Facing a common twist of fate

“My knee kind of popped,” my daughter said one day late in January after volleyball practice. She’d jumped to spike a ball, landed awkwardly, fallen to the ground and had to be assisted off the court. Her leg was swollen and continued to swell. She was limping.

“Pop,” when referring to a knee, sounded ominous -- and so it proved to be. After an initial misdiagnosis, a series of doctors manipulated her leg this way and that way then crisply pronounced the dreaded words, “anterior cruciate ligament.” A subsequent MRI confirmed the diagnosis: the ACL, an important stabilizer of the knee joint, had been trashed as her leg hit the court.

It’s a common sports injury, especially among female athletes, and especially in these days of high intensity athletics among the young.

Once torn, the ACL doesn’t heal itself, and the knee joint is forever left less stable -- you can walk around on it but it’s apt to re-pop, especially if you do fancy things such as leap, abruptly decelerate or swivel to reach a ball -- moves common in sports such as soccer, basketball and volleyball.

Surgery isn’t inevitable. If a person is older and the most they do is stroll around gently (perhaps with some cycling and running thrown in), doctors and patients may opt to leave the knee alone. (Knee strength can be built up through physical therapy.) But they may have to curtail their activities, and they risk further damage to the joint, and arthritis.

A child who hasn’t finished growing may also need to wait.

But Renee is 15 and an avid, year-round athlete. Though the prospect was a drag, it was clear she’d need to have her knee surgically fixed -- and soon. Recovery can take six months to a year.

Now she has started the longest and most costly phase of recovery: physical therapy to get her left leg back to where it was, so that she can return to the volleyball court for her next varsity and club seasons. And -- athletics aside -- it would be nice if she could have the best left leg possible to help walk her through the next seven decades of her life.

Progress is slow. Her knee is scarred with several holes and a 2-inch incision, and underneath her flesh she is wounded in two places -- first, where the surgeon harvested a piece of tendon attached to her knee bone to fashion a new ligament, and second, where that ligament went in to replace the one that had ripped.

Renee was fortunate to have injured her ACL now and not in earlier decades when doctors immobilized the knee in a cast and waited many weeks before starting to rework it.

The movement has been toward more aggressive therapy: In the mid-1980s, researchers found that patients who went against doctor’s orders and worked their knees sooner did better, ultimately -- with less knee stiffness, more flexibility and stronger muscles.

The ligament giving my daughter such trouble is a short band of tissue running inside the knee between the thighbone and the shinbone. It’s crucial for knee stability: It stops the shinbone from sliding too far forward, and prevents the two bones from twisting relative to each other. Land from a jump with a too-straight knee, or twist the leg as you abruptly swivel, and the stress can rip or stretch it. Once damaged, it cannot be restitched.

An estimated 200,000 Americans annually, most of them dedicated athletes, tear an ACL, and between 60,000 to 75,000 of those injured will opt for surgical repair.

Women are especially prone to this injury. Although nobody quite knows why, theories abound: Women tend to bend less at the knee when they land or run, which may give the ligament extra stress.

Their muscles may not be as able to compensate for the stresses placed on the joint. Their knees may simply be laxer to begin with; the ligaments may be weaker, perhaps for hormonal reasons.

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The diagnosis

A year ago, I’d never even heard of the ACL. Now I’m running into ACL tears everywhere. My pal Patti. A close colleague. The buddy of a buddy. Even my mom, who ripped hers 20 years ago when she wandered into an auto shop and fell into a grease pit. If there’s a weak link in the human musculoskeletal system, the ACL appears to be it.

A month after Renee’s injury, we sat in the office of orthopedic surgeon Dr. Marc Samson, idly studying a colorful chart of sundry tendons and bones, an athlete tumbling to the ground and a disaster area of a knee described as the “unhappy triad” for its three torn structures: knee cartilage, ACL and another ligament, the MCL.

Samson delivered the expected but still-depressing news. The MRI showed there was a high likelihood Renee’s ACL was trashed, and that she’d probably also damaged her knee cartilage -- the meniscus. He’d stitch that meniscus if he could. But often the mends don’t take, which can mean arthritis down the road.

There were surgical options to consider. Renee could receive a tendon from an organ donor or one from her own body -- a sliver of tendon from her hamstring muscle, or a tendon linking her kneecap, the patella, to the shinbone. Samson recommended the patellar tendon graft; he said it provides the most reliable results. But it takes longer to heal than a cadaver graft, for obvious reasons: A new injury is created even as the original one mends.

March 25, she was under the knife. We scheduled the surgery for the Friday before spring break so she’d have a week to rest up before hobbling back to school on her crutches and leg brace. We arrived at the crack of dawn and waited our turn for the surgery, which would take about two hours. There is nothing fun about waiting for your child to come out of surgery as you turn over in your mind the possibility of some bad, freak event.

When the buzzer we’d been provided by the hospital staff went off, her father and I met Samson in the waiting room. The ACL had been torn right through. Surgery went great. No damage to the meniscus after all. Because she was a minor, we could sneak in to see her in the recovery room.

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Healing steps

No lolling about in a cast eating bonbons for Renee. Barely had she revived from the general anesthetic when she was walking the hospital floor on her crutches flanked by two physical therapists, a long black brace around her bandage-swathed leg to keep it straight. They even had her climb and descend the stairs.

Once home, a swift six hours after surgery’s start, the mollycoddling was also brief. A nice man had delivered a hulking surgical device with the look of an instrument of torture -- a continuous passive motion machine. It would bend and flex Renee’s leg to help her regain a full range of motion, and we were to crank up the angle of bending by 10 degrees each day. Renee was to put her leg in it for as many hours as she could. When she wasn’t doing that, she was to start -- right away -- doing leg drills to begin the long climb back to her original strength.

In the days that followed we went through prodigious quantities of party ice to keep the injury cool, and spent lots of time wrestling her in and out of the brace that would keep her leg straight when she walked and bendable when she was in the machine or doing certain exercises. (Whoever designed the fiddly adjustable pins on that brace needs a stern talking-to.) Three days after surgery, a pain pump delivering medicine to the surgical site was removed: It was the only time I saw my daughter turn ashen. The multiple inches of thin, clear tubing sliding out of her leg were just too reminiscent of some long, parasitic worm.

She was lucky: The post-surgery pain can be considerable, but she experienced little of it. A stash of Vicodin tablets she’d been prescribed went untouched.

Slightly more than a week after the surgery, she was off to school on her crutches, walking peg leg.

I cringed at the weight of her book bag.

Not long after, I watched as she went through her drills at Professional Orthopedic & Sports Care in Pasadena.

“It’s flabby, it’s dormant,” physical therapist Maureen Regan said, touching Renee’s quadriceps muscle as she manipulated Renee’s knee. “It comes back, but she’s just not been walking, she’s not been getting the impulses.”

The sleepiness of those muscles was evident as Renee walked gingerly to the parallel bars and began a drill of raising her left foot over a ball, lunging forward then stepping back again -- with deliberatemotions so that her leg could clearly relearn things she never had to think about before.

That was a few weeks ago. Renee is now taking physical therapy three times a week and doing a shopping list of exercises on the days she doesn’t go. Her brace lies abandoned on the back seat of my car, her crutches leaning against a wall on the front stoop of the house. Just last week, she learned she’d reached a recovery milestone: a full range of motion in her knee joint. Now comes phase two: building up her strength.

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The gritty details

Several things struck us as the weeks rolled by. One is the disconnect between what surgeons say she needs to get well -- physical therapy fast, and plenty of it -- and what her insurance gives her. No surprises there, perhaps.

We’ve experienced waits for appointments, a canceled appointment and limits on how many sessions she’ll get. Six weeks post-surgery, Renee finally had the first physical therapy session that was paid for through her plan. Because of that, we’ve opted to pay for extra sessions at another location, at a cost that will probably exceed $1,000. We are lucky we are able to do that.

We’ve also noticed a lack of doctor awareness. Initially, Renee’s then-pediatrician sent her off with instructions simply to rest up for a couple of weeks. Sixteen-year-old Will Dooley, another student who works out at Professional Orthopedic & Sports Care, said the same thing happened to him. His doctor said it wasn’t an ACL tear, and Dooley went back onto the soccer field -- popping his knee a second time. Either that time or the first, he damaged his meniscus as well.

This might have happened to us, but an orthopedic-surgeon acquaintance offered to sacrifice part of his Sunday to take a look at Renee’s knee and made a quick provisional diagnosis. We are grateful for that, and for other help he gave us in navigating the referral system.

It’s been a busy and not-fun experience filled with faxing, phone calls, waits for MRI approvals and knee-brace approvals, figuring out how to switch her medical group to get her the surgeon we wanted, endlessly scribbling instructions down on bits of paper and wondering if there was some crucial thing we were forgetting to do that would raise the risk of knee pain or disability down the road.

The main thing now is the future -- not just rehab, but figuring out how to lower the risk of another ACL tear, either to the grafted or the still-uninjured knee.

As awareness of this common injury increases, sports physicians and surgeons have been trying to devise preventive training, be it through learning better landing and pivoting skills or building muscle strength. Several programs have demonstrated success -- and we plan to investigate.

For Renee, giving up year-round volleyball is not an option.

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(BEGIN TEXT OF INFOBOX)

The vulnerable ACL

As more young athletes play sports year-round, the number of knee injuries--and the need to surgically repair them--is rising. One of the most common knee injuries involves damage to the anterior cruciate ligament. ACL injuries are most common in soccer, basketball, volleyball and other fast-paced sports that require rapid movement, jumping and quick changes in direction.

The knee and its ligaments

There are four main ligaments that keep the knee joint stable so that the shinbone (tibia) and thighbone (femur) remain in line with each other.

Anterior cruciate ligament

Injuries can range from stretches and strains to partial or complete tears.

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Preventing injuries

Several training programs have been designed to help lower the risk of ACL injuries. Here are some exercises from the Santa Monica PEP program, which was designed to reduce ACL injuries in soccer players.

1. Warm up

Jogging, running side-to-side and running backward prepare the muscles for exertion.

2. Stretching

Stretching muscles such as the hamstring (shown here), calf, quadriceps and inner thigh help prevent injury and improve flexibility and performance.

3. Strengthening

Exercises such as the walking lunge (shown here working the quadriceps) increase muscle strength. Other exercises target hamstring and calf muscles.

4. Plyometrics

Drills such as hopping laterally over a cone help build power, strength and speed. Landing with knees bent is important.

5. Agilities

Drills such as sprinting backward and forward between cones improve the stability of knee, ankle and hip joints.

6. Cool down

Allows tight muscles to stretch out and reduces soreness.

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Sources: Santa Monica Orthopaedic and Sports Medicine Research Foundation (www.aclprevent.com), Sportsmetrics USA program (www.sportsmetrics.net)