the secret to ACL repair

Monday, February 11, 2013

It will be interesting to compare the recoveries of Boston Celtic’s guard Rajon Rondo and Olympic gold medal skier, Lindsey Vonn as they both attempt to return from significant knee injuries in the coming months. Ms. Vonn crashed on a downhill run in Europe tearing the ACL and MCL and fracturing the tibial plateau of her right knee, while Mr. Rondo partial tore his ACL with a hyperextension injury of the knee. Vonn has just undergone surgery to repair the damage while Rondo is still considering his options, but it may not be the surgeon and type of surgery that makes the difference. Instead, it will be the commitment to the rehab that will determine if and when the two stars can return to play.

The anterior cruciate ligament is one of four that stabilizes the knee and its job is to prevent the joint from sliding back to front when the knee flexes and also helps control rotation. It’s a precious bit of real estate, only a couple of inches long and a half inch wide, but if it tears, the work to return the knee to normal can take a year. For the average person, it isn’t crucial to have an ACL, as long as it’s asked to do only low impact activities like jogging, bicycling or swimming. But an elite athlete is anything but an ordinary patient and they need a knee that they can trust not to give way when pivoting, jumping or cutting side to side.  And for an elite athlete like Mr. Rondo, it doesn’t matter if the ACL is partially or completely torn, a repair is required if he wants to play again in the NBA.

The ACL cannot be repaired by sewing it back together. Instead, tendons from nearby structures are used to reconstruct a replica and provide the stability the knee needs, but there are different techniques to choose from and each has its own benefit. It’s reasonable for Mr. Rondo to check out his options the elite athlete isn’t necessarily bound by health plans and insurance companies to decide what surgeon to choose and where the operation will occur. Ms. Vonn chose the US Ski Team physician in Vail but Mr. Rondo is looking outside the Boston Celtic organization, including the Vail option to find his surgeon. Regardless, it may be the physical therapist that makes the difference in how well they both do. The road to recovery requires a balance between allowing the ACL replacements in the knee o heal solidly, return range of motion to the knee and strengthen the quads and hamstrings muscles of the thigh.

This is where the weekend warrior and the elite athlete differ. The recreational athlete might be able to spend an hour or two with a physical therapist and strength coach, but rehab is a full time job for the true athlete. Physical therapy will last months and begins with small steps. The patient needs to learn how to walk again. It is amazing how quickly the muscle shut down and the leg forgets proprioception (where it is in space) causing post op patients to wobble like a new foal. After a couple of weeks, as strength and balance improve, the work outs get tougher with weight lifting and aerobic activity including stationary biking. The pitfall is that the elite athlete is driven to succeed and it the ne knee is stressed too much it will begin to swell and the patient takes a step or too back from the road to recovery. But if all goes well after a couple of months, light jogging and pool work outs begin. Still no side to side shuffling or pivoting but the knee is it’s a start. After 4 months, sports specific training starts and the knee is asked to do more. The final step is to begin agility drills like cutting and pivoting.

It doesn’t seem like much of a commitment but check out the rehab schedule recommended for his patients by Dr. Robert LaPrade of the University of Minnesota:

  • Jogging – (level surfaces) – 15 minutes at 8-10 minutes/mile pace. Add 5minutes per week. Perform daily.
  • Biking – the amount of set resistance should be increasing. Perform daily at 20 minutes/day. Legs should feel drained once off the bike.
  • Step-ups – face the step. Put foot of operative knee on step and step up on the step. Repeat with gradual build up in repetitions until doing 100 step-ups/day.
  • Agility Drills:
  •  Figure 8’s – daily – 5 minutes half-speed – tighten circle size down
  • Shuttle runs daily – 5 minutes – half-speed – repeat 10-12 repetitions
  • Zig-zag running – angle across a distance of 10-15 yards, then angle back across field to another boundary 10-15 yards apart. Continue for100 yards. Tighten up as strength/endurance permits.

This does not include the daily weight room time and other recommended recreational sports activities. Add more time for stretching and working pother muscle groups and it can become a full work day.

If all goes well in rehab (ask Adrian Peterson), return to play can be surprisingly short. If there are bumps in the road, it can take much longer (see Tiger Woods, Derrick Rose). Regardless of what the future holds, both Vonn and Rondo will have new best friends in their physical therapists and trainers. Their coming together as a team and devotion to a game plan may have more to say about how well they recover than the skill of the surgeon who performed the operation. Who knew you had to interview those people behind the scenes to make this operation a success.

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