Ahead of the eagerly awaited course on Traumatic Knee Injuries coming to Remedy Physiotherapy on the 3rd December, Andrew (Shoulder Service Clinical Lead) catches up with the Course Tutor Richard Norris. Richard is a Lower Limb Extended Scope Physiotherapist with a specialist interest in the Knee. He has recently published a paper with the renowned tendon research Professor Jill Cook (see link at the bottom of the interview) and is well regarded in the Lower Limb world.
Andrew – Hi Rich, thank you for taking the time to answer a few questions ahead of your forthcoming ‘Traumatic Knee Injuries’ course in Sheffield. We’re really looking forward to hosting you for what we have heard is an excellent course. How did your interest in the Knee develop throughout your career to the point where you are now working as an ESP within the Knee clinic?
Richard – Before I became a physio I was a professional footballer for a few years but had to retire at the age of 21 with knee problems. I underwent experimental surgery and, as part of that, you get to know the surgeon and his team very well. Once it was clear that professional football was no longer an option the natural progression was to follow a career in something to do with musculoskeletal problems. I think a lot of people will relate to this scenario; once you’ve experienced a problem first hand you tend to develop more of an interest in the subject.
Andrew – Well, I am glad you brought that up – you are clearly a switched on guy, great thinker, respected clinician, intelligent – how therefore do you explain supporting a football team like Liverpool? Especially when you live geographically close to probably the greatest team of all time in Manchester United?
Richard – The truth is that my dad brain washed me into becoming a Liverpool fan, in the same way that I will be brainwashing my offspring. It may not be that obvious because I still can’t grow facial hair, but I was born in the late 70’s so at that time Liverpool were the kings of the country and Europe. I’m hoping Manchester United’s steady decline since Fergie left continues, and Jurgen Klopp (who seems to have got my share of facial hair) can take us back to the summit.
Andrew – Wishful thinking but this can wait until after a beer in December! What can the attendees expect on the course?
Richard – I have tried to make this course as practical as possible – both in terms of doing lots of practical work but, more importantly, making sure the content is clinically relevant. As nice as it is to know what type of collagen the meniscus is made up of it’s not something that will particularly help you with your patients clinically. We start with potential serious pathology as this should always be priority number one regardless of which part of the body we are looking at. We then progress to making sure the clinician is performing a thorough, relevant subjective assessment rather than bombarding the patient with random questions that don’t really help formulate a working diagnosis. The rest of the course concentrates on the objective assessment to include basic principles, special tests and their diagnostic ability, evidence-based management and lots of real life case examples of patients that have had various knee problems. I am very grateful to my patients that have consented to me using their videos for teaching purposes as some people will never have seen a positive special test and it is therefore important for them to know what one looks like.
Andrew – Brilliant, so an abundance of clinical insights and practical tips to enhance the practice of the attendee come Monday morning. Is the course only applicable to Physiotherapists?
Richard – Not at all. In fact the course I presented on last month had more A&E nurses on it than physiotherapists! Traumatic knee injury patients will be managed by a variety of different health care professionals, including A&E triage nurses, GP’s, physiotherapists and Orthopods. As long as you see patients that have had a traumatic knee injury then the content should be relevant to you. Naturally, if you aren’t involved in the rehabilitation of the patient then those elements may not be directly relevant to you but previous feedback has been that it’s useful getting a taste of what treatment involves, even if you are not delivering it yourself.
Andrew – You have kind of already touched upon this. Naturally, a lot of acute Knee injuries are seen in A&E. What will the course provide to those working in such an environment such as nurse practitioners or our medical colleagues?
Richard – You’re right; a lot of these patients end up in A&E because they think they may have broken something. It’s vitally important that those providing the first point of contact are aware of potential serious pathologies, how to identify these and how to manage them. Despite guidelines being available for appropriate imaging it is still apparent that some patients get X-rays they don’t need whilst others don’t get the imaging that is required. The ramifications of inappropriate imaging include waste of NHS resources and exposing patients to unnecessary levels of radiation so these elements are covered on the course. I always stress how important the subjective assessment is for those that work in these environments as objective assessment can sometimes be tricky so relying purely on the objective assessment, which a lot of people do, can leave you with limited information.
Andrew – Great, we hope to see some A&E staff on the December course. It appears well accepted that you cannot rely purely on the objective assessment and that the subjective assessment holds greater weighting. Orthopaedic Special Tests are quite rightly on the receiving end of some tough critique within clinical practice at the moment in areas such as the Hip and the Shoulder, is there still a role for them in the Knee?
Richard – And this is rightly so. We need to know how good tests are at ruling in and ruling out a condition to guide our management, rather than assuming they are reliable and valid. Even the most commonly used clinical tests, such as the varus and valgus stress tests, have limited evidence behind them and this is an area for potential future research. The one test that has seemed to stand the test of time is the Lachman test for anterior cruciate ligament rupture and I would say this may be the best all-rounder test in the whole body. In my experience, when you show clinicians how to do a test in the way it was intended to be performed they have a lightbulb moment and my personal bias is that when the clinical tests for traumatic knee injuries are performed properly, they are definitely useful. However, clinical tests are only one piece of the assessment jigsaw and it is important to understand the limitations of each test. Pivot shift for instance gives you good information if it is positive but doesn’t really help you if it is negative.
Andrew – I’m glad it’s not only me with the personal bias – I am exactly the same with the Shoulder! In a similar fashion, there is a lot of debate regarding the indications for and even use of imaging within clinical practice. I got the sense earlier that in your experience there are issues around imaging for acute Knee injuries?
Richard – I still think some people have X-rays they don’t need but don’t get the appropriate imaging when it is indicated. Having a picture in front of you, or an imaging report is always reassuring but it is important to understand that they are not 100% accurate and can sometimes confuse the situation or have iatrogenic effects. Arthroscopy is the gold standard for diagnosis of intra-articular problems but the reality is we are not going to scope everyone to find out what is going on. I agree with the current suggestions that imaging should only be performed if the results affect the management. For example if you are suspecting a quads tendon rupture because the person cannot straight leg raise then the patient may or may not have surgery within a couple of weeks based on the results of the ultrasound scan. Similarly if the patient presents with a locked knee then you would want to know what is causing the mechanical block, if anything. More often than not the MRI shows a displaced meniscal tear, which would direct you down the surgical route, but sometimes the scan will be normal or show an isolated ACL rupture, and by the time they come back to see you the leg is no longer locked. If the patient has an isolated ACL rupture then the decision to operate may be influenced by whether they place themselves or others at risk should the knee give way; if it would then routine reconstruction may be warranted whereas if it wouldn’t then it may be more appropriate to trial conservative management first.
The grey area for me is whether to image for certain types of meniscal pathology. There has been increased interest regarding meniscal root tears, which are not that common but have been shown to have similar effects on the knee as total meniscectomy. We know partial and total meniscectomy significantly increases the chance of the patient going on to require joint replacement surgery so there is a case for repairing meniscal root tears routinely. There are features on MRI that help to differentiate meniscal root tears from other types of tears, which again may change the direction of management.
Andrew – Brilliant, I look forward to learning those features to enhance my own practice! To end our chat, Rich. Can you provide us with a random, little known fact about the Knee that only those with a borderline unhealthy interest the Knee will know?
Richard – Early this year some researchers found a 5th quadriceps muscle; Tensor Vastus Intermedius, which sits between Vastus Lateralis and Vastus Intermedius. Move over VMO, you’ve had your time now it’s all about TVI training!! (https://www.ncbi.nlm.nih.gov/pubmed/26732825)
Andrew – Haha, thank you, Rich! I look forward to hearing more from you on the 3rd December and welcoming you to sunny Sheffield!
Rich’s Paper with Professor Jill Cook – https://www.researchgate.net/publication/309211029_VISA_A_sedentary_-_A_patient_reported_outcome_measure_for_patients_with_Achilles_tendinopathy_who_do_not_participate_in_sport
To book your place on Richard’s excellent course please follow this link: https://www.eventbrite.co.uk/e/assessment-and-management-of-traumatic-knee-injuries-tickets-26866117280Tags: courses, hands on physiotherapy, Knee injury, Physio, physiotherapy, Richard Norris, Sheffield, Sport injury