FanPost

The Anterior Cruciate Ligament: A Users Guide

Kim Klement-USA TODAY Sports

We need a distraction. So here it is: my description of Marcus Stroman's ACL repair and the likely time-line for his return. Skip to the bottom of you don't care for the details.

An FYI: I'm talking about surgery of the knee in this one. I've left out the surgical aspects of opening the joint etc: I understand that not everyone wants to know about the incisions and so on. But still, there's no way to discuss the ACL repair without getting into that joint to some degree. So what follows will contain some description of surgical procedure and stuff. Sorry about that if it makes you squeamish. There are no images of surgeries or open wounds because even I find that stuff a touch grody to look at.

Also, as before, the disclaimer stands: If an orthopaedic surgeon or anyone with greater knowledge of the subject reads this, please weigh in with corrections and embellishments. If you must sue me for infringing your copyright, well you'll get nothing because that's what I have. As ever, a simple cease and desist will be sufficient to get me to stop stepping on your feet.

So, What's an ACL and Do I Have One?

Well, the anterior cruciate ligament is a ligament of the knee. It serves to keep the tibia (your shin bone) from sliding out in front of your femur (your thigh). It's not the only cruciate ligament in there. There's the Posterior Cruciate Ligament (PCL), too. These two are known as "cruciate" (which means "cross") since they make an "X" figure together, as they run diagonally within the knee. One in front (the ACL) and one in back (the PCL). And yes, you DO have an ACL. You have two of them, unless you're really unlucky, one in each knee.

The ACL is probably the most damaged support structure in the knee, if not the whole leg. Its right out there stopping pretty much all of your weight as you stride and has to deal with momentum shifts that load the knee at all sorts of funny angles.

What Did Marcus Stroman Do to His ACL?

Marcus Stroman literally ran into trouble. He stopped, probably from full speed, planting his foot hard and likely twisting hard. If he'd jumped into that landing it would have made it worse. I did something very similar but, rather than tear the ACL, I ruptured the ACL's footprint in the tibial head with a big chunk of bone and associated bone chips coming free. What I did is known as an "avulsion". What Stroman did is known as "shredding your ACL and needing surgery to fix it". Of the two injuries, you'd way rather have had him avulse the bone. The ligament would be intact (though likely strained) and surgery might have been avoided. Wherever possible, avoid joint surgery: the chances of osteo-arthritis (OA) are nearly 100% from joint surgery and the associated surgical scar tissue can cause you no end of trouble as it interferes with the normal, smooth function of the knee. With an avulsion you cast or splint the leg and keep it in good position for the bone to sit down onto where it came from. Leave it alone for a few weeks and it all heals up. Shredding it, though? Yeah. Not so easy. That gets a grade. A Grade One tear and you get the rest and rehab. A Grade Two tear and you get the "maybe. Lets try it with rest, approach". A Grade Three? Yeah, that's Our Boy, Stroman. He gets a date with a surgeon.

Now We Need Surgery, eh? Bummer

Dang it. Now we gotta rebuild the ligament. So, when you shred the ACL you often do more damage than just that. But, if you're lucky you don't have a concurrent medial collateral ligament tear or lateral meniscus tear (Saunders did his meniscus: more on that if interest is there). Nothing said so far indicates that Stroman has any of these problems. But it's still not simple. Like repair of the Ulnar Collateral Ligament (UCL) of the arm, you need a graft. And where that graft comes from is hotly debated, especially in high level athletes. You can use a cadaver graft (an allograft: don't be grossed out. They are sterile and work well. Research indicates that there is virtually no difference between success of allo vs auto grafts) or an autograft (piece of tendon from the patient's own body). Right now, world wide, the graft of choice is the ever popular hamstring autograft (the hammy's a popular choices for ligament replacement surgeries: you have more than one per leg, they attach to small stabilizing muscles that can be compensated for, and they are long and durable). However, North American surgeons are doing something slightly different.

Instead of using one of the hamstrings (either of the semitendonosis or semimembranosis hamstring) surgeons here often opt for the patellar tendon. There's a reason and it's not just "because we want to be different". See, in order to use a hamstring for this repair you have to drill holes into the ACL's footprint in the tibia and femur, right down to the marrow and embed your graft into that. The marrow MUST be accessed in order to provide nutrients for the graft. Position of the graft, mechanism of connection to the bone (either screws and washers, bio-absorbable fixture, or some other device), and length of graft all contribute to the success of the surgery. There are many variables.

However, with the middle third of the patellar tendon used, you use a shorter, thicker graft with bone on the ends. Rather than attempt to affix the soft hamstring tendon to bone you instead affix bone to bone. In a way, you mock-up the avulsion of the ACL and have bone healing into bone. This has proven to be a better surgery for athletes. The healing is quicker in some people (especially the young ones), much less chance of a fixture device ripping loose, and the patellar tendon isn't as likely to stretch and create a loose knee as is the hamstring. Along the way, the surgeon will examine and repair the MCL, meniscus, and Anterior Lateral Ligament (ALL) too, if deemed needed.

They Wanted Him To Go To Rehab

So, it's a brace and crutches for the young man. It's a pretty strict and aggressive regiment for him from here and it takes anywhere from 6-12 months to return to baseball. Barring associated MCL or meniscus injury he should be on the shorter end of the spectrum. Now, as I said, its an aggressive process. Once upon a time they treated you real careful post op. Not so much any more. Here's the process:


2 Days Post-Op: 90 degrees of knee flexion with rotation and full extension. So there he is on his bike at day 2-ish. Yeah. That hurt to look at. Its in an effort to reduce the swelling and promote blood flow.

7-10 Days: full knee extension, quad strengthening exercise. Core work.

2-3 weeks: progress to full weight-bearing, and hope to get the brace off full time.

5-6 weeks: weight bearing soft impact drills and obtain 120-130 degrees of joint movement.

10 weeks: strength work. Lots of it. Plyometrics begin.

4-6 months: Advancement to full exercise and a return to full activity

So the kid's probably right around weight bearing with impact drills right now. He's walking and pedalling his stationary bike with pressure on the pedals and weight training in the pool. He's got his eye set on strengthening work and will be attempting to keep from getting lopsided as his uninjured right leg is far stronger than his injured left. He's young and healing bone: a young person's bone is more flexible and has a higher cartilage content. The upshot is that young people repair bone much faster than us old folks. So, all going well, he could, in theory, make his return right around the end of August, maybe early September if he has no setbacks. He's over the infection hurdle. He's onto rebuilding strength. So far, so good.

From the looks of the starting pitching at this point, we sure could use him.

Editor's Note: This is a FanPost written by a reader and member of Bluebird Banter. It was not commissioned by the editors and is not necessarily reflective of the opinions of Bluebird Banter or SB Nation.