Recovering From a Torn ACL with Joe Tramer, MD

John Horton:

Welcome to the podcast, Dr. Tramer. We have really been looking forward to you joining us.

Dr. Joe Tramer:

Thanks. Super happy to be here. Appreciate you having me.

John Horton:

So in your line of work, it sounds like you meet a lot of folks who come in with a bit of a limp. Knee injuries are just so common. I've seen stats that say more than half of all sports injuries involve the knee.

Dr. Joe Tramer:

Yeah, I mean they are super common. And you think about what a lot of people are doing when they're being active. I mean, the majority of sports are on your feet, you're cutting and pivoting, you're turning. And so the knees can be very vulnerable to injury in various ways. So unfortunately, it happens a lot, but it is what keeps me in business. And I'm excited to talk about that stuff with you guys today.

John Horton:

Well, definitely. And I mean, we have some personal experience here because I know Dr. Wichman has been on the wrong end of a knee injury.

Dr. Lauren Wichman:

Yes, unfortunately. I wouldn't wish an ACL injury on my worst enemy because while I was playing college soccer, I did, unfortunately, tear my ACL and went through the whole process that we're going to talk about today. So looking forward to not only being able to share the sports doc side of things, but also from the lens of a college athlete, what's involved throughout this whole process.

John Horton:

Well, let's dive into it then, the knee and the ACL and the whole architecture that we're talking about, because that's why we have these issues. It's a complicated joint, and there's a lot happening there. So, Dr. Tramer, if you can kind of walk us through a little bit as to why ACL injuries are so common.

Dr. Joe Tramer:

Yeah. So I guess I would start with just clarifying what the ACL is. It's the anterior cruciate ligament, which is one of the major ligaments in your knee. A ligament is basically a rope that connects two bones together. So this connects your femur, thighbone to your tibia leg bone, and it helps keep your knee stable. So an ACL's job is to keep your tibia bone from going forward too much, and also from spinning underneath you.

So when you plant and twist, the ACL's doing a lot of work to keep that knee stable, make it so you can make a cut. And that's why it's vulnerable to injury, because, like we talked about at the start, a lot of these sports involve cutting and pivoting. And that's also why you hear about it a lot. And we could talk about what an injury looks like. I guess, Lauren, I'm interested to hear … there's a lot of different ways ACLs can tear. How did it happen to you?

Dr. Lauren Wichman:

So it's actually kind of crazy because the same game that I tore my ACL, a girl on the other team tore hers, too. So she went down maybe 10 minutes before I did. And I think the ways that people feel after these injuries vary quite a bit, too. So she had more of a traumatic collision-type injury and went down screaming, was in a ton of pain. Ten minutes later, I was cutting after passing a ball to my teammate and something just didn't feel right. I actually ended up playing for another three minutes before I was like, "Hmm, this just doesn't feel stable." But my family and I, we were like, "Well, I wasn't down like her, so I'm probably fine." Lo and behold, same injury.

John Horton:

Yeah. And that's crazy to me because you hear that a lot when people do tear their ACL and they keep going. I mean, I think a lot of us, we think of it as a really traumatic injury where you should just be down. How is it that you can kind of tear an ACL and still be running around the pitch like you were?

Dr. Joe Tramer:

Yeah. I guess, I mean there's kind of two flavors, and you illustrate them very well. One is a more traumatic one, where someone falls into your leg or it's a football and a tackle and your knee bends funny. We've all seen those horror videos where your ACL tears, plus maybe more. And so, yeah, very difficult to play after something like that.

But a lot of the people I see, they just have a cut, they get their cleat caught in the turf, or they land just a little funny. And it takes a little bit of time. Sometimes they'll feel a pop and immediate pain. Other times, they'll say they felt something. But when the ACL tears, it has a lot of blood supply to it. It often will start to bleed in your joint. People often get a little bit of joint swelling. And so as that stuff starts to set in, your knee starts to send signals saying something isn't right here.

And that's potentially why people typically don't play a game the next day. They might last a little longer in the current game because sometimes these things can take a little bit to set in. But a lot of ACL injuries do come with that kind of big, swollen knee that occurs.

And so I would say for people, it's never normal, especially in an adolescent athlete, to have a swollen knee. And so if you have an event and a knee swells up, something probably is happening in there that should get looked at.

John Horton:

Dr. Tramer, you mentioned that pop sound, and that's something you hear often when it comes to an ACL injury. I mean, is it really that noticeable? I mean, is it that pop that you hear or feel?

Dr. Joe Tramer:

Fortunately, I've never experienced it personally, but-

John Horton:

…maybe that's more of a Dr. Wichman question.

Dr. Joe Tramer:

Yeah. Did you feel something?

Dr. Lauren Wichman:

I didn't feel a pop, which is why I kept playing. And all these things where I was like, "Oh, yeah. Well, I didn't feel a pop. I didn't go down yelling. I maybe just tweaked something, I'll be back next game,” what have you.

But I think it's kind of varied how it happens. It's kind of varied how people feel. But just like Joe said with the swelling in the knee, that usually is pretty characteristic. I do remember my knee swelling up pretty big. So with all that bleeding that happens there, there are only a few things that can cause that kind of swelling.

Dr. Joe Tramer:

Yeah. And I think it's pretty variable whether patients do feel or hear something, but I would say more often than not, they do. And not only does the ligament pull apart during the injury, but oftentimes, they get a major shift in their joint where the bones kind of go out of place a little bit. They can hit each other as the knee shifts back into place. And that whole thing can be a varying degree of violent, but can be interpretive as kind of like a pop.

John Horton:

All of that sounds very painful, something you don't want to experience. So when we're talking, you had mentioned where the ACL is, and just to give people even a better picture of that, it kind of runs almost, like we said, in the front of your knee and it connects your thighbone and your shinbone there. So basically, when it tears, you're just getting so much force as it's pivoting one way or twisting, and it just snaps?

Dr. Joe Tramer:

Yeah. I mean, there's different types of ACL tears. It can tear at any place along the ligament. In some occasions, the part where it attaches off the thighbone pulls right off. Other times, the mid-substance kind of pulls apart. That's probably more common. And like you said, the reason it happens is it's a pretty violent shifting mechanism, and the ligament just can't withstand the force that's going through the knee as it shifts. And it tears just because you pull on something so hard, it only has so much strength. And it's not uncommon that someone experiences a force enough to basically rip it in half.

John Horton:

Where are we most likely to see this injury happen? Obviously soccer. We already know that one from Dr. Wichman. What other sports is it pretty common to see these ACL tears?

Dr. Lauren Wichman:

I would say, personally, I see it a lot in soccer, for sure. I've seen it a lot in basketball, similar thing with a lot of cutting. Football, not only from the cutting perspective, but also you have a lot of collision, a lot of high likelihood for a traumatic-type mechanism. And then, I'll see it in other sports with a lot of jumping and landing because I think landing mechanics can be a really big thing that can cause that ACL to have too much or an atypical stress put to it. So things like volleyball or gymnastics, where they're doing so much landing, I see it there a lot, too.

John Horton:

I would imagine, too, tennis and pickleball, which I feel like we mention on this podcast all the time. I'm starting to think that that sport has become just an absolute boon for sports medicine.

Dr. Joe Tramer:

I see a few a day, that's for sure.

Dr. Lauren Wichman:

Absolutely. But yeah, all about that cutting, just like you said, John, that we see it, and we're seeing it, I think, more and more in a lot of variety of sports. We'll see it a lot, too, in skiing. I think that's, obviously, from a lot of attention to it recently, but I think we'll see it a lot there, too, whether a ski gets caught or a landing in an awkward way that can cause these injuries as well.

John Horton:

Silly question here, but is an ACL injury something that becomes more likely as you age? Because I feel like a lot of the people that we talk about having these, they're younger. So is it something that you see more in younger athletes just because they're cutting and moving so aggressively? Or is it something that as you get older, everything gets a little looser in there and it's more prone to happen?

Dr. Joe Tramer:

Yeah. I mean, it's usually the younger person who's doing that higher-level cutting activity where the force is going to be enough to pull the ligament apart. That's not to say I don't see it in older age groups, but it tends to trend toward that younger athlete. And I think it's one because maybe they're exposed to a little bit more high-energy during practice and play, but also they have more athlete exposure, meaning they're practicing every day after school, they're playing multiple games. So it's like they're not going to work and playing pickup once a week. They have much more opportunity for injury, which I think contributes a lot to that.

But I certainly see it and treat it in many age groups. I actually just did someone yesterday in her 50s who had an ACL injury and tried to rehab it and was a very active patient. So it's more activity level, physiologic age, whether or not we have to eventually do something about it, which I'm sure we could talk about.

John Horton:

Well, and that's where we're going to go next. And so when somebody, they have that pop, they have that traumatic incident that happens, obviously, they come to see you. So what's the process that takes place once you hurt your knee and you realize something's got to get done?

Dr. Lauren Wichman:

From the athlete side of things, when you're going through that process, really starting from the beginning where that injury happens and you're on the sideline, a lot of times, we have our athletic training colleagues who are right there on the sideline ready to do an eval. Many times, we're on the sideline as well, where we can kind of weigh in, do an exam to figure out, OK, do we think that’s an ACL injury or one of the other CLs, because there are multiple ligaments in the knee, do we think that something could be torn here? That's more of a sideline eval, but ultimately, we definitely want to get these athletes into our office. And many times, it does require a more definitive diagnosis with things like an X-ray and even an MRI.

Dr. Joe Tramer:

Yeah. And I would say certainly see these on the sidelines, but the majority of them are people who are sent to my office. Really, anyone with a knee injury, I'll start by getting an X-ray. An X-ray just looks at the bones. You can't see the ACL, you can't see other soft tissues, but it can help rule out major things, like a fracture or any major abnormality. So I'd say that's pretty much standard of care after any type of joint, but especially a knee injury.

And then, a key for the ACL is physical examination. Well, first history — we've talked a lot about that, how it happens, the type of people it happens to. And so from the story, I'm already formulating what is this going to be. And a young soccer player with a non-contact pop, ACL is starting to rise up my differential diagnosis list. And then, an exam is really good at nailing this down. I mean, a lot of these people have swelling in the knee. That's one of the more common ways that young athletes get a swollen knee is an ACL injury.

And so sometimes, it can be so swollen that it's stiff, and actually taking out the fluid can be beneficial. So that's something that may be considered in the office to try to get things moving a little bit, help with the pain. On exam, there is a maneuver where you kind of move the tibia bone forward and try to feel how much looseness there is in the ACL compared to the other side. And so that's really most patients who have a story and exam, you're able to make the diagnosis on the spot. But I would always order an MRI to take a closer look at the ACL, the meniscus, the other CLs, like you talked about, to really get a full picture of what's going on.

John Horton:

And when you get that MRI, too, and if you see that there's a tear, there are a couple grades of tears, correct?

Dr. Joe Tramer:

Yeah. I mean, there's different locations where it can tear. There are some partial ACL injuries. And so yeah, the MRI kind of helps paint that picture for you. I don't typically give the patient a number or letter grade. I'll tell them, I think this is the complete tear that is going to cause you issues or this is something that we can maybe rehab through. And there's a lot of things that go into which of those categories they're placed in.

John Horton:

So what's the step after that then? I mean, is it something where you're always going to have surgery to kind of put things back together or are there times where you don't need it?

Dr. Joe Tramer:

Yeah. So I always tell people a similar story, where I tell them, you do not need an ACL to live, certainly, and you don't even need it to walk. Even running in a straight line, your ACL doesn't really come into play during any of those activities. An ACL's purpose is to keep your knee stable when you're pivoting and cutting. And so, one thing I'll say is that when the ACL tears, the ligament typically kind of pulls apart.

And the ACL is pretty bad at healing up normally on its own compared to an MCL or another one of our ligaments that has a great propensity to heal normally. The ACL doesn't. And so people will often ask, Is this going to heal up on its own? And the answer is probably not. It's unlikely to reform the way it was anatomically made when you were born. But some people can live and get back to their activities without an ACL, and that all depends on their age, activity level and their goals, which is what the main discussion is in the early visit.

John Horton:

Is that something, if you go that route, then, is it just a matter of you need a brace or a sleeve that you have to wear on to maybe help with a little stability?

Dr. Lauren Wichman:

Those things can be helpful for sure. I think, like Dr. Tramer said, too, it all just kind of depends on what they're planning to do. Because if you are somebody who's going to be really active and plan on doing a lot of those cutting sports and things like that, and you don't have your ACL, you can put yourself at an increased risk for injuring some of those other structures, too. The structures, in addition to ligaments, cartilage, the meniscus, all of those different things that are within the knee, become at a higher risk for developing something else going on. So I think that's a big part of, it just depends on what their activities are. And if they are doing a lot of that stuff, it probably is worth strongly considering the surgery.

John Horton:

Would most people end up probably going the surgical route? Because even if you're slowing down with age and you don't think you're going to be cutting much, it still happens. I mean, I've got grandkids and I'll tell you, they zig and zag a lot. So I think I definitely need my ACL just to play defense with them.

Dr. Joe Tramer:

Yeah. I mean, that's a sport in and of itself. Yeah. So to your point, say it's someone who's moderately active, they don't really cut and pivot, they play a sport here and there. Those types of people often say … oftentimes, the ACL has to be reconstructed, meaning we can't stitch it back together. We're going to take something else and make a new ACL with it. And so that makes it not necessarily time-sensitive like other ligament or sometimes tendon tears, it's like we got to fix it right away. This is something where we can see what happens.

So I'll often send those people to a course of therapy. Building up the quad, the hip, the hamstring muscles around the knee can help stabilize it and can help make some people feel stable enough to get back to doing things. And taking a six to eight- — even longer period — week course of therapy to see if we can get your knee feeling stable is sometimes worth it. And if it stays stable, great. If you're doing those activities and it is kind of giving out on you, you have another big shift pop, or just it doesn't feel right, those are reasons to have the surgery.

And then, I'll say in the adolescent who's like, "I need to get back for next soccer season," I tell those people it's very hard to get back to high-level sporting activities without an ACL. So those people, I will typically recommend surgery right away in order to maximize their opportunity to get back in a timely manner because the recovery's long. It requires missing seasons. And so if your goal is to get back to cutting and pivoting, I think these are things I like to jump on.

John Horton:

Now, let's talk about the surgery itself because you kind of hinted at it a little bit here, but you go in and it sounds like there's a few options. And there's either A, you harvest a ligament from somewhere else in the patient's body, or B, you use a donor ligament. So walk us through what's going on with both of those and how one may be better than another in some cases.

Dr. Joe Tramer:

So harvesting your own tendon is called an autograft, meaning it's being taken from your body versus an allograft, which is usually from someone who passed and donated their tendons, and they are taken and shaped into something that can be used for medical purposes. And so that's a major early branch point deciding which one to do.

We've done a lot of research, including much of it done here at the Cleveland Clinic, examining the use of those two things. And a lot of our studies consistently show that using an allograft or a donor tendon in a young patient, and young is typically, for sure, adolescents up to early to mid-30s, has an unacceptably high retear rate. And so I would certainly not recommend that for the typical high school/college athletes, as it, in my mind, has an unacceptable retear rate, which is the major downside of an allograft or donor ligament.

The autograft, on the other hand, is your own tissue. Maybe that leads to some more familiar healing. It's stronger. But the downside is I have to take something from your body and remove it and make a new ACL. And so it's a little bit more morbidity involved in the surgery. There's a few different options of where we take it from. I think a lot of them work well and have their pros and cons, which is something that I typically talk about with all my patients. And we kind of take a full picture of what the patient's doing, what their goals are, and it helps us land on what I think is most appropriate for them moving forward.

John Horton:

Yeah. Where are those spots that you go and harvest?

Dr. Joe Tramer:

So the three most common ones are the patellar tendon in the front of the knee, the quad tendon, which is at the top of the knee, and then the hamstring tendons, which are kind of on the side and wrap around the back. A lot of people use various ones. Some people only do one, some people use all of them. Again, it's very personalized. In my mind, I'm like a patellar tendon, quad tendon guy. I think the hamstrings are a little less reliable in their size, and there's some studies to show that that also has a little bit higher of a retear rate in some of our adolescent athletes. I think both of the patellar tendon and quad tendon work really well. The quad tendon's a little newer. The patellar tendon I consider more of the gold standard historically, but both work very well and I think get people back to sport at a very high rate.

John Horton:

And there's enough in there to take a little out of one and use it on the other.

Dr. Joe Tramer:

Yeah. And that's always a question I get. I mean, both of the tendons are fairly wide. I will show patients my hand and say the tendon is wide and I'm going to take this little strip out and then I sew the rest back together so you have enough tendon. There's very low risk of long-term issues, although it's kind of like a “robbing Peter to pay Paul.” There is a risk that there's not as much tendon left, that you can have injury there, pain there. But the way that I do it, I haven't had much kind of donor-site morbidity or any significant issues with where I take the tendon from. But that is certainly part of the conversation and the consent process, making sure the patient understands that where I'm taking it from was normal, now it's not going to be. And so that's definitely part of the process as well.

Dr. Lauren Wichman:

And, Dr. Tramer, I know if you're making that decision with that adolescent athlete like, OK, surgery's going to be the route that we go, are there specific things that you tell them, whether it's in general or site-specific based on that graft you're going to choose? Are there certain things that you recommend they try to do in the weeks leading up to surgery to try to optimize their success with that?

Dr. Joe Tramer:

Absolutely. And so talking about the risk of surgery is a big part of the visits. After an ACL surgery, this knee gets stiff and swollen. And so, one thing that's super important is — we talked about at the beginning — the knee gets stiff and swollen after an ACL injury. It's important to take the weeks leading up to the surgery to get the swelling down with the usual ice compression, elevation, work on range of motion, bending and straightening, because we want the knee to be kind of what I call “quiet and normal-ish” before we go into surgery. Because if you go into the surgery stiff, you're going to come out really stiff. And so often spending a few weeks to a month before the surgery to work out that stiffness and swelling actually makes the recovery on the backend better.

So sometimes people are surprised when I'm not rushing them off to the operating room tomorrow when they come in. I say, "We need to take a few weeks to make sure this thing is ready." And so that's a big one.

And the other one is quad strength. So no matter which graft we take, and even after I do a donor allograft, something about the knee, the surgery makes the quad muscle just really shut down. There's something about it that not only makes the muscle smaller, but the brain's connection to the muscle to get it to fire just kind of gets thrown off. And so, one thing I tell people is always to work on building up the quad beforehand if they're able to. And then, that's the main focus of the therapy afterward, is getting that motion back, getting that quad working. And it's often the rate-limiting step to getting all the way back to sport, which can be quite a journey as you're aware of.

Dr. Lauren Wichman:

Yeah. And I know we'll dive into that, too, but it's interesting, now looking back, I was, just like you said, probably about a month from the injury is when we had surgery, but it was every day working on getting that mobility back and trying to do as much strength, which seemed a little bit counterintuitive because it's like, "Well, I'm going to have to go do all this over again." But I think that hearing that you tell that to all of your patients and it really does help the recovery afterward, that's huge.

Dr. Joe Tramer:

Yeah. And I tell most of my patients, my job is the easy one. I am in the operating room with my awesome team. It takes 60, 90 minutes. I'm listening to music, we're using power tools. It's fun for me to put the ACL back together. And so my job is pretty easy. The hard job is theirs, which is getting through it physically and mentally, and our physical therapy colleagues who are the ones who are really seeing them on a regular basis. And they're the ones who are driving a lot more of the recovery than I am.

John Horton:

Well, then, let's put the power tools away, which is just a great image-

Dr. Joe Tramer:

…ah, man.

John Horton:

...I have to tell you right off the bat … so we're done with the surgery. Everything went great. You patched it up or you got that new ligament in there. Everything's looking good. I think as you said it, you had the easy job. Now comes the hard part. So what can somebody expect during this recovery process?

Dr. Joe Tramer:

So I would say the early recovery — because we let the knee quiet down before the surgery, most people come into the OR without much pain or swelling or stiffness. And so sometimes they're like, "Do I even need this surgery to happen?" Because it's like feeling pretty good, because I'm telling them not to do their sport. And so afterward, you will have an increase in pain. There's a lot of different things we do to help minimize that. Sometimes, we'll have anesthesia do a shot to numb up the leg, try to minimize how many pain medications we're taking.

We're actually doing a lot of research here at the Cleveland Clinic on minimizing narcotic pain medications. And some of our more recent pain protocols have led to less than 10 and sometimes almost no narcotic pain medications after an ACL. So we're making a lot of strides in minimizing needing pain medication. But certainly, you take a strong anti-inflammatory afterward, you're icing it a lot, you're getting it moving. And so there's that initial getting over the pain from the surgery, which I would say takes a couple of weeks. Oftentimes, you're on a brace and have crutches afterward.

The length of time varies based on what was done during the surgery. A lot of that's driven by whether your meniscus needs treatment as well or another ligament, which can kind of change things for us. But assuming it's an isolated ACL, oftentimes, people are walking pretty normally. By the time I see them back at the six-week visit, their knee range of motion is improving. I usually see people again around three months, at which point you would never know they had a recent surgery. They're walking around nicely, the incision's well healed. It's not swollen. And so that is kind of the early recovery, but they're going to physical therapy once or twice a week. They're working on their exercises really daily, like you mentioned.

And so there's a lot going on there. And then, I will always quote people, "You need your quad muscle to be strong again, to support the ligament before we're going to get back to high-level cutting and pivoting." And sometimes, that can take nine to 12 months. And so between months three up to a year, it is a long time, you're just slowly building that muscle up. And I always tell people, even professionals who do this for a living, their job is to go to therapy and get back. And sometimes, they're out for the whole season. And so it would have a similar expectation for someone who has a life outside of sports, or longer.

Dr. Lauren Wichman:

I feel like a lot of the questions that I get asked, which I definitely defer to my orthopaedic surgery colleagues, but crutches, just like you addressed, I think that's the number one thing is, "Well, how long am I going to be on those crutches?" And it varies. I think a lot of people always then start to wonder too, well, not only when can I start walking without the crutches, but what does it look like to start back to the running piece? Although slow initially, what does that look like?

Dr. Joe Tramer:

So I kind of give people an average of four months before return to running. A lot of it is before you do something impactful like that, you want to make sure that you're walking without pain, that your range of motion is full, that you don't have swelling. And then, I let therapy guide that a lot because, I mean, my exam room is not the biggest room, I can't have people running laps in there, so I really can't assess it very well, but you can do that stuff with physical therapy. And once they have a lot of experience in knowing, OK, your muscle's this strong, you're doing these weightlifting activities nicely, I can see you're walking well, now it's time to do a little bit of a walk-jog, and they kind of will progress from there.

But it's relatively on the early end because, it's like we talked about before, you do not need your ACL for straight-line activities. And so if someone's saying, "I want to get back to running as my main activity after this," I encourage them to do that early because it's very good for rebuilding your cardiovascular strength, your quad strength. And so I definitely encourage that, and a lot of it's based on how they are progressing with therapy.

John Horton:

Dr. Tramer, you had mentioned in this rehab process then, so what are we looking at as far as a return to basic life and just walking around, going grocery shopping, doing all those things that we do? How many weeks or months are we looking at for that?

Dr. Joe Tramer:

Yeah. I mean, I would consider being off crutches when you can do a lot of that stuff, which sometimes is as early as two weeks, but I give people the average of four to six. And even if you're still wearing the brace, you can do a lot of those activities of daily living with the brace on. And again, a lot of that is kind of dependent on the meniscus and the recovery. I do find that some of my older patients, where I do an allograft and don't have to harvest a tendon, by their two-week visit, they're moving it around pretty well, their walking is progressing.

And so that is one of the benefits of the donor tendon, is that it definitely is less trauma to the knee. And so some of those people who are like, I got to get back to work and my kids and my grocery shopping and I want to play pickleball, like we said, in nine months, those people do get back pretty quickly. But I kind of quote six weeks for kind of a return to life, but you fatigue faster, your muscle isn't there yet. And so it's not as it was before the surgery quite yet.

John Horton:

It's got to be a long and frustrating process as you're building that back up, especially because it sounds like with your quad, I guess, regressing a little bit, it sounds like you really have a lot of work just to get back to, not even close to where you're at before, but just to really move and run and do basic things.

Dr. Lauren Wichman:

Speaking from the athlete side of things, I vividly remember I tore my ACL pretty early in my soccer season that year. So I was coming off of being in some of the best shape of my life, pre-season fitness testing, lifting, doing strength stuff all summer. So I'm going from doing deadlifts and agility and all of that stuff to just basic leg lifts. And then, OK, we're going to move up and put an ankle weight on your leg while you're doing leg lifts. It really does seem like in an athlete mindset, this is something that normally is very, very easy to do. But when that quad goes to sleep, you're working really hard to make that happen. And you're like, "Two months ago, this would've been nothing. What is happening right now?"

Dr. Joe Tramer:

Yeah. And I think that's a huge struggle because like you were, I'm sure, your life revolves around these sports for a lot of these kids and you're just so used to being able to do what you want. You have such a big baseline of fitness and now it's gone. You get removed from your team. You're doing rehab where you're doing boring exercises to make your quad stronger, oftentimes, kind of alone with a therapist. And so it's hard physically, but it's really hard mentally as well.

I mean, a lot of kids' identities is being able to participate in sport. And so I think that's a major barrier to progress. We definitely have some services where I'll pretty routinely refer some of my adolescent athletes to one of our sports psychiatrists, a psychologist, just to bounce some ideas on how to cope with this major change because it's not just a physical recovery that these people are going through.

John Horton:

And I know athletes are not known for their patience and things like that. What happens if you do try to push that ahead and just like, "I'm going to work through this and just force it to get healthier and stronger"? I take it that's just not a good formula to bring your ACL back.

Dr. Joe Tramer:

Yeah. Another conversation I have a lot is part of it is you being motivated and working hard and pushing things, and part of it is, frankly, time. It takes time for the ligament to mature. It takes time to build the quad up. A lot of our research shows that if you go back too early, it puts you at an unacceptable risk of retear, which is devastating. And so when I say “retear,” and we start the whole process again, I think that helps them say, "All right, that's not a good idea." But it is frustrating. It can be kind of a slog.

I mean, you hear these stories of an athlete who got back in six months. I mean, I think that that type of person is very few and far between, and probably a professional who, 1), has crazy genetics to get there in the first place and, 2), spends their whole life— this is their whole life and their career. That is not the typical. And so, yeah, every office visit, I'm always reminding you like, "Hey, don't forget nine to 12 months." I say that a lot because I feel like they probably try to forget it every time I say it.

John Horton:

So if you are a patient, you do everything right, you follow all the instructions, you do the rehab, all that, you're looking at a year to get back to your regular sport, it sounds like, nine months to a year. How likely is it that you might re-injure that? Or once this repair is made, do you have a pretty good likelihood that it's going to last and hold up?

Dr. Joe Tramer:

Yeah. So ACL reconstruction is one of our more successful surgeries. The vast majority of people are able to get back to some degree of sporting activities. Sometimes, it can be hard to get back to the full level you were at before, but most people do, which is the reason we're doing the surgery in the first place, is to get you back out there. So I tell people, "I want you to go back and do those things. That's why we're doing the surgery. So I definitely want you to get out there and test our work and see if it's going to hold up."

That being said, like you mentioned, there is still a slightly higher risk of retear on the graft compared to your native ACL. Some of our studies also show that people who've had an ACL injury also have a higher risk of now tearing the other knee. Doesn't mean I don't want you to go out there and play, but it's something to note. Maybe there's something about you anatomically that's predisposing you to having an ACL. So certainly the risk of reinjury or reinjuring the other knee goes up a little bit after a single ACL injury statistically. But the vast majority of people get back to their activity and do not have issues with the ACL retearing.

Dr. Lauren Wichman:

And I think one of the big advantages of physical therapy is not only recovery from the surgery, but also prevention, right? So we talked about there are a lot of different mechanisms in the ways that these injuries can happen, and landing mechanics and cutting mechanics and those things can play a big role. I know, for example, for me, when I had my surgery, I ended up doing one of the Cleveland Clinic Match Fit programs that we have, which is a performance program that takes a really, really detailed look at all of those things to make sure, OK, is there anything that we can see from a mechanic standpoint that would predispose you to this happening again? And if we can make those slight tweaks and changes to prevent this from having to start the process over, it's well worth it.

John Horton:

Yeah. I was going to ask, are there things you can do to bolster your ACL or protect it a little bit? It sounds like a lot of these injuries happen, it's a cut and it pops, or a violent collision or something like that. Is it just kind of bad luck that it goes or are there things we can do to prevent an ACL tear?

Dr. Joe Tramer:

I'd say a lot of time, it's unluck of the draw. But like Dr. Wichman mentioned, making sure … sometimes, people will land with their knee kind of buckling inwards, and that just puts more stress on the ACL. So some of the prevention methods are getting people to land with more proper mechanics. Having a strong quad muscle and well-balanced quad and hamstring muscles are — I say this a lot, but as humans, we can't make our ACL stronger or that's not something that you can modify. The thing we have the best chance of modifying is our muscle strength and then maybe some mechanical factors. And so it's really all we can do, is try to have strong muscles to support the knee. Hopefully, if you get into that precarious position, your quad muscle is kind of stopping your knee from going too far before the ACL goes.

John Horton:

That's just fascinating that your muscles can get to that point maybe where you just kind of prevent that tweak or twist that just ends up with that tear.

Dr. Lauren Wichman:

It's hard because you still see it at the professional level. The pros are as strong as can be, and they've got the most resources you would think to be able to try to prevent this, but it still, unfortunately, happens. So like Dr. Tramer said, some of it really is luck of the draw, but that's why, if I have an athlete who is in the thick of that recovery process, reminding them about how these little things can make a big difference, it's worth it to at least explore and work at it to the maximum.

John Horton:

So, Dr. Tramer, wrapping things up a little bit here, I want to ask you, if somebody thinks they have a knee injury or they suspect maybe they have a torn ACL, what are the first steps they should do? What's the process?

Dr. Joe Tramer:

Just call me.

John Horton:

Easy enough.

Dr. Joe Tramer:

Yeah. Problem solved. Or Dr. Wichman. So I would say first of all, it's never normal to have a big swollen knee, especially if you are a teenager. And so if that's the case, if something feels wrong, I mean, we have a fantastic group of a lot of people, a lot of doctors at the Cleveland Clinic who love doing this, who specialize in it. And so if there's any suspicion, I would hold off on your activities.

If it's swollen, I think, especially again in a teenager, it's worth getting evaluated sooner than later. If you kind of twisted it wrong, you're not sure, you want to give it a couple of days, that's fine. But I would have a low threshold if you're worried about something, especially a major ligament issue, come see one of us and we're happy to hopefully reassure you that it's not. But if it is, we can take care of things, regardless.

John Horton:

Trust your gut on it, it sounds like.

Dr. Joe Tramer:

Totally. Yeah.

John Horton:

Because I think a lot of it, we know if we have something that's really hurt. And if you think that, it sounds like you need to go in and really get it looked at.

Dr. Joe Tramer:

That's why if a wrestler ever comes in finally complaining about their knee, you got to listen to them because those guys don't complain about anything.

John Horton:

And, Dr. Wichman, I want to tap into your experience here because you went through this. So if anybody knows the difficulties and just the frustration even that comes with tearing an ACL, it would be you. So what guidance would you give to any athlete who's looking at this, they got this diagnosis, and they just … man, they're at a bad spot. So what do they need to know or feel good about moving ahead?

Dr. Lauren Wichman:

I, number one, don't envy them at all. Like I said, this isn't an injury I would wish on my worst enemy. I think a little bit of reassurance that you're not alone. There was actually another girl on my team who is going through the process at the same time that I was, and leaning in on your support system is so critical. I'll tell athletes, just because you have an ACL injury where you aren't able to participate doesn't mean that you're not a valued member of your team. Showing up, being a leader on the sidelines, supporting your teammates. But then also, being able to lean on them, too, when you're going through this hard process is really, really important.

And then, I think, being really plugged into your care team. So orthopaedic surgeons like Dr. Tramer, who are going to fix things up, are such a great resource to answer questions and make sure that you're hitting all your marks and to be able to talk through expectations. Your physical therapist and even some of the athletic trainers you'll work with at your school to get back to sport, they are with you every step of the way as well.

So leaning in on them and leaning in on some of our other staff, like our sports psychologists, to talk through what you're going through, because this is a hard process to be out of the sport you identify with for a year. But there are a lot of success stories, and there are a lot of things that we do to try to optimize your success for getting back to the sport that you love.

John Horton:

Well, I think to sum it up then, it sounds like our process is call Dr. Tramer.

Dr. Lauren Wichman:

Yep.

John Horton:

Follow your rehab plan to the T, and just stay positive and stay involved with your team and know that, eventually, you're going to be right back out there competing and doing everything you were doing before.

Dr. Joe Tramer:

That's the goal.

John Horton:

Well, that sounds like that's a wrap then, too. So, Dr. Tramer, I can't tell you how much we appreciate you coming in. This was just a really great discussion. I think, really kind of educated folks about an injury we hear a lot about, but maybe don't understand all the complexities that come with it and coming back from it.

Dr. Joe Tramer:

Thanks, guys. Yeah, I love talking about this. So it was a pleasure.

John Horton:

So, Dr. Wichman, I have to tell you, after listening to that, I feel like I have such a better understanding of just how difficult it is recovering from an ACL injury, but that if you have this happen to you, it's not the end of the world. I mean, there is a light at the end of that tunnel.

Dr. Lauren Wichman:

It definitely is not only a physical journey for recovery, but also definitely a mental one. And I think Dr. Tramer did a great job of outlining all of those things, like I talked about before, where the worries that patients may have, the questions that may come up, he gave us a lot of great information and reassurance that a career in sports is definitely still a possibility.

John Horton:

And it sounds like, I mean, you have the surgery, you have a lot of time it's going to take to get back to being able to do what you want to do. You have to be patient. You have to follow the rehab instructions. You can't push it. But eventually. if you do all of that right, it sounds like your odds of success are very good and you should have a fully functioning ACL by the time all the healing's over.

Dr. Lauren Wichman:

And that's what I think, that's why this injury gets so much attention, right? It's because it is an injury that, unfortunately, you're out for so long. But I completely agree with you. As somebody who's lived it, I tore my ACL my sophomore year, came back, played a successful junior and senior year to be able to live that out. And I definitely want to reassure patients that that is something that you can do, too.

John Horton:

Well, that is a perfect optimistic way to end this discussion.

So if you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, play hard and be well.

Speaker 4:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.