Dr. Arthur, can you tell me a little bit about yourself and what you do? 

I have been a surgeon here at the Bone and Joint Institute for about 15 years. My specialty is Sports Medicine. I enjoy taking care of athletes of all ages. With this specialty, I tend to see a lot of knee and shoulder injuries – ACL being one of the more common ones. Fall seems to be ACL time of the year with football, soccer, and volleyball. 

What is an ACL and what is an ACL tear? And what is the general population that tends to get these types of injuries? 

ACL means anterior cruciate ligament. Basically there are two ligaments that cross in the knee – the ACL and the PCL – this is called the cruciatal cross. The ACL is the ligament that stabilizes the knee with translation, or shifting, front or rotational. Typically it is a high-energy, athletic type of maneuver that tends to cause these problems. It can happen with something like jumping over a fence, or other kind of normal day activities, but most of the time you’re going to see it in athletics. You’re most often going to see this in adolescence, high school, college, or even the professional level. However sometimes you can see it in younger populations or older populations. 

What is the treatment for a torn ACL? Is it always surgical or can it be non-surgical? 

Unfortunately, most ACL tears are complete. Occasionally you will have a partial injury that you can rehab and brace, but that’s not terribly common. With a complete tear, it really depends on what you want to do. You can change your activity level and go to a lower activity level. This would mean that you would not be running, jumping, cutting, or anything athletic. A lot of the time, you can live without an ACL if you want to continue with low-level athletics. Unfortunately surgery is really the main option. The problem is that if you want to try to compete at a higher level without an ACL, the knee is inevitably going to give out at some point. This could cause additional damage to the joint surface or the meniscus. 

What all does the surgery involve? And what types of technology advancements have happened recently? 

Ultimately we have to make a new ACL. Typically a torn ACL is not adequate for good tissue, so we use a graft. For the vast majority, we like to use tissue from your body, but we do use donor tissue in certain situations. For young, healthy people, we tend to like to use the hamstring tendon, the quad tendon, or the kneecap tendon. Through the scope we are able to make a tunnel through the knee to put that graft in. As time goes on, we continue to get better at this surgery as far as where to put the graft, how to position it, what type of graft to use, and more. The rehab and recovery process also continues to improve, which I think is the biggest advancement that we’ve made. 

Can you tell us a little bit about that therapy? How long does it generally last? 

We typically start therapy prior to surgery. We like to let the knee calm down from the initial injury. This allows the swelling to resolve, to get some muscle tone and mobility back. What we have learned is if you do that therapy prior to surgery, you recover faster. If you do not do therapy before surgery, we find that those people tend to have more issues with getting mobility back and controlling swelling. Typically we like to do 2 to 3 weeks of early rehab, or prehab. This really just helps prepare the knee for surgery. We are being pretty aggressive with getting people into therapy the day of surgery. We’re doing some different things with blocks and doing different combinations. We do non-narcotic medications, which allow people to do more within that first week. The return to sport is more based on when you have your coordination, function, and muscle strength back. The more that we can limit loss and attacking on the front end, the better it is on the back end. With an isolated ACL, you’re typically looking at crutches for 2 to 3 weeks. It would be about 10 to 12 weeks before you can start jogging. Ultimately returning to Sport is more at the 6 to 8 month range. We have some programs in place that allow us to check the functional recovery of someone’s ACL. This really helps at determining when they’re safe to return to sport. Obviously the last thing that you want to do is go through a big surgery like this and then re-injure it. Unfortunately, while it’s not super common, it does happen in about 5 to 10% of cases. There are people who are ready at six months, but then you have people who are not even close to being ready by 8 months. We want to play it safe and make sure that they are safe before they return. We can really personalize a patient’s care to their needs. That might mean going back to rehab just to make sure that everything is okay. 

Is there anything that we can do to prevent an ACL tear? 

We can look at at risk movement patterns. You can take video to watch someone’s running, jumping, cutting – when watching, there are some identifying risk factors that can tell you that you might be more likely to tear your ACL. If you look at men’s soccer versus women’s soccer, you are four times as likely to have a tear playing women’s soccer than you are men’s. Some of those are anatomy things where you run, jump, cut in different positions, but some of it is modifiable. We can work on hip strength, quad strength, core strength, stability. There are some drills that can teach running, jumping, cutting with better body mechanics. Can you prevent them all? No. However we want to do our best to make sure that we’re using the programs that we have to at least cut down on the number of injuries that we do see. A lot of teams are incorporating programs like this during their off-season. 

How does the comprehensiveness of the Bone and Joint Institute of Tennessee help the patient experience? 

I think it makes all the difference. Our team works really well together to assess them, get them and diagnosis, and start therapy if needed. If they need surgery, we will do the surgery to repair their ACL, and then get them right back into therapy. We also coordinate a lot with her athletic trainers. We have a great program here where we take care of all of the Williamson County schools high schools, as well as a few of the private schools in the county. The coordination between physicians, athletic trainers, and therapists is key because a lot of return to play is on the field. We can work on strengthening in therapy all that we want, but the real test is going to be when you get back on the field.