ACL Tears: To Operate or Not?
In the wake of the aftermath of last week’s extremely unfortunate injury to Philadelphia Eagles star quarterback Carson Wentz, ACL tears are on the minds of many Eagles fans and athletes across the nation. The ACL diagnosis surprised many fans because Wentz remained in the game after the touchdown dive.
People I know have been asking me, “Well if he played after the tear, can’t he just finish out the regular season?!”
Obviously die-hard Eagles would ask such a question. As someone who has Carson on his fantasy football team I too was hoping he would stick it out. This blog will hopefully provide some answers to Eagles Nation on why Carson needed to have the surgery, whereas someone else may not need to.
ACL: Anterior Cruciate Ligament
Let’s first talk about the purpose and the importance of the Anterior Cruciate Ligament (ACL).
The ACL is a band of connective (connects one thing from another) tissue that starts at the end of your thigh bone (femur) and ends in your shin bone (Tibia). Simply put, its main purpose is to prevent/resist your Tibia from going too far forward leaving your femur behind (excessive anterior translation) and it also controls the amount of rotation within the knee to essentially restrict you from being able to rotate all the way around on your knee (similar to an owl being able to turn its neck to look behind itself). The big picture for the ACL is that it is the main ligament of your knee that provides stability to the joint. It also works to prevent your knee from buckling on you.
To Operate or Not?
So here comes the real question: Do we operate?
Many believe that once you tear your ACL you have to have it repaired. However that may not always be the case. There are many professional athletes who were able to compete at their sport without undergoing the reconstruction immediately after tearing their ACL. Check out this article by complex magazine (not to be confused for legitimate source of medical advice) on athletes who played without undergoing the surgery.
Some big names included on that list are Tiger Woods, who famously won the U.S. Open after tearing his ACL, as well as Hall of fame NFL players Hines Ward, Joe Namath and John Elway. All three of those players played their entire NFL careers without the ligament.
Think you need to be a pro to succeed without an ACL? Think again
Coach Regina of Atlantic Coast Gymnastics of Williamstown, NJ informed me in conversation that she was able to rehabilitate following her ACL tear, and that both her and her surgeon agreed that the surgery was not necessary for her. It does help that Coach Regina is a physical therapy assistant by training. It’s safe to say she has a good understanding of how to recover from her injury.
Many of you are probably asking how is this possible?! Well the human body is arguably the most amazing structure on the planet. It can “learn to adapt” following a significant injury like an ACL tear, or use other structures within and around the knee to compensate for the missing ACL. The ACL provides proprioception, or the understanding of joint position sense, to the brain. This means it helps the brain understand where our body parts are without actually having to look at them. (You can test this. Close your eyes and have someone take your arm and put it either up or down. Now guess where it is. If you guess right your sense of proprioception is correct).
The stability of an ACL deficient knee could be improved without reconstruction following specific rehabilitation focusing on neuromuscular (nerve and muscular) control provided by a skilled physical therapist. Also, numerous studies have determined that hamstring activation following ACL tears increases to further provide stability to the knee. The University of Delaware performed a 10 year study on highly active individuals with subacute (injury after 72 hours) ACL tears.
They determined that individuals who met the following criteria were labeled as potential copers (individuals who can perform without an ACL) :
Performing a single leg hop test score of 80% or more compared to non-involved leg for timed 6 meter hop test.
Knee Outcome Survey of daily activities >80% 3) global rating of knee function >60% 4) no more than 1 episode of giving-way since the injury.
146 subjects were labeled as copers of the 345 who met the criteria for the overall study. Of those 146, 83 subjects were able to complete the rehabilitation process with 63 individuals returning to their sport. Ultimately 25/345 (7%) ended up not having the ACL reconstruction, whereas the rest did or were lost to follow up. ( Hurd et al, Am J Sports Med. 2008)
Final Thoughts
So, could Carson Wentz have continued to play? In my opinion, I believe the Eagles did the right thing in shutting him down and opting for surgery. Why? First, while he was walking to the locker room his leg did buckle, indicating loss of control/stability. Second, he is very young in his career and he is a mobile quarterback. The stability provided by the ACL reconstruction will help him return to his previous style. Thirdly, the Eagles have a very capable back up in Nick Foles, who as I was writing this threw for 4 touchdowns. We at Trifecta wish Carson a perfect recovery and cannot wait to see him back on the field!
In conclusion, I hope this blog gave everyone food for thought. It is possible to compete at high levels following an ACL tear without the need of the surgery. However, it is dependent on the person, the style of the athlete, the level of play, and many other factors. If you have any questions about this please feel free to contact me, I would love to discuss this more! And for some exercises to help strengthen key muscles that contribute to injury prevention for the knees, check out our piece on addressing knee cave!
Until next time,
Dr. Jeremy Boyd
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