Why are professional athletes prone to ACL injuries?

Many professional sports involve explosive cutting and pivoting. Professional athletes subject their knee joints to a high volume of extreme biomechanical forces. Seasons are long, and there is often little time to rest and recover. This exposes the professional athlete to greater risk of tearing their anterior cruciate ligament (ACL). Although most ACL tears are non-contact injuries, contact sports further increase an athlete’s knee to a greater risk of injury.

ACL injuries are the most common ligament injury, occurring in as many as 300,000 people a year. The primary function of the ACL is to hold the tibia in line with the femur, preventing the tibia from sliding forward in front of the femur. The typical ACL injury occurs when there is a sudden cutting and pivoting force across the knee or due to one suddenly decelerating. Professional football players, soccer players, and skiers are at a particularly high risk of an ACL injury due to the amount of rotational forces placed on their knees repeatedly during their sport. Athletes with a knock kneed (ie. valgus) alignment, those with muscle imbalances, and female athletes are at higher risk of tearing their ACL.

Do Professional Athletes Need Surgery After an ACL Injury?

Like every patient, the professional athlete who has experienced a significant knee injury will first be asked to provide a thorough history of how the knee was injured and what the immediate symptoms were.  Dr. Cunningham will then perform a comprehensive knee physical examination to diagnose the extent of the injury. Xrays and oftentimes an MRI will be obtained.

If the ACL is not torn and there is a less severe knee injury such as an MCL sprain, then conservative treatments will be recommended. This may include bracing the knee, pain management, rest, ice, and physical therapy. However, if the ACL feels unstable on exam and an MRI confirms an ACL tear, then conservative management would not be recommended in a professional athlete. In this case, surgical intervention will be recommended if the athlete is intent on getting back to their sport at the same high level. ACL surgery is minimally invasive and has a long track record of successfully getting back most athletes to their prior level of sports performance.

For a professional athlete who has sustained an ACL tear and requires surgery, there are several considerations. As for ACL graft options, there are allografts (from a donor source) or autografts (harvested from the athlete). The gold standard for professional athletes (or any younger athlete) is an autograft. Numerous studies have shown better results in patients who have had their ACL reconstructed with an autograft instead of an allograft.

Historically, the majority of professional athletes who have undergone ACL reconstruction surgery have had a patellar tendon autograft. The central third of the patellar tendon is harvested along with a 1 inch section of bone taken from both the patella and the tibia onto which the tendon attaches. This graft is then secured to the femur and the tibia where the native ACL once attached.

The results of ACL reconstruction surgery with a patellar tendon autograft have been good with high success rates reported. However, other graft choices are currently being considered and utilized by the next generation of surgeons. A quadriceps tendon graft has some distinct advantages over a patellar tendon graft.

Firstly, a quadriceps tendon graft is nearly twice as thick as a patellar tendon graft. This additional collagen makes the tendon graft stronger and may lead to lower re-tear rates.

Secondly, a common complaint of patients who have undergone a patellar tendon graft is pain over the front of the knee when kneeling. This is increased with a patellar tendon graft because a piece of the knee cap bone is being harvested in addition to the tendon. This bone must be harvested with a patellar tendon graft because the patellar tendon itself is too short to be used as a graft without the bone sections attached to it. By contrast, our quadriceps tendon is approximately twice as long as a patellar tendon. Because of this, there is no need to take a section of the patella when harvesting a quadriceps tendon graft, and therefore there is a lower incidence of kneeling pain in patients who have had a quadriceps graft compared to a patellar tendon graft.

Thirdly, another possible complication of harvesting a portion of the patella is that there is a higher incidence of patella fractures. This is of particular concern for contact athletes.

Fourth, there has been some evidence in the orthopedic literature that patients who have had a patellar tendon ACL reconstruction surgery are at higher risk of developing arthritis in their knee sooner than patients who have had other ACL grafts.

Finally, many female athletes are more prone to knee cap pain in general and following a patellar tendon graft, the chances of having knee cap pain may be increased.

Because of these factors, ACL surgeon Richard Cunningham, MD utilizes the quadriceps tendon autograft option for the majority of the professional athletes he treats.

What is Recovery Like After ACL Surgery for Professional Athletes?

Overall, the recovery process for professional athletes is similar to other young athletes. The professional athlete will want to return to play as soon as possible. However, to achieve an excellent long term outcome, progressing rehabilitation methodically is necessary. Typically, it is 8 months of rehabilitation until an athlete can resume their sport.

Physical Therapy is started immediately after surgery. The first goal is to limit swelling. The knee is iced and elevated. Easy range of motion exercises are started immediately. Patients can start to weight bear as pain and swelling allow with the assistance of crutches and a knee brace. Patients can spin on an exercise bike as soon as possible but initially with minimal resistance and limited time on the bike. Gentle strength training on the lower extremity begins at 6 weeks. Patients can ride a bike outdoors at 8-10 weeks from surgery. They can start to run at 4 months. More aggressive strengthening and endurance training allows for a return to one’s sport at 8-9 months depending on progress.

Why Do Pro Athletes Recover Quicker After ACL Surgery?

The professional athlete, unlike the casual athlete, has devoted their life, and considerably more time and energy to their sport. They are a pro. It is their profession. Thus, when a professional athlete is in recovery from an ACL surgery, they have several advantages for the quickest possible recovery and return to play.

These advantages include:

• Optimal physical fitness, including well established training discipline
• Access to a team of professional physical therapists and trainers
• Access to highly specialized rehabilitation systems and equipment
• Large amounts of time each day to devote to their recovery
• High level medical team oversight and ongoing use of all diagnostic tools
• Access to performance psychology support

The professional athlete begins the recovery process at a high degree of overall physical fitness, with well-established health disciplines, highly efficient body systems, and typically a keen awareness of their body and its needs. This along with access to a high level of therapeutic and rehabilitation care, allows the athlete the most optimal outcome possible and the opportunity to return the desired level of play as quickly as possible.

If you have sustained an ACL injury, contact ACL surgeon Richard Cunningham, MD.