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.

Managing a Knee Torn Cartilage

Understanding a Torn Cartilage

The menisci or “cartilage” of the knee remains a common source of knee pain for athletes of any age.  The “C” shaped grisly structures assist in the congruent relationship between the femur, thigh bone, and the tibia or shin bone.  The medial (inside) meniscus and lateral (outside) meniscus have a flat under surface that rests on the tibia while the concave topside of the menisci is perfectly shaped to houses the convex (rounded) distal end of the femur.

Both the medial and the lateral menisci have basically two functions:

  • Shock Absorption – Decreasing the forces distributed to the knee joint surfaces.
  • Joint Stability – By limiting motion and somewhat directing the relationship between the femur and the tibia, the menisci add stability to the knee joint.

The medial meniscus is more prone to injury compared to it lateral counterpart. The great amount of overall stability of the medial meniscus with it’s attachments with the medial collateral ligament and the knee joint capsule contribute to this problem.  It is not uncommon to see injuries to the medial joint line indirectly injure the medial meniscus.

The “Unhappy Triad” injury is a three-structure injury involving the medial meniscus, medial collateral ligament (MCL), and the anterior cruciate ligament (ACL).

The manner in which the medial meniscus “heals” is worth noting.  The peripheral zone or outer rim of the cartilage is the only part of the structure that has a blood supply.  The central zone or inner part of both menisci lacks any significant blood supply.  Because of this fact, only the injuries to the outer periphery of a meniscus will have any chance of healing.

Common mechanisms of medial meniscus tears include a direct blow to the outer part of the knee joint, forceful twisting of the knee and chronic pounding of the joint surface for a substantial length of time, as with older distance runners.

Degenerative conditions predispose the medial meniscus to injury.

Signs & Symptoms of a Torn Meniscus

  • Knee joint line knee pain, which typically increases with twisting and bending movements.
  • Knee swelling and joint line tenderness usually accompanied by a general inflammation throughout the knee. 
  • There may be joint locking, catching and/or clicking within the knee. 
  • Range of motion in bending and straightening the knee joint will be limited and painful.
  • Stiffness around the joint, which hinders walking physically and psychologically.
  • Difficulty bearing weight on the knee secondary to pain.
  • A general sense of uncertainty with the knee when active, leading to the old label of a “trick knee”.

Professional Treatment for Meniscus Tears

The severity and type of tear sustained will guide the proper treatment approach for a torn cartilage injury.

  • Seek a clinical exam so you know exactly what you are feeling and how to treat it without damaging other structures of the knee.
  • “Ice is your friend” so spend some time together.  Ice the entire knee, front, sides and back, for 10-15 minutes as often as possible.
  • Rest the joint to minimize the swelling, which will decrease your symptoms while increasing your strength.
  • Knee sleeves and stabilizing braces can help protect the joint from additional stress and improve the outcome.
  • Utilize the latest physical therapy modalities and rehab devices to reduce swelling and decrease pain.
  • Easy flexibility exercises while avoiding complete knee extension and knee flexion greater than 110 degrees is wise.
  • Conservative strengthening of the quadriceps and hamstrings is important to start when the joint symptoms and swelling start to improve.
  • Minimal weight-bearing cardio exercises such as biking, swimming and elliptical trainers should be included if both swelling and pain is under control.

Asking the Right Questions Like a Pro

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports:

  1. Do I need to be worried about any long-term complications to this injury?
  2. Is my body alignment contributing to this injury?
  3. Do I need a rehabilitation program?
  4. Do I need further diagnostic tests like an X-Ray or MRI to properly evaluate my knee for any structural damage?
  5. How would you grade my knee’s articular cartilage in both the knee joint and behind my kneecap?
  6. Do you think that I will need a micro-fracture knee surgery now or in the future?
  7. What kind of exercises or home remedies do you recommend?

Elite Sports Medicine Tips from Mike Ryan

  • Control Your Activities – Be smart now by limited what you’re doing, rest the knee joint & ICE/ICE/ICE now so you have a much better chance of not needing surgery and getting back on your feel FAST.
  • Look Down – Check out your shoes.  If they’re flimsy, have a big heel, lack great cushioning and/or have minimal lateral support, get them off your feet fast.  You need a stable and supportive shoe if you have knee joint line pain.
  • Eat Right – Healthy foods should be the order of the day. More fruits, less fatty foods.
  • Listen to Your Knee – You need to know what makes your knee feel better and what makes it feel worse.  It’s important for you to know the answers to these questions and I hope your doctor will be asking you the same questions.