It was an away basketball game, and just as well that Abby Navarro’s parents weren’t in the stands. Navarro, then 16 and a forward for Lawton High School in Oklahoma, was dribbling left-handed down the court, a rival player close behind. “I remember trying to cross the ball over to my right hand when she kind of shouldered me, and that made my knee pivot in,” she recalls. “It hyperextended, and I felt the pop.” Navarro dropped to the floor and grabbed her leg as the burning sensation hit. “All I could do was just hold my knee and wait for somebody to come help me.”
Notorious Injury
A severe injury to the anterior cruciate ligament – the dreaded ACL tear — is the bane of athletes everywhere. Surgery and recovery leave young athletes sidelined for months, as they put in the strenuous work of slowly building their knees back up.
The knee — made up of bones, ligaments, cartilage and tendons — is the largest joint in the body. Two crescent-shaped pieces of cartilage, called the meniscus, serve as shock absorbers between the femur (thighbone) and tibia (shinbone). The patella (kneecap) is the third bone. Four ligaments hold the bones together and stabilize the knee. The anterior and posterior cruciate ligaments cross each other and control the knee’s back-and-forth motions.
ACL injuries are tied to sports involving jumping, pivoting and rapid changes of direction, such as basketball, soccer, volleyball and football. They’re often complicated by damage to other parts of the knee.
Females at Higher Risk
Female high school and college athletes are significantly more likely to sustain knee injuries than males playing comparable sports, studies show. Women who play competitive basketball are at four times the risk for an ACL injury as men, and at nearly double with soccer, says Dr. Answorth Allen, an orthopedic surgeon at the Hospital for Special Surgery in New York City.
When females jump, they tend to land in riskier positions, with greater inward hip movement, studies find. “Neuromuscular adaptation” is another factor — a combination of muscle strength, timing and preference, with females favoring quadriceps over hamstring use. All this results in less knee stability.
Prevention programs have been shown to decrease injury, Allen says. Programs teach safe jumping and landing and incorporate warm-ups, hamstring strengthening, balance, agility, stretching and plyometrics.
Surgery or Not?
“Not everybody who tears their ACL needs a reconstruction,” says Dr. David Teuscher, president of the American Academy of Orthopaedic Surgeons. “Some people don’t have instability, and they don’t have a meniscus tear.”
But about 70 percent of the time, he says, “If you tear your ACL, you’re going tear one of the meniscus cartilages.” Left untreated, he says, that could result in further injury to cartilage surfaces of the knee bones. And even decades later, osteoarthritis can develop.
Older adults may opt for nonsurgical treatment such as bracing and physical therapy. In younger people, Teuscher says, an ACL injury is usually “much more important” because these patients are far more active.
Surgery, if chosen, “takes you out for the rest of the season,” and rehabilitation lasts about six to 12 months, says Teuscher, who is also a partner at the Beaumont Bone and Joint Institute and team physician for the NCAA Division I athletic teams at Lamar University in Texas.
Graft Choices
The first question when considering a knee operation is “Do I really need the surgery?” Teuscher says. Patients undergo X-rays and an MRI to confirm the ACL has been torn. If it has, the physical exam will show a “big swollen knee” from bleeding within.
The second question is “Do I have other damage?” More often than not, Teuscher says, if the ACL ruptures, a meniscus tear is also involved. Sometimes multiple ligaments are injured.
Reconstructive surgery requires a graft either from the patient’s own knee, an autograft; or an allograft from a deceased donor. Autograft options include patellar tendon and hamstring tendon grafts. The graft serves as a scaffold on which the new ligament can grow. Each method has pros and cons, Teuscher says. “It’s most important that you sit down and talk to your surgeon.”
Allen notes that the surgical infection rate is quite low at roughly 0.5 percent, with orthopedic surgeons using preventive measures including antibiotics. ACL reconstruction is done arthroscopically, often on an outpatient basis under regional anesthesia. Overall, Allen says, it’s “really one of the most successful procedures we do, in terms of ability to return to play.”
Knee Prehab and Rehab
Before surgery, the patient goes through “prehabilitation” to get the knee in operative shape and avoid future stiffness. During that couple of weeks, “we’ll either put you on ice or an immobilizer and on crutches,” Teuscher says. Patients may be given gentle exercises to perform.
Abby Navarro had her outpatient surgery at Southwestern Medical Center in Lawton. The recovery process started quickly, with bandages removed the day after surgery. “The first week, they had me stretching out my knee out as far as I could, and that was painful,” she says. But she knew she had to exercise. “Each week, they had me doing more stuff.”
Recovery became more challenging as time went on, Navarro says. “You do feel like you can run and walk again. You do feel like your knee is strong,” she says. “But at the same time, the middle of the recovery is when it’s healing the most. You have to take it easy, and you have to take it slow.”
Sports and Social Sidelines
Allen, a team physician for the NBA’s New York Knicks, performs four to six ACL reconstructions each week. He says professional athletes are “logical and disciplined” in their approach to recovery — their goal is to return to the field of play.
College and high school athletes may handle it differently, Allen says. “When you’re younger, you’re willing to take more risks,” he says, and young athletes may feel more pressure to recover quickly. Allen has empathy for them. “You can imagine a teenager who self-identifies by sports and athletic performance — it’s devastating,” he says, along with the disruption to their school and social life.
Navarro’s surgery, done in the summer, left her on crutches for a month. “My friends would do fun stuff like rollerblading and, of course, I wasn’t able to, so I just sat on the sidelines,” she says, although friends did their best to include her. But she was most eager to return to playing basketball.
Back in the Game
Just like sports, ACL surgery recovery is a team process, surgeons say — including the patient, family members, doctors and nurses, as well as physical therapists, athletic trainers and coaches — each with their role in getting the patient through.
“I knew I would get a pretty good-looking scar,” Navarro says. “I’m almost kind of proud of it. It’s a remembrance of hard times I’ve overcome.” At first, she was nervous about getting back on the court with the grafting and surgical screws in her knee. But she strapped on her brace and went for it.
Now 18 and a freshman at Maryville College in Tennessee, Navarro plays intramural basketball and softball and works out daily. And, she says, her reconstructed knee feels “completely strong.”
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The Dreaded ACL Tear — and How to Recover originally appeared on usnews.com
