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 I I developed a return to practice battery that I have been using for over five years and my unpublished data shows a significant reduction in re-injury rates for the athletes who have passed all aspects of testing.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.
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.
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.
Add another player to the Eagles “out for the season” list. Jordan Hicks ruptured his left pectoralis major in the final minutes of this past Sunday’s game against Dallas. The injury occurred as Hicks reached his left arm out to tackle Cowboys receiver Cole Beasley. These injuries are usually the result of an eccentric overload on an outstretched arm. The injury occurs as the player is trying to move the arm forward (ie tackle) as the arm is forcefully pushed backwards (ie player running through the tackle). This sudden eccentric load causes the tendon to either rupture near its attachment on the humerus or to pull off of the humerus itself.
The pectoralis major muscle originates on the sternum and ribs and inserts on the proximal humerus at the bicipital grove. The main function of the pectoralis major is to elevate and internally rotate the arm and is the key muscle when performing activities that require power in these planes of motion. Most athletes are unable to return sports that require pushing and tackling, such as football and wrestling, without surgical repair.
A 2014 study by Tarity et al looked at pectoralis major ruptures in the NFL from 200-2010. They found 10 complete ruptures during this period. 5 of 10 were in defensive players and 9 of 10 occurred during games. All 10 occurred on the football field with none occurring in the weight room. The authors were able to obtain the mechanism of injury for 6 of 10, with all of the reported mechanisms involving either tackling or blocking. The incidence of pectoralis major ruptures during the 11-year study was 0.004 showing that it is a rare injury in professional football. All 10 athletes returned to play in the NFL but the study was unable to obtain data to further investigate the long term effect the injury may or may not have had on their careers. Previous studies have shown a much higher success rate with surgical repair versus non-operative treatment with 70% of athletes having excellent results.
The results of the NFL study are very promising for return to play after pectoralis major injuries. This is great news for Jordan Hicks. I’m sure we’ll see him back on the practice field sometime this summer and in the starting lineup come August.
Posted: Tuesday September 22, 2015
We’ve all heard the news that Kiko Alonso injured his left ACL Sunday against Dallas. This is the same knee that he had reconstructed last July. The internet is saying he has a partial tear, while Les Bowen states that it’s a grade 2 sprain. Alonso is to meet with Dr. James Andrews for a second opinion. What exactly is his injury? Is it a partial tear or a sprain? And what does this mean for this season?
A ligament strain is a partial tear. There is a spectrum of sprain/tear from very mild with no laxity, or looseness, to a complete tear. Partial ACL injuries come down to how stable, or loose, the knee is and whether the athlete can play without instability/giving way. Typically, a grade 2 injury stretches the ligament to the point where it becomes loose. This is usually referred to as a partial tear.
An MRI is helpful to see if the reconstructed ACL is injured but can’t assess the degree of laxity/looseness. The stability of the knee is best assessed with a physical examination. Often times, a device called a KT 1000 is used to give an objective measurement of the looseness. Generally, if the involved knee has more than 3-4 mm difference compared to the uninjured side the knee will be unstable.
However, if the ACL laxity is within an acceptable range, rehab may allow the athlete to return without surgery. We call these athletes “copers” as they are able to function with a lax ACL. However, most athletes with a partial ACL injury are unable to return to cutting and pivoting sports without surgery. Another thing to consider is that this is Alonso’s 3rd ACL injury which may mean he is predisposed to repeat injuries.
As we await the results for Alonso’s second opinion with Dr. Andrews, let’s hope he has a stable, partial tear with only minimal laxity. This would give him the best shot at returning this season.
Posted: Thursday, September 17, 2015
I know, why in the world am I writing a blog post about a Dallas player? We know Dez Bryant is out next week after surgery on his 5th metatarsal. But will he be back for the November 8th game against Philadelphia which is 7 weeks away?
Here is what we know. He fractured his 5th metatarsal Sunday and had surgery Monday. The team is giving a time frame of 4-6 weeks to return. What we don’t know if it’s it a mid-shaft fracture, a tuberosity fracture, a Jones fracture, or a diaphyseal fracture. These are all different fractures with different treatment options, return to play considerations, and complications.
In a pro athlete, surgery to stabilize the fracture is almost always done regardless of the type of fracture. Screw fixation allows earlier weight bearing and rehabilitation, decreases the risk of malunion/non-union, and ultimately helps with a faster return to sports. Complications following surgery include malunion/non-union of the fracture, bending or breaking of the screw, re-fracture, and persistent pain that can limit athletic ability.
What does Dez’s rehab program look likely following surgery? Weight bearing typically begins around 7-10 days post-surgery. Running is often started around 6 weeks if early healing is occurring and the athlete doesn’t have pain. CT scans can be helpful to document healing of the fracture. Typical return to play in a high level athlete is 8-12 weeks. With Dez Bryant, the Cowboys will throw the kitchen sink at him to help speed up his recovery. This will likely include a bone stimulator to facilitate fracture healing; accelerated rehabilitation to regain flexibility, strength and balance as well as maintain fitness and football specific skills; and possibly other modalities that “may” influence recovery such as hyperbaric treatment, laser therapy, etc.
A study published in 2015 in Foot & Ankle International looked at 25 consecutive NFL players who underwent surgery for 5th metatarsal fractures by a single surgeon. There was a 100% return to play with an average return in 8.7 weeks (range 5.9-13.6). The fastest return to play was 5.9 weeks. However, the fastest return to play for a wide receiver was 8 weeks. Re-fracture was fairly low with only 4 players experiencing re-fractures.
So, will Dez be ready to play against the Eagles on November 8th? The statistics are not in his favor. And if he does play, it will likely be his first game back. Will he be performing at his pre-injury level by then? Time will tell but the research shows that Eagles will likely be putting together a game plan against a Dallas team that won’t include Dez Bryant.
Philly.com Sports Doc
Posted: Friday, March 13, 2015, 10:16 AM
Sam Bradford. (Photo by Streeter Lecka/Getty Images)
All the sports buzz in Philly this week is revolving around the Sam Bradford trade. Is he a good QB? Don’t ask me, but ACLs are something I know about.
His first ACL injury was to his left knee in October 2013. From the video, it looked like it was a contact injury where he was pulled down from behind. It appeared that his foot got caught with a flexion rotation mechanism of injury. He injured the same knee this past August, which also looked like a contact injury from a direct blow to the knee causing hyperextension.
As we know, there are two types of ACL injury mechanisms, contact and non-contact. Contact injuries like Bradford’s are usually more bad luck than pre-disposition. If he tore them running in the open field I would be more concerned about predisposition.
That being said, statistically, he is at high risk for re-injury, according to the research.
A study published in Arthroscopy in 2005 found that 12% of patients re-injure their same knee or injure their other knee in the first five years following surgery. Another study published in the British Journal of Sports Medicine 2006 found that soccer players with a previous ACL reconstruction had at least four times the risk of re-injury or injuring their other knee. Numerous research articles show continued deficits in strength and lower extremity control that can persist for years following ACL reconstruction. If you’ve followed ACL injuries in professional athletes, not everyone recovers as quickly as Adrian Peterson. Many end up like Derrick Rose and RG III.
An article published in Orthopedics 2014 by Erickson titled “Performance and Return-to-Sport After ACL Reconstruction in NFL Quarterbacks” looked at 13 NFL quarterbacks who underwent ACL reconstruction. They concluded that there is a high rate of return to sport in the NFL for quarterbacks and that performance was not significantly different from pre-injury. Another study published in the American Journal of Sports Medicine in 2010 found that only 63% of NFL players returned to play in approximately 11 months after surgery. More experienced and established athletes are more likely to return to competition at the same level than those with less professional experience. Being selected in the first 4 rounds of the NFL draft was highly predictive of return to play (Bradford was the number 1 pick in 2010).
An article published in the American Journal of Sports Medicine in 2009 showed that a history of meniscus surgery, but not ACL reconstruction shortens the expected career in NFL players. They also concluded that a combination of ACL reconstruction and meniscus surgery might be more detrimental to an athlete’s durability than either surgery alone.
There is a high rate of re-injury or injury to the other knee in patients following ACL reconstruction. NFL players in general show about a 63% return to play after ACL reconstruction. However, quarterbacks showed not only a high rate of return to play but a return to previous levels of performance. That said, we don’t know for sure if other structures were injured in the knee that could affect his return to play. From a research standpoint, the odds are in Bradford’s favor to be back to the player he was prior to his injuries. But the question to be answered is, will he be AP or RG III?
Philly.com Sports Doc
Posted: Friday September 19, 2014
Most of us by now have at least heard about, if not seen, RG III’s ankle injury against the Jaguars on Sunday, September 14. The sports media reports that he suffered an ankle dislocation without fracture. This type of ankle injury is very rare as ankle dislocations almost always happen in conjunction with a fracture of the lateral malleolus, medial malleolus and/or the distal posterior aspect of the tibia.
From watching the video of the injury, RG III’s ankle looks to roll inward. It is unclear which direction his ankle dislocated and whether it was an open or closed dislocation but one would assume that there is significant damage to his ankle ligaments, specifically his deltoid ligament.
Treatment for this injury will involve a period of non-weight bearing with cast immobilization. Once the cast is removed, his ankle will be re-assessed for any ligament laxity that may not have healed with immobilization and may require subsequent surgery. If surgery is required, the loose ligaments will either be repaired (sewn together) or reconstructed (other tissue used to replace the injured ligament).
Return to sports after ankle ligament surgery usually takes 3-6 months. If surgery is not required, he will start progressive weight bearing and rehabilitation to regain ankle range of motion/flexibility, ankle and general lower extremity strength, and lower leg balance and motor control. From there, he will initiate sports-specific activities including running. This rehab program is relatively the same whether he undergoes surgery or not. There is less published research on return to sports following ankle dislocation without fracture, but one case study showed a time frame of 6 months in a recreational athlete.
The latest news coming from the team is that he will be casted for about 10 days, will not require surgery, and that he will be back in 4-6 weeks. That time frame is extremely optimistic if it was truly an ankle dislocation. There should be a much clearer prognosis once he is out of the cast and re-evaluated. But until then, make sure you don’t have him in your starting fantasy line up.
Philly.com Sports Doc
POSTED: Tuesday, May 14, 2013, 6:00 AM
Justin Shaginaw MPT, ATC
Baltimore Ravens linebacker Ray Lewis speaks during an NFL Super Bowl XLVII football news conference on Wednesday, Jan. 30, 2013, in New Orleans. Lewis denied a report linking him to a company that purports to make performance-enhancers. The Ravens face the San Francisco 49ers in the Super Bowl on Sunday. (AP Photo/Patrick Semansky)
We all marvel in the extraordinary recovery of athletes following injury.
Ray Lewis returned to play less than 3 months following tricep repair surgery. Adrian Peterson nearly broke the single season NFL rushing record less than a year after ACL reconstruction. Kyle Lowry played point guard for Villanova less than 4 months following his own ACL reconstruction.
How is this possible? Do these gifted athletes just work harder during rehab? Do their bodies heal faster than the rest of us?
Or could it be the fear of most sports fans in the 21st century? Could these be using performance enhancing agents to speed up their recovery? Let’s discuss the factors and controversies that contribute to a speedy recovery in more detail.
Ray Lewis and his tricep. Ray injured his tricep on October 14th, 2012. He had surgery three days later and played in his first game on January 6th, 2013. That’s less than 3 months after injury—an unheard of turnaround time. There are many factors contributing to his extraordinary recovery.
First and foremost, Ray took a great risk at returning that soon. His chance of re-tear was very high as the surgical repair takes at least 3-4 months to be even close to being strong enough to withstand the forces involved in football. I’m sure that his rehab was rigorous in regaining the strength needed to block and tackle in the NFL. One would think his age would be a detriment to a speedy recovery, but it doesn’t seem to have been a factor.
The big question: did the deer antler spray help? There is little scientific evidence that IGF-1 (insulin-like growth factor) has any performance enhancing or injury recovery benefit. And IGF-1 is not affected when delivered through a spray. In Ray Lewis’ case, he probably beat the odds of re-injury by playing as early as he did vs. having an amazing recovery aided by performance enhancing supplements.
Adrian Peterson. He is still the talk of the town when it comes to returning from ACL surgery. In his first season back, he nearly sets the NFL rushing record.
Adrian’s first game back was 9 months after his ACL surgery. Although his level of play was astonishing— many players never quite get back to their pre-injury level—the time frame that he returned to play in is within the normal range of 9-12 months. Was there anything more than hard work and determination that contributed to his recovery? A good surgeon and rehab staff helps. But probably more than anything is what makes him such an amazing athlete is the same thing that gave him such a remarkable recovery… great DNA. There are no rumors or whispers about deer spray or any other performance enhancing substances with Peterson, just old fashioned hard work.
When we look for an unbelievably quick recovery from ACL rehabilitation, we don’t need to look any further than the Main Line and former Villanova basketball star Kyle Lowry. Kyle tore his ACL the summer before his freshman year at Villanova. He had surgery on September 17th and played in his first collegiate game on December 31st. That’s just 3 ½ months after ACL reconstruction! Not only did he return to play so quickly, but he had a great season and was named to the Big East All-Rookie team as well as being tabbed Philadelphia Big Five Rookie of the Year. Kyle has gone on to have a successful NBA career without any inkling of a previous ACL injury.
In Lowry’s case, his recovery can be based almost exclusively on his genetics as even performance enhancing substances couldn’t have produced such as a rapid return to basketball.
Genetics, hard work, or performance enhancement? How do these athletes return so quickly? Even though in Ray Lewis’ case there are questions regarding hormone usage, all the deer antler spray in the world won’t get players back on the court and field as quickly as these players returned. These players get back to sports on the accelerated track due to their genetic makeup, excellent surgeons and rehab staff, hard work, and willingness to play in a time frame that puts them at higher risk for re-injury.