I was thinking about Robert Griffin III the other day, with all the hoopla surrounding his jumping jacks and bouncing around at a recent team event. Made me think about what to expect from him this season, whether he’s going to lean more towards Adrian Peterson or a guy like Deuce McCalister. It’s obviously impossible to say at this point, but here’s my post from early January with my initial thoughts when the injury occurred:
If we learned anything from Week 16 and the Wild Card round of the playoffs, it’s that watching someone tear their ACL remains one of the most gruesome things to experience, whether it’s in person or while watching TV. Sitting at a friend’s house watching the 49ers/Seahawks game during Week 16, I knew it the second I saw it that Mario Manningham tore his ACL. I actually remember saying that I thought he tore both his ACL and MCL, mainly based on how much his knee dove in when he got his foot caught underneath his body. Same goes with watching RGIII this past weekend against the Seahawks, although initial reports say that he only has partial tears of the ACL and MCL. Maybe short of a broken bone, nothing makes me cringe more than seeing an athlete tear his ACL, partly because it almost always seems like they KNOW they just tore their ACL and that the next year of their lives just changed in an instant. Despite the improvements in surgical intervention and rehabilitation, recovery post-ACL reconstruction remains both tricky to predict and a long, arduous process.
The point of this post today is not to point out what we already know: ACL tears are bad. But it’s to give you some insight into why exactly this small bundle of collagen fibers plays such a crucial role in an athlete’s function and what goes into the rehab process following this gruesome injury.
First question we have to answer: What is the ACL? Essentially, and very simply, the Anterior Cruciate Ligament (ACL) stops the tibia (shin bone) from gliding anteriorly (forward, towards the front of the body) on the femur (thigh bone). The significance of this knee ligament is that it provides the stability of the knee during movements such as planting-and-pushing-off, stopping quickly on a dime, cutting, and decelerating during a run/sprint. When you take this ligament away from a football player, it’s essentially taking away their burst, change of direction, and ability to accelerate/decelerate all in one pop (literally). Check out this diagram to get a visual of everything I just rambled on about:
Now that we understand the function of the ACL, our next question to answer is this: How does a person tear an ACL? Typically, the most common mechanism of injury (MOI) for an ACL tear is a twisting motion occurring at the knee while the foot is planted on the ground. This can happen with or without another player/person present, as it is quite common for an athlete to tear their ACL with no one anywhere near them (RGIII is a perfect example). What typically happens is the torsion that’s imparted on the knee places maximal strain on the ACL itself, and without the sufficient supporting joint and muscular strength to take on this force, the ACL overstretches. And with the right amount of excessive force, this leads to a partial or full tear of the ligament. Also, if the movement in question or the blow to the knee causes the knee to dive in enough, this is very commonly how people tear both the ACL and the Medial Collateral Ligament (MCL) and, potentially, medial meniscus at the same time. The MCL is the ligament that stops the knee from collapsing in when someone hits your knee from the outside. The combo platter of an ACL and MCL is typically a bit more tricky to surgically repair and rehab due to the addition of even more instability at the knee. Always remember, the more structures involved, the more difficult the rehab is.
Another common MOI with ACL tears is excessive knee hyperextension. When this happens, the femur can glide posteriorly (to the back) on a stable tibia when the foot is planted to the ground, which causes relative excessive anterior tibial motion. Think about what we said was the function of the ACL, stopping the tibia from moving anteriorly (forward) on the femur. Well, if you keep the tibia stable and move the femur posteriorly, it basically causes the same movement, except the femur is doing all the moving. This can also put strain on the Posterior Cruciate Ligament (PCL), which stops the tibia from moving posterior on the femur.
Ok, so we’ve gone over what the ACL is and how people tear their ACLs. Now, what goes into rehabbing this important ligament? Post surgery, the most important thing to regain is range of motion (ROM). Since a person is typically placed in a brace of some sorts (most of the time, depends on the doc) to help protect the new ligament, the knee becomes very stiff and does not move very well once the rehab process begins.
[Quick side note before we move on: When reconstructing the ACL, there are typically 3 options when deciding what type of graft to use: Your own patellar tendon, Your own hamstring tendon, or an ACL from a cadaver. Typically, cadaver grafts provide the best combination of quick recovery and great results long term, but there’s always the chance of rejection because you’re putting foreign tissue in your body. Patellar tendon grafts typically are super stable, but take a bit longer to heal because you’re using a tendon instead of a ligament, as tendons are not as pliable as ligaments. Also, taking a chunk of your patellar tendon can weaken your quadriceps muscle group significantly, as the patellar tendon attaches the quads to the tibia. Hamstring grafts are used the least because the tendon isn’t as strong as the patellar tendon and has shown to not be as stable as the other two]
While concurrently working on ROM, initial strengthening of the quads, hamstrings, and gluts are in order, usually beginning with isometric strengthening (activating musculature without movement). In addition, it’s imperative to work on surgical scar mobility so that adhesions and scar tissue don’t lay down, restricting mobility.
Following these initial phases and once the athlete is cleared by the orthopaedic surgeon, there’s a progression from isometric strengthening to isotonic, which involves moving resistance as muscle length changes. This progresses from mat exercises to sitting exercises to standing exercises, all based on achieving milestones before moving on to the next phase.
Once this phase is reached, we move on to dynamic movements, in straight lines first, then adding lateral and diagonal motions to help rebuild stability around the knee. This goes on until the individual is ready to do sport-specific exercises, which is the last step before return to play.
Last important question we need to answer is what is the prognosis for recovery from this terrible injury? This varies depending on the individual and whether multiple structures were involved, but as Peterson showed us this year, timetables can be thrown out the window when it comes to world class, once in a lifetime athletes. BUT, in general, prognosis for return to sport can be anywhere from 6 months to 12 months, depending on complications, past injury history, and response to rehabilitation. But as you’ve probably heard many times, a player in any sport is typically not back to normal until the second year following reconstruction. What does this mean for guys who suffered late in the season ACL tears?? It’s hard to say at this point, because every athlete’s recovery is independent for another and they could come back at any point. For every Adrian Peterson there’s a Rashard Mendenhall, Jamaal Charles, and Deuce McCalister. So when thinking about drafting a Manningham, Scott Chandler, or RGIII, keep that in the back of your mind, especially when you’re drafting your starting QB (RGIII).
In terms of draft strategy, I wouldn’t hate on a decision to draft RGIII in the 9th-11th rounds as a flier after you’ve already drafted a starting QB, but I’d be hard-pressed to rely on him to be my starting QB right out the gates in September, only 9 months after tearing his ACL, LCL, and MCL. On the flip side, I think Mendenhall and Charles, going into year 2 post reconstruction, are going to be undervalued and will have fantastic years. I like both guys as early as Round 3 for Mendenhall and Round 2 for Charles, with the potential for both guys to move up a round if they have great off seasons. We’ll talk a lot more later in the offseason as I’ll do a post all about guys coming back from injury, where to draft them, and what things you have to watch out for moving forward.
Thanks for reading kids! Much more to come to help you get ready for the 2013-14 season.
Reaction 4 months later: I still stand by my comment about not relying on RGIII to jump right back in and be the stud he was last year right away. That will most definitely take some time, in my mind, but I think the expectation now is that he’ll go somewhere closer to rounds 5-7 at this point. Still remains to be seen until we see how he looks back on the field, but all signs point to him definitely moving in the right direction.