ACL re-tears are more common in the first year back: on Bradford

Sam Bradford is not injury prone: ACL re-tears are more common in the first year back. Dr. David Chao

Dr. David Chao

http://www.nationalfootballpost.com/Monday-Morning-MD-3766.html

The Rams held great optimism for the post-ACL return of quarterback Sam Bradford this season. After their starting signal-caller exited the third preseason game and was examined, initial reports indicated his ACL was not torn. Unfortunately, that expectation disappeared after an MRI, as it turns out Bradford re-tore his ACL and will miss all of the 2014 season.

ACL re-tears happen and this does not make Bradford injury prone. The Rams may have been shocked to discover they lost their quarterback again, but medically speaking, a re-tear is more likely in the first year post-injury. Usually teams are not surprised by MRI results as the medical staff can easily diagnose ACL tears with physical examination. Typically, initial examination prior to the knee swelling and guarding is even more accurate than MRI.

Some of the initial optimism stemmed from the fact that Bradford didn’t feel a pop and wasn’t in significant pain. However, this is not unusual in early re-tear as the graft still has no nerves in it. Bradford also was walking around fine in the locker room without crutches or a limp, leading to more of a false sense of security. Not only does the graft not have nerves, it also doesn’t have a blood supply yet. So when it tears, there is not the usual level of swelling that leads to a limp.

Football fans have been lulled into a false sense of security after Vikings running back Adrian Peterson’s much publicized ACL recovery several years ago. Despite medical advances, ACL recovery is not without peril. There is a higher risk for ACL graft tear in the first 12 months of recovery as the ligamentization process is not yet complete.

Even when an athlete returns to sports early, full ACL recovery takes a minimum of 18 months. All the rehabilitation in the world can’t speed up the biology of graft incorporation where donor tissue becomes a ligament. Once the graft is fully ligamentized, the rate of re-tear can drop to half that of the other side native ACL tearing.

I am not criticizing St. Louis doctors or Bradford’s surgeon. Early return has become the industry standard. In a perfect world, an athlete would sit out two seasons before playing, but this is simply not practical.

Looking at the video, the hyperextension mechanism did not seem severe. The initial hope was for scar tissue or bone contusion. Bradford’s brace may have stabilized the knee enough that the shift was not seen on replay.

Quarterbacks often wear a prophylactic brace on their lead leg. Although it did not save Bradford from graft tear, the brace still likely prevented additional cartilage damage. Typically, a brace can decrease the severity of injury by a degree and, hopefully in this case, helps his injury remain an isolated tear.

The statistics show Bradford has an uphill battle ahead of him. 95 percent of athletes return to the same level of play after their first ACL injury. That rate of return drops considerably after a second same-knee ACL tear. Given this injury is likely isolated, I believe Bradford still has an excellent chance to return despite the longer odds.

Patella tendon is the most common graft choice in the NFL. Since the middle third of Bradford’s kneecap tendon was used ten months ago, it cannot be reused. Bradford’s surgeon will likely choose the hamstring tendon as the graft. Other options include quad tendon or patella tendon from the other knee. A cadaver is usually the last option, as it has higher failure rates.

Once we examine the medical facts and increased frequency of early ACL re-tear, it would be unfair to label Sam Bradford injury prone. More accurately, it is the desire for quick return accompanied by bad luck.