As Keenan Allen lay on the turf Sunday, the steps that will lead to his return were already starting. From the moment James Collins, the Chargers’ head athletic trainer, laid his hands on the knee, confirming that the ACL (anterior cruciate ligament) was ruptured, Allen’s fate became part of an all-too-common process. The NFL is a factory, creating patients for surgeons and clients for rehab professionals. However, few understand that process, so let’s take a look at what happens along the road to recovery.
The injury is usually apparent. We’ve all become armchair diagnosticians and Allen crumpling to the ground comes with the realization of “oh no, ACL.” The same is true on the field. If the athletic trainer doesn’t see it, the coaches and other players do. When they get to the player, it’s about calming him down. “They know,” said one NFL athletic trainer, who spoke anonymously due to NFL regulations, “by the time I get to him. He’s in pain, he knows his season is over.” The medical staff is usually comprised of two ATs, plus the team doctor, who is normally an orthopedist.
The diagnosis can be immediate. Manual tests are performed and most are very accurate. Teams will occasionally do them on the field, but if the diagnosis is apparent, the player is usually carted off immediately. “We usually know,” said the athletic trainer, “so it depends on whether he’s in a lot of pain or not, how he’s reacting.” Once the manual tests are done, the diagnosis is all but locked in. Teams know at this stage. There are very few situations where it’s ambiguous, but a player can be in so much pain that the tests are tougher to do.
So if the manual tests are so accurate, why do an X-ray? Really, there’s no reason to do so. There’s seldom an expected fracture, but every NFL stadium has an X-ray machine so it doesn’t hurt anything or cost anything. An MRI is more needed, but not for the reason you think. “It’s just a confirmation,” the trainer explained. “The doctor wants to be sure, but more than anything else, it’s for the insurance. We can move things along if we just go ahead and do the MRI.”
Only one team has an MRI in the stadium and even that is a clinic that just happens to be a use for the extra space at Paul Brown Stadium in Cincinnati. An MRI is large and expensive and an NFL team wouldn’t use it enough to make it worthwhile. It’s much easier to contract with a local clinic – “The Official Radiologist of the Raiders!” – but it does usually mean that the imaging won’t come until the next day. It’s really not an issue of timing, but cost and efficiency.
Once the diagnosis is set, the team doctor will meet with the player. Some teams use the head athletic trainer as the voice, since they’re more familiar with the player. In some cases, the player’s family or agent will be involved at this stage. “It’s like telling someone they’re dying, but not really,” the AT explained. “You have to be firm. You have to get them to acknowledge it and get moving.”
Often, a player or agent will request a consult or a second opinion. These terms are used interchangeably but mean different things. A consult is normally just sending images to other surgeons. Since it’s almost always very clear that the ACL is ruptured (Grade III) or even a Grade II where the integrity of the ligament is in question, there’s not much in the way of disagreement about the injury or the required surgery.
At this point, surgery is about getting on the schedule. If the player elects to have the surgery done by the team physician, that can be done quickly, but often, they want to get in with one of the top surgeons in the game. It doesn’t take too long for a pro player to get an appointment with a James Andrews or Neal ElAttrache, but it’s not instant. Add in travel and there’s often a delay of a week or more. That doesn’t affect the surgery or the rehab, but it does add a week or so to the overall process.
Almost all ACL reconstruction surgeries use the same technique. While there are some experimental techniques out there, the one used on NFL players (and most elite athletes in the U.S.) is about the same as that from 1990. The surgery is performed arthroscopically, necessitating two or three small incisions. The ACL is replaced by cutting a small section out of the patellar tendon, then looping it into holes drilled into the bone. On occasion, a hamstring tendon is used, but few use a cadaver tendon anymore due to an increased risk of failure.
The technique itself is relatively simple. The video below – which includes no graphic footage – explains what the surgeon does.
The biggest difference in modern ACL reconstructive surgery is not the surgery, but the rehab. It starts from the first moment. Instead of placing the patient in a large immobilizer, the use of removable braces is near universal. This allows easier access for simple rehab to start almost immediately and seldom more than 24 hours after the procedure. Simple passive motion allows the knee to move rather than being stuck in one place. That reduces the risk of contractures – where the muscle “locks up” – and reduces atrophy (shrinkage of the muscles.)
All the steps of the rehab are more aggressive, as compared to past schedules. Motion and weight bearing start earlier and the knee is back to normal in a shorter period. Some are seeing normal motion in as little as two months. Think back to Super Bowl 50 when Joe Flacco walked out to the field as part of the MVP parade. He was just over two months post-surgical and was walking so normally, it didn’t even register to me when I first saw him that he was injured. Playing it back, he was wearing some kind of thin brace under his suit, but it was pretty stunning nonetheless. This isn’t unusual.
There’s some debate over when a player can actually return. Adrian Peterson said he could have gone full-go at mini-camp in May after having had surgery in late December. While possible, the football calendar makes this unnecessary. Almost all players will have a minimum of eight months for healing – seven if they were injured in the Super Bowl – so there’s an artificial floor on the return time.
Even extended rehabs are taking less time and are usually more about getting a player back to his previous level rather than some minimum level of playing. Jamaal Charles is an example here, with the Chiefs holding him out until they feel his confidence in the knee has returned, as demonstrated by being able to do a complete set of physical activities. This kind of understanding is also new and will help teams, assuming they’re willing to trust their medical staffs and not get impatient.
ACL reconstructions may be almost an assembly line at this point, but the fact that it’s nearly standardized and well-practiced contributes to the high success rate. The most recent study of ACL returns showed that 92 percent of quarterbacks return to play and that performance didn’t seem significantly affected. A quick anecdotal look – Tom Brady, Carson Palmer, Joe Flacco and Sam Bradford come to mind – shows the same results. It’s not an easy process, as you have learned, but every step is key to getting the player back.