Ep 285: How well does a ruptured ACL heal? With Dr Joanna Kvist

[00:00:00] I'm Danu J. Acelin, editor of the APT Orthopedics Independent Study Courses, and I'm happy to announce that it's here. Current Concepts of Orthopedic Physical Therapy, the 6th Edition, is now available. This is the most rigorously peer reviewed edition yet. It's built to elevate your practice. You already know how important it is to stay current in your practice. Evidence evolves, best practices change, and your patients deserve the most up to date care you can give them. This is exactly what the 6th Edition was built for. There's 12 comprehensive sections,

[00:00:30] covering every major body region from head to toe, all grounded in the latest evidence. Each section walks you through the anatomy, examination, diagnosis, and intervention and wraps up with real-world case scenarios designed to sharpen your clinical reasoning so you can apply what you learn the moment you walk back to the clinic. Whether your patient's presentation is complex or not, Current Concepts gives you the evidence-based framework to examine more competently, diagnose more accurately, and treat more effectively.

[00:01:01] Also, if you're preparing for your OCS exam, this is your resource your peers have relied on for years to walk into that exam ready. Visit orthopt.org to register for the 6th Edition today. But then it's another thing what the patient feels, if they feel stable or not. So the patient reported stability because we asked them, do you feel that your knee is stable during activities of daily living or sports activities?

[00:01:28] There we could not find these associations. The feeling of stability is not the same as laxity. Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Claire Ardern, the Editor-in-Chief of the Journal of Orthopaedic and Sports Physical Therapy. It's great to have you listening today.

[00:01:59] Does the ACL have the capacity to heal? And if it does, what might that mean for how we approach ACL rehab? For a long time, the prevailing assumption has been that a ruptured ACL has limited capacity to heal and restore structural continuity without reconstruction. But emerging research is challenging that assumption and narrative.

[00:02:20] To help us answer those questions and more, we're joined by Professor Joanna Kvist, lead author of the paper and professor of physiotherapy at Linköping University in Sweden. Joanna leads the Sports Knee Injury Research Group at Linköping University, and her research has focused extensively on ACL injury, rehab, treatment decision-making, return to sport, and the factors that influence recovery following knee injury.

[00:02:47] She's also one of the researchers behind the NACOC study, which provided the data for the study we're discussing today. I'm Marc Perron. I'm a doctor of physical therapy in Baltimore, Maryland at Summit Physical Therapy and Performance. And I'm Chelsea Kuman, a physical therapist and athletic trainer at Stanford University Athletics. Joanna Kvist, thank you so much for joining us today on JOSPT Insights. We're so excited to get into your article. Thank you.

[00:03:12] Okay, so I'm just going to lay out the title. Obviously, we'll put it in the show notes as usual, but it is Structural Changes of the Anterior Cruciate Ligament, Evaluated by MRI, and their relation to clinical outcomes within two years after ACL surgery. And this is results from the NACOC cohort study. So even before we actually dive in, we have to kind of take a step back. Can you take us through what that NACOC cohort study is and then how your study came out of that?

[00:03:36] This is actually a pragmatic cohort study. And it started when we're looking at the ACL patients when they have an injury in Sweden. Approximately half of the patients are treated with ACL reconstruction and half do not have reconstruction and only are treated with rehabilitation alone. We have quite good results. Some of the patients have increased laxity. They have not so many instability problems and many function very well.

[00:04:04] We can go back to sports. As you know, there are a lot of research that have been done to identify the copus and the non-copus, but we still don't know what happens. So we wanted to see in this cohort, we have included 275 patients after an acute ACL injury, six weeks from the injury. And then we have tested them with a lot of things. We follow them with questionnaires every week in the beginning, every second week, later on, and then every month.

[00:04:32] And now we're going to start the 10-year follow-up for this. And we're looking at all the biological, psychological, social factors. We're asking them about if they choose surgery or not and what makes them to choose that. And then we follow them to see to return to sports, if they have new injuries, new surgeries. And finally, we want to see about early onset of osteoarthritis.

[00:04:58] We have a lot of questionnaires. We have clinical examinations, but we have also these MRIs, the longitudinal MRIs that we take at the baseline, and then at 3, 6, 12 months, and 24 months. And then we have also five years, and now we're going to take 10 years older. So the MRIs were initially for the osteoarthritis. It is so interesting to see what happens with the ACL. I try not to use the word healing, because we don't know it is healing, but to regain the continuity.

[00:05:27] The orthopedic surgeon says that when they're doing the arthroscopy, they can actually see that the ACL is still there, but maybe there's not so much tension. And maybe that it is bald or elongated, so they say that maybe the function is not good. So we want to see with this MRI, see what happens within the ACL structure. We have a huge study looking at a lot of things, and then we found and we zeroed in on, hey, what's going on with that ACL?

[00:05:54] Because maybe we actually don't know why people are coping or not coping, and maybe this will give us a clue. Yes, something like that. I was very interested for this question already from the beginning, but we didn't have the method to look at it on the MRIs. So we didn't know how to do it. So we have been waiting, and I have tried to persuade all my colleagues, the radiologists and the orthopedic surgeons that we need to do that.

[00:06:18] I think for a long time, the notion was that, hey, if you rupture your ACL, it's not going to heal, or it's not going to have the structural continuity. And everyone needs to get a reconstruction. Now we're starting to kind of challenge some of that narrative with some of this research. So I think there were two main objectives that you really wanted to hit. Can you kind of lay out those objectives for us?

[00:06:44] The main objective, you could say, was the one was to see about the structure of the ligament. How does it look like? And then also to see if possible changes of the structure can correlate or are associated to functional outcomes, like instability, patient-reported outcomes, muscle strength. Yeah. And how are you assessing some of those structural changes of the ACL over time?

[00:07:10] And that was the biggest problem, to find a way actually to assess the ligament on the MRI. I've been collaborating with radiologists, mostly one radiologist from Linköping, Sweden, and also from Melbourne in Australia. There was Nicola Gianotti there and Angie Liu at Linköping in Sweden. When they're looking at the MRIs and looking at the ACL, you can never say that it's actually now it is torn or not torn. It is not like on-off.

[00:07:39] It is always somewhere there in between. It can be torn a little bit, a lot. Looking at the fibers, you look at the synovia around the ligament. We decided about to look at the overall structure, that is the one term. Then we looked at the fibers, if we can say continuity of the fibers. And then going on looking at the thickness of the ligament and also the shape.

[00:08:03] We don't have the common two-dimensional MRIs, but we have special clinical settings using the three-dimensional high resolution proton density fat saturated MRI. That's the more research setting. The primary question was arthritis. So the radiologist took these sequences and developed this score with the four features that we felt were the most clinical relevant for the patients.

[00:08:30] The overall structure, by doing this reconstruction in three-dimensional, they can see in parallel the fibers. So they can see if the fibers have a continuity or not. Then they can see the thickness of the ligament. And that is possible because we have MRIs on both legs. So they compare the injured leg with the non-injured leg. That is not a normal clinical scientific pattern just for this research.

[00:08:58] So they can see the thickness and then also the shape. So it's not that we weren't looking at it before or that we were disregarding it before. It was just that we physically couldn't see all of those details because of the MRIs we had available. And now we can see them? Yeah. Many of these details couldn't be seen before. And the radiologist says that, of course, you see what you see. But yes, they can see the fibers.

[00:09:25] It is never 100% with a subjective imaging assessment. But it is as good as they can do it. And in our study, they have done it blinded. Two radiologists have done this blinded and then looked it together. That's great. I love that we can now use our modern advanced imaging in order to see some of these structural changes. I think that that's really going to help us long term here.

[00:09:51] And then some of your second thing that you were looking at is that you were trying to look at how those structural changes maybe impact some of the clinically important measurements. Can you walk us through what some of those measurements were that we were kind of looking at to see if the structural changes have any relationship towards some of those clinically important measures? So as I said before, in the NACO study, we have a lot of other patient-friendly measures.

[00:10:18] So we had to decide from the beginning what we want to see, to look at, what we want to compare it. And instability is maybe the most important that we're thinking about. We had the question for the patients if they have any given ways. So it is a yes-no question that they have answered after the injury. We asked them to grade their stability in a scale from 1 to 10 if they have an instability during ADL or during sports.

[00:10:47] And then we also measured with KT-1000 for the laxity and looked at both the side-to-side difference and then also if it is more than 3 millimeters difference or not. Then we also, from the massive testing, so the quadriceps, concentrics is 6 degrees per second. And then also activity level, where did they participate? You had some pretty fun findings.

[00:11:13] So I kind of want to go through each of them bit by bit so that we can just get, everybody gets the attention that they deserve. What did you guys find and what the fibers were looking at at about that 24-month mark? Were there like consistencies in which patients like showed better fiber structure or fibers in continuity or shape? What kind of patterns did you find there? The fibers improved. So the ACT score is from 0 to 3. So we have 4 steps.

[00:11:38] At the 24-month mark, we had 78% of the patients who actually improved at least 1 step. Sorry, just really quick too. So the ACL, just as a reminder, is the ACL continuity, thickness, and shape. So that's what ACT is looking at. So they improved. You broke it down by steps and everybody got better by at least 1. Yeah. So if we're looking at the fibers continuity, so it is the C of the ACT. So we had 78% that actually improved at least 1 step in the fibers domain.

[00:12:06] Again, 78% also improved in the overall structure. So looking at the ACT score, so we have the structure and we have the fibers. Then looking at the thickness, we don't know what is improvement and what is not. We don't know if it is good to have a thick or a thin, so we cannot talk about improvement. And also the shape is like the shape is as it is. So that way we have only to choose the structure and the fibers.

[00:12:31] What we know is that when you have a ligament that is ruptured or another structure in the body, often you have first swelling, so it is getting thicker. And then when you have the healing process or after a time, then it will be thin again. So we looked at the patients who had a thick ligament at that time. They had much better results in structure and fibers continuity later on.

[00:12:56] The patients who had a thin ligament at the beginning, it was not so many patients, but they had worse results. Maybe it is good at three months to have a thick ligament. We talked about the structure and the fibers and the thickness. Okay, and then how about the relationships with all of those patient-recorded outcome measures and laxity measurements and muscle strength, all the other things that you were looking at. Any other relationships that you found with those with the structural changes?

[00:13:25] In the aspects of stability, if they had giveaways episodes or not, patients who had a better continuity, a better structure of the ligament, had less giveaways, and had better knee stability measured with the KT-1000. But it is interesting that actually the ligament is actually helping with that. In my head, I would think, oh, that could also just be quad or neuro-whatever. There's just so many other things.

[00:13:51] But the fact that the ligament, it seems that, is definitely a part of that stability feeling. It makes a difference. That's a good finding. And that is interesting because you can see that the structure is good and then the laxity is good. But then it's another thing, what the patient feels, if they feel stable or not. So the patient reported stability because we asked them, do you feel that your knee is stable during activities of daily living or sports activities? There we could not find these associations, statistical associations.

[00:14:21] And that is always that we know that the feeling of stability is not the same as the KT-1000. We looked also at the ICDC, subjective knee score. So it is a patient-reported feeling of knee function. We didn't find any associations there with the structure. That may be the same as I said before. The laxity is not always associated with the feeling of stability. There can be structural changes of the ligament.

[00:14:48] If you have increased structural continuity, they have less laxity. So it would seem more stable. But that's not necessarily correlated to that feeling or the subjective feeling of having stability. One, this is huge because we didn't know if the ACL could have an affinity to have structural changes. And we have a pretty good majority of people who do see structural changes and continuity of the ACL.

[00:15:17] It does kind of show some promise from a rehab perspective or even a patient education perspective. Knowing what we know, how do you see this kind of fitting into some of the conversations that we have with patients or maybe directing some of them towards operative management or non-operative management? How should we kind of take away some of that info? I think that's very important what you said. We know that the knee and the structure can be improved, can be better.

[00:15:46] And that is very important actually to inform the patient that they can have also the structures getting better. In Sweden, it's very common that we say to the patients that you can have a good function. You can go back to sports with no surgery. But I know that that is different from the States, for example. Here we know that in Scandinavia and Sweden and in Norway. And they ask you, yes, but the ACL is gone. You are not very good at having back my ACL.

[00:16:14] But now I can say to them, yes, but the ACL can be better. So the structure can be better. If you don't have a surgery, if you have rehabilitation alone, you have rehabilitation for some months, maybe six, seven months. You need maybe four, five, six, seven, whatever. If you have a surgery, then you need to do some prehab. Then you have the surgery. And then you have at least nine, 10, 11 months of rehab. So actually you save a little more rehab also.

[00:16:39] In our study, we're actually writing another paper now also, looking at some patients who had both arthroscopy and did this MRIs. And there we have looked at the patients. Many of these patients are going back as playing football or European football. So many of these patients, maybe they are not at the highest elite level, but they are playing soccer. They are playing handball, back to floorball, for example.

[00:17:06] So they are doing cutting sports and they can manage it well. The world of ACL research is so massive. There's so much of it. And I'm just curious to hear kind of how you feel like these findings fit in with all of the rest of that research. I think that the most important is to see what should be the treatment of the ACL, surgery or not surgery.

[00:17:33] And in this paper, you can say that, or evidence that can say that you don't always need to have a surgery. Many patients may need to have it, but not all the patients. And it's really good to wait for some months, I would say. And we have a lot of other previous research also say that wait three, four months before you can take a decision to have a surgery.

[00:17:55] And at least three, four months, we can also see that look at the structure with MRI to see if it is a better continuity. And then also by helping the patient to inform the patient, educate the patient about, yes, the ligament actually, it's a structure that can get better. So all this together is important. I don't want to say many things about the bracing protocol. Or you use a brace and immobilize the knee at nightly grace for quite a long time.

[00:18:25] In our study, we don't immobilize. They're just doing the rehabilitation as they wanted to do. Some of them are back running after two or three weeks after they enjoy. Some wait for longer times. So they're just doing the rehab. So maybe that is enough. Maybe you don't need to have immobilization. We are doing now a pilot study looking at the immobilization like a modified bracing protocol to see what happens.

[00:18:54] So maybe in some months, I can have some results. Joanna, I am super excited to hear when some of that research comes out. The more information that we can have to better make that decision and to help give the patients all of the information that we absolutely have. Because this surgery, yeah, you kind of just hit it. Nine to 12 months is a long time.

[00:19:17] If there is a cohort of people who we know can benefit and get structural changes, and then if we see, hey, maybe there's a certain bracing or a certain technique that we use initially that will see more promising results, I think that that would be really helpful for someone. This certainly helps to be able to just have a nice collaborative conversation with that patient about, hey, this is what we sometimes see. There are a cohort of people that do get structural changes.

[00:19:47] And then if we can see later on in future research that we also see those objective or subjective changes for the stabilization, returning to certain activities, I think that that would really help a lot of people. I can say that from the NACOX study, that is one important aim to see how it's going with non-surgical treatment. And we have 18, 19 publications now from the NACOX.

[00:20:15] So in another paper, we also can see that the risk of new injuries and new surgeries, many say that if you don't have an ACL reconstruction, you have an increased risk for new injuries and surgeries. But we found that exactly the opposite. So the patients who have the ACL reconstruction, they have more injuries and more new surgeries. So if you can choose a non-reconstructive pathway and function well for you,

[00:20:43] then you may also decrease the risk for new injuries. And we're going to see now about what happens with osteoarthritis. It is important, though the problem is that we still don't know who will benefit. The results of this study is one point more that you should wait before you take the decision to have a surgery. You may need to have a surgery. That is okay. But just wait. Wait. We have a lot of research on psychological factors. And we know that patients, especially the young people,

[00:21:14] they have to wait because they have to understand that they have an injury. They have to understand that it is a bigger limitation. And also to see for them if it is so important to go back to this sport. Maybe they don't want to go back to the sport. Many do not manage to go back to sport. But it is a lot because they don't want to go back. Wait some months. See what happens. Educate the patient. Let them understand what the injury means and what their rehabilitation is. And now you can say that maybe you have a better structure also without a surgeon.

[00:21:43] Joanna, thank you so much. Thank you for joining us on JOSPT Insights. And we will look forward to likely discussing some of your future research. Thank you very much. Thank you for having me there. We want to thank Dr. Joanna Kvist one last time here. And as always, we want to thank you for listening to JOSBT Insights. Thanks for listening to this episode of JOSPT Insights.

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[00:22:39] Talk with you next time.