Should we sign our patient’s knee at discharge from rehabilitation like surgeons do before surgery?

Not because we want to autograph our great work, but to signify that we have completed the safety checks to ensure we have removed all modifiable risk factors for injury. Why did surgeons implement signing the operative knee before surgery? As ridiculous as it sounds, the wrong knee had mistakenly been operated on. It doesn’t happen very often, but what it does, it can be catastrophic. Why should rehabilitation providers sign that they have removed all modifiable risk factors after rehabilitation?

Because we are unknowingly discharging  numerous patients with modifiable risk factors for future injury. In fact, almost certainly many more patients are being discharged with modifiable risk factors than wrong knees are being operated on — and the long-term consequences can be just as catastrophic.

Let’s hear what happened to Jane:

Jane walking with her child

Jane is a 36-years-old mother of two, whose youngest is 18 months. Since the birth of her children Jane’s priorities have shifted and she no longer gets to the gym as much as she’d like. She enjoys exercises, but with two kids and full-time job it’s hard to squeeze in a regular routine. As a result, Jane has put on few pounds, a fact that pushed her to recommit to getting back into shape despite her busy schedule.

In the course of her new workout routine, she developed hip and knee pain. She went to her physician and he diagnosed her with early onset knee osteoarthritis. How can that be, she’s only 36?

Looking back over Jane’s medical history, we discover that 20 years ago she had an ACL reconstruction, with several months of rehabilitation. Considering this prior injury, was Jane’s early onset of osteoarthritis just a natural course of the ACL tear, or was there something that could have been done differently to prevent her current condition? Let’s look at her post-operatively:

The rehabilitation provider that worked with Jane had her start with basic range of motion and strengthening and then progressed her through a myriad of exercises from low to high level. Finally, Jane was doing plyometrics (programs proven to reduce injury), running, and cutting and was ready to return to sport. Her strength and ROM looked good and so did her running and cutting. Jane said she was feeling great! So she went back to sport.

Here’s the problem: Previous injury is the most consistently reported risk factor for future injury in athletics. Here is one of my favorite injury epidemiologists summarizing his research findings:

“Looking at 70 teams, in 18 countries, over 8 seasons (9,000 injuries), we have found that previous injury is by far the greatest predictor of future injury in football.”

Jan Eckstrand
Soccer Industry Medical Symposium 2009

But what is more important is that, numerous researchers have found that modifiable risk factors remain after rehabilitation (eg. jump landing asymmetry remains 2 years after ACL reconstruction and predicts second ACL tear). If you would like to dive into that concept in more depth, check out this short video

What this means is that without standardized, systematic, and stringent return to sport and discharge testing, we are likely to discharge patients with modifiable risk factors. We MUST stop this. Since I have implemented systematic discharge and return to sport testing, I am SHOCKED to find out how frequently I am wrong — the patient appears to be normal (even by my “trained” eye) but testing reveals something completely different.

So, are you willing to sign your patient’s leg, arm or back? I am…..but in the mean time, I have to go apologize to some of my previous patients.  Fortunately, Jane is fictional but represents a large percentage of our patients.

Over the next several posts, I hope we can all discuss what the evidenced based discharge tests should be and what is considered passing. What tests do you think should be included? Post them below so we can discuss them in this forum.

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4 Comments:

  • By Kenny 11 Jun 2013

    I understand this is a fictional patient and am not in disagreement that we need better RTP criteria, but I think we need to consider what we know about current neuroscience and the experience of pain when talking about these issues. It is important not to conflate (previous or current) injury and pain.

    “In the course of her new workout routine, she developed hip and knee pain. She went to her physician and he diagnosed her with early onset knee osteoarthritis. How can that be, she’s only 36?
    Looking back over Jane’s medical history, we discover that 20 years ago she had an ACL reconstruction, with several months of rehabilitation. Considering this prior injury, was Jane’s early onset of osteoarthritis just a natural course of the ACL tear, or was there something that could have been done differently to prevent her current condition?”

    A few questions to consider about this fictional patient’s pain:
    Can we say there is a causal relationship between the experience of pain and the findings of a single x-ray image? If the patient had an x-ray the day before beginning her exercise routine, would it look the same as when she was imaged the day after onset of pain? Can we say that we need to do something differently to prevent the onset of arthritis, knowing that imaging findings and symptoms are poorly correlated? Is the development of arthritis something we can prevent through physical therapy intervention?

    • By Phil Plisky 13 Jun 2013

      Hey Kenny,

      Great comment! Your point is well taken and spot on! You are right, my goal was not to say that OA is the cause of her symptoms (or that ANY imaging study correlates with symptoms — we know that is not that case). You got the key message — We are discharging patients with modifiable risk factors (motor control deficits) for future injury and we need to be more systematic and stringent with our discharge criteria.

      Thanks for contributing! We need to solve this together!

      Phil

  • By Greg Dea 12 Jun 2013

    I love this dialogue. I’ve worked at different levels of sport, from amateur to elite international, and resources of the athlete are a massive factor when deciding what actually happens. The actual is very different from the ideal. In the front of my mind are the battery of tests/screens/assessments that are based on various degrees of evidence. They don’t always present to an athlete as they don’t always meet competency levels before they cease attending. Further, not all of the tests/screens/assessments are presented depending on sport played and injury. In Australia where allied health services are often privately funded, where money runs out or pain ceases, patients OFTEN don’t find physical therapy or rehabilitation to be a priority. But, in my processes, SFMA breakdowns, then SFMA top tiers, LQ-YBT and/or UQ-YBT, FMS, and then symmetry on various performance capability tasks are assessed, eg. single leg hop for distance (to stick the landing with safe form), triple hop for distance (same landing parameters), triple crossover hop for distance (with landing), lateral hop over 40cm distance in 30 seconds, vertical leap and/or other S&C tests that are assessed against normative data or against baseline (pre-injury) levels. In order of priority – this changes based on injury and sport and how far they’ve come and how much they’re prepared to continued. As I said, love the dialogue. It’s an education for those who have heard about this topic and another mention of it adds to their interest.

    • By Phil Plisky 13 Jun 2013

      Thanks Greg! We definitely need to work through the barriers (financial, psychosocial, athletic pressures, etc.) to cause this to ultimately change. I just think of how concussion management has changed over the past 15 years — return to sport testing needs to go through the same dramatic change.

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