FEATURES: High School Athletes Deal With ACL Injuries

(Photo courtesy Catie Rice)

(Photo courtesy Catie Rice)

By Colleen Rice – Staff Reporter

Catie Rice was prepared to have a stellar sophomore soccer season at Jonathan Law. Rice was ready to play in her first preseason scrimmage of the year at West Haven High School. As the whistle blew, Rice’s athletic life would soon be changed forever. She was running on the left side of the field as the ball was kicked in the opposite direction. Alone, Rice pivoted to follow in the direction of the ball, suddenly collapsing to the turf. In serious pain, Rice was taken off the field and later examined at a local hospital. Soon after the MRI, the doctor told her that she had suffered a torn ACL and that she would need surgery in order to have a future in sports. After an extensive six months of physical therapy and doctor appointments, Rice returned to athletics, needing a brace until a full season passed.

“Tearing my ACL was one of the most difficult things I’ve experienced in my athletic career,” Rice said. “I think I’ll always play different now after my surgery but I’m glad to be back doing what I love.”

Rice is one of 100,000 athletes every year who tear their ACL in the United States. The anterior cruciate ligament (ACL) is a crucial stabilizer for the knee. Most ACL tears occur in athletes of high demand sports and activities. Many studies have shown that a majority of tears occur in high school sports such as soccer and basketball. This injury is most prevalent (1 in 1,750 persons) in patients 15-45 years of age.

Approximately 70 percent of injuries are non-contact and occur when the athlete is trying to change directions, slow down or land from a jump. In contact injuries, a direct blow can cause the knee to hyperextend or bend inward (valgus stress) according to Beaumont Orthopedic Specialist.

The anterior cruciate ligament (ACL) is in the middle of the knee. It prevents the shin bone from sliding out in front of the thigh bone. Most ACL tears are seen in the middle of the ligament, or the ligament is pulled off the thigh bone. These injuries form a gap between the torn edges, and do not heal on their own if athletes intend on returning to sports.

Eighteen-year-old “Amy” expressed her story of tearing her ACL. When she was a freshman in high school she tore her ACL, meniscus, and LCL in a jv basketball game. She then got surgery and used her hamstring for the new graph. Once Amy recovered she played softball in her sophomore year and yet again tore lateral and medial meniscus, thus undergoing her second surgery. Junior year went smoothly and she finally thought she was going to get past her ACL struggles. Speaking too soon, Amy ended up tearing her ACL, lateral and medial meniscus in her right knee during the last week of her senior basketball season. Amy was in and out of the operating room for her knees but never gave up hope and is on the road to recovery.

For most tears, especially for athletes, surgery is necessary. The cost of ACL surgery varies across the country and from facility to facility. The average cost of ACL surgery in 2010 was between $5,000-$6,000. But this cost did not include the surgeon’s fees or the anesthesiologist’s fees. The total cost of ACL surgery can be as high as $11,500. During the operation, the surgeon will either prepare the graft, if from a cadaver or harvest it from another area of the patient’s body. Then the surgeon places an arthroscope in the knee to examine the joint. Any cartilage injuries are repaired, then the surgeon removes the torn ACL stump, drills into the femur and tibia, puts the ACL graft in place and attaches it. The surgeon then checks to make sure the graft has good tension and the knee has full range of motion.

In preparation for surgery, patients should do several weeks of physical therapy in order to strengthen the knee and get it as straight as possible for a better outcome from surgery. One single physical therapy session costs around $100. Some exercises patients do are made to stretch out the knee. For example, patients do a lot of work on the bicycle and light weight training. It is crucial to minimize pain and swelling, restore range of motion in the knee, and to rebuild quad muscle.

There is mental preparation that patients need to undergo as well. The recovery and rehabilitation process following ACL reconstruction is long and difficult, thus this is a good time to begin to mentally prepare the patient for the process.  In addition, doctors can educate the patient on the time and effort that will be required to return to a sport at an even higher level than prior to their injury. A major obstacle most patients face is the set back the injury causes. Being prepared and knowing how much effort and time it takes to recover fully from the surgery will cause a better outcome both physically and mentally.

“Sitting on the bench and watching my team play was definitely one of the hardest parts mentally speaking,” Rice said. “You want to be able to be on the field and help your team out but you know you can’t.”

Talking about one’s feelings to an adult or physical therapist will help as well.

Dr. Vivek Sharma explained the step by step procedure of an acl reconstruction surgery. Surgery can be both arthroscopic and open surgery. Reconstruction of the ACL begins with a small incision in the leg where small tunnels are drilled in the bone. Next the new ACL is brought through these tunnels, and then secured. As healing occurs, the bone tunnels fill in to secure the tendon. The normal ACL is a taut rope-like structure which goes from the femur to the tibia. Probing of this ACL indicates that it is lax and frayed. This indicates a functionally incompetent ACL (torn ACL).

To reconstruct the ACL, it is necessary to remove all of the existing damaged ligament. This is done with a motorized device which is called a shaver. In some patients, the “notch” where the ACL is located is extremely narrow. If the notch is not widened, then the newly reconstructed ACL may be at risk for re-rupture. To decrease the probability of injury to occur, the notch may be widened using a burr.

At this point, attention is directed to the patella tendon. Incisions are made at the inferior pole of the patella and at the tibial tubercle. Each incision is approximately 1.5 inches in length. After making the skin incisions, the tendon is identified, and the central third is harvested with a bone block at each end of the tendon. Initially, the tendon is removed from the tibial tubercle area. The graft is then passed beneath the skin and retrieved from the superior incision. Harvesting is completed. For the graft to heal, blood vessels must grow into the reconstructed ACL. To hold the graft in place, a screw is inserted into the femoral drill hole. This particular screw is a bioabsorbable screw. A second screw is inserted into the tibia to hold that part of the reconstruction in place. Following this, the reconstructed ACL is inspected. Now the procedure is completed and the healing process may begin.

Once the surgery is over patients start to undergo recovery. Patients are set to start physical therapy and light workouts immediately after surgery. The first two weeks after  concentrates on decreasing the swelling in the knee and regaining knee extension, with less concern about knee flexion. This is accomplished by elevating/icing the leg and riding the stationary bike.Two weeks after surgery, the goal is for patients to achieve and maintain full knee extension and increase quadriceps muscle function. While knee flexion of only 90 degrees is the goal for this stage, obtaining full extension is more of a priority.Patients can typically return to driving two weeks after surgery because crutches won’t be needed. Some people heal differently though so it all depends on the person.

The American Physical Therapy Association (APTA) recommends that patients do exercises without pressure on their leg (called “non-weight-bearing exercises”) and ones that have they placing weight on the leg (“weight-bearing exercises”). These exercises might be limited to a specific range of motion to protect the newly-healing ACL graft. The therapist might use electrical stimulation to help restore the quadriceps (thigh) muscle strength and help the patient achieve those last few degrees of straightening the knee.

Rice had a successful surgery and recovered in about six months and is now back and ready to play sports.

“I’m going to work hard to be a better athlete than I was before the surgery,” Rice said.

(Some information courtesy ryortho.com, sports-injury-info.com, apta.org, orthoinfo.org, viveksharmamd.com)

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