying to say that you're

[00:19:44] not good enough and they're meeting

[00:19:45] all these landmarks and we're

[00:19:46] letting them back a bit too early.

[00:19:49] What I see now in clinic is that when I

[00:19:53] see patients doing really good and I

[00:19:55] see these patients meeting

[00:19:58] the quite simple landmarks of

[00:19:59] staying using LSI 90 at four months

[00:20:02] for a strength test and hop test,

[00:20:04] I start feeling that okay these tests

[00:20:07] may not be relevant for this patient.

[00:20:10] They're too good and this is too early.

[00:20:12] So I try to race the bar a little bit

[00:20:15] and one way of trying to do this

[00:20:17] is trying to use patient report

[00:20:19] outcomes, trying to measure their

[00:20:22] personality traits or psychology or

[00:20:25] what we may want to call it and a little

[00:20:27] bit see how things line up because

[00:20:30] sometimes they're doing really good

[00:20:32] muscle function-wise.

[00:20:33] They're doing really good at patient

[00:20:35] report outcomes or it could be the other

[00:20:36] way around.

[00:20:37] They're doing bad at both or there's

[00:20:39] a mismatch there and something

[00:20:41] tells me the mismatch may be

[00:20:44] a bit more worrying.

[00:20:45] The patient feels really confident but

[00:20:47] their muscle function is not there

[00:20:49] or their muscle function is there but

[00:20:51] they're not feeling that good.

[00:20:54] And this is where we have to invest

[00:20:56] more of our time.

[00:20:58] I feel as clinicians trying to

[00:21:00] understand but then if we try to

[00:21:02] seek support and literature of what to

[00:21:05] do, there's not much out there that

[00:21:07] intervention-wise will make us more

[00:21:11] more secure or more make smarter

[00:21:13] decisions yet.

[00:21:14] I hope there will be quite soon.

[00:21:17] Let's pick the situation where the

[00:21:19] patient is doing really good.

[00:21:21] That's where we need to be more

[00:21:23] gradual with the return to sport

[00:21:26] space.

[00:21:26] Where we make sure they have some

[00:21:29] kind of on-field rehabilitation,

[00:21:31] this is very difficult in the

[00:21:32] scenario because there's usually

[00:21:34] not time or economy to have this

[00:21:36] done unless you're in a

[00:21:37] professional setting but we really

[00:21:40] should consider it and given some of

[00:21:42] the data out there showing that

[00:21:44] well, I'm to return sports is

[00:21:46] important, maybe just making sure

[00:21:49] those hours of training and making

[00:21:52] good decisions and training have

[00:21:54] played an important role in

[00:21:56] preparing the athlete for what

[00:21:57] they're going to.

[00:21:59] So just taking things a bit more

[00:22:01] slow or finding new tests.

[00:22:04] We love new tests and our little

[00:22:08] it's not that little our project

[00:22:09] but our project is we're trying

[00:22:10] new tests, we're trying to change

[00:22:11] the direction test, we introduced

[00:22:14] the Nordboard test, the eccentric

[00:22:16] hamstring test a few years ago

[00:22:19] or you find it does not correlate

[00:22:21] that well with the with the

[00:22:23] isokinetic testing, the seated

[00:22:25] isokinetic testing.

[00:22:26] So we're trying to find other

[00:22:27] things which maybe helps us

[00:22:29] find pieces of the puzzle which

[00:22:32] may protect the athlete better

[00:22:33] going back too early and having a

[00:22:35] big setback in terms of the

[00:22:38] second injury or failing to

[00:22:40] prepare for what they're doing.

[00:22:42] And this is why we need people

[00:22:44] like you who are truly

[00:22:46] clinician researchers, clinician

[00:22:48] scientists because you're taking

[00:22:50] those questions that come up

[00:22:52] all of the time, those clinical

[00:22:54] challenges, those naughty issues

[00:22:55] that you see in the clinic

[00:22:57] and translating them into

[00:22:59] research questions and into

[00:23:01] projects with a design that is

[00:23:04] scientifically set up to give us

[00:23:07] information that we can trust

[00:23:09] when we go back into the clinic.

[00:23:11] I just want to add one thing

[00:23:14] to be fair, which I think is

[00:23:15] very important because

[00:23:19] when I spoke about this,

[00:23:23] it sounds like I have a bias of

[00:23:25] time.

[00:23:26] But giving things more time,

[00:23:27] things will work out.

[00:23:29] And I sort of do, but given

[00:23:32] that some of the things that I

[00:23:33] said that if the patient has

[00:23:36] too many risk factors, say the

[00:23:38] risk-persistent laxity, the

[00:23:40] patient's hypermobile, they have

[00:23:42] uncommon injuries.

[00:23:44] They're not meeting landmarks.

[00:23:46] They may be young, they may be

[00:23:48] playing soccer.

[00:23:50] Maybe one ACL injury is enough

[00:23:54] and that patient will be better

[00:23:55] off actually being recommended.

[00:23:58] You should probably quit soccer.

[00:24:00] We could find something else for

[00:24:01] you to consider and play.

[00:24:04] And we have to have the courage

[00:24:05] within ourselves to push those

[00:24:07] decisions.

[00:24:08] And I hope to see research

[00:24:10] transition a little bit more

[00:24:12] towards this direction as well

[00:24:13] that given the certain amount of

[00:24:16] risk factors, the risk may

[00:24:18] actually be too high for us to

[00:24:20] recommend.

[00:24:20] And our recommendation should be

[00:24:22] you should consider a different

[00:24:24] sport.

[00:24:25] I'm so glad that you get us

[00:24:26] to that place, Eric, because

[00:24:29] that's, I think, one of the

[00:24:31] biggest challenges in clinical

[00:24:33] practice is when is it time

[00:24:35] to stop and how do you broach

[00:24:38] that conversation in a way that

[00:24:40] respects the athlete's agency

[00:24:42] and capacity to make a decision

[00:24:45] that is right for them versus

[00:24:48] sharing information in a way

[00:24:50] that's honest and that conveys

[00:24:53] just how serious the long-term

[00:24:56] ramifications might end up.

[00:24:58] And this is the constant

[00:25:00] challenge.

[00:25:00] We are not fortune tellers.

[00:25:03] We can't tell you with

[00:25:04] certainty what's going to happen

[00:25:05] in the future and whether you're

[00:25:07] in your future is severe

[00:25:09] knee osteoarthritis that's going

[00:25:11] to really debilitate you for the

[00:25:13] rest of your life.

[00:25:14] Or maybe you're completely fine.

[00:25:16] It's really challenging.

[00:25:17] So I'm really glad that you

[00:25:19] remind us of that conversation

[00:25:21] or conversations, I think it's

[00:25:22] not a one-off discussion

[00:25:25] that you have with athletes.

[00:25:26] It's a much more ongoing

[00:25:29] discussion information sharing.

[00:25:31] So Dr Eric Amarin-Sinorski

[00:25:34] thanks so much for bringing your

[00:25:36] clinical hat

[00:25:37] and your research hat to

[00:25:38] JOSPT Insights today.

[00:25:40] It's been wonderful hearing from you

[00:25:41] about how you reconcile the

[00:25:43] information coming from both of

[00:25:45] these places and use that

[00:25:47] information to really boost

[00:25:49] the work that you're doing in

[00:25:50] both the research environment

[00:25:52] and the clinical environment.

[00:25:53] We're all very thankful for

[00:25:55] people like you helping us

[00:25:57] helping us support athletes.

[00:25:58] Thank you.

[00:26:03] Thanks for listening to this episode

[00:26:05] of JOSPT Insights.

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[00:26:08] in musculoskeletal rehabilitation

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