In the first episode of our health geeks podcast, our sports science intern Ang Yixuan chats about ACL rehab in Singapore with our new physiotherapist Eric Fernando.

Podcast Transcript

[00:00]

In this first episode of our ‘Health Geeks’ podcast, we talk about what an ACL tear rehab looks like, the latest science on surgical versus non-surgical rehab, as well as the cost of both options in Singapore.

Hosting the episode is our sport scientist and personal training intern, Yi Xuan. And Eric, our new physio, will be answering the questions.

A reason why we’re starting this podcast is because, according to our survey, more than 80% of private health practitioners are science-based but unaware of newer evidence.

Hence, we’re encouraging people to check out our ALLWIN platform, where we help practitioners keep up to date with the latest science.

On the platform, you can see a list of practitioners who believe in updating themselves so as to provide you with cost-effective services.

Which we believe, should be the way forward.

That aside, if you’ll like personalised guidance from my team, please feel free to reach out.

This is Jing Zhi, founder of ALLSET, let’s get into it.

[00:48]

Ok so, why do you think ACL tears are such a common injury?

Right, so to answer that question, I think we need to first understand how does an ACL injury happen.

An ACL injury happens because of a twisting motion of your lower leg or with an anteior shift or a forward shift of the shinbone.

And that can happen in either a direct trauma.

Like if someone tackles you sideways or forward, as well as in a pivoting movement with sudden deceleration like when you’re changing direction or if you’re cutting when you’re playing football, for example.

[1:21]

And it is the most frequently seen orthopaedic condition – a knee injury.

But its prevalence and incidence is actually quite low, about 0.2 to 5 per 10,000 participation or about 0.0007/person-year.

[1:38]

Okay, so what are the risk factors that are associated with ACL tears?

Interestingly, the highest risk factor is actually sports participation.

Most of ACL injury happen during sport, yeap.

So, and of all the sports that we do in Singapore, football has the highest incidence of ACL injury.

And it has been found to have; there is no difference between like a contact versus non-contact forms of injury.

So between whether it’s like a traumatic injury or whether it’s like something that happens with your feet off the ground.

Another risk factors is age.

But this could be linked to sports participation as well.

The highest number of ACL injury seems to happen between the ages of 25 till about 30.

[2:28]

Sort of like a weekend warrior kind of perspective?

Yes, so at least in Singapore’s context.

So it goes between like a; it climbs slightly higher from adolescent when you start participating towards sports and then increasingly increasing participation in sports like in your secondary school, JC, uni.

And then as potentially your conditioning starts to become a bit worse and you continue participating in those sports like a weekend warrior.

And then your incidence start to become a little bit higher as well.

I see, okay.

So if, actually, yeah, but do note that a lot of studies done on like prevalence and incidence are actually taken off like European, US countries or Caucasian countries and there’s very little studies done in Singapore alone.

So a lot of these numbers are a bit arbitrary in that sense.

Okay, that makes sense.

[3:21]

So in that case right, would it be necessary to undergo surgery in the event that you tear your ACL completely, for example?

Because I’ve heard of stories where some people have said that they don’t actually require surgery.

So in that sense, they are able to return to sport at a competitive level, but they have not gone through surgery lah.

Yeah. Would it be possible?

Yeah, that’s interesting.

Okay, so I think studies are a bit comforting or they’re a bit divergent in this question currently.

So to be clear, there are generally two main ways for you to recover from an ACL injury.

One is a surgical method, the other one is a non-surgical method.

Okay.

Um, surgical method includes replacing the graft, right.

So it’s reconstructing the graft.

What they do is they actually take a piece of tendon or ligament from somewhere else and then they put it into in between your knee to kind of replace the ACL itself.

It can be done either through a tendon within your body or from, which is called an autograph or an allograft, which means they’re taking the tendon or ligament from a source out of the body.

Hm, okay.

And then the non-surgical method is rehab, through physio basically.

And there is, so there is pre-habilitation as well as rehabilitation which happens after the surgery.

So, as far as your question goes, I think, yes, you actually can recover without surgery, but it really very much depends on the level of participation that you that you do in your sports, the level that you want to go back into, as well as kind of like your general goal in terms of like the surgery.

So as far as the outcomes between surgery and non-surgical method go, the long term and the short term, long term outcomes are quite similar.

However, the short term outcome might favour one or the other, depending on what your goal is.

Like for example, after a surgery, you might find that that laxity that you feel or the level of instability that you feel is a little bit better.

Um, but there are, but your general strength, your general function, pain level, would usually be a little bit better if you had gone through a non-surgical method.

Okay.

There were some beliefs previously that reconstruction could reduce the risk of osteoarthritis after an ACL injury because that is one of the large secondary problems that comes in with ACL injury.

But recent studies have seem to shown that, to show that, there is not much of a difference between reconstruct as well as non-surgical means of recovery.

Okay.

As far as returning to competitive sports, it is a bit debatable. It really depends on how much you are willing to commit.

[6:21]

It’s a lot of like, so for (example), let’s go through a bit about prehab and rehab.

So prehab and rehab means it requires a lot of commitment.

Rehabilitation after surgery is usually about 9 to 12 months for the general population, and it can be very intense.

So it starts off with like once a week session for perhaps the first two, three months before going through, before dialling it down to like once every two three weeks review with the physio subsequently.

But even then, your commitment towards the exercises and doing the rehabilitation need to be pretty much daily.

You need to be consistent with your exercises, doing the things that you need to help with your recovery.

Okay, that makes sense.

Okay.

So the goals of rehabilitation after surgery usually comes in a few ways.

We are looking at, first making sure that your swelling, pain, and everything is settled, then aiming at returning you to your normal range before getting you back in normal.

Walking normally.

Once you can walk normally without any kind of crutches or any walking aid, then we look at really getting you stronger, getting back your coordination as well as your kind of jump running, jumping before progressively working towards agility and returning back to your sports.

Hmm. Yeah. Okay.

[7:52]

Another interesting thing is that reconstruction actually doesn’t improve your outcome just by itself.

So your outcome in terms of, like returning to sport as well as your functional recovery hinges quite a lot on your commitment as well as your rehab after the surgery.

So it’s not it’s not like, oh, I’m going to do my surgery and then after the surgery, you just wait for nine months and you can you can go back to playing sports.

Exactly.

So you actually need to put in the work.

Exactly.

Yeah, yeah, yeah, yeah. Okay.

[8:26]

So in that case, would you, what would you recommend for an average individual who tore their ACL?

Yea, you’re still young, and still like have quite a few competitive seasons, for example, but in that case, what would you recommend?

Because I would think that it would require a lot more intensive work, a lot of like strength and conditioning, a lot of of proprioceptive work and neuromuscular balance, that kind of thing, for you to get back without going through surgery / a nonsurgical option.

[8:53]

So what would you recommend for the average individual in Singapore?

Okay. I think as far as Singapore’s recovery process go, it’s usually quite standard in the sense where most surgeons and physios do have a common consensus in that sense.

After an ACL injury, most surgeons wouldn’t actually want to do any surgery for at least about 3 to 4 months as well, just because right after your injury there is quite a fair bit of swelling.

There is some degree of pain and potentially some of the loss of range as well, like you wouldn’t be able to straighten or bend your knee as much as you could before because of pain and swelling and a few other factors.

And so just try not to do the surgery when all of these are around, because that actually reduces the outcome after the surgery.

Oh, I see.

And this is also kind of like where your prehab comes in.

So before going for certain, before even considering for surgery, I think it is good for everyone who has had an ACL injury to go through a period of prehab.

Give yourself about like six months, six to eight months, kind of period to really go through the exercises, improving your strength, improving your range, managing the pain and swelling, kind of working on your neuromuscular control, your coordination, and potentially working a bit of your agility and seeing how you perform in your sport with the pre-habilitation.

Okay.

So when you go through the surgery, there will be a period of time right after the surgery where your, you are actually a lot weaker than before the surgery.

So building your strength up before the surgery is important so that like, you know, after you build it up and then like once you go through the surgery and then it kind of like goes down to this level.

Instead of like you stay in this level and then you go to surgery and then just, like, down all the way.

Okay. Yeah. Okay.

[10:45]

So in that sense, it would be safe, right, for an individual without an ACL to perform conditioning exercises and strength work?

Yes.

So I would think that it might be a common misconception.

You know, like the moment I tear my ACL, I’m not allowed to do any form of exercise.

But I think that studies have shown that it would be good to actually keep moving, to maintain the form of range of motion or that level of strength.

Because like, I think we all know that like the moment we stop exercising, muscle atrophy happens and you’re just gonna: you’re exercising at this level of participation and if you stop completely, you’re just going to lose a lot of the muscle strength.

And like what you say that after you go for surgery, then it falls even further.

So you have a lot more to climb back up. Yes, exactly.

So it’s safe lah.

It is definitely safe.

And in fact, movement and mobility is important right after injury.

The current consensus is that mobility is what helps to reduce swelling and inflammation the fastest.

So you want to move around at a suitable level, of course. So you don’t want to tear your ACL and then like, ah, I feel, okay, let’s go play another football game kind of thing.

Some degree of like supervised, or even like prescribed exercises would be good for you.

So my take is probably don’t / it wouldn’t be the best if you just go to YouTube and then find like some exercises for you, for you to do and try to rehab on your own.

It would be good to seek some kind of professional help so they can guide your progress through the injury recovery and tailor it to a level that is suitable for you, because under loading as well as overloading can be a problem.

So you do want to find that kind of sweet spot. Okay.

Another interesting, but kind of like it’s a very new topic and semi controversial in a way.

[12:37]

But there are a few studies that have shown that there can be a complete recovery of the ACL ligament itself within about 5 to 12 months after even a complete tear.

Okay.

But of course, this complete tear is seen on MRI, so that could be some bundles in there that’s not seen on the MRI that promotes the recovery.

Okay.

So don’t be too quick to want to do the surgery.

Give yourself a chance before thinking about it.

Okay. Okay.

[13:07]

So I think the next follow up question would be, what are the necessary recovery steps?

I think we’ve touched on a bit like rehab, but could you go a bit more in detail about how the rehab journey would be like?

You know, the moment I come out of the surgery, the first 24 hours, for example, like what would I be feeling?

What would I be seeing? And in the next week or so?

What should I really be focusing on so that I can recover as quickly as I can?

Yeap, sure.

First 24 hours, right after you come out of surgery, you’re probably seeing a lot of stars and being very groggy.

But in most hospitals in Singapore, within either on the day itself, or the day after, a physio should come to you to prescribe you some simple exercise to help you with your movement, returning your range, maintaining the range, managing your swelling as well as pain.

And most of the time, the nurses will help you with some degree of pain management that can be in the form of painkiller or ice therapy.

Okay.

So that’s within the first 24 hours.

And the exercises that they do give, that the physios give you are actually quite important.

They can be / they’re usually something very simple.

Just like trying to bend your knee, squeezing your thigh just to make sure you get the activation of the quads a bit earlier, as well as improving and managing your swelling quickly.

Right after that, usually most people will be discharged within like one or two days.

And then you, depending on what the surgeon/surgeons order, you could be walking without a crutch or with some crutches.

Yeah.

And then within the first week of the discharge, you should actually be going back to your physio.

And then that’s when you start of your rehab process in an outpatient setting.

Okay.

And so, like I mentioned earlier, the goals in the early stages are managing your swelling and pain as well as improving your range.

The first thing that you want to get is make sure you can straighten your leg all the way, back to zero.

And then after that, bending your knee as much as the brace allows.

Okay.

Yep. So that’s the first one.

And then next thing you want to do will be improving your quad strength, as well as making sure that you can walk without aid in a normal manner.

Okay.

So that’s the next step.

After that, then it’ll be a series of like strengthening.

It can, it could, most people start out with some degree of close kinetic chain.

So that can be in the form of like double leg squats, standing up, lunges, leg presses.

And then at some point in time, usually at about fourth, fifth week, we start with some open kinetic chains.

So that’s in the form of like knee extension machines.

Okay.

Like some leg curls, depending on the graft site that you use.

Hmm. Okay.

Then moving on, we’ll be looking at some kind of neuromuscular control so that can be like proprioception, your balance, and then a little bit of like jumping, control, your landing, your knee control in a single leg squat, your knee control when you landing, when you’re hopping before moving on to harder stuff like plyometrics, high jumps, agility, like your lateral jumps, change of direction, agility ladders, before going towards more sport-specific drills towards the end of your rehab process.

[16:29]

Okay, so you mentioned that 9 to 12 months is what the recommended or the average amount of time for recovery, right?

So in your experience, what is the shortest amount of time that one would need?

Okay. Yeah.

Again, that would kind of depend on whether you go through the surgical or non-surgical mode.

Usually in a non-surgical process, it can be a bit quicker because you don’t have to go through the whole process of like getting weaker and all of those and it really depends on how committed you are and how quickly you get stronger and get back your neuromuscular control.

But in a surgical method, 9 to 12 months is the recommended not because, usually that’s the average time frame, not because of time, but because of criteria.

They are certain criteria that you need to meet in order for you to get back to running.

In order for you to get back to playing your sports, things like making sure that your strength is symmetrical on both sides, making sure that you have the control, as well as making sure that you are able to manage the sudden changes in direction with returning to sport and having those ability.

Okay, okay.

[17:37]

So I have one final question for you.

So what are the estimated cost for this entire ACL recovery journey?

Like including, in the event people do opt for surgery, right?

So how much would the ACL reconstruction surgery cost?

Right, then how much would the physiotherapy cost as well, like in both public and the private setting as well.

Okay.

Um, so contextualizing it here, I think I will break it down into like the surgeon’s fee, the physio as well as the hospital stay around this, surrounding the surgery.

So just for consultation fee both pre and op, we’re looking at about $120 for private and public hospital.

That would be / that would bring you up to about maybe about $600 and then $250 if it’s in subsidised (track), or about $750 in private.

The surgery itself, with the hospital stay’s about $12,000 if you’re non-subsidised, $5000 if you’re subsidised and it can go up to $30,000 if in private.

Hmm, okay.

Physios, we’re looking at about a 12 month recovery period.

So about $3000 for non subsidised, $1.5k for subsidised, and $6000 in private.

So overall, we’re looking at maybe about $15,000 if you are paying a non-subsidised rate in a public hospital, maybe about $7,000 subsidised rate, and it can go up to like $35-40,000 if you’re paying, going / doing it in a private hospital.

And with that, we’ve come to the end of today’s sharing.

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