History of the ACL Reconstruction

Analyzing the history of the ACL injury including high level athletes who were able to succeed without an ACL and potential complications later in life.

Welcome back to Banged Up Bills! Today’s post will take us back in time to the 1970’s and 80’s, before the Bills reached untold greatness and the legends of Orchard Park were coming into their own. Looking back to 1986, RB Thurman Thomas of the Oklahoma State Cowboys partially tore his left ACL in a pickup basketball game in the off-season, placing his junior season into question. Fortunately, despite recovering and achieving All-American status his senior year, the known history of this partially torn ACL ultimately caused his draft stock to slip, allowing the Bills to steal the future HOF in the 2nd round of 1988. The article above mentions that he suffered the ACL injury and had arthroscopic surgery to assess the damage, but the ACL was ultimately never reconstructed at the time. Recently, it was revealed on Twitter that Thomas successfully played his entire career with a partially torn ACL; according to him, 85%.

While some said he was a GOAT for playing with an injury of that magnitude, it is more astonishing that he was able to perform at such a high level despite knowing what we know now about ACL tears. Today’s post will explore the history of ACL repair, why Thomas most likely did not have the surgery, other NFL players who were able to succeed without an ACL, and potential complications they may have today as a result.

Looking at a brief history of the ACL injury, these types of maladies have been explored for centuries, going back to ancient times when the true gladiators battled against each other. When injuries such as the ACL tear occurred, doctors such as Galen would be able to further explore the inner workings of the knee through gashes suffered in battle and identify these complaints, though surgical intervention was centuries away. Fast forward to the late 1800’s, further examination and surgical intervention came into vogue with the advent of X-ray and a better understanding of the function of the ACL.

However, it would still take nearly 100 years to develop effective treatment of the ACL to what it is known today. In the 1970’s, doctors were aware that the ACL had an impact on knee function but testing for injury and surgical intervention were still in its infancy which led to many methods of repair with a wide variety of overall poor outcomes. Initial surgeries would open the knee up with rather large incisions and attempt to repair the knee with a variety of material including hamstring, patellar, cadaver, and synthetic grafts.

Surgical techniques were improved in the 1980’s with the use of arthroscopy, however, this time period also saw high rates of materials failure and complications several years after a repair due to synthetic grafts. There was also not a general consensus on the best method to repair the damaged ligament. In addition, there was published research arguing that nonsurgical interventions was just as effective as surgery in outcome scores with regards to function, though they did note that surgical repairs led to a more stable knee in comparison.

Attempts were made to identify a consistent rehab plan for the ACL as surgery techniques improved. Regrettably, the rehab plans were determined later to hinder the patient recovery and led to greater failure rates after returning to sport. Several pearls from the above mentioned ACL rehab plan that would not be considered today include:

  • casting and immobilization of the surgically repaired leg for 6-8 weeks
  • immobilization between 30-60 degrees in flexion
  • either toe touch weight-bearing or no weight-bearing allowed during this time frame

Most of these interventions were thought to preserve the integrity of the ligament by limiting movement with the ACL on slack with the knee in a flexed position. The thought was a fully extended knee placed undue stress on the repair and could cause premature rupture in weight-bearing.

Research later found patients that were non-compliant with their rehab protocol actually had better outcomes than those who followed the rehab precisely. Those that were non-compliant were removing their casts and beginning movement/strengthening sooner than advised but were found to be able to return to full function with less pain and overall greater satisfaction which forced the medical community to reevaluate the protocols.

As there was so many varieties of materials for repair, no gold standard for repair technique, and a poor understanding on proper rehabilitation, its no wonder that Thurman Thomas avoided having the surgery all together. He would most likely been worse off having the surgery than playing without a repair. I believe that with all the uncertainty of surgery methods/outcomes, the experience with ACL repairs of the treating orthopedic surgeon, and his potential career prospects, reconstruction was not performed. Fortunately, his knee was able to withstand the demands required of his position with protective bracing throughout his career despite the tear.

Thomas was not the only one that declined surgery and managed to play with an ACL deficient knee through their career. HOF QB John Elway tore his ACL in high school but was still able to recover without surgery and have a long career in the NFL. It is noted that this was his non-plant leg which reduced the incidence of pivoting which may have allowed him to avoid further issues. It has also been reported that Yankees great OF Mickey Mantle tore his ACL during his rookie season and was able to play his entire career without an ACL. I believe that Yankee fans are unanimous with how great he was despite his injuries. As I stated in my previous article, it is possible to live a normal life without an ACL, though still very difficult to play at a high level without one. Thomas, Elway, Mantle, and a more recent example of WR Hines Ward of the Steelers are several exceptions.

The only consistency that I see is that all of these players were relatively young; >20 years when they tore and may have still been growing into themselves, which allowed their bodies to adapt and compensate with the deficiency. However, pediatric ACL tears still benefit from surgical intervention with nonoperative management and potentially causes problems later in life which refutes the statement above regarding youth ACL tears.

Research supports the use of surgical intervention with some variances in techniques and rehab but generally, surgery is the gold standard in order to return to full ability. We have seen the power to return to sport after ACL reconstruction with an 82-95% success rate. Through rigorous studies, the medical community has also found that proper reconstruction has reduced future injuries and complications significantly. These included future meniscus tears, corresponding ligament injuries, and arthritis. In Thurman Thomas’ case, it is unknown whether he has had any further complications, though several reports in 2001 indicate that he tore the right ACL which ended his NFL career in Miami.

With these complications arising from avoiding ACL surgery as several studies supported in the 1980’s, eventually the ACL injury could have degraded the knee to where loss of function was significant and few interventions available to provide relief once it got to that stage. Knee replacements are available which restore function and movement, but those are typically reserved for those patients that are much older with ages into 50+ and have reduced their athletic activities. People in their 20’s-30’s are not ideal for a knee replacement and should not be considered unless certain exceptions arise which are typically not sport related. If the players mentioned above have not already had a knee replacement due to the punishment of the sport, they are most likely considering the possibility.

As a whole, ACL reconstruction continues to be the primary intervention to allow athletes to return to sport. There are doctors that have begun to swing the other way again, rejecting surgery in the case of Miami Dolphins QB Ryan Tannehill when he partially tore his ACL late in the 2016 season. The corresponding rehab was ultimately unsuccessful as he re-injured his knee in training camp the next year. Eventually there will be interventions which reduce the healing time in the surgically repaired knee or there may be effective non-surgical interventions. It took over 20 years to really establish a consistency for ACL repair; it may take even longer to identify interventions that don’t involve surgery.

I found this research to be fascinating as the history of medicine has changed so drastically over the years and its incredible to think that these previous methods were cutting edge at the time. Thankfully, studies and constant refinement of the process has allowed high level athletes return to full ability instead of potentially ending their careers. The quality of interventions will continue to improve with medical advances and maybe 30 years from now, we will be looking back and say “what were we thinking?” Until then, we will work with what we know best.

Continue to check back for the latest updates from @BangedUpBills on Twitter and at www.bangedupbills.com. I will be pumping out a lot of content with training camp coming up and as players begin to suffer injuries. As always, thank you for reading and GO BILLS!!

Reggie Ragland- Return to form

Analysis of Reggie Ragland’s 2016 ACL injury and the journey back to recovery.

It’s been just over a year since Reggie Ragland ran down Reggie Bush towards the sideline, pulled up and fell to the field, ending his 2016 season with a partially torn ACL. Going into the 2017 season, the big question is whether Ragland will be ready to suit up and become the heart and soul of the Bills defense. To understand why there is so much uncertainty going into this season, we must understand why the injury is so severe.

The ACL is a ligament that connects the tibia to the femur and acts as a stabilizer in the knee to prevent the femur from shifting too far forward over the tibia; it also assists in preventing hyperextension in the knee. When the knee is placed into unnatural positions such as cutting and sudden stops, the ACL typically keeps the knee intact, but in the instance of injury, the ligament either stretches out, partially, or fully tears based on the activity. Along with the ACL tear, meniscus and MCL tears occur, referred to as the “Terrible Triad”. This does not occur in every case, such as Ragland’s, but is certainly a cause for concern for long term rehab potential.

There are two types of ACL tears, direct contact and non contact. Direct contact being a direct blow to the knee, such as a chop block. Non contact is when the player changes direction suddenly and the knee gives way, which is what occurred during Ragland’s injury. In Ragland’s case, he partially tore the ACL, leading to instability, similar to what occurred last week with Ryan Tannehill of the Dolphins. Without the ACL providing stability, the individual is unable to stop suddenly or pivot to change direction without the knee giving out, resulting in further damage to the surrounding structures in the knee. These movements are vital for any football player, regardless of position. This would increase missed playing time and significantly reduce the length of careers. It is possible to live a normal lifestyle with an ACL deficient knee, but nearly impossible to resume a high level of play post ACL tear without reconstruction as an adult.

In May 2017, Ragland reported that he has been cleared to return to full contact participation, which is 9 months after his surgery, indicating that rehab went well and that he has passed all the initial conditioning tests. This includes, but not limited to: demonstrating that his left knee is at least 90% strength wise in his quadriceps, and 80% in his hamstrings that of the right knee. He must demonstrate no pain/swelling in the right knee during activity, exhibit full range of motion, demonstrate basic agility activities and resume a running program that is pain free. A general, comprehensive ACL reconstruction protocol can be found here. (Note: this is unlikely the exact rehab protocol used with Ragland, most orthopedic surgeons vary based on personal preferences and training.) Once this has all taken place, he is cleared and able to resume football related activities. A non professional athlete would be able to resume normal activities without restriction, save a stabilizing knee brace for extra protection. In Ragland’s case, he is a multi million dollar athlete that extra precautions will be taken to ensure the surgery success. He will most likely be required to wear a knee brace, but will reduce the incidence of another non-contact ACL tear.

As of now, Ragland appears on track to return to participating in training as a full participant. This has been evident through the first week of training camp, easing back in with the 2nd team to limit reps, according to McDermott. This will allow Ragland to step on the field to knock off the rust, but between rehab and an extended look during training camp will really allow him to round back into football form. Professional opinion, I fully expect to see Ragland return to full form, easing back into game play on a snap count as the preseason begins. Currently, he’s listed as 2nd on the depth chart at MLB behind Preston Brown. This is a great spot for him as this indicates that he will see significant playing time, but not expected to contribute right away while still learning the defense. While there is a risk of retearing the ACL, as seen with RGIII, Casey Hampton, and Thomas Davis, the risks remain low. Expect to see Ragland fine tune his game in the preseason, get back up to game speed, and then released to pick up where he left off in college, shoring up the LB corps and fitting into McDermott’s defense.