Featured Speaker:

Joseph Rabe, MD

Dr. Rabe is a graduate of Georgetown University School of Medicine in Washington, D.C. He completed his residency at Medstar Georgetown University Hospital and a surgical sports medicine fellowship at Cleveland Clinic. He is a member of the American Academy of Orthopaedic Surgeons.

 Scott Webb (Host): ACL injuries are common in athletes and even weekend warriors. And my guest today is here to tell us about the ACL, the various treatment options, and how we can prevent ACL injuries as much as possible anyway. I'm joined today by Dr. Joseph Rabe. He's an orthopedic surgeon with Summa Health. This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb. Doctor, it's so nice to have you here. We were just kind of laughing a little bit anyway about how common ACL injuries are, whether it's teen athletes or 50-year-olds playing pickleball, it seems like it's happening a lot lately. So, let's start with the most basic ones here. What is the ACL? Where is it located? And what's its role in the body?

Dr. Joseph L Rabe: You know, the ACL, or the anterior cruciate ligament, is one of the main ligaments in the knee. You know, it's located in the very center and connects the thigh bone or the femur to the shin bone. Essentially, its primary role is trying to provide stability to the knee by preventing the tibia from sliding too far forward relative to the femur. It also has a certain amount of rotational control that it lends itself to the knee. And because of this, it's crucial in stabilizing the knee, especially for activities that have sudden changes in direction, jumping, pitting, cutting, stuff like that.

Host: Yeah. We were saying pickleball, but of course, soccer, basketball, other sports as well. Let's talk about that, some of the leading causes of ACL injuries. You know, so my 50-year-old friends, I tell them, "Well, you tore your ACL because you're, you know, 50 and you're going at it way too hard." But does your knee know that it's 50, you know, or is it just the nature of the types of sports and the different movements?

Dr. Joseph L Rabe: There's a few kind of most common ways that are talked about, you know, sudden changes in direction, cutting, pivoting type of thing. The classical is non-contact pivoting injury. But a lot of times, it's associated with, you know, jumping and landing, especially landing awkwardly. Females are much more common to have these type of injuries just to some of their underlying mechanics. And so, that's a big push, and especially in like grade schools, high school, is to teach some of that stuff to kids. But it can be due to muscular imbalance, weakness, certain anatomic factors, previous injuries, stuff like that.

Host: Sure. Yeah, we actually did PT with our daughter to try to teach her how to do some of these things to land properly in basketball, but also just sort of rebalance her body a little bit. I can't remember all the specifics. But basically, as you were saying, it's more common in females, especially younger female athletes, that just the way they're built, the way they're designed, the way they jump, all of that. So, we try to prevent ACL injuries in her, for her. And so far, knock on fake wood, you know, so good. Do you recommend that? Do you recommend people sort of try to get out in front of it just a little bit? 

Dr. Joseph L Rabe: You know, I do give that to people, especially like you talked about the young soccer player, the female soccer players, female basketball players who have ruptured their other side and have already seen me, had the whole surgery stuff. You know, as they're starting to get back, I talk to them very much about the jump mechanics and getting into some of these programs or continuing with their physical therapist, trying to prevent it from happening on the other side, because it's such a common injury with those people.

Host: Yeah, it sure is. And having seen like professional athletes suffer ACL tears, you know, on the field or on the courts, it seems really painful. And it seems usually that it's pretty obvious that something serious has happened to the knee. Do folks know? Do they hear a noise, a pop or, you know, can they walk at all? Like what are the signs basically that they've torn their ACL?

Dr. Joseph L Rabe: Yeah, I agree. It's not subtle. Most people do talk about hearing some type of or feeling some type of audible pop. Pretty instantly, they go down, sudden pain, swelling within the knee occurs pretty quickly, usually within the hour. And they may feel, you know, even right away that just any type of movement, not straight line, walking to and from, that they get a sense that their knees are unstable, it's going to give way or buckle on them. 

Host: You know, some injuries, like my daughter has a torn labrum, but she could basically just stop playing softball and just continue to play basketball and was told basically through physical therapy, you know, that she'll be fine as long as she doesn't try to play competitive softball anymore. And she may consider that option, but I'm guessing with ACLs, , especially if someone is any kind of athlete, wants to continue to be an athlete, they really can't count on those things healing themselves, right?

Dr. Joseph L Rabe: Now, it's unfortunately not going to heal itself. You don't need an ACL for daily life, kind of like you're describing. Certainly, straight line stuff, walking, even jogging, some people do just fine. Maybe upwards of 30% of people are "copers", meaning that they are fine without an ACL, it's hard to judge who those people are. But really, for any type of explosive or athletic movement, you need that ACL, otherwise people will feel that their knee continues to buckle on them.

Host: For sure. Yeah. So, I'm guessing it's imaging, probably patient history and imaging, but how do you diagnose and treat ACL injuries?

Dr. Joseph L Rabe: Even some simple kind of exam maneuvers can give you a pretty good sense or concern that they did tear their ACL. Almost everyone gets an MRI to kind of confirm that diagnosis, check and see if there's meniscus tears, any other type of cartilage lesions, stuff like that. Treatment there kind of goes on to, like we talked about, who's the person. You know, if it's 65-year-old, maybe it's okay. They're fine with straight line stuff. They can get back to doing things with just physical therapy and bracing and things like that. The younger, healthier people, you know, it's almost always some type of surgical intervention.

Host: Yeah. And we talk about the surgery, you know, I know that seems like some folks when they tear things in their knees, they tear more than one thing. But staying focused just with the ACL and folks who've had surgery, what's the recovery process? It seems to me that I hear that it's somewhere between nine and 12 months, but maybe that varies?

Dr. Joseph L Rabe: Yeah, nine to 12 months. And that's not that you're bedbound for, you know, that entire time . In general, people were trying to get back their full range of motion within the first few weeks, getting back to their activities of daily life by six weeks, straight line jogging stuff starts at around three months, as long as they're progressing well. And then, you know, basic cutting, pivoting five, six months. And then, full return to the field is nine months. And a lot of times I'm holding people back from that six to nine-month time period, because it's not that they don't feel ready. It's that the graft that we use to reconstruct the ACL just isn't ready yet. It needs time to fully mature.

Host: Sure. Yeah. And I'm sure that there's mental side of this as well. I live outside Chicago, and Derek Rose, you know, suffered catastrophic knee injury. And it really seemed to me that even though he was physically cleared to play, that it took him a long time to be mentally ready to play again. So, let's talk a little bit about that. So once reconstructed, sounds like folks, most folks can return to sports. And, you know, are they more likely to tear the same ACL again? Are they more likely to tear the other ACL, because they're sort of doing things a little differently? And then, I would love you to get into kind of the mental part of that, of just trusting the doctor, trusting the knee that it's going to be okay.

Dr. Joseph L Rabe: Those are great questions. In general, I would say that the re-rupture rate is somewhere about 5-10% for the same knee. Obviously, certain people are much more predisposed to that, like the young, very ligamentously lax, double jointed female who's In competitive soccer year round, you know, re-rupture rates can probably be as high as 20% or so. But I agree, a mental portion is a huge issue in how to get people to return. You know, I can tell them that their knee feels stable, that their ligaments or that their muscles feel strong, their physical therapist has cleared them, but mentally they're just not ready to run the risk of going through this process again. And it is a long process. I mean, the time from injury to surgery on average is somewhere like a month and a half, because they need to get the range of motion back. The full recovery can be a year. And, you know, some people aren't willing to push that. So, it's very difficult.

Host: Yeah. And I've noticed that girls that my daughter plays against who had ACL injuries and had them repaired, it's like they'll start the game without a brace on. And then, about halfway through, I'll notice they put the brace on, and it makes me wonder, you know, is it the knee that's bothering them, or is it more sort of psychosomatic? Is it kind of in their heads a little bit, that feeling of, "I should probably put my brace on. I'll probably be better off if I wear my brace"? And I feel like that's a big part of this is just, you know, trusting the surgeon, trusting the knee, trusting everything that they've done. And as you say, medically, they might be ready after nine months, but it might take them a year or more until they're really mentally ready, right?

Dr. Joseph L Rabe: Yeah, exactly. I feel like sometimes I see him back at nine months, and I'm basically like, "You know, the therapist and I have talked, you're cleared. Your knee looks great." And they will get back to playing basketball, but they're like, "You know what? I'm just gonna start playing like 10 minutes and then I'll see how I do with that. And maybe I'll bump it up to 20 minutes," which is fine. And I agree that I think a lot of that is just the mental component. You know, a lot of people ask me, do they need a brace? And I tell them that there's no studies that show that a brace is going to help you from re-rupturing it again or prevent anything. But I do think it lends a very strong kind of mental security blanket that they have or that they're doing everything possible to try and prevent this from happening again.

Host: Yeah, it's kind of like a whoopee in a way, you know, those things that we all had as kids, right? Our favorite stuffed animal or blanket, whatever it is. This has been really educational. Good stuff today. I just want to finish up. We touched on it a little bit earlier, but what are your best recommendations anyway, to try to prevent ACL injuries? Besides, of course, well, just don't play sports or don't play pickleball when you're 50 or, you know...

Dr. Joseph L Rabe: Yeah. I mean as much as possible, we kind of touched on it already but for the young female athletes, I wish there was more education out there, especially like the jump chain that you talked about, helping them understand the things that they need to do to at least minimize their risks, especially in the soccer players, the basketball players, stuff like that.
 Skiers, people like that, you know, teaching them how to fall correctly so that their skis don't get tied up underneath them and put their legs in awkward angles. But there isn't necessarily a foolproof method to help prevent these from happening. You are active, it is a certain risk, no matter what age you are.

Host: For sure. And we hope that podcasts like this help to educate folks, as you say, spread the word, that there are ways to teach young athletes, especially how to jump and land properly, as you say, with skiers, how to fall properly, right? Like, that's a whole thing. It's a whole science and probably a separate podcast. But for today, thank you so much.

Dr. Joseph L Rabe: Of course. Thank you very much for having me. I appreciate it. 

Host: And for more information, go to summahealth.org/orthopedic. And if you enjoyed this episode of Healthy Vitals, we'd love it if you'd leave us a review. Your review helps others find our educational content. I'm Scott Webb. Thanks for listening, and we'll talk again next time.