The KINETIC Pathway: A Triage and Early Intervention Model for Acute Knee Injuries in the Canberra Health Service (CHS)

Written By Nick Ilic

The KINETIC Pathway is a proven and implementation-ready model that delivers cost savings, faster diagnosis, and more appropriate bracing for acute knee injuries—reducing unnecessary imaging, repeat appointments, and premature surgeries, while supporting evidence-based innovation in conservative and pre-operative ACL care.

The Problem

Acute soft tissue knee injuries—such as ACL ruptures, patellofemoral dislocations, and meniscal tears—are among the most common reasons adolescents and active adults present to Emergency Departments and GPs.

Tertiary musculoskeletal care is frequently seeing patients with missed instability injuries (e.g. MRI declined due to mild symptoms despite clear mechanical episodes) or mismanaged bracing (e.g. full-extension splints for injuries better suited to relative flexion or ROM protection).

The default care pathway remains inconsistent and outdated—often delaying imaging, missing opportunities for injury-specific bracing, and failing to position the knee for optimal healing or symptom relief. This contributes to increased secondary damage, a higher surgical burden, and poorer long-term outcomes—for both patients and the broader healthcare system.

Proposal: The KINETIC Pathway (Knee INstability Evaluation, Triage, Imaging & Care)

I propose the establishment of a dedicated KINETIC Clinic within CHS — a centrally coordinated, multidisciplinary model that delivers timely identification, diagnosis, and early management of acute knee instability and soft tissue injury.

Key Features:

  • Staffing:

    • 1.0 FTE Advanced Practice Physiotherapist (APP)

    • 0.2 FTE Medical Doctor, or Sports & Exercise Medicine (SEM) Physician for clinical oversight and access to MRI Medicare Rebates

  • Location: Outpatients or Physiotherapy Department (no new infrastructure required)

  • Referral Sources: Direct from ED, GPs, walk-in clinics, or community physiotherapists

  • Care Model:

    • Triage based on mechanism and objective signs

    • Immediate bracing aligned to injury type:

      • ACL: WBAT + 30° ROM

      • Meniscus: ROM 20–90° or tolerable range (block at 30 if concomitant ACL rupture)

      • Patella dislocation: Extension, and tolerable range up to 30deg

    • Access to Medicare-funded MRI (age ≥16, per current guidelines)

    • Structured education and rehabilitation within 7–10 days of injury

Evidence Base

  • Time to diagnosis reduced from 123 to 14 days (1)

  • MRI access expedited from 6–8 weeks to 1–4 days (2)

  • Total care costs reduced by 63% in Calgary AKIC model (3)

  • Australia has one of the highest ACL reconstruction rates globally, especially in adolescents (4)

Implementation Requirements

  • Recruitment of APP and SEM oversight

  • Equipment: Hinged ROM braces, Zimmer splints, crutches

  • Early allocation of MRI slots for triaged patients

  • Referral system integration with ED, GP, and community providers

Alternate Model: A Blended Public–Private KINETIC Pilot

If immediate investment in a dedicated public clinic is not feasible, I propose a blended KINETIC pathway leveraging existing private physiotherapy providers.

Key Elements:

  • Referral from ED or GP to participating private clinics

  • No-Gap first appointment via Medicare EPC (bulk-billed)

  • Assessment, bracing recommendations, and injury-specific education

  • Patients may:

    • Purchase a hinged ROM brace (typically $100–$200)

    • Continue privately, or

    • Be referred into the CHS outpatient system for follow-up care

Strategic Opportunity: Canberra as a National Leader in Conservative ACL Management

The KINETIC model provides a timely opportunity to implement and evaluate early conservative management of ACL injuries, leveraging mounting international evidence that structured rehab-first protocols can lead to equal or better outcomes compared to early surgery.

Multiple trials (5-8) have shown:

  • Significant ACL continuity rates on follow-up MRI (50–90%)

  • Comparable functional outcomes at 2–5 years

  • Reduced surgical burden and long-term OA risk

Australia’s ACL reconstruction rates are among the highest in the world, and conservative management pathways remain underutilised. Canberra is well-positioned to become a leader in testing and implementing these evidence-informed approaches.

For a detailed review of the research, rationale, and proposed protocols, see Appendix A: Research Case for Early Conservative ACL Management – The KINETIC Opportunity

Summary

The full KINETIC Clinic would provide a structured, evidence-based solution to a longstanding care gap—reducing delays, improving outcomes, and avoiding avoidable surgeries.

However, even without full investment, the blended KINETIC model offers an immediately deployable pathway using existing infrastructure, while unlocking a nationally relevant trial of conservative ACL care.

I welcome the opportunity to discuss which model is most appropriate for initial implementation—and how both could ultimately operate in tandem to modernise acute knee care in the ACT.


 

Appendix A: Research Case for Early Conservative ACL Management – The KINETIC Opportunity

Purpose

This appendix summarises the growing body of evidence supporting early conservative management of ACL injuries and outlines how this approach can be integrated into the proposed KINETIC Pathway (Knee INstability Evaluation, Triage, Imaging & Care). The objective is to improve outcomes, reduce unnecessary surgeries, and lessen the long-term burden on the healthcare system through timely identification, protective bracing, and early rehabilitation.

The Problem

  • Australia has one of the highest ACL reconstruction rates in the world, with annual growth of 5–6%.

  • Only 55% of patients return to competitive sport post-ACLR(9)

  • Up to 50% develop radiographic osteoarthritis within 10 years (10).

  • Early surgical pathways are often initiated without structured conservative management, despite growing evidence that rehab-first models can offer equal or superior outcomes for many patients.

  • There is currently no formalised public triage model to determine which patients may benefit from bracing, rehabilitation, or delayed surgery.

 

Evidence for Conservative Management

KANON Trial (6, 7)

  • 53% of patients in the rehab-only group retained ACL continuity on MRI at 2 years.

  • No differences in function at 2 or 5 years compared to early ACLR.

  • Delayed surgery did not negatively impact outcomes.

Filbay et al. (BJSM 2022) (11)

  • MRI-confirmed ACL healing in 53% of non-operative patients.

  • Healed group reported higher KOOS Sport and QOL scores than early or delayed surgical groups.

Delaware-Oslo Cohort (8)

  • 50% of patients successfully managed non-operatively at 2 years.

  • Only 11% had poor knee function.

  • One-third underwent delayed ACLR, demonstrating the value of a structured rehab-first approach.

CBP Protocol Data (12)

  • Controlled bracing at 90° flexion showed 90% ACL continuity on follow-up MRI.

  • Confirms that ACL healing is possible when early protection and load management are applied.

Blex Protocol (Clinical trials to be published 2026)

  • Developed by one of Australia’s leading Specialist Physiotherapists, Kieran Richardson.

  • Involves early full weightbearing with a 30° extension block for 6 weeks.

  • Encourages posterior tibial glide and collagen cross-bridging.

  • Represents a lower-risk alternative to CBP, with improved function and significantly lower VTE risk.

  • Compatible with daily activity and safer for broader clinical use.

 

Evidence of Degeneration Despite Early Surgery

Patterson et al. (10)

  • In a cohort of 78 young adults, 68% showed worsening of at least one OA feature between 1 and 5 years post-ACLR.

  • Full-thickness patellofemoral cartilage defects more than doubled (19% → 41%).

  • Worsening bone marrow lesions in 29%, and meniscal degeneration in 22%.

  • BMI >25 kg/m² was a major risk factor, increasing the odds of degeneration 2–5×.

  • Suggests that mechanical stability via surgery does not protect against early OA progression.

 

System-Level Benefits of Conservative Triage

  • Reduces inappropriate or premature surgical referrals.

  • Allows time for natural healing to occur in a protected environment.

  • Creates a structured decision-making window based on real functional progress.

  • Improves downstream surgical outcomes for those who do eventually undergo ACLR.

  • Lowers lifetime costs from complications, re-injury, and early osteoarthritis.

 

Application in the KINETIC Pathway

A conservative ACL stream embedded within the KINETIC model would include:

  • Early triage and injury-specific bracing (WB30 protocol for ACLs)

  • Structured rehabilitation over 12 weeks

  • Follow-up MRI at 3 months to assess ACL healing status

  • Shared decision-making process to determine if surgery is needed or can be avoided

 

Conclusion

ACL injuries do not need to default to early surgical pathways. There is now robust evidence that early conservative care—particularly with protective bracing and structured rehabilitation—can achieve equivalent or better outcomes in many cases.

Integrating this approach into the KINETIC Pathway would provide ACT with a nationally significant opportunity to lead conservative ACL management, improve care equity, and reduce long-term surgical burden.

 

References

 

1.       Ball S, Haddad FS. The impact of an acute knee clinic. The Annals of The Royal College of Surgeons of England. 2010;92(8):685-8.

2.       Clifford C, Ayre C, Edwards L, Guy S, Jones A. Acute knee clinics are effective in reducing delay to diagnosis following anterior cruciate ligament injury. The Knee. 2021;30:267-74.

3.       Lau BH, Lafave MR, Mohtadi NG, Butterwick DJ. Utilization and cost of a new model of care for managing acute knee injuries: the Calgary acute knee injury clinic. BMC Health Services Research. 2012;12:1-8.

4.       Maniar N, Verhagen E, Bryant AL, Opar DA. Trends in Australian knee injury rates: An epidemiological analysis of 228,344 knee injuries over 20 years. The Lancet Regional Health–Western Pacific. 2022;21.

5.       Filbay SR, Roemer FW, Lohmander LS, Turkiewicz A, Roos EM, Frobell R, et al. Evidence of ACL healing on MRI following ACL rupture treated with rehabilitation alone may be associated with better patient-reported outcomes: a secondary analysis from the KANON trial. British journal of sports medicine. 2023;57(2):91-9.

6.       Frobell RB, Roos EM, Roos HP, Ranstam J, Lohmander LS. A randomized trial of treatment for acute anterior cruciate ligament tears. New England Journal of Medicine. 2010;363(4):331-42.

7.       Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. Bmj. 2013;346.

8.       Grindem H, Eitzen I, Engebretsen L, Snyder-Mackler L, Risberg MA. Nonsurgical or surgical treatment of ACL injuries: knee function, sports participation, and knee reinjury: the Delaware-Oslo ACL Cohort Study. JBJS. 2014;96(15):1233-41.

9.       Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. British journal of sports medicine. 2014;48(21):1543-52.

10.      Patterson BE, Culvenor AG, Barton CJ, Guermazi A, Stefanik JJ, Morris HG, et al. Worsening knee osteoarthritis features on magnetic resonance imaging 1 to 5 years after anterior cruciate ligament reconstruction. The American journal of sports medicine. 2018;46(12):2873-83.

11.      Filbay SR, Grindem H. Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture. Best practice & research Clinical rheumatology. 2019;33(1):33-47.

12.      Rooney J, editor How I rehab non operative ACL ruptures. How I Rehab - The Sports MAP Conference 2024; 2024; The Hanger, Essendon Football Club, Victoria, Australia.

 

Nick Ilic