The Knee Injury Bible

INTRODUCTION

by Dr. Nicholas Kennedy

Autumn mornings in Vail, Colorado, have a certain feeling to them. There’s fresh dew on the ground, a crisp chill in the air, and a medley of yellow aspens dotting the valley. The year is 2012, and I’m taking advantage of the cool weather, playing some flag football with a few friends from my work at a sports medicine clinic, most of whom happen to be doctors or medical students. The league may be amateur, but for this group of former competitive athletes, winning is definitely still a top priority.

This competitive, take-no-prisoners attitude has earned my team a spot at the championship game—which we are currently losing. Badly—down 21 to 6 already and only in the second quarter. Frustrated doesn’t even begin to describe my mental state. To make matters worse, I have a pulled groin on my left side, easily one of the worst I have ever experienced, and it’s causing some annoying—and I admit, embarrassing—limping.

“Hey Max,” I shout at one of my teammates, “play safety. I’m gonna rush the QB from now on!” With levelheaded thinking having gone by the wayside hours ago and the championship title on the line, this flag-football game has morphed into NFL Game Day.

After the next snap, I take off after the quarterback with a desperate fervor, sprinting at a completely unimpressive speed. Just as I reach the opposing quarterback, who I might add is thirty years my elder, he sidesteps to my right but takes off to the left, an incredibly effective juke. When I attempt to recover from his tricky change of direction by cutting from my right leg, which is already bearing most of my weight thanks to the groin pull on the left, my right foot inconveniently finds a pothole in the grass. As my awkward cut turns into a rather dramatic plunge to the ground, I hear a crack like a firework on the Fourth of July.

The knee pain that follows is as nausea-inducing as it is excruciating. Rolling on the ground, I’m utilizing a full arsenal of vocabulary to describe my pain. But if you are going to hurt yourself playing flag football, might as well do it with a team full of orthopedic residents and medical school students on site to diagnose you.

And the diagnoses start flying.

“I think it’s his ACL [anterior cruciate ligament],” one declares, after he’s finished his spur-of-the-moment evaluation.

“His ACL feels fine to me, but I think maybe his FCL [fibular collateral ligament] is loose,” proclaims another.

The battle between diagnoses continues, but one thing is for sure: whatever is torn or broken, my knee hurts like the dickens. As I rise to take my first step to get off the field, my right leg does a sideways curtsy, and it becomes abundantly clear that some things that should be working are definitely not.

The morning after that fateful flag-football championship game, my boss (now friend and mentor) Dr. Robert LaPrade, an orthopedic surgeon, performs a thorough exam on me, including several maneuvers to assess the status of the different ligaments of my knee. From the look on his face, I can tell I have done a number on it.

He shakes his head. “Your FCL is torn for sure. ACL too, probably. You need an MRI [magnetic resonance imaging] and stress x-rays.”

Later that day, the MRI confirms his suspicions. I have torn my ACL and my FCL, and also have a small tear of my meniscus, which is the knee’s cushion. Surgery is in my near future.

Still, pain aside, none of this seems to faze me; why should it? I’m twenty-three years young, and figure it’ll heal fast. With a quick surgery and rehab, I’m sure I’ll be back to reliving my glory days in the local basketball, flag-football, and softball leagues in no time. I even say to Dr. LaPrade confidently, “I’ll be back in time for Hoopfest, no problem,” a three-on-three basketball tournament in my home state of Washington the following June.

I was fortunate enough to have some background in the field of orthopedics, which deals with bone, muscle, and ligament injuries. At the time of my injury, I was completing a year of sports medicine research in Vail. While I was still very green, I knew what my knee ligaments were, and I had a basic understanding of what surgery and physical therapy encompassed. I had also grown up around surgery and sports medicine—my father is a sports orthopedic surgeon in Yakima, Washington. I was often on the sidelines at semiprofessional games or touring hospitals on weekend rounds with my dad. Additionally, over the years I’d seen my younger sister, my wife, and my sister-in-law all tear their ACLs and undergo reconstructive surgery. It had been easy for them, right?

So I was more than confident this process would be smooth. I was going to have my surgery done at Steadman, arguably the best place to have ACL reconstructive surgery. Names like Kobe Bryant, Ed Reed, Alex Rodriguez, Ricky Rubio, and a whole host of other professional athletes have had their surgeries done here. On top of that, I was going to be treated at Howard Head Physical Therapy, a mecca for sports rehabilitation. I wasn’t just in good hands; I was in the most capable hands you could ask for. This was going to be a breeze!

How’s that Montgomery Gentry song go again? “Lord, I’m learning so much more than back when I knew it all.” Or said in another way, ignorance is bliss. I came to find out that injuring your knee is no joke. Surgery is not the walk in the park that I had made it out to be in my head, nor is physical therapy the leisurely bike ride you might want to take around the park. My ten-thousand-foot view of watching others go through the journey of knee recovery would be nothing like actually experiencing it.

During my recovery, I remembered words I had spoken to my sister once during her ACL rehab: “Just do your exercises, Julia. Physical therapy is easy.” Those words would be the purest form of karma during my weeks of struggling to regain my normal motion and strength. Let it be known that I was definitely not playing full-contact basketball at eight months post-injury, as I had so arrogantly proclaimed. It would be months, and honestly years, until I was back to doing the things I love to do: everything from playing basketball and football to hiking and fishing.

THE PURPOSE OF THIS BOOK

If you have suffered a knee injury, this book is meant to be your road map to recovery: understanding why your knee injury happened, your treatment options, and how to regain function and return to your favorite activities as quickly as possible with least risk of reinjury. When I got injured, I was fortunate enough to be immersed in the world of orthopedics, surrounded by the best care one can receive—yet despite this I still, at times, felt completely lost. I’d had unrealistic expectations when it came to my treatment and my recovery, and it was these fairy-tale ideas that led to my long and admittedly complicated rehab journey. A journey that included development of significant knee stiffness that required additional surgery, a fall in the bathroom the night of my second surgery leading to another knee ligamentous injury, hours of continuous passive motion device usage (see here), and more than fifty physical therapy visits, before eventually regaining full function.

I like to tell my patients the knee is an incredibly logical joint—its logical quality is one of the reasons why we authors of this book are such fans of it and have a passion for treating injuries of the knee. By “logical” I mean that its function is very easy to understand. The knee mainly does two things: flexes and extends. It does not want to move in and out (abduct or adduct), nor does it want to rotate internally or externally like the hip and shoulder; it is a very stable joint. But because it only wants to do two things, there are a lot of movements that can cause injury, and furthermore its location along our biomechanical axis exposes it to a lot of force with every step. This is a good explanation for why the knee is the most common joint injured by adolescent athletes, responsible for approximately 2.5 million emergency department visits per year.

And all the force the knee joint is exposed to day in and day out, combined with the high prevalence of acute injuries, helps explain why the knee is also the most common joint to be affected by arthritis. Nearly one in five adults over age forty-five have knee osteoarthritis. This is a fairly staggering statistic, even more so when one considers our current aging population and the number of people in the United States in that age group, approximately 120 million people.

Even though knee injuries are highly prevalent, they can be challenging to manage. Why is this? We think it boils down to three major factors: lack of adequate information, lack of patient comprehension, and lack of access to proper care and implementation of necessary rehabilitation steps.

All three of these factors are intricately related. Some of you are probably familiar with the saying “too much of anything is bad.” That saying definitely holds true for medical information. In today’s culture, where Google searches make answers available at the click of a button, everyone can feel like an expert. The problem is that a good deal of the information presented as fact is not vetted and is actually far from fact. A wealth of resources sometimes actually makes it more difficult to get the knowledge you need, and this is particularly evident in medicine.

The lack of good information and abundance of misinformation then help lead to the second problem, which is lack of comprehension. Patients read something they believe to be true, or hear a doctor on TV, and assume it applies to them, which can lead to a poor understanding of their problem. This then directly leads to not receiving proper care or taking the timely, necessary steps for recovery. In our practices, we’ve found that often patients do not fully grasp the importance of their knee injury—not just the current impact but the impact on the long-term health of their knee and whole body.

We want to help people learn from our mistakes, and also make decisions in as informed a way as possible. It is our goal to give you the power, knowledge, and encouragement to succeed, and to not only help you understand what your knee injury is and how to treat it but give you a more holistic and educated view of your injury and the journey that lies ahead. We will cover what to do, where to go, who to see, and what it all means. We will help provide a good estimate of what one can expect with surgery in regard to pain, medications, rehabilitation, diet and its effects, the new advancements of what is called “stem cell therapy” and beyond, and how and when you can expect to get back to doing the things you love.

This book is for the seventeen-year-old senior in high school who has just torn their ACL in the middle of their last year of high school sports. It’s also for the seventy-five-year-old mother and grandmother with daily knee pain that is beginning to make it tough for her to enjoy her hobbies or keep up with her grandkids. This book is for the forty-five-year-old office worker who has seen the number on the bathroom scale continue to climb but is experiencing too much knee pain to stop the climb. It is even for the parents of the teenager who is trying to decide if knee surgery is the right decision. Is it too invasive, aggressive, or maybe just plain unnecessary for their child to undergo?

In short, this book is for you—the patient, the patient’s parent, family member, or loved one—to provide you with an arsenal of information so that this whole process feels less overwhelming. We don’t expect you to emerge from reading this book with a medical degree, but we do hope you come away with an improved understanding of your injury and what can be done for it.

ABOUT THE AUTHORS

So who are your Mr. Miyagis to teach you the wax on and wax off of the knee joint? There are four of us. The veteran of the group is Robert LaPrade, MD, PhD. He is a sports-certified orthopedic surgeon who practices at Twin Cities Orthopedics in Edina, Minnesota. He has more than twenty-five years of experience in the field and has helped thousands of patients (including scores of professional athletes) address their injuries and eventually return to the life and activities they love.

Dr. LaPrade also has a passion for research and has published more than four hundred seventy-five peer-reviewed papers, which serve not only to help shape his practice but also to help advance the field of orthopedics as a whole. He has traveled around the globe to present his work and educate others in the field. Among his numerous awards for his research is the Kappa Delta Award, which is the highest career honor for orthopedic research. Time and time again he likes to say, “There is nothing like your health.” He knows how important your knee health is for your overall health, and he aims to help patients understand and treat their injuries.

Luke O’Brien is an Australian-born physical therapist and head of the Howard Head Sports Medicine Center in Vail, Colorado. Luke is a well-respected physical therapist in the field of sports medicine and has led the way in several areas, including developing return-to-sport criteria. He has worked with all-pro NFL players, all-star NBA players, soccer players in the top European leagues, NHL stars, and of course, a moderately athletic and overconfident medical student whom he then agreed to write a book with years later.

In his practice, Luke has developed rehab plans for people from all walks of life, from the casual outdoor enthusiast to the professional athlete. He has a wealth of knowledge on the physiology and biomechanics of the human body, and he also has widely published his research work and been invited to give presentations all over the world.

A native of Argentina, Jorge Chahla, MD, PhD, is an orthopedic surgeon and researcher who now works at Rush University Medical Center in Chicago. He is someone who could not get enough education. Not only did he complete the usual five years of medical residency, but he also has completed two years of research fellowship and two years of clinical fellowship in the field of sports medicine at two of the top ten programs in the country, at the Steadman Clinic in Vail, Kerlan Jobe in Los Angeles, and Rush University in Chicago. He too has done extensive research, publishing in more than two hundred peer-reviewed publications, and he has a particular interest in biologics in orthopedics—things like stem cell, platelet-rich plasma, and other biologic healing modulators, and how they affect your knee, and whether or not they actually work. (We’ll discuss these in-depth in Chapter 11.)

Dr. Nicholas Kennedy is currently in his third year of orthopedic resident training at the Mayo Clinic. He completed medical school at Oregon Health & Science University and spent about two years in Vail working on research with their world-renowned staff. He has more than fifty peer-reviewed publications focusing on biomechanics, reconstruction, and rehabilitation of knee ligamentous injuries. At the age of twenty-three he won the Excellence in Research award, given to the best research paper at the American Orthopaedic Society for Sports Medicine annual meeting in 2014. Having had a serious knee injury himself, he also knows firsthand what it’s like to be on the other side of the operating table as an orthopedics patient.

Together, we have a combined fifty-plus years of experience with all aspects of treating knee injuries. Here we’ve shared our expertise to give you the most up-to-date and comprehensive view possible.

YOUR ROAD MAP: HOW TO USE THIS BOOK

Many of you reading this book are probably already overwhelmed regarding your injury, what it means for your life, and what to do going forward. This book is meant to help ease the burden—it should be a tool that should act to reduce stress, not a homework assignment that adds stress. With that in mind, here’s how to best utilize this book as your resource.

We have written the book in the order of how most patients address their injury. First you get hurt, and you find yourself asking, Why and how did this happen? That is the focus of Part 1, and why we start the first chapter with an explanation of what the knee joint is, how it gets hurt, why some people hurt it easier than others, and what traits you may personally possess that lead to an injury. We also give you some brief anatomy—not so much that you will feel like Billy Madison in biology class, but enough so that it gives you a foundation for understanding later chapters. Next, in Chapter 2, we address the question of what to do. Whom do you see? What tests are performed? How are they performed? When can you wait to see a doctor versus when is it urgent? We’ll look at the steps leading to a diagnosis.

Chapter 3 gives you a closer look at the top twenty-five knee injuries. We’ll talk about your diagnosis, explain some more regarding the anatomy and biomechanics (aka the “what” and “how” of the injury), and then give you treatment options. These include surgical and nonsurgical options.

In Part 2 of this book, Chapters 4, 5, and 6 are all things that involve surgery. What things happen leading up to surgery, what your day of surgery and recovery in the hospital or at home look like, and what common mistakes and misconceptions are regarding the entire surgical process. Our attempt in these chapters is to minimize surprise! We hope to give you as much information regarding the process as possible so that you can be more prepared. The authors of this book are firm believers in educating our patients and not sugar-coating. If we tell you, “After surgery, you won’t hurt at all,” or “Rehabilitation will be easy” and the medications have “no side effects,” it may convince you to have the surgery, but it does nothing to establish good rapport, and in actuality leads to worse outcomes and loss of trust between patients and doctor. These chapters should help educate you on the process as much as we can on paper. Chapter 7 is your guide to the medications you may be prescribed for a knee injury.

Part 3 is all about how to maximize your recovery to get your knee function back. In Chapter 8, we’ll talk about how to avoid complications postsurgery and what’s important to do—and not to do—in those early days and weeks. Chapter 9 discusses the rehab and physical therapy part of treatment, both for those undergoing surgery and for those opting to go the nonsurgical route. This part of the book has a significantly increased photo-to-word ratio with photos demonstrating how to do each of the exercises we suggest. Here, Luke also lays out some specific rehab exercise plans with set and repetition ranges to give some guidance for each phase of recovery.

Chapter 10 covers some nutrition and diet basics. The topic of how diet affects systemic health, and our musculoskeletal health, is a constantly evolving topic. We’ll look at the importance of protein and how the food you eat may improve healing and ease inflammation. Many types of diets may be effective for health and weight loss, from Mediterranean to vegan to paleo, and dozens of books are available. With that in mind, here we are giving some basic recommendations based on the best of our knowledge and the best scientific evidence available.

Chapter 11 addresses some of the nonsurgical treatment options, such as cortisone injections, which we find many of our patients have questions about. We also talk about more cutting-edge treatments you may have heard about in the media, or in professional athlete circles, such as stem cell therapy and platelet-rich plasma. Our goal in this chapter is not only to explain the options but also to explain the evidence. A lot of treatments being pushed on the public actually have very little evidence to suggest they have a measurable effect, and while they are relatively safe and sometimes worth the old college try, you as consumers should know as much as possible about the product you are about to pay (sometimes a hefty ransom) for.

Finally, Chapter 12 covers prevention—or how not to be living Bill Murray’s life in Groundhog Day when it comes to your injury. We discuss some ways to help maintain your knee strength and avoid reinjury.

As the book is organized chronologically, should you want to go through the journey of injury from start to finish, you can easily do so. But let’s say you have already had surgery, and you are just looking for some information on recovery and return to sport—simply jump to Chapter 8 and beyond. Or if you just want information on your diagnosis, skip to the subtopic in Chapter 3—or even just the “Rundown” box that follows each entry for the short version. If at any point you decide you want more information about the anatomy of your injury or why it happened, then you could backtrack to opening chapters.

The point is that you can use this book in any way you see fit. This book is a tool—you do not need to conform to the book; it should conform to you!

Lastly, although yes, this book is written by medical professionals, and yes, it is based in scientific evidence and combined decades of experience, please note that it should not replace seeing and receiving direct care from medical professionals. That is to say, please do not consult this book instead of going to see a doctor. Please don’t think to yourself, Well, I know what my diagnosis is based on the book, so I do not need to see anyone. The book is meant to supplement your care with your physician, physical therapist, dietician, and treatment team. It should work in concert to empower you, so that you can have informed discussions with them, but please follow your own physician’s and medical team’s advice. And be sure to talk with them before starting any exercise program.

YOU CAN DO IT

One thing we want you to remember throughout this book is that the process of bouncing back from a knee injury won’t always be easy. It won’t always be fun. But you can do it—and it’s worth it! Surgery, rehab, the long hours involved, the medications you take, the pain and soreness, they are all a part of the process. You can and you will improve if you stick with it.

My journey from a torn FCL, ACL, and meniscus involved multiple surgeries. At one point in time I was a twenty-three-year-old who suddenly couldn’t bend his knee further than 60 degrees (remember 90 degrees is a right angle; you need about 100 degrees just to sit in a stadium or movie theater seat) or go up and down stairs normally. It took me a year to walk without a limp, and eighteen months to jog again. As I recovered, I managed to reinjure my knee twice. But eventually I got there. In time you will, too.

Thanks to the amazing care I received, the hours of rehab, eating right, and pushing myself to regain my knee functionality, the local community flag-football leagues are still graced with my mediocre quarterbacking skills, and open gym basketball courts still get to see my attempts to take shots that don’t quite find the bottom of the net. Seven years after my injury, I’m able to work out, bike, and hike. I’m on my feet all day in a bustling hospital, and my knee manages to keep up. And I’m happy to say I can now do these things with minimal pain. All this is to say: if I can do it, so can you. The Knee Injury Bible is your guide to getting the best possible outcome for your knee.