ACL Recovery -The Long Road Back

Dr. Beth Sullivan | June 15th, 2019

Klay Thompson suffered a torn ACL in the third quarter of game 6 of the NBA Finals Thursday night. This is just the latest in a long list of injuries suffered by the Golden State Warriors this season. This injury occurred just 3 days after Kevin Durant suffered a ruptured Achilles Tendon in Game 5.  The common issue in both of these injuries is that both players had recently returned from a different injury before suffering their more devastating injuries. Did the prior injury contribute to the new injury? Did the GSW medical staff doom the team because they cleared both Durant and Thompson to play? I am sure questions like these will make the rounds during this offseason.

I discussed the Durant injury in my article – The Pop Heard Around the NBA so I invite you to check it out and we will move on to the newest injury.

The Anterior Cruciate Ligament (ACL) and the Posterior Cruciate Ligament (PCL) are located deep in the knee and function to prevent anterior-posterior movement of the Femur, upper leg bone, on Tibia main lower leg bone. The ACL/PCL complex acts to prevent hyperextension and hyperflexion of the knee. Besides the ACL and PCL, the knee also has ligaments on each side called the Medial and Lateral Collateral Ligaments (MCL & LCL). These ligaments are designed to prevent side to side movement of the tibia on the femur. The terms valgus and varus are used to describe this movement. It is based on the position the distal part is in relation to where it normally would be. In terms of the knee, if the lower leg is more lateral than normal then the knee is in a valgus position.  If the distal part is more medial than normal the knee is in a varus position.  The mnemonic taught in medical school, lateral and valgus go together because they both have an “L”.

In terms of understanding knee injuries, An ACL injury is associated with a Toe Out Knee In position. When watching a film of the injury I  look for the knee going forcefully inward while the knee is slightly flexed and if the player is landing from a jump the majority of the weight strikes on the heel first. This sequence is the commonality seen in most ACL injuries. If you watch this video of Thompson’s injury as it happens, you will see how the above description plays out in real life.

As I have explained several times, everything in the body depends on other parts to function properly.  The knee uses the hamstring complex of muscles to help protect the ACL and the quadriceps muscles to help strengthen the PCL. A weakened hamstring muscle complex caused by a previous injury or inadequate training or a quadriceps complex that is stronger than the hamstring because of training one muscle set more than the other can also lead to problems.  In Thompson’s case, there is certainly a possibility that the hamstring injury that knocked him out of Game 2 of the finals on June 2nd and kept him out of Game 3 contributed to his ACL injury.  His stat line in the fourth, fifth and sixth game until the injury was close to his season average so there will be those who say he was fine, it had no relationship to the knee injury. I disagree. I believe that the inherent weakness in the hamstring to help support the ACL compromised the secondary function of the hamstring to help support the ACL in times of stress.

Thompson will undergo surgery to repair the torn ACL and then will begin a long recovery period to allow the repair to heal and then slowly maximize the movement to the knee joint and strengthen the supporting muscles.

The rehabilitation of an ACL reconstruction includes reducing knee swelling thru the frequent use of ice packs. Maintaining mobility of the kneecap to prevent anterior knee pain problems or intermittent motion restrictions. Regaining full range of motion of the knee in flexion and extension. This is generally started with a Continuous Passive Motion Device immediately after surgery. This torture device is shown in the following video.

About four to six weeks after surgery Thompson will begin an intensive physical therapy program to maximize motion and strengthen the quadriceps and hamstring muscles.

An athlete may return to sports when there is no longer pain or swelling, when full knee range of motion has been achieved, and when muscle strength, endurance and functional use of the leg have been fully restored. This normally takes nine to twelve months.  Some doctors will allow the use of a stationary bike to allow an easy range of motion exercise while limiting the cardio deconditioning that will occur due to the inactivity following surgery.

The athlete’s sense of balance and control of the leg must also be restored through exercises designed to improve neuromuscular control. This usually takes 4 to 6 months. Once this has been achieved, jogging and agility drills will be started.

Advances in the grafting techniques, as well as the rehabilitation, have led to an improvement in the return to sports statistics over what they were just twenty years ago.  In a Study by Harris et al published in Sports Health November 2013 86% of NBA players who underwent reconstruction to their ACL returned to play in the NBA with an average time to return being 11.6 months after the injury.  In the season following returning the players had declines in all of the major statistical factors but better than 50% showed improvement in the second season post repair.

Questions and comments?

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Main Image Credit:  Embed from Getty Images

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