Microfracture Surgery for NFL Players

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As we await for the bright lights to begin Round 2 of the 2016 NFL Draft, the big looming medical question on the minds of the football fans is:  Will UCLA’s star linebacker Myles Jack’s knee injury negatively impact his career in the NFL and will he need microfracture surgery?  Everyone agrees that his knee was the reason he remains un-drafted after the 1st round.

The issue needing clarity relates to the potential need for a microfracture surgery on Myles’ injured right knee.  The whispers regarding such a procedure quickly became screams when Myles himself reported that he may require microfracture in the future.

Jack has not played since his September 2015 knee injury that required a repair, not simply a trim, of the lateral meniscus cartilage in his right knee.  A meniscus injury is not unusual in football but two key elements make his particular injury concerning to NFL teams.

  1. His injury involves the lateral or outside meniscus.  This lateral “compartment” bears more weight than the medial or inner compartment, therefore, it is often more symptomatic when injured.
  2. A repaired meniscus is less common for football players compared to the typical “trimming” of a torn meniscus.  Only a small area of the meniscus cartilage actually has a blood supply so that is the only part of the tissues that actually has the potential to heal.  Repairing the meniscus is wonderful, in theory, because it preserves the all-important meniscus.  With that being said, if the repaired cartilage fails to heal or is reinjured, the results are concerning.

Pothole in a Joint…Needing Microfracture Surgery

Unrelated to the meniscus cartilage, the articular cartilage at the ends of bones that come into contact with each other to form the knee joint is smooth and solid.  The slick surface of the articular cartilage protects it’s underlying bone, which has both a blood supply and nerves.

When the articular cartilage is damaged, from a high-force trauma or over time with arthritic changes, the articular cartilage can break away exposing the bone to the joint surface.  Unprotected and exposed bone in a joint is painful.  It often bleeds into the joint resulting in a chronically painful and swollen knee.

A defect in the articular cartilage and bone is similar to having a small pothole in the road.  The remainder of the road is fine and you can still drive your car over the hole.  Both the size and location of that pothole will ultimately determine how deep and impactful that pothole becomes.

Only when excessive pain and/or impaired function of the joint cannot be controlled by standard physical therapy techniques, will a microfracture procedure be considered as an option.  Microfracture surgery is an aggressive procedure and its rehabilitation is extensive.  In other words, no one rushes into a microfracture procedure until it is absolutely necessary because the recovery is long and the outcome is undoubtably cloudy.

What is Microfracture Surgery?

Don’t confuse the simplicity of the procedure with the complexity of the healing steps following a microfracture surgery.  The surgical procedure is almost barbaric in nature.  It consists of picking and drilling into the exposed bone in the base of the articular cartilage “pothole” with one simple objective: promote the bone to bleed to stimulate a healing response.

The healing, stated in very simple terms, consists of the production of a different type of cartilage to fill in the existing hole in the articular cartilage.  This new filler is mostly fibrocartilage, similar to the cartilage in your external ears and the tip of your nose.  It is not as strong or as smooth as the original articular cartilage.  If given ample time and the appropriate physical therapy care, the new pothole filler serves a valuable role.  It can improve both the mechanics and the symptoms of the injured knee.

Recovery From NFL Knee Surgery

A common myth with microfracture surgery is a lengthly recovery but the athletes will recovery 100%.  I’ve rehabbed dozens of NFL players following microfracture surgery and I can tell you that the first part of that myth is true.  The athletes are not allowed to put any weight on the injured leg for 6 to 12 weeks.  The rehab protocol is slow and methodical for good reason: the healing of that pothole is #1 factor related to a healthy knee 6 months after the surgery.

As for the outcome, it ranges greatly based on the size of the athlete, the extent of the lesion and the length of time since the initial injury.  With that being said, with the players that I have been fortunate enough to rehab following microfracture surgery I have never had a player tell me that he was ever greater than 90% of his pre-injury abilities.

In closing, knee microfracture surgery is a proven technique to improve the function of a damaged joint for high-level athletes like NFL players.  It is not an option for every knee injury nor is the decision to perform the procedure ever rushed into.  Lastly, when the surgery is performed, the recovery is long and the end results are optimistic yet always in question.

When an ACL Surgery & Rehab Goes Bad

Anterior cruciate ligament tears have become too common.  Most non-professional athletes just assumes that an ACL surgery is a simple procedure with little chance that anything could go wrong.

ACL reconstructions (ACLR) are often thought about in a similar manner as the Space Shuttle program was five years ago.  This huge 240,000 lbs space ship would be launched into space at over 17,000 mph and it might only get a quick 30 second side-comment on the local news.

It’s not that simple and when there is a problem, with an ACLR or with the space shuttle, the results are not good.

Here’s a look at a present ACL reconstruction situation with a friend of mine that will show you what happens when all doesn’t go according to the plan.  She’s struggling to get her knee and her athletic career back on track.

The Background

“Katie” is an athletic 42 years old rockin’ soccer player at the time of her ACL tear in June 2011.  She gave me permission to share her story with MikeRyanFitness readers.

Katie had ACL surgery reconstruction (ACLR) in mid-July 2011 with an allograft.  I was surprised to see that she used a tibialis anterior tendon from a cadaver.  When this form of harvesting tissue from the surgical patient themselves, it is referred to as an autograft.

Initial Rehab

Braced in week #1 along with ice, very little weight-bearing and no physical therapy.

Katie’s rehab started during week #2 with 50% weight-bearing, strengthening exercise only in open chain (foot off the ground) and range of motion (ROM) drills.

The brace was removed during week #4, full weight-bearing was started, only open chain exercises continued, ice and starting Russian Stimulation using an electric stimulator to aid in muscle strength.

Time for Concern

During the start of week #5, the surgeon expressed concern with the limited ROM.

His Plan:  He drained fluid out of the knee, gave her a cortisone injection and instructed physical therapist to implement closed chain activities, which is a great way to rehab ACLR patients by exercising them with their feet on the ground.

The Result

Katie has endured dozens of hours of painful rehab with minimal improvement and few examples of improvement.

“My frustration is mostly due to the inconsistency in treatment and shifting focus constantly with my rehab plan…”

This 10 to 14 week phase of rehab should be the exciting part of her knee marathon but it has turned into a painful and stressful time for Katie.

The knee remains significantly stiff, swollen and limited in range (limited by approximately 10 degrees from full extension).  Katie complains of pain during all activities and while at rest.  Her family and social lives are significantly limited.  It’s understandable that Katie is frustrated with her care and her inability to remain active.

The Plan

Her doctor wants to perform an arthroscopic surgery (“a scope”) in the next two weeks to remove scar tissue, based on the recent MRI.  I assume some form of a manipulation may be performed at the same time to regain needed ROM after the scar tissue is removed and while the Katie remains under anesthesia.

“I have let this knee consume me for months and I finally just took a mental vacation from it the past few weeks.”

After the scope, rehab will continue immediately.  A continuous passive motion (CPM) may be utilized to help the knee to remain in motion while Katie is resting and sleeping.  I think the CPM is a great tool to help maintain ROM and decrease pain.

My Advice to Katie

  • Have a detailed discussion with the surgeon before the ACL surgery.  Ask the important question:

“What do you expect to find in my knee and what are my options in managing these findings?”

“What kind of ACL surgery graft will you use with me and how many of these types of surgeries do you perform every year?”

 “Do I need a micro-fracture surgery?”

  • Your articular cartilage may be damaged and it may be the reason why you’re having so much pain and swelling.
  • Excess scar tissue is not too common but I’ve seen it with pro football players.  They did very well after a scar tissue removal scope.
  • After the scope, start your aggressive rehab ASAP. (note the capital letters!)
  • Use a CPM machine as much as possible.
  • Seek the opinions of other knee doctors and physical therapist in your area.  Remember that it’s your knee that’s in turmoil so stop worrying about their feelings.
  • As for the mental vacation, it’s needed and truly justified.  Get your mind “right” because you still have some heavy work ahead of you, Katie.
  • Keep your quad strong!!  Gains in quad strength may come in smaller chunks after the scope but it may prove to be the #1 variable if you want to be an athlete for the next 30 years.
  • From what you’ve been thru, the next phase will be a bit easier and MUCH more rewarding.

Mike Ryan’s Sports Medicine Tips for an ACLR Rehab Plan

  1. Research your doctor and his/her exact surgical technique before your ACL surgery.
  2. Get a copy of your surgeon’s WRITTEN rehab protocol before your ACL surgery.
  3. Meet your physical therapist and review your rehab protocol with her/him.  Ideally, schedule 1-3 rehab appointments with your therapist before the surgery to increase both knee ROM and quad strength
  4. Plan on a marathon.  Get your body and mind right to put in the necessary work for 6-9 months to successfully put this injury in your rearview mirror.
Let’s all wish Katie the best of luck with her ongoing ordeal.  I keep bragging to her about how smart my followers are so please share your thoughts & suggestions with Katie as she continues to follow this blog during her rehab.

Football Injuries: Learning from the Best

Football Injuries Happen
Football Injuries Happen

I arrived home last night after a wonderful “working” vacation in Destin, FL.  I was very fortunate to be asked to speak at the Andrews Institute’s Injuries in Football Conference 2011.  The event is the brainchild of Dr. James Andrews, one of the most respected orthopedic surgeons in the world.  The conference is one of the most organized seminars for athletic injuries in the country and a true credit to the efforts of those associated with the Andrews Institute.

I’ve known Dr. James Andrews personally for over 15 years and admire his commitment to helping athletes at all levels of sports.  Anyone who has witnessed his devotion to the care of athletes, both young and old, can attest to Dr. Andrews’ passion for his role as a true leader in the sports medicine field.  He continues to amaze me with his schedule and the number of elite athletes that he cares for all over the world.

Dr. Andrews continues to be a true inspiration to me in the world of sports medicine.

The conference was uniquely informative with an impressive lineup of speakers and attendees.  The topics were all focused on football related injuries, which was perfect for me with my present position with the Jacksonville Jaguars.  Preventing, treating and rehabilitating football injuries is very different than other sports.  The best way to learn the “art & science of pigskin medicine” is to learn from those who live and breath football.

The various groupings of topics included Concussions, Upper Extremity Injuries, Lower Extremity Injuries, Traumatic Head & Neck Injuries, Treatment of the Spine, Athletic Performance Enhancement, Catastrophic Head & Neck Management and priceless hands-on labs to practice all of the material covered.

Needless to say, it was a comprehensive 3-day seminar for the hundreds of attendees and speakers alike.

Sports Medicine Presentations

I presented three talks and co-managed a hands-on lab session titled “Catastrophic Injuries Spineboarding and Facemask Removal”.  The titles for my talks were as follows:

  • “Non-Operative Management of Ankle Sprains”
  • “Emergency Management in the NFL”
  • “Life After Football: The Truth”

In my opinion, learning from my peers and sharing our experiences about football injuries and sports medicine are two of the most important steps to success.  The medical field is not an exact science and opportunities such as the Andrews Institute’s conference last week helps all of us to get better at taking care of our athletes. It’s also this unique experience that I share here online with you, which keeps all athletes competing each and every day.

Having fun and enjoying those that I learn with sure helps the process!