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 I I developed a return to practice battery that I have been using for over five years and my unpublished data shows a significant reduction in re-injury rates for the athletes who have passed all aspects of testing.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.
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.
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
The evolution of ACL injuries
POSTED: Tuesday, April 9, 2013, 5:55 AM
Justin Shaginaw and Arthur Bartolozzi
We all have heard someone talk about their ‘trick knee’ they hurt in high school football, or the stories of players losing their college scholarship due to a knee injury. So how does Adrian Peterson return in less than a year and just miss the NFL rushing record? Let's look back and see how we've gotten from there to here—from career-ending setbacks to near-record setting comebacks.
An online search reveals little specifics when looking for career ending knee injuries. This may be because the injury kept players from ever having a recognizable career. Joe Namath was one of a few players to have a successful career in early days of ACL injuries. Namath had a brace made especially for him that allowed him to continue to play without surgery. Back then, surgery was almost always career ending due to the procedure itself and the poor rehabilitation afterwards.
It wasn't until the 1970s when Temple physician Dr. Joe Torg first discussed the Lachman's test for assessing an ACL injury. In the 1980s the MRI helped us to diagnose an ACL tear. Around this same time, arthroscopy was first used for knee injuries. Since then there has been an evolution in both the surgery itself and the subsequent rehabilitation.
Surgery has gone from using a button outside the skin as an anchor for the ACL graft to bioabsorbable screws for anatomical reconstruction. Rehabilitation has also progressed from being casted for 6 weeks to riding a stationary bike the next day following surgery. These advances in surgery and rehab are what allow exceptional athletes the opportunity to return to same level of play in such a short period of time.
But players like Adrian Peterson are the exception and not the norm. In reality it takes a year or more to fully recover from ACL surgery. And even Peterson has not fully recovered as evidenced by some physical measurements and teammates' reports. Now when players suffer career ending injuries it is not solely due to the ACL, but multiple ligament injuries or articular cartilage damage.
New surgical and rehabilitation techniques are allowing players to return to pre-injury levels of competition—but only through months of hard work. In the past, surgery ended careers. Now it allows extraordinary athletes to return in such short periods of time, and average athletes to eventually return to the sports they love.
Justin Shaginaw, MPT, ATC is an assistant athletic trainer for the U.S. Men’s National Soccer Team. Arthur Bartolozzi, MD, is Director of Sport Medicine at Aria 3B Orthopaedic Institute
The most recent information on Marcus Lattimore's knee injury is that he sustained a knee dislocation without fracture. This is a devastating injury for a high level athlete and likely jeopardizes his chances to play professionally. Knee dislocations are a complex injury requiring precise diagnosis of which structures are injured and subsequent surgical procedure/procedures to reconstruct and repair the involved structures. By definition, a knee dislocation involves at least 3 of the 4 main ligaments in the knee. The injuries sustained in a knee dislocation can include the cruciate (ACL, PCL) and collateral ligaments (MCL, LCL), posterolateral corner, menisci, articular cartilage, fractures, and vascular injuries just to name a few. Most of the the research on these injuries involve significant traumatic injuries such as automobile accidents. There are few papers on return to sports following knee dislocation.
Hirschmann MT published an article in 2010 in the American Journal of Sports Medicine titled "Surgical Treatment of the Complex Bicruciate Knee Ligament Injuries in Elite Athletes: What Long-term Outcome Can we Expect?" The results showed that only 8 of 24 athletes returned to their pre-injury level of sports activity. This is dramatically different from isolated ACL injuries where almost all athletes return to their pre-injury level of play. The athletes that had the best outcomes had early, open, complete single stage surgery. Luckily Marcus will have the best care possible increasing his odds for a full recovery. I am hoping that he proves the statistics wrong with a return to his football career.
Combined ACL and MCL injuries can be difficult to treat, especially in the high level athlete. Partial MCL injuries (grade 1 & 2) will heal and standard ACL reconstruction can be performed without significant risk of complications. Complete MCL injuries (grade 3) need to be repaired or reconstructed to regain valgus stability. There is debate on the timing of these surgeries. Should the ACL reconstruction and MCL repair/reconstruction be performed at the same time or done as two separate procedures?
The results of a recent study by Grant in the journal of Arthroscopy showed that "Outcomes were better if the ACL was reconstructed and reconstruction was delayed to allow a return of knee range of motion. In many cases, this delay may allow the MCL to heal. MCL repair or reconstruction may be required if valgus instability remains after an appropriate rehabilitation period." It concludes that "ACL reconstruction should be performed in a subacute time frame once full motion has returned. Valgus instability should be assessed at that time and MCL repair or reconstruction performed in those patients with persistent valgus instability."
Partial ACL injuries pose a problem of their own. Is the knee stable enough to return to high level sports without ACL reconstruction? Patients that are able to return sports without surgery are considered "copers." In 2011 Tjoumakaris published an article in the American Journal of Orthopedics, "Partial Tears of the Anterior Cruciate Ligament: Diagnosis and Treatment." The article states that the "Natural history studies following patients with these injuries have demonstrated that fewer than 50% of patients return to their preinjury activity level. Several studies have also documented that progression to complete rupture is a common outcome for patients who want to return to an active lifestyle."
Although the research isn't conclusive, the evidence supports subacute ACL reconstruction with concurrent MCL repair/reconstruction if valgus laxity persists. In the case of partial ACL injuries, reconstruction may be the best option due to their high likelihood of progression to complete rupture and the poor rate of return to pre-injury levels of sports participation.