Experts say re-injured ACLs are common

Experts say re-injured ACLs are common
• By Jim Thomas

http://www.stltoday.com/sports/football/professional/experts-say-re-injured-acls-are-common/article_9d095957-3152-5870-85a7-50ff848fc5ee.html

For the Rams to have two of their top players suffer ACL knee injuries in the same season seems like an extreme case of bad luck. For those same two players to both re-injure those ACLs within a 12-month period, well, that must be incredibly bad luck.

One expert in the field of knee injuries says it’s not unusual for a player that has undergone surgery on a torn anterior cruciate ligament to re-tear the same ACL.

“It’s fairly common, actually,” said Dr. Bert Mandelbaum of the Institute for Sports Medicine in Los Angeles. “When you look at all data and you compare people who’ve torn their ACL, they have a 10 times greater likelihood of tearing their other ACL or the same one. The probability’s about 10-fold greater.”

Quarterback Sam Bradford tore the ACL in his left knee on Oct. 20, 2013 against Carolina. The ACL in the same knee was re-injured 10 months later in an Aug. 23 preseason game in Cleveland.

In the case of left tackle Jake Long, he suffered a torn ACL in his right knee on Dec. 22, 2013 against Tampa Bay. The same knee was re-injured, again 10 months later, in last Sunday’s 34-7 Rams loss in Kansas City.

Both re-injuries occurred 10 months apart, but Mandelbaum’s general opinion was that neither player returned too soon from their initial injuries.

“Certainly 10 months is not being rushed back,” he said. “And certainly the docs there and the surgeons in St. Louis are premier guys who are extremely talented.”

Actually, the knee surgeries on Bradford and Long were not performed by doctors in St. Louis or the Rams’ team doctors. They were performed by Dr. James Andrews, who has offices in Birmingham, Ala., and Pensacola, Fla.

Throughout the NFL it’s common for players to have surgery performed by doctors unaffiliated with the team. Often players have their own preferences for doctors and frequently are steered to doctors by their agents.

In any event, the Rams must decide at the end of this season whether they should go forward with Bradford, who has one year left on his contract, and Long, who has two years. The Rams are asking themselves whether they than can count on the availability of Long and Bradford in 2015, and perhaps beyond, after a second surgery.

Are chances of a full recovery lessened by a second ACL surgery?

“If you take all the literature, overall the answer is they’re not as successful,” Mandelbaum said. “But I think in my view, in the sub-group of athletes and professional athletes, that’s probably not the case.”

In other words, the likelihood of a full recovery after a second ACL injury by pro athletes “probably is not a whole lot different” than after the first surgery. But for the overall group of people who undergo ACLs, a full recovery after a second surgery is less likely.

Dr. Scott Rodeo of the Hospital for Special Surgery in New York would only go as far as saying the results of a second knee surgery for a torn ACL are a little less predictable than the first time around.

“And you can say that for anything, whether it’s something in the shoulder, or a hip replacement, or an ACL surgery,” Rodeo said. “In revision (second) surgery, it’s a little more complex on these knees that already have prior surgery. So the prognosis can sometimes be a bit more guarded.”

In terms of deciding when a football player’s surgically repaired knee is good to go, there’s a set of criteria that isn’t based on the calendar.

“A lot of it’s based on the athletes’ functional ability. That is their strength, their balance, coordination — things like that,” Rodeo said.

First off among the criteria is having a stable knee so the ACL graft is successful. Other factors include: Full range of motion. No swelling in the knee. Regaining not just the strength of the leg muscles and muscles around the knee, but also strength of lower-back and abdominal muscles.

Even so, Rodeo said, “The reality is it’s hard to simulate the high loads they’re gonna have on the athletic field in your office or in the physical therapy area.”

It’s not an exact science.

Mandelbaum said an ACL re-injury is not usually the result of “a surgical thing.

“It’s not a rehabilitative thing. I think at times there is a neuromuscular thing. Sometimes we just can’t see it. We don’t understand it. It just appears in itself.”

He is at the vanguard of a movement studying ACL injuries, particularly those that involve little or no contact.

The study started about 10-15 years ago, when it came to light that ACL injuries were prevalent among female soccer players, particularly those playing at the high school or club level in their teens. For some reason, they were found to be more at risk than their male counterparts.

“We’re seeing that some of that risk is due to differences in how they land from a jump,” said Rodeo, an orthopedic surgeon and former assistant physician for the New York Giants. “It’s kind of how you land, and how you pivot, and how you plant.

“There are, in fact, prevention programs built around that. Teaching athletes how to land from a jump, things like that. Because there are certain positions of the hip and the knee that seem to predispose an athlete to risk. Or at least that we see the differences in those athletes that are injured, versus those that are not.”

That research into knee injuries in soccer has result in the PEP program — short for Prevent Injury and Enhance Performance — and FIFA 11-plus. Both are exercise programs that have helped reduce ACL injuries in that sport.

Mandelbaum is now spearheading ACL prevention research in the NFL.

“Actually in St. Louis, Rob Brophy and Matt Matava have been our collaborators looking at these things,” Mandelbaum said. “Trying to understand these ACL injuries in football players. Trying to gain some better understanding.”

Brophy and Matava are Rams team physicians.

“It turns out that many of these non-contact injuries are very much like our soccer players’ injuries, both on the boys and girls side,” Mandelbaum said. “So what we’re trying to do is figure out exactly what those mechanisms are (causing ACL injuries), and how we best can prevent them using some of the same lessons we’ve learned in the past.”

The idea is to develop a program specific to football players that can train them how to land, jump, keep their balance, etc., in the hope that it will prevent many of the non-contact ACL injuries.

Out of 62 ACL injuries in the NFL in 2013, Mandelbaum said 18 of them were non-contact injuries.

“We haven’t seen (the non-contact injuries) in this magnitude before,” he said.

Mandelbaum — who had reviewed the tape — puts Bradford’s initial injury at Carolina in the non-contact category. True, he was shoved out of bounds, but it wasn’t with great force, and it wasn’t a case where there was direct hit to the knee, such as with a helmet or shoulder.

“It’s not the contract ones necessarily where someone’s hitting a knee like the injuries to Navarro Bowman or Rob Gronkowski,” he said.

Mandelbaum studies every NFL ACL injury on tape. When interviewed Tuesday, he had yet to take a look a Long’s injury in Kansas City. But he has studied both of the Bradford ACL injuries, and considers them both of the non-contact variety.

“The real issue is what I call control,” he said. “The muscular control rather than the contact with the field.”

Mandelbaum likened it to driving a high-powered Ferrari at a high speed around the track, and suddenly the steering gets loose. “In this situation, the control really becomes the problem.”

“We’ve been looking at this football thing for two years trying to gain some understanding of how these happen in the first place, and also how they happen (again),” Mandelbaum said. “Because in reality, with Sam Bradford, it’s the same damn thing the second time.

“It’s not a question of his ACL graft. It’s not a question of how the surgery was done. It has nothing to do with that. It has to do with these other issues that we need to continue to understand and potentially train out of to some degree.”