Dec 6, 2016

Dr. Miller: You've torn your ACL. Is that a game changer for the young athlete? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. "The Specialists," with Dr. Tom Miller, is on the Scope.

Dr. Miller: Hi, I'm Dr. Tom Miller, and I'm here with Dr. Travis Maak. Travis is a professor of orthopedic surgery in the Department of Orthopedics here at the University of Utah. Travis, got a young athlete who's playing football, hears a pop, falls down the ground, torn his ACL. Is that it, you no longer play football, or what can you do?

Dr. Maak: Absolutely not. I think, obviously, no one wants to get injured at any point in their sporting career and it is extremely psychologically impactful for the athlete when they injure themselves. And the first gut reaction is, "I'm never going to get up. I'm never going to play sports. I'm never going to be the athlete I was before."

Dr. Miller: Pretty traumatic emotionally for the young and talented athlete, I'm sure.

Dr. Maak: It absolutely is and, in fact, as an area of expertise, sports psychology is a growing area, because it really is a hard thing to recover from.

Dr. Miller: Let's talk about the first piece of this, which would be the diagnosis of an ACL tear. How do you do that and how are you assured that the patient actually has an ACL tear?

Dr. Maak: The way to differentiate between an ACL and everything else is fairly straightforward. If you fall, you twist, you feel a pop, and your knee swells right away, and you can't walk off the field...

Dr. Miller: You know you got it. Something's going on.

Dr. Maak: It's a good chance.

Dr. Miller: Well, how do you definitively diagnose that? Is that the coach on the sideline or the trainer, or do you think that that belongs to a specialist, such as yourself in sports medicine?

Dr. Maak: Well, I'll tell you, actually, trainers are fairly good for the most part. There's an example, the Lachman exam, where you test the knee instability. That being said, right out of the gates, when the knee is extremely swollen, the athlete's in pain, it's really hard to diagnose it. So generally speaking, if there's a concern of any sort that there might be an ACL, a referral to a specialist is probably the best answer.

Dr. Miller: Now, treatment or therapy doesn't begin until that swelling is reduced or is eliminated. Is that correct?

Dr. Maak: That is correct.

Dr. Miller: We think the first thing, athletes, they want to get it repaired right away, and the assumption is that, "I've got to go to the ED," and then the surgeon comes down and operates on him, like as if it's a terrible fracture. But that's not true. You want things to cool down.

Dr. Maak: You're 100% right. In fact, we know now that operating for an ACL when a knee is extremely swollen and stiff, all it does is make the knee continue to be swollen and stiff. And so we let things calm down with therapy. And once the knee is back to moving appropriately, that's when you fix it.

Dr. Miller: Well, the million-dollar question and the question that I've been asked by patients is, do we have to have the ACL repaired? Do I have to have the ACL repaired once we know that it's torn?

Dr. Maak: It is 100% the million-dollar question. Fortunately, we have some statistics behind this. So looking at all of these different types of repairs, reconstructions that we've done, we've learned the following things. Number one is if you're extremely young, and by that, I mean under the age of 18, you cannot have a kid do activity modification.

No matter what you do to try, they are going to run, they are going to jump, and you can try, even if you're a parent, you know quickly it's not going to happen. So in those patients, they actually have a higher risk of other injuries to their knee if they don't have an ACL because they will not modify their activity. So in the 18 and younger, most of us will recommend surgery for them almost across the board.

When you get above that, in the 20, 30, 40-year old range, the question then becomes, can you modify your activities, and do you need an ACL at all? And actually, there's fairly good evidence to suggest that a third of patients actually don't need an ACL.

Dr. Miller: How would you determine if a patient didn't actually need their ACL for the types of activities they're interested in doing, such as running, tennis? I imagine if they're going to play basketball or running sports like soccer, they probably would need their ACL in almost all cases. But maybe, that's wrong.

Dr. Maak: Sure. So, Tom, that's a really good question. If we could do that, if we could identify who the individual was that didn't need their ACL, we would be winning the game. And unfortunately, we can't. So a third of people don't need it to do anything, including rotational activities. So I saw one of the players who actually used to be on the women's national Olympic soccer team for the US and she actually was diagnosed as having no ACL, and the reason it was diagnosed is they got an MRI because her knee hurt.

Dr. Miller: No ACL.

Dr. Maak: No ACL. And she actually had to see four separate orthopedic surgeons, all of whom had to tell her she did not need her ACL fixed before she could return to playing high-level soccer, at that level. That being said, she'd torn it years ago, and her knee was totally stable. So there are some people, it's about a third, that don't need it. A third of people need it to do rotational activities. So to your point, that's soccer, that's pivoting sports like tennis, especially singles, you can run without an ACL, that's generally fine if you're in that group. Then there is a third of people that need it for everything, and that is walking down the stairs and saying hi to your friend. That is turning, stepping.

Dr. Miller: Walking, stepping off a curb, get away, we fall down.

Dr. Maak: Basically, exactly. And those people need it for everything. To answer your question, can you figure it out for yourself? The answer is yes. And generally speaking, if you're tending towards saying, "Hey, you know what, I'm okay giving up these activities," and this is what I tell my patients. If you take those numbers, about two-thirds of people need it, if they're not going to modify their activities. So if they're going to go back to playing basketball, tennis, bump skiing, things like that, there are good odds you're going to need your ACL.

Dr. Miller: Well, that begs the question. So you let the swelling recover, you let that inflammation calm down, and then, do you allow them to go back and play their sport to see if they can manage it without the ACL, or do you recommend that they proceed with surgery?

Dr. Maak: For me, it is very patient dependent. So in terms of the statistics, what I would tell you is, and what I tell my patients, is if there is a good chance they're going to retry to return to rotational activities, and they're somewhere between the ages of 20 and 50, then my recommendation is unless they're absolutely against surgery, they probably fix it.

Because if you don't fix your ACL and you return to rotational activities and you need it, what you end up doing is risking further injury to your knee, and that is mainly the meniscus. We know that if you tear your meniscus, your risk of arthritis down the road is much higher than if you didn’t, and we're not talking about the ACL, we're talking about the meniscus.

Dr. Miller: So for the patient who rips that ACL, now you've repaired it, what is the time to return to activities? Is it a month, is it two months, is it six months, is it a year?

Dr. Maak: Sure.

Dr. Miller: I mean, some time ago, I believe, it was like a year before you can get back on the field. Things have changed since then.

Dr. Maak: Well, to some degree. So the devil's in the details, actually. And I think what you mean by return to activity, it can vary depending on the person. So you can walk within two to three weeks. If that's, if your activity is walking your dog around the block, number one, you probably shouldn't get your ACL fixed if that's all you want to do, but number two, you can definitely do that. If you're talking about rotational activities like basketball, football, baseball, high-level tennis, anything of that nature, you're looking about six to nine months.

Dr. Miller: Now, let's say that this individual has heard that pop, they had swelling in the knee, where do they go first to have that evaluated? Should they come and see an orthopedic surgeon? Should they go to a sports physician? Should they just end up going to their family practitioner? What do you recommend?

Dr. Maak: I would say all three of those, yes. The truth of the matter is, at this point, the vast majority of individuals, number one, should have a family practitioner as a doctor. So if you don't have a doctor, my plug here is please go get one. That being said, if someone you are familiar with, go ahead and get evaluated. I would say just about everyone is comfortable diagnosing an ACL.

Dr. Miller: To summarize, then, if you have that pop, and you have swelling, you might have pulled, ripped out that ACL, a chance of that. Secondly, if you're about 18 years old or under, you recommend that that be repaired surgically. If you're older, it might depend. You said a third of the people that have complete ACL tears may not actually need that ACL and time will tell. And it also depends on the type of activity that they're going to engage in as well. And then, finally, once you have the surgery, it depends on what you plan to do with that knee again in terms of how quickly you'll get back into that activity. Would that be fair?

Dr. Maak: That is fair. And the other thing I would say is one of the hardest things about tearing your ACL is the idea that you'll never return to what you wanted to do the way you were before. And I can, fortunately, say that there's very good evidence, that in fact, you will be able to do that. And the idea and the reason that I do the job that I do is to get people back doing all of the high-level activities at the level they were training in before as quickly as we can. So your life is not over, your career is not over, you will be fine.

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