Archive for November, 2009

The ACL: Killing your Fantasy Team, One Knee at a Time

by G. John Mullen, DPT 2011

Tom Brady tears his ACLYou’re watching the NFL and your top fantasy player suffers a season-ending knee injury. The commentators are stalling and discussing all the possible ramifications of a knee injury, filling the dead airtime with their own “medical insight” on the injury.  Their medical brilliance refers to the  “pop” they think they heard from the press box.  This “pop” is common in ACL injuries.  After ripping your foam finger in half and banging your head repeatedly into the wall, you rush to the computer to find out how long he will be side-lined and what he will be like when he returns. Before we get to that part, let’s breakdown the ACL and what causes a tear:

What is the ACL?ACL

The ACL (anterior cruciate ligament) is a ligament that connects the thigh bone (femur) to the shin bone (tibia) and prevents forward movement of the shin bone and knocking of the knees (internal rotation).

Stat Fact: The ACL has been shown to withstand an ultimate load of 1725 ± 269 N1 (roughly half the force of a Zinedine Zidane headbutt…too soon?).

What causes an ACL injury?

Non-contact injuries are the most common source of ACL tears (tough news clumsy folks).  An ACL tear usually occurs while landing or pivoting (Watch at own risk: Shaun Livingston’s ACL tear). Contact injuries still present a risk for ACL tears mainly from hits to the front and side of the knee (Watch at own risk: Willis McGahee).  Torn ACLOther risk factors for ACL tears include improper structure and movement of the knee joint, poor timing of muscle activation, and the release of various hormones (estrogen plays an important role in protecting the ACL).

Stat Fact: Women have a 4-6 times higher incidence of ACL injury and tears… sorry ladies.  The science behind this is still being investigated, but it is believed to do with their body structure (wider hips, don’t hit me, leading to an increased force on their knee), late onset of gluteal (butt) muscles in landing which doesn’t adequately protect the knee, and hormones that may lead to increased ligament laxity2.

ACL Repair?

Once the ACL is proven torn (usually by MRI), the tear is graded on a scale of 1-3, where a complete tear is graded as a 3.  Most grade 3 tears are recommended for surgery.  If the injured person is not highly active, then repair is recommended but not essential.  If your fantasy player has a grade 3 tear, it is likely they will go under the knife and be out for the remainder of the season.  The question is what surgery will they have?  There are a few surgical options to choose from, the most common of which are outlined below:

  • Patellar Tendon GraftPatellar tendon graft: An new ACL is created by taking the middle 1/3 of the patellar tendon.  This tendon can be taken either be from the injured person (autograft) or from a cadaver (allograft). Using an autograft will slightly weaken the muscle where the tendon was harvested but has no risk of an immune reaction to the tendon.

  • Hamstring graft: The tendon from two muscles, the gracilis and semimembranosus, are used to recreate the ACL.

  • Cadaveric (dead body!) graft:  The ACL from a cadaver is taken and implanted in the injured person. Stop freaking out…the cadaver is sterile and there is minimal risk of disease transmission and immune reaction.

The surgeon weighs multiple factors when deciding what type of graft to use.  Studies have shown that all of the various surgical options have similar clinical outcomes meaning that they all pretty much guarantee the same results.

Stat Fact: There are approximately 100,000 ACL reconstructions performed annually3.

ACL Rehabilitation

ACL rehabilitation is a long process that takes anywhere from 6-12 months to return to sports.  The large range in recovery time is based on the severity of the injury.  Many ACL tears are accompanied by damage to the meniscus and the medial collateral ligament (MCL).  The rehabilitation process has been under great scrutiny recently.  The process used to be extremely conservative, but has become increasingly more aggressive over the past few years.  The process emphasizes the following:

  • 2-3 Days Post-Operative: Goals are to obtain full extension, decrease swelling and, while wearing a knee extension brace, obtain 90 degrees of knee flexion

  • 7-10 Days Post-Operative: Goals are to maintain knee extension, decrease swelling, return of voluntary muscle control, begin stationary bike, and quadriceps strengthening

  • 2-3 weeks: Want to obtain full extension, decrease swelling, progress to full weight-bearing, and discontinue brace if goals are met

  • 5-6 weeks: Begin functional drills and obtain 120-130 degrees of flexion

  • 10 weeks: Continue strengthening and functional drills, begin plyometrics

  • 4-6 months: Continue advancement of exercises and return to full activity4,5

The rehabilitation protocol is different for every surgeon and the recovery time line is varies for each person depending on their prior activity level, health, and if any other knee structures (MCL, meniscus, etc.) were injured.

Stat Fact: The risk of ACL re-rupture is 5% within 5 years of surgery.

Returning from an ACL Tear

After months of missing your best fantasy player you probably doubt that he will be the same stellar athlete he was before the injury.  However, 90% of ACL surgical recipients return to play and are satisfied with their athletic abilities post-op.  In fact, many athletes are performing with a repaired ACL injury including Carson Palmer (NFL), Baron Davis (NBA), and Tiger Woods (Golf)…not too shabby if you ask me.  At the same time, contradicting data shows that specifically in running backs and wide receivers, only 79% of players return to action and these players have a statistically significant decrease in power production in their injured knee7.

Stat Fact: Isolated ACL surgery recipients did not have a significant reduction in length of career in the National Football League8.

Ways to Prevent an ACL Tear

There are many ways your top player could have prevented his knee injury.  Contact injuries, as a general rule, are unavoidable and are the result of being in the wrong place at the wrong time.  On the other hand, non-contact injuries can be prevented with some specific exercises.  Gluteal StrengtheningObtaining optimal strength and activation of the butt (gluteal) muscles during single leg exercises can protect your knee from wear & tear damage.  Specialized stretching, strengthening, agility and jumping exercises are recommended. During these exercises it is important to keep the alignment of the hip, knee and foot by using your butt muscles to prevent your knees from coming together as you squat.

Stat Fact: Athletes who performed a specific physical therapy warm-up that included stretching, strengthening, agility and jumping exercises had an ACL injury rate 41% lower than a group of athletes who did their regular warm-up9.

Standard ACL Rehabilitation Protocol:

Below is an example of an accelerated ACL rehabilitation, keep in mind each surgeon and physical therapist have their own protocol depending on the patient and surgery.  It is essential to have an individualized program to address the patient’s weaknesses.

Phase I:

Pre-operative: Heel slides, knee extension and quadriceps sets, and straight leg raises.

Phase II:

0-2 weeks post-operative: Isometric strengthening of quadriceps, continuous passive motion (CPM), straight leg raises, gait training allowing ½ of body weight through reconstructed knee. Initiate stretching of the hamstrings, quadriceps, IT band, and calf.

Phase III:

2-6 weeks post-operative: Continue exercises from 0-2 weeks, begin leg press, stationary bike, marching, sidestepping, aggressive core strengthening program and balance training, possibility to begin resistive exercise protocol of lower extremity,

Phase IV:

6-12 weeks: Begin lateral strengthening, lateral stepping, slide board, agility exercises, step downs land jogging protocol, and dynamic balance training.

12-20 weeks: Sport specific training with emphasis on proper muscle activation with jumping and plyometrics that includes multidirectional movements. Continue jogging program with increasing intensity and duration.

24 weeks-36 weeks: Continue sport specific training and return to practice with team.  Return to prior functional level, 100% of speed prior to injury.  Participate in a scrimmage prior to full return to sport.


  1. Siliski, J. (1994). Traumatic Disorders of the Knee. New York: Springer.

  2. Arendt EA, Agel J, Dick R.Anterior Cruciate Ligament Injury Patterns Among Collegiate Men and Women. J Athl Train. 1999 Apr;34(2):86-92.

  3. Fu, F. Cohen, S. (2008). Current Concepts in ACL Reconstruction. Thorofare: SLACK Incorporated.

  4. Shelbourne KD, et al: Accelerated Rehabilitation after ACL Reconstruction.Am. J. Sports Med.18:292-299, 1990.

  5. 2. Blair DF, Wills RP: Rapid Rehabilitation Following ACL Reconstruction.Athletic Training. 26:32-43, 1991

  6. Carey JL, Huffman GR, Parekh SG, Sennett BJ. Outcomes of anterior cruciate ligament injuries to running backs and wide receivers in the National Football League.Am J Sports Med. 2006 Dec;34(12):1911-7. Epub 2006 Jul 26.

  7. Carey JL, Huffman GR, Parekh SG, Sennett BJ. Outcomes of anterior cruciate ligament injuries to running backs and wide receivers in the National Football League.Am J Sports Med. 2006 Dec;34(12):1911-7. Epub 2006 Jul 26.

  8. Brophy RH, Gill CS, Lyman S, Barnes RP, Rodeo SA, Warren RF. Effect of anterior cruciate ligament reconstruction and meniscectomy on length of career in National Football League athletes: a case control study.Am J Sports Med. 2009 Nov;37(11):2102-7.

  9. Vescovi JD,Vanheest JL. Effects of an anterior cruciate ligament injury prevention program on performance in adolescent female soccer players.Scand J Med Sci Sports. 2009 Jun 23.


11 2009

28 days a month, 13 months a year….

by Tania Houspian, PharmD 2011

Birth ControlDid you know that there are 13 months in a year? Maybe not true for everyone, but true if you’re a woman using birth control pills. How is that possible you ask? Let’s do the math. There are 365 days a year and 28 days worth of pills in each month’s supply of birth control, while we’re all aware that most months have 30 or 31 days. So 365 divided by 28 gives us 13. That’s right. Women have to pay for an extra month’s worth of medication. This is unheard of for any other medicine. With no medical reason to only give 28 days worth of pills when 30 or 31 would work just as well, what’s a woman to do? Maybe we can embrace this special month that only we get, by naming it. I personally like the way “Notpregnantember” rolls off the tongue. Really though, short of demanding two more pills from your pharmacist every month, a request that sadly the pharmacist can’t possibly oblige, what’s a woman to do if she’s really put off by this extra co-pay and daily pills? Women can choose to be informed consumers. There are a multitude of products out there that work just as well, if not better than, the traditional birth control pill and they don’t require us to cross days 29-31 off our calendars or make up new names for imaginary months, as fun as this may be.

Before we dive into the world of contraception, let’s do a quick recap of what birth control is and how it prevents pregnancy. Almost all birth control products in the market today contain progesterone and an estrogen component. We women are no stranger to estrogen.  It the hormone that is blamed for any slight fluctuation in mood we may experience or tear we may shed.  However, it’s actually the progesterone component of birth control that does most of the work.

What does progesterone do?

  • Send a signal to the body not to develop an egg in your ovary

  • Thickens the cervical mucous so the little swimmers can’t get through

  • Alters the uterine lining, making it impossible for a fertilized embryo (egg + sperm) to attach, build a house with a white picket fence, and grow.

What does estrogen do?

  • Stops the uterine lining from breaking down and causing menstruation

Now that we know the key players, let’s explore the world of birth control products that don’t force us to re-invent our calendars:

Nuva Ring

  • The reason for those catchy “Monday, Tuesday, Wednesday, everyday”commercials you see on TV

  • Contains both progestin and estrogenNuvaRing

  • It’s a flexible plastic ring that you insert vaginally at beginning of the month

  • No, you wont feel it in there and neither should your partner

  • You can remove it if you feel the need to, but for no longer than 3 hours a day

  • Take it out after three weeks.  You’ll have one week of menstruation and then start a new ring the next week.


  • Contains both estrogen and progesterone that is delivered through a patch that sticks to your skin (yup, it’s a birth control sticker)

  • A box of ortho-evra comes with 3 patches (a one month supply)

  • You’ll apply one patch a week for three weeks and go patch free the fourth week of the month so that you get your period


  • This option contains a long acting form of progesterone only (no estrogen)

  • An injection is given in the arm, hip, upper thigh, or abdomen by your doctor once every 3 months

  • Some women competely stop having their period after using this continually which is completely safe and sounds like great news to me

  • Possible downside: it can take 3-14 months to become fertile again after stopping injections…not a good idea if you’re in a rush to start baby-making.



  • It’s a little plastic device in the shape of a T that sits in your uterus and prevent implantation of a fertilized egg

  • The device contains only progesterone

  • The doctor will place this into your uterus during an office visit.

  • The Downside: Expect some discomfort during the procedure (be sure to ask your doc for local anesthesia to make this part much more tolerable) and some abdominal cramping for the next 24 hours after the prodecure.

  • After the initial procedure, you’ll never notice it’s in there

  • It can be left in for up to five years and will continue to prevent pregnancy the entire time, maintenance-free

  • Once you decide its time for more kids you can have it removed and you’re ready to start the baby-making process immediately


  • It’s a small device looks like a “T” and is about the size of a quarter

  • Contains neither progesterone nor estrogen.  It’s made of copper which prevents sperm from reaching the egg.

  • Yes, the small amount of copper the device releases is safe for your body.  It’s less copper than you would absorb from eating shellfish, whole grains, nuts and leafy greens.

  • Like the Mirena, it will be placed in your uterus by the doctor which causes discomfort during the procedure and about 24 hours of cramping.

  • It doesn’t have any hormones in it so normal menstrual cycles will continue to occur

  • It can be left in for up to 10 years and will continue to prevent pregnancy the entire time

  • As soon as its taken out you can go back to making babies


  • Contains only progesteroneImplanon

  • It is an implant a little thicker than a toothpick is placed under the skin of your arm by a doctor (Note: discomfort occurs here as well)

  • Effective for 3 years

  • Baby making potential returns soon after the implant is removed…exact time till conception can occur is vague, however.

No 28-day cycle needed and no need to name your 13th month.  Of course these products may not be right for every woman, so a discussion needs to happen with your doctor to decide what is the best choice for you. Until we find out who decided to add a month to a woman’s reproductive calendar and make them pay, it may be worth exploring these other options and seeing which one is best for you.  Now, you’ll have to excuse me while I go copyright “Notpregnantember”.

Knocked Up


Besinque, Kathy Pharm.D, MSEd.. Class Lecture. ‘Rings and Things: Whats New in Contraception’ University of Southern California. Los Angeles, CA. October 26, 2009.

‘Birth Control: How Hormones Work to Prevent Pregnancy.’ Association of Reproductive Health Specialists. November 8, 2009.

‘Choosing a Birth Control Method.’ Association of Reproductive Health Specialists. November 8, 2009.

‘Counseling Patients on Birth Control’. Paragard. November 7, 2009

Nuva Ring Package Insert. Organa USA, Inc. November 8, 2009.

Mirena Package Insert. Bayer healthcare Pharmaceuticals. November 7, 2009.

‘What to Expect’. Implanon. November 9, 2009.


11 2009

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