An Interview of Dr. Derek Ochiai
The midfielder catches a pass over the shoulder on a break. Only one defender has a chance at stopping the play. One quick spin move and the defender is foolishly waving at air. However, instead of a 1-on-1 with the goalie, the midfielder lies on the ground, clutching a knee. Sound familiar? Unfortunately for many, it probably does. So we talked to Dr. Derek Ochiai, an orthopaedic surgeon in Northern Virginia, about ACL injuries.
IL: What is the ACL anyway?
Ochiai: The ACL, or anterior cruciate ligament, is one of the major knee ligaments that stabilizes the knee. Its main action is to prevent the tibia, or shin, from sliding forward on the femur (thigh). It also prevents the knee from rotational twisting.
IL: A lot of lacrosse players have this injury. Is it common? What causes it?
Ochiai: ACL rupture is the most common major knee ligament injury requiring surgery. Overall, one in 3,000 people every year injures his/her ACL, with the vast majority happening through sports. Sports with a lot of quick cutting movements, such as skiing, basketball and lacrosse, have the highest percentages of ACL injuries. Most of these injuries occur from changes in direction, frequently with no or only incidental contact from other players. Females actually suffer ACL injuries four times more frequently than men. IL: Why more female athletes?
Ochiai: This is still under investigation. Initially, the thought was that male athletes had more experience with organized athletics, and therefore were in better condition for their sports. Now, we realize that it's a lot more complicated than that, with several factors, including the differences in the anatomy of the knee between the sexes and hormones, playing a role. IL: Is there a certain age range for ACL injuries?
Ochiai: Traditionally, the peak age range is about 15-25. However, we are seeing more pre-teens with ACL tears, especially as they get involved in organized athletics. With the "weekend warrior" crowd, I've seen several patients in their late 30s and 40s with recent ACL tears. I have even had a 62-year old with a new ACL tear.
IL: How do you know if you injured your ACL?
Ochiai: About one-third to two-thirds of people actually feel a "pop", or tearing sensation with the injury. Almost uniformly, the patient will be unable to continue playing. About 4-8 hours after the injury, an effusion, or swelling inside the knee, will develop. A trainer or physician will perform maneuvers on the knee to diagnose the tear. This will include a Lachman Test, where the doctor will see how much the tibia can slide forward on the femur. A doctor may also order an MRI, which picks up most ACL tears, as well as associated injuries to the knee.
IL: Is there any way to prevent ACL injuries?
Ochiai: Obviously, no one tries to tear his/her ACL, and the situations that put the ACL at risk are somewhat unavoidable. However, injury is more likely to occur if the player is out of shape and immediately attempts to play at a high level. My recommendation would be to start working out at least one month prior to the start of the season, with conditioning (running) and also weight training (especially the quadriceps and hamstrings). My other advice would be to work on your stick work, practicing the various dodges that you will use during games both before and after conditioning sessions. Before, so you get muscle memory of proper footwork, and after, so that even when tired, you become accustomed to having your feet and body in proper, balanced position.
IL: Does every ACL tear require surgery?
Ochiai: Not necessarily. If it is only a partial tear and the overall stability of the knee is okay, sometimes these players can manage without surgery. However, with full tears of the ACL, in most cases, the best way to restore function, especially with sports such as lacrosse, is to perform a reconstruction.
IL: You said reconstruction, not repair-why?
Ochiai: The ACL has poor healing potential. Therefore, if you took the torn ends and tied them together to repair the ACL, it wouldn't work. The ends will not heal together, and the repair will fail. The treatment for complete ACL ruptures is to replace the ligament.
IL: How do you do that?
Ochiai: A strip of tendon is used to replace the ACL. This can be from the front of the patient's knee (the patellar tendon), the hamstrings or the quadriceps tendon. Alternatively, the surgeon may use donated tissue from a cadaver. The surgery involves drilling holes in the tibia and femur, passing the new graft inside these holes, and locking the graft in place.
IL: Is one way better than the other?
Ochiai: No. There are pros and cons to all of them. The patellar tendon is the one that has been around the longest. If patients need a reconstruction, they should definitely talk to their surgeon about all the options.
IL: How quickly can players return to the field?
Ochiai: That depends on their rehabilitation. It is usually at least eight months after surgery before patients can get on the field for competition. It takes a lot of hard work on their part before they can get to that point.
IL: Is there any way to speed up rehab?
Ochiai: That's something to discuss with your particular orthopaedic surgeon. My normal protocol involves walking immediately after surgery and using a machine that bends and straightens the knee. At three weeks, physical therapy starts, until full active range of motion and normal walking gait are maintained. At two months, straight-ahead jogging starts. At four months, straight-ahead full-speed running begins. At six months, proprioceptive sport-specific exercises are initiated. These include practice cutting around pylons and dodges and changes of direction without any competitors or teammates (the added variables of running into other players or meeting an overly aggressive competitor increases chance of injury). Finally, at eight months, full competitive lacrosse is allowed. The thing that slows rehab is the healing of the graft to the tunnels and the body's incorporation of the graft. Currently, there is no technology to speed up that process.
IL: After reconstruction, is the knee ever the same?
Ochiai: Well, I never promise that. However, the goal is not to get the knee "back to normal" so much as to have a stable, painless knee that can last through a player's career on the field and beyond. There is a very good chance of achieving that goal.
Dr. Ochiai specializes in sports medicine. He is the author of several books, the most recent being The Orthopaedic Intern Pocket Survival Guide.