Hogs Haven’s Journal of Medicalness: ACL Edition

In our second installment of Hogs Haven’s Journal of Medicalness, our very own sports blog doctor Sam Lawrence returns to discuss ACL injuries.

Ken: Sam, good to talk to you again. I assume you are waiting in line for Georgetown season tickets now that they have signed Patrick Ewing to coach?

Sam: Absolutely. I’m hoping some of these high school players will start to realize that he knows someone in every NBA front office and we can draw some big names to the team.

Ken: The Redskins could use a hand in that department—not sure how much play Bruce Allen gets when he tries to convince free agents that he plans the best alumni picnics and Harvest Feasts…EVER. On to the topic of the day…thankfully, the rate at which Redskins are injuring themselves these days is very low…although, is disorderly conduct a real disorder? Can it be treated? I’m asking…for a friend. Let’s talk ACL’s.

Sam: Redskins fans are no stranger to the dreaded ACL tear and we all know DeAngelo Hall is currently in the midst of his recovery. But why are ACL injuries so unfortunate? Well, they are complicated, traumatic injuries that are usually accompanied by additional problems. Only 50% of athletes who suffer an ACL tear are able to return to full activity. The ACL is the most important stabilizer of the knee. It prevents our shin bone (tibia) from translating forward in relation to our thigh bone (femur). It also has a role in preventing rotation of the knee - our knees are not supposed to do that.

Ken: First of all…only 50%!?!? I feel like every player in the league tears an ACL at some point. That is one of the saddest things I have read this week, and that is saying something given I started the week by reading a list of things Bruce Allen has done this year. So half of the injuries fully heal…damn. What is the main cause of such a disastrous injury?

Sam: The common mechanism of injury we see is a non-contact, pivoting movement. And while most sports fans know the feeling of anxiously waiting for MRI results, this is usually a diagnosis that can be made on the field. How? Players are going to say they heard a “pop” and these knees are going to swell FAST! Immediate effusion (swelling) points toward ligament injury. On physical examination, players will have a positive Lachman’s test (similar to the anterior drawer test, which is far less sensitive). For this test, the physician will grab the back of the player’s calf with the knee at a 90 degree angle and pull forward. If the calf translates forward relative to the thigh, we know the ACL isn’t doing its job.

Ken: Kevin Ewoldt’s anterior drawer is extremely sensitive. Or so he says…he won’t shut up about it.

Sam: The reason ACL injuries are complex is because there is usually more going on behind the scenes. During ACL reconstruction surgery, hidden meniscal tears are often found. Each of our knees has a medial and lateral meniscus, and they act as the knee’s shock absorbers, resting between the tibia and femur. Over 50% of ACL tears have an associated lateral meniscus tear. Players can also get an avulsion fracture of the tibia, where the stress of the injury actually causes another knee ligament to pull off a piece of the tibia bone. When we see this on x-ray, it equals ACL tear. Finally, you may hear the term “unhappy triad,” which refers to concomitant tears of the ACL, MCL, and medial meniscus, usually caused by taking a helmet to the outside of the knee. This is the injury Marcus Lattimore suffered in college. All of these associated problems only make ACL recovery take longer.

Ken: Jesus...an ”unhappy triad?” Are you guys running out of titles for injuries or something? That’s the least tough-sounding injury I have come across. Sounds like something you prescribe Xanax for (full disclosure—I am not a doctor). So what then?

Sam: For elite athletes, recovery starts with surgery. They need a new ACL! Orthopedic surgeons will take a slice of the player’s patellar or quadriceps tendon or harvest an ACL from a cadaver (dead person). Ever wonder why every athlete goes to Dr. James Andrews for this repair? Incorrect positioning of the tunnel (path for the new ACL) is THE most common cause of ACL failure. If this tunnel is in the wrong spot, 70% of patients will re-tear. Also, you may remember that this isn’t a surgery that’s performed the night of the injury. Prior to surgery, the patient’s swelling must be decreased and they must have regained FULL range of motion (this is called “pre-hab”). Ensuring those two things prevents the patient from losing range of motion post-operatively.

Ken: So Dr. Andrews gets the best cadavers? Can ordinary people like me sell their ACL’s? Blogging can get tricky, but my triad has never been happier. I feel like I could probably part with one of my ACL’s for the right price.

Sam: Maybe not in the USA.

Ken: So the player has been operated on, and he now has his eyes set on returning to the field.

Sam: Rehabilitation then begins immediately. New approaches to ACL rehabilitation develop continually. However, we know that certain principles are crucial to recovery. Players will perform exercises that emphasize full range of motion and balance, along with closed kinetic chain exercises (both feet planted on the ground with the legs in a fixed position). These exercises avoid placing excess strain on the new ACL. Ensuring range of motion and knee stability are the crucial goals. This takes time. Most patients return to full activity and sports between 6-12 months after surgery. Elite athletes fall closer to the 6 month mark, if not earlier, due to their constant access to top-tier rehabilitation. Unfortunately, recent studies are suggesting that early return to activity is correlated with increased risk of osteoarthritis of the knee later in life.

Ken: Redskins fans also have seen a correlation between early return to the field and increased risk of the owner demanding playing time for his best friend despite the presence of an incredibly handsome and accurate passer on the sidelines. But I digress…what about #23?

Sam: DHall? At this point, he’s roughly 6 months out from surgery. With training camp starting in another three months, he should be a full participant when practices begin. But with his age and the multitude of injuries in his past, we’re going to have to wait and see the level of player he can still be.

Ken: Take us out by educating us more on knee injuries…they really are the bane of these athletes’ existences.

Sam: Let’s end by talking about clean-up procedures. When you hear teams mention these, they are usually referring to meniscus injuries in the knee. As I mentioned earlier, the menisci in our knees are our primary shock absorbers. They also play a critical role in distributing the forces transferred from our upper body to our lower body by providing a large surface area between the intersection of our thigh bone and calf bone. Menisci are one of the two types of cartilage in our knee. The reason these injuries hurt is because when the cartilage tears, the torn segment can get caught in the knee during movement. When it gets caught, it pulls off surrounding nerves. Players will often complain of hearing popping in the knee or feeling that they knee gets “stuck” very briefly. Small meniscal tears are treated by cutting out the portion that is torn. Menisci have very bad blood supplies, so there is little hope of them healing on their own when injured. We think of them as “clean-up” surgeries because they are painful more than anything, and football players are no stranger to playing with pain. There is little risk of further injury, so players often have these procedures in the offseason. While the surgery is minimally invasive (a camera and small scissors inserted into the knee), it requires some rehab, so having them done in the midst of the season isn’t often practical.

Ken: Sam, please don’t ever be minimally invasive in our lives here on Hogs Haven. (Did that come out right?) Thanks for the knowledge and we look forward to our next lesson!