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 ACL 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 ACL 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 ACL 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 ACL 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 ACL 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 ACL

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.

References:

  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.

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