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Continued: Joint efforts: Today's knee injuries aren't the career-enders of old

  • Article by: CHIP SCOGGINS , Star Tribune
  • Last update: July 17, 2012 - 2:19 PM

The play called for a reverse punt return, an odd decision since the Chicago Bears already held a comfortable lead on the New England Patriots in the 1985 Super Bowl. Bears returner Keith Ortego signaled a fair catch before deciding to hand the ball to Leslie Frazier, whose left foot got stuck in the Louisiana Superdome's turf.

Frazier's career was over.

He suffered extensive damage in his knee, the most severe being a torn anterior cruciate ligament, which required reconstructive surgery. He spent the following season on injured reserve for the Bears and then failed a physical in training camp in 1987. He accepted a tryout with the Philadelphia Eagles, but he wasn't the same player and retired.

"I just couldn't get my range of motion," Frazier said. "I couldn't sprint."

The Vikings coach reflected on his experience with ACL surgery an hour after witnessing All-Pro running back Adrian Peterson sprint up a steep hill abutting the team's practice field at the five-month mark of his ACL rehabilitation.

Frazier smiled and shook his head.

"It's a totally different procedure than when I had mine," he said. "It's no comparison. The cut on my knee looks a lot different than the cut on Adrian's knee."

Advances in technology and rehab protocol in ACL reconstruction the past two decades have improved the long-term prognosis for athletes and enabled them to return to competition significantly faster. A normal timeline for return from ACL surgery now is six to nine months, which is encouraging news for Twin Cities sports fans tracking the progress of three high-profile athletes in the midst of ACL rehab -- Peterson, Timberwolves point guard Ricky Rubio and Gophers forward Trevor Mbakwe.

Doctors note that ACL surgery and rehab vary by patient, but the injury has become so common that nearly 100,000 reconstructions are performed in the United States each year, according to medical literature. Athletes still view ACL surgery as a significant career setback that promises a long, arduous recovery process. Many also acknowledge that they didn't feel completely normal until their second full season after surgery. But medical improvements and overall awareness of the injury provide a much brighter outlook nowadays.

"You put the best technology with the most motivated person, you get some spectacular results," said Randy Twito, a HealthPartners Medical Group physician who practices at Regions Hospital.

Twito, a veteran surgeon, has witnessed the procedure's transformation over the years. One example: Previously, patients had their knee immobilized in a cast after surgery so that it would stiffen. Now, many patients awake from surgery with their knee in a machine that stimulates range of motion in order to avoid stiffness.

"It's such a perfect science now so they're efficient," Vikings head athletic trainer Eric Sugarman said.

Surgery advances

Dr. David Fischer, the Timberwolves' orthopedic surgeon since their inception, began performing ACL surgery in his practice in the late 1970s when, he notes, "we really didn't know much about this injury at all."

Surgery was performed on an open knee because arthroscopic technology was still developing. Surgeons experimented with different tissue grafts to replace the torn ligament, including synthetic material, allografts (donor tissue from a cadaver) and xenografts (animal tissue). Eventually, doctors found the most successful grafts come from the patient's own patellar tendon or hamstring tendon.

Advancements in science, technology and surgical techniques over the years made surgery less invasive. Doctors also gained a better understanding of the ideal placement of the graft inside the knee. Those improvements led to better results and more confidence that the knee could withstand physical punishment at the same force as preinjury.

Early postoperative protocol required the knee to be cast for at least a month to make sure it healed and stabilized. That, however, caused stiffness and atrophy and severely diminished range of motion, which never completely returned for many athletes.

"I was in that boat," said Frazier, who was in a cast for six weeks after surgery. "I got real stiff."

That side effect added months to the rehab timetable.

"You take [someone] out of a cast six weeks later and his leg looks like a toothpick," Sugarman said. "You take Adrian six weeks after his surgery, his quad is almost back to normal. They were at such a disadvantage that way."

Fischer credits Indianapolis-based Dr. Donald Shelbourne for revolutionizing ACL surgery and rehab protocol in the early 1990s. Shelbourne determined that an aggressive approach could accelerate the rehab timetable without jeopardizing the graft, according to Fischer.

"That was an observation that grew into what we have now," Fischer said.

Learning to wait

Now, rehab begins immediately after surgery. The goal is to improve range of motion and build strength in the knee while healing takes place. Doctors now also allow some lag time between injury and surgery -- typically a week to two weeks -- to let swelling subside and the knee to "calm down," said Moira Novak, the Gophers' director of athletic medicine who is overseeing Mbakwe's rehab.

"It used to be that a kid would tear an ACL on Saturday and we'd have him in Monday morning doing surgery," Novak said. "What we're finding is, even though you may have done surgery two weeks earlier than the next guy, the post-op response is a better response if you wait it out. At the moment it's injured, it's a very angry knee. It does not want to be assaulted again with surgery."

Rehab protocol is more layered and aggressive now, but athletic trainers caution that every individual is different, their timetables largely dependent on the scope of damage. For example, Peterson also tore his medial collateral ligament in addition to his ACL. Rubio suffered a torn ACL and lateral collateral ligament.

Mbakwe tore his ACL, MCL and suffered some articular cartilage damage that required a microfracture procedure.

"In terms of what we're doing with [Mbakwe] at the five-month mark versus what I would be doing with a person at five months with an uncomplicated ACL tear, it's different for sure," Novak said. "The earlier phase of his rehab was much slower."

Sugarman said athletic trainers "press the envelope" in their rehab approach, but they also realize there's a limit to the physical demands on the knee. The graft actually weakens around three to four months and becomes susceptible to reinjury if pushed too hard too soon.

"As an athletic trainer that's the scariest time because you know you're at your biggest risk," Sugarman said. "In my opinion, I don't think it's safe to put a guy out there before six months. It's too much stress. The body has to heal."

Time to heal

An occasional outlier patient will trim that timetable, but it's not recommended, even for elite athletes. Doctors have improved their understanding of biomechanics and the importance of proprioception (balance), but they haven't discovered a way to make the body heal faster.

"We hold our breath if somebody is going back out there in less than six months because of the biologic maturation process necessary," said noted surgeon Dr. Neal ElAttrache, who performed Tom Brady's reconstructive surgery. "So far, we've been able to really improve the technique, the actual anatomic placement of the graft to mimic the normal ACL. And we've been very good at regaining range of motion, strength and endurance."

Those advancements have prolonged careers and allowed athletes to return to action sooner. Of course, it's also beneficial, doctors note, if a patient possesses a genetic makeup in the highest percentile.

"We're operating on superior creatures physically," ElAttrache said. "It certainly helps a surgeon when you're operating on that kind of a canvas."

  • related content

  • Chart: Comparing the surgeries, rehabs of Mbakwe, Peterson and Rubio

    Monday July 16, 2012

    Medical advances mean today's knee injuries aren't the career-enders of old.

  • Ricky Rubio

  • Adrian Peterson

  • Trevor Mbakwe

  • Leslie Frazier (21)

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Minnesota 16 FINAL
Buffalo 17
Atlanta 7 FINAL
Baltimore 29
Tennessee 17 FINAL
Washington 19
Seattle 26 FINAL
St. Louis 28
Cleveland 6 FINAL
Jacksonville 24
Cincinnati 0 FINAL
Indianapolis 27
Miami 27 FINAL
Chicago 14
New Orleans 23 FINAL
Detroit 24
Carolina 17 FINAL
Green Bay 38
Kansas City 23 FINAL
San Diego 20
Arizona 24 FINAL
Oakland 13
NY Giants 21 FINAL
Dallas 31
San Francisco 17 FINAL
Denver 42
Houston 7:30 PM
Pittsburgh
San Diego 10/23/14 7:25 PM
Denver
Detroit 10/26/14 8:30 AM
Atlanta
Boston 95 FINAL
Brooklyn 90
Minnesota 112 FINAL
Oklahoma City 94
Golden State 83 FINAL
Houston 90
Charlotte 96 FINAL
Chicago 101
Utah 91 FINAL
LA Lakers 98
Minnesota 1 FINAL
Los Angeles 2
San Jose 0 FINAL
NY Rangers 4
Calgary 4 FINAL
Winnipeg 1
St. Louis 0 FINAL
Anaheim 3
TX-San Antonio 20 FINAL
Louisiana Tech 27
Syracuse 30 FINAL
Wake Forest 7
Purdue 38 FINAL
Minnesota 39
Western Ky 38 FINAL
Fla Atlantic 45
(12) Baylor 27 FINAL
(22) West Virginia 41
(11) Kansas State 31 FINAL
(17) Oklahoma 30
Iowa 31 FINAL
Maryland 38
So Florida 38 FINAL
Tulsa 30
Tulane 13 FINAL
UCF 20
Virginia 13 FINAL
Duke 20
Akron 20 FINAL
Ohio U 23
Western Mich 26 FINAL
Bowling Green 14
Eastern Mich 14 FINAL
Massachusetts 36
Appalachian St 53 FINAL
Troy 14
(25) UCLA 36 FINAL
California 34
Texas A&M 0 FINAL
(4) Alabama 59
Army 17 FINAL
Kent State 39
Kansas 21 FINAL
Texas Tech 34
UAB 22 FINAL
Middle Tennessee 34
Rutgers 17 FINAL
(13) Ohio State 56
(8) Michigan State 56 FINAL
Indiana 17
New Mexico 31 FINAL
Air Force 35
NC State 18 FINAL
Louisville 30
(21) Clemson 17 FINAL
Boston College 13
Ball State 32 FINAL
Central Mich 29
Cincinnati 41 FINAL
SMU 3
(9) Georgia 45 FINAL
Arkansas 32
Oklahoma State 9 FINAL
(10) TCU 42
San Jose St 27 FINAL
Wyoming 20
Miami-Ohio 41 FINAL
Northern Ill 51
New Mexico St 17 FINAL
Idaho 29
Colorado 28 FINAL
(20) USC 56
(23) Marshall 45 FINAL
FIU 13
Southern Miss 30 FINAL
North Texas 20
Georgia Tech 43 FINAL
North Carolina 48
Tennessee 3 FINAL
(3) Ole Miss 34
Utah State 13 FINAL
Colorado State 16
Missouri 42 FINAL
Florida 13
Kentucky 3 FINAL
(24) LSU 41
(16) Nebraska 38 FINAL
Northwestern 17
Georgia State 27 FINAL
South Alabama 30
Washington 20 FINAL
(6) Oregon 45
Iowa State 45 FINAL
Texas 48
(7) Notre Dame 27 FINAL
(2) Florida State 31
Nevada 42 FINAL
BYU 35
Stanford 10 FINAL
(14) Arizona State 26
Hawaii 10 FINAL
San Diego St 20
Arkansas State 10/21/14 7:00 PM
Louisiana
Connecticut 10/23/14 6:00 PM
(18) East Carolina
Miami-Florida 10/23/14 7:00 PM
Virginia Tech
So Florida 10/24/14 6:00 PM
Cincinnati
Troy 10/24/14 6:30 PM
South Alabama
BYU 10/24/14 8:00 PM
Boise State
(6) Oregon 10/24/14 9:00 PM
California
North Texas 10/25/14 11:00 AM
Rice
UAB 10/25/14 11:00 AM
Arkansas
Rutgers 10/25/14 11:00 AM
(16) Nebraska
Maryland 10/25/14 11:00 AM
Wisconsin
Texas 10/25/14 11:00 AM
(11) Kansas State
Minnesota 10/25/14 11:00 AM
Illinois
Memphis 10/25/14 11:00 AM
SMU
North Carolina 10/25/14 11:30 AM
Virginia
San Jose St 10/25/14 12:00 PM
Navy
Northern Ill 10/25/14 12:00 PM
Eastern Mich
(25) UCLA 10/25/14 1:00 PM
Colorado
Akron 10/25/14 1:00 PM
Ball State
Massachusetts 10/25/14 1:00 PM
Toledo
Ohio U 10/25/14 1:00 PM
Western Mich
Ga Southern 10/25/14 1:00 PM
Georgia State
Kent State 10/25/14 1:30 PM
Miami-Ohio
Oregon State 10/25/14 2:30 PM
Stanford
Fla Atlantic 10/25/14 2:30 PM
(23) Marshall
Louisiana Tech 10/25/14 2:30 PM
Southern Miss
(1) Miss State 10/25/14 2:30 PM
Kentucky
Georgia Tech 10/25/14 2:30 PM
Pittsburgh
(22) West Virginia 10/25/14 2:30 PM
Oklahoma State
Texas Tech 10/25/14 2:30 PM
(10) TCU
Michigan 10/25/14 2:30 PM
(8) Michigan State
Boston College 10/25/14 2:30 PM
Wake Forest
Central Mich 10/25/14 2:30 PM
Buffalo
Vanderbilt 10/25/14 3:00 PM
Missouri
Old Dominion 10/25/14 3:00 PM
Western Ky
UNLV 10/25/14 3:00 PM
Utah State
Temple 10/25/14 4:00 PM
UCF
(15) Arizona 10/25/14 5:00 PM
Washington St
Texas-El Paso 10/25/14 6:00 PM
TX-San Antonio
Wyoming 10/25/14 6:00 PM
Colorado State
Syracuse 10/25/14 6:00 PM
(21) Clemson
Texas State 10/25/14 6:00 PM
ULM
(3) Ole Miss 10/25/14 6:15 PM
(24) LSU
(4) Alabama 10/25/14 6:30 PM
Tennessee
So Carolina 10/25/14 6:30 PM
(5) Auburn
(13) Ohio State 10/25/14 7:00 PM
Penn State
(20) USC 10/25/14 9:00 PM
(19) Utah
(14) Arizona State 10/25/14 9:45 PM
Washington
Nevada 10/25/14 10:59 PM
Hawaii
Columbus 3 FINAL
Red Bull New York 1
Seattle 2 FINAL
Los Angeles 2
Ottawa 6 FINAL
Hamilton 16
Montreal 20 FINAL
Toronto 12
Calgary 33 FINAL
Winnipeg 23
Edmonton 24 FINAL
Saskatchewan 19
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Date/Opponent Time W L Score
2014 preseason     
Aug 8 - vs. Oakland 7 pmX10-6
Aug 16 - vs. Arizona 7:30 pmX30-28
Aug 23 - at Kansas City 7 pmX30-12
Aug 28 - at Tennessee 7 pmX19-3
2014 regular season     
Sep 7 - at St. Louis NoonX34-6
Sep 14 - vs. New England NoonX30-7
Sep 21 - at New Orleans NoonX20-9
Sep 28 - vs. Atlanta 3:25 pmX41-28
Oct 2 - at Green Bay 7:25 pmX42-10
Oct 12 - vs. Detroit NoonX17-3
Oct 19 - at. Buffalo NoonX17-16
Oct 26 - at Tampa Bay Noon
Nov 2 - vs. Washington Noon
Nov 9 - Bye
Nov 16 - at Chicago Noon
Nov. 23 - vs. Green Bay Noon
Nov. 30 - vs. Carolina Noon
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