Part II of a Q&A with an Orthopedic Surgeon on RGIII
July 31, 2013 in Washington Redskins
Last week I had the opportunity to interview Orthopedic Surgeon Dr. David Geier about ACL surgeries and recovery times for athletes, with a primary focus on Robert Griffin III's situation. Though Dr. Geier was not personally involved with RGIII's surgery or recovery process, he is the head of a major sports medicine practice in South Carolina, and performs well over 100 ACL surgeries a year.
Dr Geier has also assisted in the orthopedic care for both the St. Louis Rams and the St. Louis Cardinals. In addition he has been used as a medical expert for just about every major media outlet there is. The following quotes are from my conversation with him, and my thoughts are below his quotes.
Q: On if recovering from an ACL injury can lead to other injuries not related to the knee. Using the example of RB Rashard Mendenhall last year who was recovering from his ACL injury from the year before, and injured his Achilles last year. Some reports tied the injuries together:
A: I think it’s certainly possible. I think the opposite knee’s ACL is probably far more likely (to be injured) and there’s rehab issues that lead to that phenomenon. We haven’t 100% figured out exactly why the opposite knee is so at risk. But as far as other injuries, it’s possible. You see that a lot with other surgeries generally. One body part isn’t 100%. You might very subtly change how you run or walk just a little bit and put more stress on another body part and then you potentially injure it.
I don’t know if that’s what happened to Mendenhall or not. I haven’t heard of that combination (ACL & Achilles) very often – not just in my practice but just generally. But it’s certainly possible. It’s not uncommon, for instance, if you have somebody with wear and tear of the cartilage in the knee and it bothers him and he walks just differently enough that maybe the other knee starts to hurt or his hip on that side or his ankle starts to hurt. That’s absolutely something that we see a lot.
My Take: This was something I was really interested in because I've seen the link before with injuries in another part of the body connected with the original injury, but wanted to ask a professional for his opinion.
While I brought up the Mendenhall example, I'm not sure if it was ever proven to be the case that they were linked, just that the speculation was there. I found the explanation to be very interesting and it absolutely makes sense that that the rest of the body has to make up for the injured knee in this case and it could lead to other issues.
It's good to know that they aren't super common, but unfortunately with Griffin and other guys recovering from injury it is another thing to consider, especially from a risk vs reward stand-point.
Q: On if there is any real medical and rehab difference as to whether or not the fact that Griffin didn't fully tear his ACL, but did need a full reconstruction:
A: I can’t say specifically with him because I hadn’t heard that report, but I will tell you, I get the question about partial ACL tears all the time. When a lot of athletes tear it, they don’t necessarily tear every single fiber or every single ligament fiber in the ligament itself.
The term partial tear, to be fair, is a structural definition or diagnosis based on MRI findings. When you get in there and scope it, you may find that some of it may be attached. But what matters is, how much of the ligament is still intact. If a ligament of an ACL is intact, there may be enough there that provides stability to a knee. More often though, even though there is some it still there and intact, the ligament is stretched out enough that the knee is still not whole and it’s not going to allow the athlete to plant his foot and turn or land from a jump without it just finishing off and giving out.
So, to be fair, there aren’t many partial tears, not just in pro NFL players, but just in anybody active. It’s rare to have partial tears where it’s not still a functionally unstable knee. What matters is the percentage of the ligament that is there, is it stabilizing the knee? Very, very commonly, if part of an ACL is torn, the knee is still unstable.
Q: Because of the patella graft, it is labeled a full reconstruction so that would seem to negate any discussion of partial tear?
A: You can’t just go back and repair the part of it that’s torn or reconstruct part of it. You do a complete ACL reconstruction, again, because what does stay intact, is usually stretched out and not able to provide any stability. So I don’t know that I would take any solace in that fact that Griffin’s was not a complete tear.
Again, I can’t say that about RGIII since I wasn’t involved and actually hadn’t heard that report. But if a patient came to me with that exact same MRI diagnosis, a high grade partial tear, we very likely would be talking about a complete ACL reconstruction to get him back to sports.
My Take: I wanted to make sure I asked the follow up here, because I think this is an important point that I've talked with various Redskins fans about. Both answers really debunk the thought that since it wasn't a full tear, it isn't as serious as say his previous ACL injury.
With the patella graft, this is a total reconstruction from a medical standpoint of the ACL (and not only that it's a revision surgery meaning it's higher risk). This has been a key area of confusion and one that needs to be put to bed.
Q: On what is the biggest concern with a player (specifically Griffin) coming back from the injury? Is it contact or day-to-day wear and tear?
A: It’s interesting, one of the misconceptions about ACL injuries is that it typically happens by being tackled. Actually, that is not at all very common. What happened to Tom Brady a few years ago is in the minority of these injuries. How they typically occur is much more like what happened to Robert Griffin, depending on when you think he injured his ACL last year. Basically, it’s one of two mechanisms – you’re running and plant your foot to change directions and turn and the knee gives way, or, you land from a jump with your leg fully extended or hyperextended and it completely ruptures. Those are almost always the way it happens – they are almost always non-contact injuries. There’s no question that tackling is a concern, but I think more than anything, it’s going to be running and cutting and pivoting.
In terms of your question about the biggest concern, I think is the risk of re-injuring it and doing further damage to his knee. Because every time your knee gives out, you risk tearing the meniscus and damaging the articular cartilage which can lead to long term degeneration. And he had an ACL surgery before, so this is the second one. I would worry about, not just him, but any athlete tearing it for a third time ever getting back to play or ever getting back to at least getting back to the level that athlete was before.
So, I think that I would expect that any doctor taking care of him or any other athlete in this multiple-surgery situation is going to make sure that the graft is as strong as it can be, and certainly compared to the other side. They can do all these computerized muscle tests that just tests strength. They’ll put him through all sorts of landing and cutting and pivoting drills. And they’ll do everything they can to really see if he’s as normal as he can be.
You can never completely predict it, but I expect that they will be overly cautious. And I don’t know that that’s a bad thing.
My Take: This is a very sobering look at the future for Griffin. One thing that is rarely mentioned much is what happens if he were to tear it again. Even if it doesn't happen in his working back from this injury, it has to be a serious concern to protect him, and not have another tear.
If he comes back full strength like is projected, he can be successful, but a 3rd tear in the same knee could be devastating. I really hope that Dr. Geier is right and the Redskins are overly cautious because they simply can't afford not to be. Another interesting tidbit is how getting hit is a secondary concern for Griffin going forward, my guess is most people thought it was the other way around.