After the Eagles announced Carson Wentz would undergo surgery to reconstruct a torn ACL, everyone is wondering when he can play again. This is the first question athletes ask me after ACL surgery and my answer is always, “when you’re ready.”
Athletes want a definitive time frame but that’s nearly impossible to give. Return to play is extremely individual and needs to be based on achieving objective, measurable goals and not an arbitrary time frame.
In the past, sports medicine professionals would give an estimated time frame, often six months, for return to play. But research and clinical experience has shown that athletes rarely fit into arbitrary time frames. Returning too soon following ACL reconstruction can put an athlete at high risk for re-injury or injuring the opposite knee. A 2016 study published in the British Journal of Sports showed that athletes returning to play prior to nine months had as high as a 40 percent re-injury rate. More importantly, athletes who passed an objective-based return to play testing battery reduced their re-injury risk to only 6 percent.
So, what is an objective-based return to play testing battery? There is still debate on which tests are most effective at teasing out any deficits or limitations that would predispose an athlete to re-injury, but most research supports assessing balance, strength, and the athlete’s ability to hop. I I developed a return to practice battery that I have been using for over five years and my unpublished data shows a significant reduction in re-injury rates for the athletes who have passed all aspects of testing. The battery assesses balance, strength, power, hopping, and landing mechanics using simple clinic-based tests and incorporating newer technology such as force plates and 2-D video analysis. This test also helps the athlete return to their pre-injury level of performance.
The last part of the process is the progressive return-to-practice programming. Athletes need to slowly progress activity from simple, straight drills to higher-level cutting and pivoting. They need to progress from non-contact to contact practice. There is also a newer term in sports medicine called acute/chronic work load. This simply means not increasing training load too quickly and not returning a player until they have reached their pre-injury training loads. Professional sports have high-tech ways of measuring this such as GPS tracking and heart rate monitoring where we use more lo tech monitoring for athletes who don’t have access to GPS monitoring
Returning to play following ACL reconstruction is a measurable process based on testing and training data. The Eagles will base Wentz’s return on these objective criteria. Eagles fans can be confident that Wentz will be back on the field, at or near his pre-injury performance level, for pre-season next August.
On Sunday, the 76ers released an update on guard Markelle Fultz’s right shoulder injury. They stated that after a visit with Dr. Ben Kibler in Lexington, KY, it was confirmed that Fultz did not have any structural impairment but he would be out indefinitely with soreness and scapular muscle imbalance.
Scapular muscle imbalance, also known as scapular dyskinesis, is an asymmetry of the shoulder blades characterized by an abnormal movement pattern of the overused side. This is often seen in baseball pitchers and tennis players due to the repetitive overuse of the throwing or hitting arm. Although typically in basketball, shoulder injuries occur when the arm is blocked during a shot or hits the rim after a dunk.
Media reports stated that Fultz had a cortisone injection earlier in October. These are typically used to reduce inflammation and pain but with Fultz’s continued symptoms, we can assume that the injection didn’t have significant benefit. This supports the scapular dyskinesis diagnosis as injections generally don’t offer relief for this problem.
Return to play can be very difficult to predict, especially with the diagnosis of scapular dyskinesis. Some athletes respond to rehab in a few weeks whereas others require months of work. Rehab focuses on improving scapular stability and movement patters, but also addressing any kinetic chain dysfunctions that may be contributing to the shoulder issue. Sometimes another injury, such as Fultz’s previous ankle sprain, can cause certain muscle groups to overcompensate, resulting in dysfunction elsewhere in the body, like Fultz’s shoulder injury. Think of it as your car’s alignment being off.
The good news in all of this is that the injury appears to be non-surgical. The Sixers will be on top of Fultz’s rehab and will have him back on the court once the scapular dyskinesis and any other movement dysfunctions are addressed. Correcting these dysfunctions will allow Fultz to return to his previous level of performance while minimizing his risk of re-injury.
August 2nd, 2017
Undrafted rookie cornerback Randall Goforth tore his ACL in practice on July 28 during what appeared to be a contact injury. This is a season-ending injury and he will likely undergo ACL reconstruction surgery within the next few weeks.
The timeline to return to play following ACL reconstruction varies, especially if additional injuries occurred such as a meniscal tear or articular cartilage damage. Most professional athletes return to pre-injury levels between 9-12 months. Recovery is based on the athlete passing a battery of tests, which include evaluations of balance, strength, and hopping distance, as well as, performance on the field and position-specific testing.
I wrote previously on the research surrounding return to play following ACL injuries in the NFL. The finding showed that 63 percent of NFL players returned to play with an average time frame of approximately 11 months. Veteran players were more likely to return to competition at the same level than those with less professional experience. Being selected in the first four rounds of the NFL draft was highly predictive of return to play.
A 2016 study in the Orthopaedic Journal of Sports Medicine reported a 55.5 percent return to play for NFL cornerbacks. In that study, higher draft status was again significantly associated with a greater likelihood of return to play.
Lastly, a 2017 study in the American Journal of Sports Medicine concluded that 61 percent of NFL defensive players returned to play with only 26 percent remaining active in the NFL three seasons after surgery. Those who did return were above-average NFL players before their injury but relatively average players after their return.
With ACL rehabilitation, there are multiple variables that influence a player’s ability to return to sports: surgical technique, quality of rehabilitation, athlete’s drive to recover, and skill level pre-injury. The Eagles will provide Goforth with the best opportunity for a successful recovery; let’s hope he can beat the odds and get back on the roster next season.
May 1st, 2017
With their second pick in the 2017 draft the Eagles chose cornerback Sidney Jones. Jones was originally projected as a high first round pick with a lot of potential but then he ruptured his left Achilles tendon during his pro day workout in early March. Howie Roseman has stated that the Eagles medical staff are confident that Jones will make a full recovery from his surgery. But what does the research say on returning to the NFL following an Achilles tendon rupture? Will the Eagles' 43rd pick be a steal or a bust?
The risk of Achilles tendon rupture is low — around 18 per 100,000 people. Ruptures typically occur in males between 30 and 50 years old and account for around 40 percent of all operative tendon repairs. Approximately 75-80 percent of cases can be attributed to participation in athletic activities, including ball and racquet sports. Re-rupture rates for surgical repair is low at 3-4 percent.
However, returning to sports following Achilles tendon rupture can be difficult. A 2009 study by Parekh et al showed that 30 percent of NFL players did not return to play following this injury.
A more recent article from 2016 in the American Journal of Sports Medicine reported on 80 Achilles tendon ruptures from March 2003 to 2013. They found a return to play rate of 72.5 percent with a return to play time frame of one year +/- four months. The study showed a significantly higher proportion of defensive lineman who sustained the injury. Their results showed a 9.3 percent decrease in return to play with each increasing year of age and 6.3 percent decrease with each increasing year of experience.
Achilles tendon repairs led to significantly fewer games played following return (27 games) compared to many other procedures. These players showed a reduction in performance during their first season following surgery but returned to pre-injury levels between their second and third years. Findings showed that Achilles tendon repair — as well as ACL reconstruction and patellar tendon repair — have the greatest effect on the careers of NFL players.
What does this all mean for Sidney Jones? Although Achilles tendon ruptures are a difficult injury to recover from, Jones has some advantages. His young age, 20, and limited NFL seasons are a positive predictor for return to play. Although research hasn’t looked at draft position and return to play from Achilles tendon injury, this has been studied for injuries to the ACL. A 2010 paper in the American Journal of Sports Medicine showed that being selected in the first 4 rounds of the NFL draft was highly predictive of return to play.
With this information, the odds are with Jones to have a successful recovery from Achilles tendon surgery. Jones may not be ready for the 2017-18 season but we can hope to see him in an Eagles jersey for years to come.
OCTOBER 28, 2016
In Sunday’s Eagles game against the Minnesota Vikings, cornerback Ron Brooks went down with a non-contact right knee injury in the first half. The Eagles have confirmed that he suffered a ruptured quadriceps tendon that will require surgery, making it likely that he will be out for the season.
Quadriceps tendon injuries occur when the tendon tears away from the patella (knee cap). It typically result from a forceful eccentric load where the muscle is resisting bending of the knee. They commonly occur in males over 40 during sporting activities or resulting from a fall. Other potential non-traumatic causes include tendinosis, use of corticosteroids, or the use of specific antibiotics (fluoroquinolones). However, this injury is very rare in football.
While Achilles tendon ruptures are becoming more frequent in the NFL, ruptures to the quadriceps tendon are hardly seen. A 2013 study by Boublik in the American Journal of Sports Medicine looked at quadriceps tendon ruptures in the NFL over a 10-year period starting in 1994. During that time, the study found only 14 quad tendon ruptures in 10 years. By comparison, NFL injury rates for Achilles tendon ruptures are between 4-10 per year with the 2015-16 season seeing more than 15.
The injury can vary in severity from a small partial tear that heals without surgery, to a larger partial tear or complete rupture, both of which require surgery.
Recovery from a ruptured quadriceps tendon can be difficult, particularly for professional athletes. There are many factors that can influence return to play including partial versus complete tear, age of the player, years in the league, and pre-jury performance (starter vs substitute).
Boublik et al found in their studies that only 50 percent of the athletes with this injury returned to play. By comparison, 80 percent of athletes return to play after a patellar tendon rupture, while another study by Parekh et al in 2009 found that 70 percent of Achilles tendon ruptures return sports.
Only time will tell if Ron Brooks will return to his pre-injury level of play. Hopefully, he will prove the statistics wrong.
July 13, 2016
This past Sunday FIFA player of the year Cristiano Ronaldo was injured in the eighth minute of the finals of the European Championships. He attempted to play through the injury but was unable and came off in the 25th minute. For the world’s best player to come off in a final, it meant that he sustained a serious knee injury, with pundits around the world speculating on the extent of his injury.
Watching the match live, it appeared to me to be an MCL injury as he was hit on the outside of his knee forcing the knee inward. These types of valgus stress injuries usually result in an MCL sprain. Other structures such as the ACL and/or meniscus can be injured but since he did not come out of the match immediately it is less likely that they were. It’s very difficult to play soccer with an MCL injury due to not only the cutting and pivoting required, but even more limiting is the inability to pass with the inside of the foot due to the stress on the ligament.
Now that the a few days have passed and Ronaldo has had more thorough evaluations, it has been determined that he indeed has an MCL sprain. This means Ronaldo suffered a stretch in the ligament, and fortunately not a complete tear that would require surgery. These injuries are typically graded on a 1-3 scale with grade 1 being mild with no significant laxity and minimal injury to the ligament. Grade 2 is moderate injury with some laxity and partial tearing of the ligament. Grade 3 is a severe injury with gross laxity and complete ligament disruption often requiring surgical repair. Other structures such as the ACL and either meniscus can be injured as well as the articular cartilage (joint surface cartilage). These all add to the severity of the injury, time frame to return, and if surgery is indicated.
Return to play is variable with this injury, especially in soccer players. With grade 1 injuries, it’s based on the player’s symptoms and ability to progress through rehab and training. Caution needs to be taken with early return as re-injury is possible and if the knee is not 100 percent there is a greater risk of ACL injury to the involved or uninvolved knee. In grade 2 injuries, progression through rehab is based more on the healing of the ligament which is assessed through the amount of laxity or looseness in the knee. This laxity decreases as the ligament heals and the knee “tightens up” over time. Grade 3 injuries require a much longer time frame to heal, if they don’t require surgery. Although the return to play time frames for MCL injuries in soccer can be widely variable, a general guideline is a grade 1 injury takes 2-6 weeks to rehab, 3-8 weeks for grade 2, and 2-4+ months for grade 3. Internet speculation has him out as little as three to four weeks, a middle ground guess of eight weeks, and as much as four to five months as a worst case scenario.
As more details come out regarding Cristiano Ronaldo’s injury, more specific time frames will be given. As a soccer fan, I’m hoping he’s ready for the start of the La Liga season and Champions League. Love him or hate him, Real Madrid matches are more exciting with him on the pitch.
June 15th, 2016
The 17th annual Philadelphia Sports Medicine Congress will be held on Friday June 17 at the National Museum of American Jewish History in center city Philadelphia. The event features lectures by nationally recognized experts in their respective fields focusing on leading edge topics in sports medicine. This course is directed primarily towards athletic trainers, physical therapists, advanced practice nurses, physician assistants, and physicians caring for athletes. The objective of the conference is to review critical issues faced by the sports medicine practitioner in the care of athletes, to provide the most recent advances in care to athletes at all levels of competition, and provide practical, interactive learning of evaluation and treatment techniques. This year’s program will include a wide variety of sports medicine topics from hip pain in athletes to future trends in meniscal repair. The program consists of the following topics and presenters:
Garrison Draper MSc, CSCS Performance Director Philadelphia Union
Topic: GPS and Heart Rating Monitoring in Sports: Implications for Rehabilitation
Theodore Ganley MD Director, Sports Medicine and Performance Center Children’s Hospital of Philadelphia
Topic: Management of ACL Injuries in Athletes with Open Growth Plates
RobRoy Martin PhD, PT, CSCS Associate Professor, Department of Physical Therapy Duquesne University and Staff physical therapist, University of Pittsburgh Medical Center's Center for Sports Medicine
Topic: Conservative Management of Posterior Hip Pain in the Athlete
Todd McGrath MD Non-operative Sports Medicine Specialist 3B Orthopaedics at Aria
Topic: Injection Therapies in Sports Medicine
Nicholas Sgaglione MD Professor, Hofstra University North Shore-LIJ Medical School, Chair Department of Orthopaedic Surgery North Shore Long Island Jewish Medical Center
Topic: Current Concepts and Future Trends in Meniscal Repair
Stephen Thomas PhD, ATC Assistant Professor of Instruction in Kinesiology Temple University
Topic: Pathomechanics of the Throwing Shoulder
Bernie Parent Former Philadelphia Flyer and NHL hall of fame inductee
The idea of the Sports Congress was originally conceived as an educational program, based at Pennsylvania Hospital. Because Joe Torg and Ted Quedenfeld were such influential icons in the field of sports medicine, it seemed natural to recognize their contributions. It was also felt that it was important to make note of the historical aspects of the origins of "sports medicine" in the area and that is why we annually pay tribute to Joe and Ted. The purpose of the Torg award as originally conceived was to recognize individual orthopedic surgeons in the greater Philadelphia area who devoted their careers to the care of athletes, who participated in the educational process, and who have made significant contributions to the body of knowledge of orthopedics. These are the qualities that are embodied by Dr. Torg. In similar fashion, as Ted Quedenfeld was responsible for teaching many if not most of the local athletic trainers at one time, and because he was a role model and one that was held in the highest regard by all of his peers and students, and because it was he who helped create the model of sports medicine with which we presently identify, we chose to honor Ted. This year’s Joe Torg award winner is Dr Michael Ciccotti of the Rothman Institute. Michael Goldenberg MS, ATC of The Lawrenceville School is this year’s Ted Quedenfeld award winner.
On behalf of Course Chairman Arthur Bartolozzi MD and the Course Committee, we are looking forward to another successful Philadelphia Sports Medicine Congress on Friday, June 17. More information can be found at our website phillysmc.org.
June 3rd, 2016
This summer’s Copa America Centenario is almost here. It is being held outside of South America for the first time ever to celebrate its 100th anniversary. Starting June 9, three group stage matches will be played here in Philadelphia at Lincoln Financial Field. These matches include third ranked Chile, ninth ranked Uruguay, and 29th ranked USA. Preparations have been underway to successfully host an event of this magnitude and this includes sports medicine coverage for each venue. Dr Arthur Bartolozzi and I were asked to lead the medical coverage for the Philadelphia matches. This includes not only match day coverage but also facilitating any medical care needed while teams are in town.
For the past few months we have been putting together our local medical team. Game day medical staffing includes stretcher crews staffed with physicians, athletic trainers, and physical therapists. After attending the Copa America Centenario 2016 Medical and Anti-Doping Committee in Miami last month, we have also been tasked with coordinating anti-doping testing at the conclusion of each match. FIFA is stepping up anti-doping efforts and these will be implemented during this summer’s matches. Game day heat index assessments are another task for the medical staff. If the index is higher than the prescribed threshold based on ambient temperature, humidity, and wind speed, water breaks will be implemented during the matches. Other game day requirements include in-stadium x-rays, EMS coverage, and emergency management planning.
While teams are in Philadelphia training prior to and following their matches, medical coverage must also be coordinated for any issue that may arise. This includes trauma care for injuries such as fractures, but also minor issues such as dental care, general medical issues, and imaging such as MRIs. Since the physicians for the visiting teams don’t have privileges here, we need to facilitate all medical care. Any medical issue needs to be addressed in a timely manner so that players can be ready for training and matches. As you can see, there is a lot that goes on behind the scenes to keep players healthy on the pitch. We’re looking forward to exciting matches in June and hope that our assistance isn’t needed.
February 11, 2016
We all know someone who has torn their ACL. The vast majority of these athletes have surgery to reconstruct the ACL and return to their previous level of activity. However, we know that there is a high incidence of arthritis in patients who tear their ACL, whether or not they have surgery. Research studies show that anywhere from 10% to 90% of people show some level of post-traumatic arthritis following ACL injuries. This large variation is due the degree of arthritic changes that were used as the cutoff in studies. Barenius et al American Journal of Sports Medicine 2014 showed that ACL reconstructed knees had a 3 times greater incidence of post-traumatic arthritis regardless of graft type using a grade of 2 or greater on the Kellgren-Lawrence (Scale is 0-4 with grade 2 showing significant osteophytes and/or cartilage reduction up to 50%). They also showed an even greater incidence of arthritis in patients with combined ACL and meniscus injuries. Why is this? Isn’t an ACL reconstruction supposed to fix the knee and prevent arthritis?
An ACL reconstruction will not prevent arthritis. The surgery is done to regain stability of the knee to prevent further injury to the meniscus and articular cartilage due to episodes of the knee giving way. Research is still trying to figure out the definitive cause of post-traumatic arthritis in order to effectively minimize or potentially eliminate it. Currently, we break down the potential causes into two groups: time of the injury and post-surgical. Time of the injury factors include the “bone bruise”, inflammation, and meniscal injury. Nearly all ACL injuries show a bone bruise on MRI. Research has indicated that this bruise results in damage to the articular cartilage and underlying subchondral bone. The theory is that over time, this damage progresses and eventually results in post-traumatic arthritis. Inflammation from the initial injury results in a catabolic inflammatory process causing abnormal tissue remodeling and damage. Meniscal injury has shown to be the greatest predictor of future arthritic changes. Bindle et al Journal of Athletic Training 2001 showed that as little as a 10% loss of meniscus volume may increase tibiofemoral contact pressure by 65 %. Potential post-surgical factors include altered knee kinematics, inflammation, and inadequate rehabilitation. Altered gait kinematics are seen in the reconstructed knee as compared to the uninvolved knee. These altered kinematics result in an abnormal shift of contact pressures and is likely to contribute to the development of post-traumatic arthritis. Post-surgical inflammation not only negatively effects the knee cartilage as mentioned above, it can potentially cause surgical tunnel widening resulting in ACL graft laxity which may further alter knee kinematics. Lastly, inadequate rehabilitation may have an effect on arthritis as well. Not fully regaining range of motion and strength as well as not fully normalizing gait and movement patterns may negatively alter knee kinematics.
You may be wondering, why the concern about post-traumatic arthritis? I’ll just get a knee replacement when I’m older, right? The concern is for the patients that develop significant and symptomatic arthritis at a younger age. Nebelung et Arthroscopy 2005 found that in a group of elite athletes who underwent ACL reconstruction, all had degenerative changes by 35 years and 42 % had undergone a total knee replacement. These patients had significant symptoms and functional limitations requiring knee replacement. Obviously, they were no longer able to participate in sports and had difficulty at work and with daily activities. As we continue to narrow down on the cause/causes of post-traumatic arthritis in order to better manage, and hopefully eliminate it, we must continue to council athletes on the long term complications of ACL injury and the best evidence in managing these injuries.
Achilles tendon ruptures seem to be on the rise this NFL season. No new Achilles injuries occurred in week 9, but week 8 had 3. So far this season, including summer work outs and pre-season, there have been a total of 15 Achilles ruptures. Is it bad luck or is there a higher incidence this season?
Previous research studies show an Achilles rupture rate of 4-10 per season in the NFL. We are a little more than half way through the 2015-16 season and we’ve already exceeded the published injury rates. Do Achilles injuries fluctuate just like anything else or is there a rise in these injuries in the NFL?
A quick Google search shows sports articles from 2013 and 2014 discussing how Achilles injuries are “plaguing” the NFL season. Recent research articles do show a rise of Achilles tendon ruptures in the NFL. But, we are also seeing a rise in ACL injuries as well. Some thought is that with a decrease in voluntary off-season workouts and mini-camps, athletes may be less prepared for the rigors of pre-season and a 17 game NFL season (Myer et al, JOSPT, 2011). However, there are many theories behind achilles tendon ruptures with no specific mechanism reported to be the primary cause of these injuries.
There are many factors considered to be potential causes of Achilles injuries. These include underlying tendonosis, use of corticosteroids, use of specific antibiotics (fluoroquinolones), as well as biomechanical mechanisms such as rapid lengthening of the tendon. After watching videos of many of this season’s injuries, I saw a common mechanism for most of them. The athlete takes some kind of back step and as he pushes off, his knee extends at the same time. Arian Foster’s injury in the fourth quarter is a perfect example of this. This combination of eccentric loading of the Achilles followed by forceful plantar flexion and knee extension may overload the tendon causing rupture. There is some thought that the knee extension may be due to fatigue, and in Arian Foster’s case his injury did occur toward the end of the 4th quarter.
Return from sports following Achilles tendon ruptures can be difficult. A study by Parekh et from 2009 showed that 30% of NFL players did not return to play. That’s a pretty significant number of career ending injuries. And unlike ACL injuries, there are no prevention programs that have been shown to be successful in reducing the risk of injury. We will see how many more Achilles rupture occur in the second half of this season and we will continue to track injury rates across season to see if this year is an anomaly or if there is an increasing incidence of Achilles tendon ruptures in the NFL.