Psychological Barriers Impacting ACL Rehabilitation

In this article we provide a detailed narrative of an interview with Julian Feller, one of the world’s leading orthopaedic surgeons based in Melbourne, Australia. In the interview Julian Feller discusses the psychological impact of an ACL injury and the associated adverse impacts on ACL rehabilitation.


Professor Julian Feller on psychological barriers impacting ACL rehabilitation

Julian also talks about the failure rates of using LARS as an ACL surgery option.  ACL reconstructions are a very predictable procedure and success rates are on the rise most likely due to improved ACL rehabilitation techniques rather than the surgery itself.

Keep reading for the detailed interview:

“I’m Julian Feller, I’m an orthopaedic surgeon here in Melbourne, I specialise in knee surgery, I’ve got an extensive clinical practise that really ranges from the elite athlete to the recreational weekend warrior.

Here in Melbourne, there’s an assumption that if you tear your anterior cruciate ligament, you must have surgery, and clearly that’s not the case. There’s a group of patients who will cope quite well without surgery, there’s a group of patients in whom it’s worth giving them a trial of non-operative management to see whether they can get by, or whether in fact they do need surgery, and I make that decision based on how their knee feels and an assessment of what their future activity goals and needs are.

I emphasise to them that there’s no urgency about the decision, we can make that at any time, and I think that helps really get them more relaxed about the surgery. It’s not urgent, there’s no panic, they can sort it out at a better time if indeed they need surgery.

I’ve noticed with professional players, particularly in Australia rules football, that there’s a lot of support leading up to the moment of surgery, and that it’s almost as though when they wake up from surgery, the full impact of what’s happened to their season really hits them. It seems to me, and again, anecdotal, but somehow that’s associated with less tolerance for pain, less tolerance for the whole ACL rehabilitation process, and it’s those, at least some of them, it’s not universal, some of them fall in a heap.

We’ve had patients in whom we’ve had them in hospital for a second night of admission purely for pain management. Maybe it’s to do with the athlete themselves, in that their tissues are firmer, harder, tighter, maybe they’ve got harder bone if we’re using a patella tendon graft, but I suspect a lot of it is the psychological impact of the injury that then influences their ability to cope with pain and swelling and the associated aspect of ACL rehabilitation.

A few years ago here in Australia, and I remember waking up one morning having treated one of our Australian rules footballers to find that there was a two page spread on how I’d done that patient a disservice by not using a LARS.

As it turns out, the concerns about LARS, in Australian rules football at least, is that although they may allow a very quick return to activity, there seems to be a higher failure rate in the younger, fitter, higher level footballer, and so the pressure’s actually dropped off.

But I think there are circumstances still where there’s certainly pressure and the first question that we hear in the media here is are they have a traditional reconstruction, or are they having the LARS.

It’s only in the older patients perhaps who’s got one or two, or maximum three seasons left in their career, particularly if their team is doing well, that serious consideration would be given to doing a LARS as a primary procedure.

One of the players that had quite a few surgeries and that it was reasonable to have a LARS because without a LARS they had no chance of getting back, and certainly I understand that philosophy, and it’s a short term philosophy, but maybe a player who gets to play their one or two seasons of professional football is going to be happy with that as an outcome.

I’m not sure that there will be big changes in surgery, I think it will be more around what happens pre-operatively and post-operatively. I’ve made that comment in previous forums, that I think that now anterior cruciate ligament reconstruction is a very predictable procedure, particularly at the high level. We don’t really see that many re-injuries, but I’m not sure that that’s really a reflection of the surgery as much as the post-operative ACL rehabilitation.

I think there will be targeting, perhaps, of graft type for specific individuals, trying to select the most appropriate graft for the individual. I think we’ll get a better idea about the rate of graft maturation in individuals and who can progress more quickly than someone else.

Probably we’re back to a balance in terms of our surgical technique about tunnel placement, graft fixation, I think we’re still exploring whether extra articular procedures have a role. I suspect it won’t be a routine procedure, but again, it may be this targeting of the surgery to the individual, and in some we might feel that they might benefit from a primary extra articular augmentation.”

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