Monday, August 22, 2011
Elite athletes can perform amazing feats on the field of play and when injured seem to recuperate faster than the spectators who watch them. Sometimes, though, even the pros can’t rush Mother Nature when it comes to healing and that’s the reason Arizona running back Ryan Williams is done for the season after rupturing his patellar tendon.
All knee injuries are not the same. Donovan McNabb was able to return to play after knee arthroscopy to repair a torn cartilage in less than a week. Osi Umenyiora of the Giants had knee arthroscopy done presumably to clean out some arthritis that caused his knee to swell and is hoping to be back in 4 -5 weeks. ACL tears take 9 months to heal and ruptured patellar tendons take at least 6 months.
There is plenty to learn from Williams’ injury. The patellar tendon crosses the knee joint attaching the quadriceps muscle on the front of the thigh to the tibial tubercle, the bump on the front of the shin just below the kneecap. When it ruptures or tears, the quad muscle can no longer extend or straighten the knee. Most often this is an athletic injury where chronic irritation of the tendon causes it to weaken and when the knee hyperflexes, the tendon tears in two. But patellar tendon ruptures also occur if the tendon becomes inflamed as a complication of other medical illnesses including diabetes, lupus, and kidney failure patients on dialysis and as a complication of knee replacement.
The diagnosis is relatively easy. The patient can’t straighten their leg and physical exam finds a divot where the patellar tendon should be and the patella or kneecap is usually displaced upward. Sometimes the rupture occurs above the kneecap where it’s known as the quadriceps tendon.
Treatment is surgery and it is usually planned relatively soon after the injury. Like much of orthopedics, it’s carpentry work. A couple holes are drilled into the tibia or the patella, and the tendon is sewn together and put back where it belongs. Waiting is the hard part of rehabilitation. It takes time for the bone and tendon to heal solid so that movement doesn’t tear things apart. Patients have to wait at least 4 weeks from the time of surgery until they are allowed to bend the knee to 90 degrees and then another 4 weeks until the knee can be fully flexed. Bending the knee too quickly can rip the sutures out of the tendon or bone and the consequence is another operation. It takes another few months to get the strength back in the injured leg.
The same or longer time frame exists for ACL repairs since bone and ligament can’t be rushed into healing strong. “Routine” arthroscopy with no reconstruction causes irritation and fluid within the knee joint that limits range of motion but that resolves relatively quickly. A routine patient can return to normal function in a few weeks. Pro athletes who have nothing better to do than work with a physical therapist for 8 hours a day can shorten the rehab time significantly. It also helps that they have the mental toughness and emotional drive to overcome the pain and fatigue that would limit most other patients.
Surgery has become an accepted part of the life a football player but it should be remembered that there is no such thing as a minor operation or routine surgery. Anesthesia carries its own risks and the specter of infection is always present. And it’s important to remember that a skilled surgeon with flawless technique still needs a patient committed to post op rehabilitation to end up with success.