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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knowing when things are right

Monday, March 11, 2013

The problem with technology in medicine is that it gives patients the false sense of security that if a test is normal, all is well. Never mind that the test may have limitations and that history and physical examination may more accurately reflect the clinical situation. Such is the case with the Chicago Bull’s Derreck Rose and the LA Dodgers’ Zack Greinke. While the tests on their knee and elbow respectively, have come back clean, that does not necessarily mean that all is well in the world.

Let’s start with Mr. Rose and his ACL tear. After successful surgery, he has spent months in physical therapy and rehab to the point where his doctor has decided that he is cleared to play. Still, Mr. Rose is not quite confident in the knee and this is where the athlete and the patient can trump the doctor. While the medical staff can say that the knee has full range of motion and the muscles that support the knee, the quad and hamstring, have return to full strength, they cannot know the exact time when the player trusts the knee to perform. While there can be some hesitancy, the other issue has to do with proprioception, the perception of space where the knee is in relation to the rest of the body and the amount of strength required to keep it there. Trust is an emotion that the player can willfully address, but proprioception is an unconscious reflex. The combination of the two allows the player to perform without hesitancy.

While Bulls’ fans wonder why Adrian Peterson can play football 6 months after ACL surgery and Derrick Rose is still working hard in practice, they need to be reminded that every patient recovers in their own time. Rehabilitation guidelines that take a patient from one step to the next on the road to recovery are just guidelines. Physical therapists are trained to gauge recovery and pushing the patient to the next level until they are ready. However, athletes participating in contact sports are a special case. While a construction worker can control their work environment, Mr. Rose has a constantly evolving workspace, where other players can force unexpected body movement and landing zones. Proprioception needs to be functioning to prevent another injury.

Mr. Greinke’s elbow is another story.  With $147 million dollar contract at stake, the Dodger management wants to make certain that there are no structural issues within and surrounding his elbow joint. For anybody else, a physical examination may be perfectly adequate to sort out minor injury from major disaster, but pitchers are not normal people. They place enough torque on their muscles and joints that a small twinge may be the early signal of a mechanical and anatomic flaw. However, it is once again a problem of proprioception. Greinke’s elbow doesn’t feel right and that sensation of twinge may cause changes in his pitching motion. Or was a subtle change of his pitching motion enough to cause a twinge of pain. The MRI may be normal, but the pain is still there.

Too often, patients demand blood tests and x-rays because having a tangible result is more satisfying than the doctor’s proclamation that he thinks all is well. The word “think” gets in the way of the message. Patients would much prefer the word “know”. Most medical people have enough experience not to be 100% sure of anything. The body has a way of reminding us that it can be devious in how it can disguise injury and illness. The same can be said for testing. Occult fractures, those that are not initially seen on an x-ray, plague physicians and patients who are subsequently found to have a broken bone. Normal white blood cell counts in the face of major infection are a reminder that it is how the patient looks in person that matters, not how they appear on paper.

Rose and Greinke may appear well on paper but that doesn’t mean that they are ready to perform at their accustomed level of athletic prowess. As with eve3rything else in medicine, if you listen hard enough, the patient will tell you what’s wrong…and what’s right.

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