acl rehab

Monday, January 27, 2014

For most athletes, the Olympics and the Super Bowl are a once in a lifetime experience. Peak athletic performance, injury avoidance and opportunity have to align to allow the opportunity to show up on center stage. One athlete’s demise is another’s opportunity. For the Broncos champ Champ Bailey, the chance to play in his first Super Bowl after a 15 year career was made possible by the ACL injury to his teammate, Chris Harris. Nine women made the US women’s alpine Ski team and one of those spots was made available when Lindsey Vonn tore her ACL in November.

Sometimes, though, ACL injuries can be overcome in less time than is customary.. The often cited example is Adrian Peterson of the Minnesota Vikings whose rehabilitation after ACL surgery took only six months instead of the customary 9-12. However, the poster child for quick recovery from knee injury may be Sarah Hendrickson, the world champion of women’s ski jumping. Shemo who will be representing the United States in Sochi just 5 months after undergoing surgery to repair, her ACL, MCL and meniscus…O’Donoghue’s terrible triad. Surgery August 29, jumping in mid January, named to the Olympic team on January 22 and at the top of the 90 meter hill on February 11.

The anterior cruciate ligament used to be the death knell for an athlete’s knee but with better surgical techniques and physical therapy, the chance to resurrect a career has become much better. While surgical technique is important, some surgeons may be more skillful than others, the key to success is in the physical therapy and personal motivation of the patient.

Generally there are three phases of rehab but each orthopedic surgeon may have tweaks to their own program.

  • Prehab occurs after the injury and before the operation. The goals are to reduce swelling in the knee, maintain range and strength in the quadricep and hamstring muscles that move and maintain stability on the knee. Without the cruciate ligament to maintain a stable joint, the knee is at risk for further damage with running, cutting and jumping or any sports. The goal is increasing the muscle strength because once the operat8ion occurs, those muscles will weaken again.
  • Physical therapy in the initial weeks after surgery concentrates on returning range of motion ad increasing muscle strength. The repaired ligament needs time to heal and the fibroblast cells that are the cornerstones for tissue repair cannot be rushed to do their job. It takes weeks before the ACL graft can be solid enough to withstand sports moves. The first 6 weeks get the knee moving and if all goes well, the stationary bike, elliptical trainer and swimming might be added.
  • The third phase of therapy aims to get the athlete back on the field. Month 3 and 4 work on strength, flexibility and cardio fitness. Month 5 adds agility. Six months after surgery is when the athlete can begin drills that are specific to the sport and a month later, practice may be allowed. This leads to return to play about 9 months after the operation.

In addition, there needs to be special attention to proprioception, the ability of one part of the body to know where it is in relation to the whole and to the rest of the world. There is an unconscious ability of a joint to adapt to its surroundings. Neuromuscular control, where nerves and muscles work together, allows subtle adjustments depending upon the forces put on a joint or a limb. Proprioception allows the body to make minor adjustments to running on uneven pavement, cutting on a basketball court or twisting away from a tackle in football. The conscious brain has to trust that unconscious neuromuscular control before an athlete can return to play, safely and at their previous level.

While the time for each phase of physical therapy is not set in stone, the common thread about successful surgical outcome is patient motivation. For elite athletes, the therapist is often charged with slowing down and tempering their patient’s desire to train. Ms. Hendrickson seemed to live at the US Ski team’s center for excellence in Park City, spending 6-8 hours per day in rehab. It is a reminder that while the weekend warrior, who has to work for a living, may spend a couple of hours a week in therapy post-op, the elite athlete’s job is to train and get better faster.

For the football players in New York and for those athletes in Sochi, their commonality is a mix of innate athletic ability, the determination to maximize potential, the good fortune to avoid injury and for all three to come together just as the opportunity to compete arrive on the calendar. For Mr. Bailey and Ms. Hendrickson, all came up roses. For Ms. Vonn and Mr. Harris, their timing was off and their flowers died a coupe of weeks too early.

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the “science” of return to play

Monday, December 30, 2013

New Year resolutions tend to be ignored or forgotten within weeks if not days, but perhaps sports reporters might help their readers remember that their team’s favorite player is a real person, whose body can be damaged and will take time to heal. Physiology cannot be rushed, and those who write the stories in 2014 need to stress that fact. Looking back at 2013, there are lessons to be learned about torn ligaments, broken bones and broken brains.

Concussions make headlines every week in the NFL. The standard play-by-play commentary is that the player has been taken to the locker room to be tested for a concussion. Let us be frank: there is no one test that can confirm the presence or absence of a concussion. The diagnosis is made based upon history. Was there a thought process or cognition issue? This can range from being knocked unconscious to being minimally confused, so minimally in fact, that the player may not recognize the symptoms. Over a period of time, new symptoms may arise from headache, nausea, vomiting, light and sound sensitivity and difficulty concentrating. To be considered a minor head injury, the neurologic exam needs to be normal, so the diagnosis is made based on the player confessing that all is not right and that may not be evident for hours or days.

Once the diagnosis is made, the next question becomes, when is it safe to return to play? This is a question that stumps the experts and the most recent consensus statement on concussion in sport gives cautious guidance. The conclusions of the meeting held in Zurich in November 2012 were published in the spring of 2013 and reminded physicians and trainers that there was no one test or group of tests that can determine when the brain has completely healed. Physical and mental rest are the cornerstone for treatment but for how long has yet to be determined. The goal is to have a healed, normally functioning brain that can withstand the next concussion without leaving devastation. The researchers stressed that children and adolescents needed more time to recover and should be handled more gently. As for the elite athlete, there is no dispensation for being a pro. The return to play guidelines are not to be bent for the star quarterback.

The rules for how the body repairs fractured bones also do not change for the star quarterback. Aaron Rodgers took 7 weeks to return from a broken collarbone to lead the Packers into the playoffs. He threw the winning touchdown to Randall Cobb who took 10 weeks to recover from a broken leg. As it turns out, neither broken bone is likely completely normal, but they had healed enough to function and to withstand the risk of spontaneously breaking. Bones take time to heal and the process is the same. Blot clots, granulation tissue and fibroblasts form a bridge that connect the two broken edges of bone. Chondroblasts move in to form a cartilage matrix that allow osteoblasts to lay down calcium and bone cells. This bone is laid down randomly and allows the edges to bridge and become stable. The final remodeling allows the bone to be sculpted, returning it to its normal tensile strength. That final process takes months but for most people, return to work or play occurs in just few weeks.

The Rodgers saga was a week to week soap opera with x-rays and CT scans trying to determine when the bone was stable enough for him to play. As it turns out, there is no specific test that can make that determination. Doctors provide a best guess based upon hoe a bone looks but that test doesn’t measure how strong that bone might be. It is also important to remember that the initial injury occurred when a normal bone was stressed and broke because of a tackle. If the same circumstances were to occur, the bone would potentially break again regardless of how well it had healed.

The news about ligaments centered around Adrian Peterson and his “miraculous” comeback to play in the NFL just 6 months after tearing his ACL. This set the presumptive standard and fans were upset that Derrick Rose of the Chicago Bulls took a year to return. Those same NBA fans were more upset that perhaps Kobe Bryant came back too quickly from an Achilles tendon injury and should not have been playing. Ligaments heal similarly to bones except that calcium is not laid down in the final healing process. That rate of healing depends upon where the injury occurred, what repair was required, and the anatomy of blood flow. Some parts of ligaments, tendons and cartilage have great blood supply and heal quickly but other areas that aren’t so blessed and need more time. Once the anatomy has healed, physiology has to be repaired. Physical therapy and rehabilitation returns range of motion and muscle strength and only when those are maximized can the player consider returning to practice. There is one final part that needs fixing and that is proprioception. The player’s brain needs to figure out where the injured part is in relation to the world and to subconsciously trust the bone or joint to move instinctively when asked to perform. Peterson’s return from ACL repair was abnormally quick, Mr. Rose’s was a little longer, but both were normal for them.

As the New Year approaches, the gift it can provide to a sports fan is patience.  For most injuries, there is more art than science in deciding when it is the right time to return to play. The obligation of the sports writer is to remind their readers that the players on the field are real and subject to the laws of physics and physiology, no matter how unreal they perform on game day.

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