Backstory
This is my story about how my worldview as a patient completely changed after my most recent Anterior Cruciate Ligament (ACL) injury. But first, let’s cover the backstory.
Back in 2012, when I was 17, I was determined to receive a tennis sports scholarship in the US, so most of my time was spent on the tennis court. I was playing a tennis tournament in Germany (on clay court) trying my best to win a match for the division team, when it started to rain. The match was restarted a few hours later when the court was deemed dry. The break in play was unsettling but I still felt motivated. Just as we restarted, I was returning a serve aiming to hit a backhand cross shot and slipped and fell. The underlying layers of the court were still not dry. My coaches immediately ran over and checked my ankle to see if it was okay as they thought that was the most likely point of injury. At that stage I was not as aware or attentive to say, “hey, I think it was my knee.” They were concerned and recommended that I stop playing. In line with the expression, “sport c’est mort,” I decided I was fine and continued to play. A few points into the next game, I went for the same shot and injured myself badly enough to know I had injured my knee. This led to my first ACL reconstruction using a graft from my hamstring tendon.
Over the next few year, I recovered and continued to play tennis but not at a competitive level. I had moved to Australia and about 5 years later, I decided it was time to start playing football/soccer again and took up mixed indoor futsal. Five seconds into our semi-finals game, just after kick-off, I tried to save a poor pass and twisted my left knee doing so. At this point I knew what had happened, I knew this feeling all too well now. My MRI confirmed that I had ruptured my ACL again and in 2018 I had my second surgery of the same knee, the ACL revision surgery, this time using a graft from my patella tendon.
Fast forward a few years (2021) and I was back to playing tennis and my knee felt great. I was playing a match with my family and yes, we are competitive. It was my match point, and my opponent lobbed the ball and in turn, I jumped backwards to hit it. I landed awkwardly on my right knee this time and again I felt the same unnerving feeling, “it’s my ACL, isn’t it?”
Exploring a non-surgical approach
I was already 2 surgeries deep on my left knee and had a fresh ACL rupture on my right knee. I decided to visit my trusted physiotherapist who had previously helped me with my rehab post ACL revision surgery. He told me about a new non-surgical approach to ACL treatment that a sports physician named Dr Tom Cross was trialling and suggested I give it a try. Eager to not have another surgery, I immediately booked an appointment.
When I first met Tom my worldview as a patient completely changed. I met a physician who was attentive, thorough, communicative, and considerate. He spent plenty of time taking my history and describing the novel treatment: the Cross Bracing Protocol (CBP) (Filbay et al. 2023). As someone who had been teaching anatomy to undergraduate and medical students for 6 years, I absolutely loved this thorough and clear overview. He shared the evidence underpinning the CBP, was transparent about the success rates for both male and female patients, and described which grades of ACL tears were most ideal candidates. It was fascinating and ground-breaking to learn that the ACL could heal on its own and that bringing the two ends of the ACL closer together could promote that healing. As a big anatomy nerd and 2 knee surgery veteran, I started the protocol as soon as it was confirmed that I was eligible for it.
My experience during the protocol
Wearing a brace for 12 weeks sounds intimidating, but at the time compared to my experiences with surgery, it did not seem so bad. The hardest part of the protocol was being on crutches for the first 4 weeks with my knee set at a 90-degree angle. The decreased mobility did lead to muscle atrophy but to a similar degree to what I experienced post-surgery. I found the tailored exercise program at each week of the protocol allowed me to prevent further muscle loss. Though walking with crutches made it difficult to go to work and was strenuous, I decided not to use a knee scooter because I wanted to maintain some physical activity. The brace ended up being a great conversation starter when teaching anatomy, especially musculoskeletal anatomy. After 4 weeks, once the angle of the brace was changed to allow for a greater range of motion, it became easier to navigate the rest of the protocol.
The hardest part for me was taking the prescribed anticoagulants as part of the protocol to reduce the risk of deep vein thrombosis. As a female who has a history of dysmenorrhea (painful periods) and heavy bleeding, taking the blood thinners led to symptoms that I could never have imagined. The excessive bleeding, abdominopelvic pain, and low iron levels impacted my energy levels and mental health during the protocol. In addition, I was recommended to stop taking my oral contraceptives as they are associated with an increased risk of blood clotting. Alongside the menstrual symptoms, I experienced a sudden change in my hormonal balance and had to consider alternative methods of contraception.
Thankfully, before I started the protocol, Dr Cross explained the side effects of taking anticoagulants and asked me about my menstrual cycle. He considered my history and suggested what could make the associated symptoms more manageable. I made the informed decision to take the anticoagulants knowing these risks. This is a brilliant example of patient centred, personalised care whereby shared decision-making, my previous history, and concerns were all considered throughout the protocol.
Outcomes – CBP knee versus reconstructed knee
I still remember the tension and stress I felt when waiting to see my MRI imaging results to determine whether the CBP was successful – whether my ACL had healed. Dr Cross made sure that we had an appointment booked in so that we could view the results together, which was extremely reassuring. I was instantly blown away when I saw the imaging, being in a brace for just 12 weeks resulted in my own ligament reattaching. The CBP was successful!
What followed was a similar rehabilitation program as I experienced post-surgery and within 6 months I had returned to tennis. I had several follow-up appointments with Dr Cross including at 3, 6, and 12 months where MRI imaging was performed. Experiencing such continuous care post treatment was a first for me and I feel it contributed to better outcomes for knee. I received regular messages, check-ins, and words of encouragement throughout the protocol.
Currently, what is preventing me from returning to more competitive tennis is not my CBP right knee, but my left knee which has undergone the 2 surgeries. Dr Cross’s care was thorough and holistic, so when it came to post CBP care, he considered my left knee as well. The patella graft in my reconstructed knee is more likely to tear if exposed to pivot movement and that fear of reinjury is what had held me back from returning to competitive sports. You can see the difference in the strength of each ACL in the left versus right knee in Figure 1.
Takeaways for healthcare professionals
Research has shown that patient-centred care: (i) is more personalised, as individual medical history and needs are considered when designing protocols and treatments; (ii) empowers patients to take an active role in their recovery, which promotes treatment adherence; (iii) is reliant on building rapport and good communication with patients; (iv) involves a more holistic approach and consideration of all aspects of a patients health; (v) leads to improved patient satisfaction and health outcomes (Leonardsen et al. 2023; Schofield et al. 2019).
This was consistent with my experiences. Dr Cross’s care was patient centred because: (i) my medical history was considered when making recommendations related to the protocol; (ii) I felt empowered to take an active role in my recovery and felt more motivated to follow the treatment than during my previous surgeries; (iii) he took the time to introduce himself and motivations behind the CBP, and I received regular communication (in-person, email, phone call, and text message); (iv) other aspects of my health such as my mental health, menstrual cycle and opposite knee were considered when providing recommendations. Due to these positive experiences, I felt that it led to improved outcomes and adherence to rehabilitation post CBP.
One field that can support and enhance patient centred care is digital health. It can also make healthcare more accessible, flexible, and improve health information seeking, health literacy, self-monitoring, and support healthy behaviour change and/or outcomes (Papavasiliou et al. 2021; Granström et al. 2020; Leonardsen et al. 2023). For instance, in a randomised controlled trial patients with knee pain indicative of osteoarthritis who used an app to receive educational information alongside standard care, had 52% higher levels of actual knowledge compared to patients who received standard care alone (Timmers et al. 2018). Moreover, another randomised controlled trial found that an SMS bot alongside standard care improved early postoperative clinical outcomes (greater range of motion, improved mood, and increased exercise) and patient engagement in total knee or hip arthroplasty patients (Campbell et al. 2019). Thus, digital health interventions alongside standard care can support the delivery of patient centred care and lead to positive behavioural and/or clinical outcomes.
In my case, the asynchronous communication via text message or email allowed me to feel connected and ask questions without feeling like everything needed to be covered during the appointment time. Dr Cross also connected me with other patients online, which fostered a sense of community and made the experience less isolating.
In addition, there is a growing body of evidence that illustrates the importance of involving patients in the design of Randomised Controlled Trials and protocols. Feedback related to lived experiences helps inform their relevance, trustworthiness, and quality (Geißler et al. 2022). It also ensures that diverse patient backgrounds and journeys are considered. During the CBP, I could actively provide feedback related to my experiences, this not only improved my experiences, but felt empowering.
Conclusion
If I could go back in time to when I first injured my knee in 2012, given the opportunity, I would have done the CBP in a heartbeat. To anyone considering their treatment pathway following an ACL injury, I highly recommend that you consider this non-surgical approach to treatment. To healthcare professionals planning on implementing this protocol in their practice, please consider how you can incorporate patient centred care in your practice. Recovering from a third injury was tough, but knowing my experiences were valued and contributed to a body of work felt extremely meaningful.
