The images of Dallas Cowboys linebacker Sean Lee crumpled on the ground in May speak volumes about the importance of the anterior cruciate ligament.
The ACL is one of four main ligaments in the knee and helps keep the lower leg from going forward or to the side involuntarily.
Spraining or tearing an ACL means limited or zero mobility for an athlete.
Lee underwent surgery recently, but just more than 30 years ago, repairing the knee and the pending prognosis weren’t as sunnily optimistic as they are these days.
The standard rehabilitation for the injury is eight to 10 months. Lee was placed on injured reserve July 1, ending his season.
Arlington orthopedic surgeon Dr. Bruce Prager said that, despite the advances, repairing the knee is a complex and serious process.
“There’s no quick fix. For my career, I actually started at about the time we started using arthroscopy instead of complete knee reconstruction,” Prager said, referring to the procedure that uses a tiny camera inserted into small incisions to give doctors a view of the joints.
“At the time, that was the gold standard in this practice, and it’s certainly easier to repair now than it was 30 years ago. Back then, almost everyone was doing a more invasive or open procedure.”
Casey Smith, the Dallas Mavericks’ trainer for the past 10 years, said improved rehabilitation practices have allowed athletes to efficiently return to peak performance.
“We are much more aggressive with rehab than we used to be,” he said, adding: “The outcomes are much better. It’s rare for someone not to return now.”
Types of repair
An industry debate has emerged with regard to the medical advances to repair a damaged knee.
Autografting — in which doctors use harvested tendons from the patient — has been the standard. But the use of tendons from cadavers recently has gained traction. That process is known as allografting.
“In allografting the tendons, you get more mass to work with on the procedure,” Prager said. “That also means you don’t invade something on the patient that is otherwise healthy.”
Still, not all physicians have bought into the procedure.
Prager said Tom Brady’s physician used the autografting technique to repair the New England quarterback’s knee in 2008 and took the specimen from Brady’s healthy knee.
“That’s just the way he did it,” Prager said. “In my opinion, it’s much easier to heal when you take the tendons from the knee that’s already under arthroscopy and not invading the contralateral knee.”
The difference set off a debate as Brady and the Patriots publicly traded concerns about the standard of care used and Brady’s ability to return.
The rehab process
The chances for Lee’s return this season are remote at best, according to Cowboys head athletic trainer Jim Maurer and Prager’s general assessment of ACL damage.
“Everybody wants to throw numbers on these things, and it’s hard to throw numbers,” Maurer said. “Seven to nine [months] is kind of a time frame, but just like any injury, when a guy is ready take his next step he is going to take it.
“Some guys need more time, and in some cases it will never be enough time. Seven [months] is not real. He will be running and doing a lot of stuff at five to six months, but is he ready to play NFL football? That’s the question.”
Prager agreed, citing Jerry Rice’s 1998 ACL injury as the ultimate example.
After injuring his ACL in the season opener for San Francisco, Rice returned to the field in 3 1/2 months. His return was regarded as a minor medical marvel.
Eleven plays into his return against Denver, however, Rice fractured his kneecap after landing awkwardly on a touchdown catch.
At the time, 49ers coach Steve Mariucci said the fracture was not related to Rice’s ACL injury.
“I’m not certain about Sean’s case, but you don’t just come back early from something like this,” Prager said.
“I think Rice came back in something like four months, and that really woke people up as to rushing this kind of thing. You can’t do that. It’s a minimum six to nine months.”
Do athletes play on injured ACLs?
It sure isn’t a common practice.
But players from Chicago Bears great Gale Sayers in 1968 to Arlington Bowie quarterback Keaton Perry in 2013 have given it a go.
In a general sense, however, Maurer said Sayers’ injury is where the measuring stick of football injuries begins.
“Today we are light-years away from where we were then — how it’s repaired, how the rehab is done and how it’s diagnosed,” Maurer said. “And the other injuries that occur when you repair an ACL are all factors on how long it takes for a guy to come back. The techniques are so much better than they were 20 years ago, and they probably will be better in another 10 years.
“Gale Sayers was the benchmark — a guy that came back and played great after his injury — but it varies depending on what else is damaged in the knee.
“A guy that had a bad ACL 40 years ago might not have made it back in today’s realm. There might have been other damage.”
In Perry’s case, he was familiar with the injury.
Last fall, he tore one of his ACLs for the third time in as many seasons. In the first two instances, the injuries ended his seasons.
But Perry pressed on, wearing a knee brace and finishing the season with more than 1,500 yards passing and 18 touchdowns.
While not impossible, it’s rare to have an athlete complete the season after an injury of that magnitude.
Julie Torre, a 20-year veteran as trainer at Cedar Hill High School, said none of her injured athletes has tried to keep playing without surgical repair.
In her program, athletes are educated about the risk of further damage.
“We have around four to five of these injuries a year,” Torre said. “We’re very fortunate to have the type of athletics programs we have and more so to have athletes dedicated to wanting to get back on the field.
“Last season we had five football players go down, and I like to say I’m a proud school mom, because all five of them worked hard to rehab, and they all went on to college and will play this fall.”