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 I I developed a return to practice battery that I have been using for over five years and my unpublished data shows a significant reduction in re-injury rates for the athletes who have passed all aspects of testing.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.
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.
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.