Anterior Cruciate Ligament Injury of the Knee - Michael Schutte, MD

Sechrest: Hello I'm Dr. Randale Sechrest. I'm the host on eOrthopodTV. Today we're talking with Michael Schutte. Dr. Schutte is an orthopedic surgeon in Missoula, MT at Norther Rockies Orthopedic Specialists. Dr. Schutte did his medical school training at Louisiana State University. He then returned to Louisiana State University where he completed orthopedics and did a sports medicine fellowship at the Cleveland Clinic. Today we're going to be talking about anterior cruciate ligament injuries of the knee. Good day Dr. Schutte.

Schutte: Good day.

Sechrest: Thanks for joining us. I understand that you are a sports medicine specialist and most of your practice or a large portion of your practice is devoted to the treatment of knee injuries and specifically ligament injuries such as anterior cruciate ligament injuries.

Schutte: Thats right.

Sechrest: And again, that seems to me to be a fairly common injury that a lot of athletes, and for that matter a lot of non athletes suffer. It seems to me that that injury has become more common as the population has become more and more active with the weekend warriors and people involved in all sorts of sporting activities.

Schutte: That's correct. I mean, it's very prevalent in the high school population, it's very prevalent in the club athletes, sport athletes and very prevalent in what I call occupational athletes.

Sechrest: Do you think that we're seeing actually more of these injuries, or do you think we are just getting better at diagnosing them, or is the incidents of those injuries actually increased?

Schutte: I think the incidence is probably stable, it's just that the diagnosis is better and if the incidence of fluctuating, it's probably fluctuating based on a number of individuals who are actually participating. For example in the state of Montana the number of high school sports has gone from three to now ten in the last 25 years. So there's a lot more individuals at the high school that will participate in athletics, so the incidence is going to be higher just from the number of participants.

Sechrest: Now is there any specific sports that you find that this injury is more prevalent in or does it pretty much spread over the whole.

Schutte: Well, when it comes to acceleration, deceleration ball sports. The number one high risk sport is soccer. There are more girls tearing they're anterior cruciate ligament in soccer than for example in boys basketball and boys football.

Sechrest: Now and I said the acceleration/deceleration injury. Can you explain that? I mean, what exactly type of an injury is that?

Schutte: It's really an injury where the athlete is moving at high speed running, changes direction. So like in football it's a wide receiver running a route and hit the plan change. A basketball player does a jump stop. Soccer, it's a similar type change direction maneuver. The majority of the time the injury occurs it's a non contact injury. Nobody hits the athlete, the athlete changes direction and there's an incoordination of movement in the lower extremity and the anterior cruciate ligament is torn.

Sechrest: So is it more when the athlete plants the foot. I mean, what happens with the knee? Is it a rotation injury? Is it a hyperextension injury or just overloading and it just overcomes the anterior cruciate?

Schutte: It's a combination of both and there has been emphasis in the last few years in individuals landing patterns, how they land. And some athletes just don't land properly. They land with their knees kind of in and their foot externally rotated which is the beginning of a wpial valgus rotational tear in the anterior cruciate ligament. A good way to think about it is like when a skier catches his ski tip and the foot just rotates out, that's one mechanism. The other mechanism is the leg hyperextends, you know it bends in a direction that it should not. That's when, you know, you mentioned that term hyperextension and those are the two basic mechanisms that are recognized to anterior cruciate ligament .

Sechrest: I probably ought to stop a moment and go back a little bit. You know, we continue to talk about anterior cruciate ligament but I suspect a lot of our listeners really don't know where the anterior cruciate ligament is. Can you sort of explain the anatomy we're talking about? I mean what are we talking about when we use the term anterior cruciate ligament?

Schutte: Well, it's very basic, the human knee has two condyles. It has a medial femoral condyle and a lateral femoral condyle and in the middle is a notch area. That's the location of the cruciate ligaments are located. There's a posterior cruciate ligament which is in the back of the knee. The anterior cruciate ligament is in the front. So the anterior cruciate ligament is torn, that ligament that's running from the femur and in the back down more to the front of the knee onto the tibia is disrupted. So, it's location is in the center of the knee. It's not a structure that the patient can actually feel, they can't put their hands on it, like the knee cap or the patella.

Sechrest: And when this person, say an athlete, undergoes an injury, what should make them suspicious that they've injured their anterior cruciate ligament?

Schutte: Well, there's an entity called a song of a torn anterior cruciate ligament.

Sechrest: Ah, the song of the anterior cruciate ligament?

Schutte: The song. So an athlete comes to see you, the song they sing is. I was participating in a sport. I had a sudden event. I was not able to continue to participate. I came down on my leg, either felt a pop or heard a pop. I had terrible pain, it may have only lasted a few seconds and the athlete realizes, I can't continue. You know, they're down on the field, somebody has to help them up. They're usually helped off to the side and it's that combination of the experiences that leads one to believe, well, one of the high likelihood diagnoses is the anterior cruciate ligament is torn.

Sechrest: When the athlete can't continue, is this because of pain? Is it because the knee is unstable at that point, or just feels wobbly or what?

Schutte: It could be a combination of all of those. Some individuals don't feel much pain but they sense it when they put weight on their leg, that initial first step after the injury. You know, the leg feels different, it feels wobbly, they are not comfortable. Other individuals have a lot of pain initially and they won't put their foot down. Now some individuals in the heat of battle, they go to the sidelines, they want to come back right away. And, they will go back on the field if it's unrecognized and lots of times we'll have second even where they maneuver and the plant and they cut and the knee buckles and gives way and then they realize oh, this is not normal, I can't go on. They have a repeat pain event and so it's basically those three types of scenarios that lead the athlete to believe, okay this is not just a little simple ding or bump to my knee, I've got a problem.

Sechrest: And when that patient shows up in your office for example and you first confront, I'm assuming you do every day, you probably see one of these every day in your office. An athlete that comes in and presents with an anterior cruciate ligament. What's the process at that point? What do you do and how do you make the diagnosis?

Schutte: First of all the most important thing initially is that the patient needs to feel that there's a certain confidence in the diagnosis so I examine both the knees. And, most the time the patient can feel there's a difference in the looseness, unstable injured knee and the normal knee. And there's a certain amount of education that the patients understand, well this is not like a regular, like an ankle ligament injury where if you just wrap the knee up and go on crutches for a few days it will be fine, the knee will tighten up. That doesn't happen. And, because lots of times there are other injuries inside the knee, between 40 and 60% of the time there could be a meniscus tear, there could be a chondral fracture which is a damage to the surface of the bones that can occur at the time of the injury and it can be bone contusions either to the tibia or to the femur at the time of the subluxation event. An MRI is very helpful in what I call staging the knee. So, when I usually see the patient I describe the injury, describe the potential for other injuries inside the knee and there's a consideration of, okay well what are they doing? Are they out of season, in season? Is this an occupational injury? How does it affect their ability to work and it sort of shapes what's going to happen like within the first two weeks. But, essentially an MRI will be obtained and they'll start on what I call acute phase rehab. Acute phase rehab is designed to try to minimize the stiffness, the decondition that will occur from having the injury in itself. So every day that goes by, the patient is not weight bearing, the knee is not moving, the whole extremity is weakening and that is an adverse factor in terms of, let's say getting ready to have the operation if the decision is made to go that way. So I'll start in acute phase rehabilitation which means that the rehab team will start working on range of motion, preliminary strength training and helping with the patient to gain some basic confidence in the knee, that they can do some things and the knee will actually tolerate it. And, usually within the first 7-10 days the swelling goes down, the acute pain settles down, they start to get their motion back and many patient's can start to walk without a limp.

Sechrest: And at that point what sort of restrictions do you put on them. I mean if the patient is two weeks out let's say, walking without a limp and says gosh, I'd like to go back and play. What do you do?

Schutte: Well what usually happens is, once this injury occurs, patients usually fall into a couple of groups. There are some patients whose knees do not buckle but they have a tremendous amount of apprehension. They are aware that the knee is different so they are careful. They watch how they walk, they watch how they put their foot down so they won't buckle again and they have these little bitty micro buckling events when they're just walking around, they can tell the knee's not right and it bothers them. At the other end of the spectrum, you have patients that totally forget about their knee. Once they get their motion back, the stiffness goes away, the pain swelling goes away, they walk around like nothing happened and all of a sudden they will step off a curb and all of a sudden the knee buckles and that disturbs them. It's painful, they don't' like it and they go, well I thought I was better. And patient's have that phenomenon, they experience that along a spectrum. So what usually happens is the patient's, I tell them, look, no matter which group you fall into, you can't fun, you can't jump, you can't engage in any type of twisting quick movements. You need to be careful that if you can't see the ground, the ground's uneven, the ground's slippery, all the circumstances potentially put you at risk to have a buckling event. And the whole goal of initial treatment is to allow the knee to recover some of it's normal capacity without having another buckling event which would be a set back.

Sechrest: But that 18-year-old soccer player, if he showed up two weeks later and says you know Dr. Schutte my knee feels great and I think that I can go back and play soccer and said I want to get one of those braces and go back and play soccer. That is what I am hearing you say is not an option for that patient at that point.

Schutte: A patient that is two weeks from an acute injury will surely have a deconditioned leg. Now whether a patient can actually appreciate that their leg is weakness, most patient's can't. But once you show them they have a tone shift, the leg is smaller, they appreciate, well yes I am underpowered, and that is why the risk factor is with premature return in terms of having another buckling event. So yes you could put a brace on and it may make them feel more stable, but if they are weak then they are at risk to have another event. So, at two weeks from an injury, yeah there are some athletes out there that could hide it and kind of cheat, but they would go back and play prematurely at a high risk which would not be acceptable.

Sechrest: So let's say that the patient comes back at two weeks and we're trying to make a decision. At that point, if this patient says, you know, I think I want to have surgery, a couple of things. One is how do we prepare that patient for surgery? And what's the time line? I mean, when are we going to say let's schedule surgery for six weeks, let's schedule surgery tomorrow, let's schedule surgery for six months. How do you make that decision?

Schutte: Well it's really basically going to come down to usually by two weeks after the injury you will have the MO information. So you'll know whether the patient has a meniscus tear or any other injuries inside the knee, which may affect the timing of the surgery. Now for example, if the patient has no meniscus tears and basically it's an isolated injury and in the acute phase rehabilitation the patient has return of range of motion, they can walk without a limp, they're able to strength train in a reasonable way so they regain strength back in their leg, then the timing of the surgery is really what I would call in relaxed mode. It's almost the patient's discretion. And for example there was some big family event they had to attend in two more weeks, well they could wait and I would basically tell them as long as you don't engage in any high risk behaviors, the outcome of the operation is the same whether we do the operation a week from now or three weeks from now and the patient has a discretion to decide one way or the other.

Sechrest: And you say three weeks, but what if that's an 18-year-old student who, it's October and he says you know, I'm going to be out of school for a week for example or two weeks, can I put this off till Christmas. I mean, is two months okay? Is three months okay do you think?

Schutte: It could be, but you see that's where all these variables comes in. For example, some athletes are multi sport so this athlete is already figuring, okay if I do it now will I be able to make my Spring sport, can I be ready in time. Also they want to start to try to compress time. Essentially if they are training well they have full motion and they're not going to engage in any risky behavior, yes they could wait longer, it could be three months, could be four months.

Sechrest: And, let's talk a little bit about the reconstruction. When you're preparing an athlete for anterior cruciate reconstruction, anything in particular, specific that they should know prior to surgery? Anything that you have them do or avoid at that point before surgery?

Schutte: Well for the teenage athlete, probably the most important thing for them to understand is that rehabilitation after the surgery is an integral part of the overall outcome. So you see a part of my approach to them is they start acute phase rehab. That allows them to get used to oh, this is what organized structured rehabilitation is and that gets them ready to have the operation. But then after the operation is over it's a continual of that so they're familiar with it. They understand, okay, I have to do this every day and they understand that what they really want is a high performance leg. What they don't understand is what it's going to take them to get there and part of that is pre-surgical education where it's important that the surgeon tells the patient now look, once the operation is over. In my world, there's three phases of the rehabilitation. Phase one, the patient learns to walk without a crutch, gets range of motion and starts to develop muscle control in their leg so that they can walk without a limp and become independent. Once they get finished with that phase which may take 3-6 weeks, then the next phase is they start to develop what I call a medium performance leg. They can walk during the day, get up on chairs, get out of cars. That takes a certain amount of leg strength of body wight they must generate though strength training. And the third phase they develop what I call a high performance leg where they can actually have the ability to hop, jump and land and the leg can absorb multiples of body weight and be comfortable. And I explain it to them, now you know you can't get that in six weeks. You'd like to think that you could but that's not realistic. And the most important thing to understand they can only compress time to a certain degree. So they somewhat have a perspective on okay unless they have some unrealistic expectations on what's going to happen and I tell all of them at the first two weeks of the dog days, that's the hardest part. They're working on range of motion, the knee is angry from having the operation, they have to overcome that. They have to make their knee move. I call it like a tug of war between the brain and the knee. When the rehab team and the surgeon help the patient understand look, we know this is not hard but it's very important that you reach these land marks such that between two and three weeks you have reasonable motion, you can ride the exercise bike, you are starting the strength training and they sort of come out of this phase and they realize, oh, I am getting better and they should know in advance, okay, what are their expectations at four week, six weeks so they know. Yeah, just because they become, let's say pain free at six weeks, can walk without a limp, somebody saw them walking around the street with regular clothes, they may not even know they had the operation. That doesn't mean they're ready to participate in a ball sport. You know, there's a lot more training that needs to be performed before they reach that point.

Sechrest: That's a very good description and it sounds to me like you really focus on education before the surgery to really sort of use that rehab time not only to get them ready for the surgery but really to get them understanding the seriousness of this and how serious you take rehab. Is that accurate?

Schutte: Well, the way I like to say it is nobody likes surprises, like I didn't know about that. Nobody likes that. And when you're dealing with teenagers and even really high expectation patients, these are the types of patient that tear their anterior cruciate ligaments, well they want to know, what's the deal here? And what I last say to them straight away at the very end of that educational is look, if you want a Ferrari you have to build with Ferrari parts. In other words if you want to have a high performance extremity, there's a certain amount of high performance training you must do. We will show you how to do it, we will show you what you have to do. But that part I cannot do for you and it's them understanding that it takes usually about three months before what I call a tone shift. Where the muscles in the legs have similar tone and it's only after that the leg starts to get big. Because lots of times the athlete will keep looking at their legs going, it's still small and I'll say well, it's supposed to be small. You're not at the point where it's supposed to get big and part of that is just helping them understand what the expectations are, what's realistic because a lot of disappointments along the way anyway and you want to try to minimize those disappointments.

Sechrest: Now this procedure, this day and age is done as an outpatient so you don't spend the night in the hospital.

Schutte: That's correct.

Sechrest: And when the patient leaves the recovery room, is discharged from the surgery center, what should they expect?

Schutte: If things have gone well, there's a pre-op appointment which usually occur within 5-7 days of the surgery. At the pre-op appointment the patient is advised of what's going to happen at th time of surgery. What's going to happen when they happen when they come to the surgery center and what's going to happen when they leave. So they know that when they leave they will be on crutches, they can put weight on their leg as they are able. Their leg will be locked straight in the brace. They'll have medications for pain and for nausea. They're going to have a knee wrap for icing their knee and their basically going to go from the discharge area in the surgery center to home or to a hotel and they're going to recline, they're going to prop their leg up and their going to rest and recover from the procedure because the very next day the rehab process starts and I see my patients usually the next day. I see them in rehab, the brace is removed. We kind of look at how their wound looks and the rehab team starts the process of moving that knee and the process of muscle reeducation.

Sechrest: Now we've gone over a lot of the important points about rehab. Let's talk a little bit about how long. I mean, can you sort of break down rehab from the standpoint of time segments and then I guess our goal is when is that athlete going to be able to return to unrestricted activity?

Schutte: Well if you look at it in a very short time frame, different individuals have a different biologic response to the procedure. That's why I see patients the first 24 hours after. Some patients have very little pain and very little swelling. Those patient's will move faster and get on the exercise bike. Now you have to be able to bend your knee up to about 110° so if that's 90° you've got to go a little bit more than that before you go round and round on the bike and all the patients know that that's one of the key land marks to improve. Because, once you get on the bike and go round and round and you're just using the bike for motion, how hard you push doesn't matter. That really helps the knee to not be stiff and to gain motion. It's a valuable tool to prevent stiffness that can occur like in the first two weeks in a patient whose been laying around. But usually within 2-3 weeks, the patient should have enough motion, enough leg strength that they can be crutch free. But the ground rule is, no limping allowed and a patient may go through a phase where they do not limp at all during the day but later in the evening when their muscle's fatigued, they start to limp again and I tell them that if their family members see them limping they just need to get a crutch and that's just because of leg fatigue. It doesn't mean that they have gone backwards and they may transition through that phase such that they can go all day and so in any event between three weeks, four weeks, the patient is usually crutch free, they can walk during the day, they actually look pretty good but they don't have a high performance leg. They know that if they walk long enough, they walk for an hour in a row, well then their knee may start aching and that's when they enter the phase where they have good motion, they're not working on motion any more. It's all about leg strength and endurance in their musculature so they can actually go the distance during the day.

Sechrest: And so how long does that rehab continue? I mean, is this a six month process, nine month process? Once they enter that phase where they're working on strength and trying to allow the graft to heal, I guess how long does the graft need to heal before you're willing to turn them loose to actually participate in cutting sports and how long do they have to rehab that leg before you're comfortable allowing them to do that.

Schutte: Well it just so happens that the muscle recovery is such that by the time the muscle is ready for them to do landing maneuvers, the graft is usually ready to manage that stress. You know in the animal studies the graft tends to go through a weakened phase as the graft revascularizes cause once the graft goes in, the graft's on the table, it goes into the knee and there's no blood supply. The blood supply has to come into, it's called revascularization. When it's in between three and five months, that process is really maturing such that beyond five, six months, the graft is strong enough that it can start to take higher loads. The real issue is, is the leg strong enough to manage body weight loads. As an athlete that's running, the leg will be absorbing 2.5 times the body weight at heel strength. The athletes jumped as high as he can and lands on one leg. Well, the leg can be absorbing 3-4 times body weight and what has to happen is the leg has to decelerate the body weight. That requires eccentric muscle strength. Now when the muscle's are deconditioned, the athlete is weaker, that's one of the biggest losses in the ability to musculature and decelerate. So, usually between around four months to five months, most athletes are ready to run on smooth surfaces in a straight line without cutting and usually that's based on how strong that leg is with muscle testing like on a leg pressing machine. How much can they move comfortably against their body weight, how well can they hop. Most patient's start what I call landing drills around three months. So, once they get to what I call level two landing drills, well for example level one landing drill means their just hopping in place, two leg/one leg so they get some vertical maneuver. When they gain horizontal distance, hop away, etc., that's more of a level two maneuver. Once they can do that repetitively day after day and are comfortable then they're ready to run or ready to start jogging and return to running. Some athletes are very motivated to start running and they want to know how soon they can do it and that's usually the time frame, usually it's around four months in my world. Now, when does an athlete have a true high performance leg. In my experience only about 10% of athletes can have a true high performance leg in seven months. I tell my patients no matter what you read in the newspapers. The average for me for most patients is between eight, nine, ten months. They can have a true high performance leg. There's a small percentage of patients in a smaller grouping that actually takes longer than that. And some patients just go through a phase of, I'm tired of all this. Between three, four and five months some patients get tired of it. They just stop training, they figure well I'm good enough, it'll just happen. Well it generally doesn't happen. So, the short of it is, it takes about an average of eight or nine months to have a true high performance leg. Eccentric strength comparable to the other side, size about the same and the athlete is fully recovered and has their agility back and psychologically feels very comfortable with their leg and doing vigorous activities.

Sechrest: Do you have any thoughts on things that patients should look out for? I mean what's the down side to having these types of surgery? What are the potential complications from anterior cruciate, what do you fear the most?

Schutte: Well, if you talk about what's common, what' common is knee stiffness. Nobody likes a stiff knee and what knee surgery is about is finding a knee that is very mobile, has good motion but stable. Nobody likes a stable knee that's stiff and nobody likes a still knee that's stable. So, that's why there has to be a certain amount of energy put into taking the knee to the operating room when the knee is ready. So like right after an injury, if the patient only has 40° of knee motion, the knee is hardly moving, that knee is not ready to have the operation because what I fear is stiffness and about 20% of patient's who have some struggle with stiffness but in the era of you starting with a patient with the knee out straight, they start moving the very next day, knee stiffness is not very common in my practice. In some patients what's the worst fear, the knee is so stiff it has to be manipulated. Well, I generally don't have to manipulate knees, that generally doesn't happen. That's historically one of the complications of the operation and that's basically why when you start thinking about stiffness, that's why you talk about timing of the surgery, most of the time the injury occurs, three's a recovery phase from the injury before you put the surgery right on top of it. So, you don't mix the surgical pain with the traumatic pain. The other complication is tendonitis where the graft is harvested and about 20% of patients have some pain where the graft is actually harvested from the front of the knee. Most of the time that pain tends to go away as the leg strength gets better and better and it's more appropriate based on the body weight. But, there's still some patients over time that do have some lingering pain and there's a very small percentage of patients maybe 1 or 2% who have chronic donor pain in front of their knee. The other complication is infection, it's less than 1%. Mostly it's because of antibiotics which are given at the time of surgery and the fact that the operation's done orthoscopically, there's a lot of fluid being washed through the knee. The other complication is patella fracture, when the block is taken out of the patella, some patients can get a crack at one of the corners, it usually occurs between three and five months. It doesn't require another operation and you seem to recognize and modify the rehab program and those are the real complications around the knee. There are other complications related to anesthesia, there's always a small risk of like a blood clot, those types of complications. But the complication in regards to the knee itself or stiffness, tendonitis, infection and the last one I haven't mentioned is graft failure. So, what happens if the graft fails. If the graft fails and it gets loose again. How do they know? Well, the surgeon usually can examine the knee sequentially after the operation and if the patient starts to say well, my knee doesn't feel right, it feels different and the surgeon examines the knee, has been examining the knee, they can usually tell if the laxity starts to change. Of course, if the knee can be shifted out of place, well the graft has failed and of course that's a catastrophic complication because the procedure has been essentially no value.

Sechrest: And revision of the graft failure? I mean that is possible just to go back in and redo the operation?

Schutte: That is possible, but of course if you use the patient's own patella tendon, most revisions are done without a graft tissue.

Sechrest: Can you think of anytying that we haven't covered that you feel like would be very useful information for anyone who is faced with the decision about whether to have anterior cruciate ligament reconstruction surgery or not.

Schutte: Well I guess the question would be in a medical community, who should do it. And, what I would tell patient's is how many a surgeon does is a pretty good indicator and what kind of results he is having, if he does a lot of them his results are out there. There __????__ left in medicine and how the operation is done and what actually occurs in the operating room has a big impact in the overall outcome and it's usually good advice for the patient to inquire about that and to inquire how much the surgeon actually looks into the post surgical recovery. How often is the patient seen by the surgeon after the operation? Because that can vary tremendously. In my practice, I see the patients every 2-3 weeks for the first three months and every 4-6 weeks until they're finished because that's really in a time frame to allow me to look at what's happening with recovery of their leg and dig out a rehabilitation process and those types of questionings about how many post-op appointments, how often is the patient seen by the doctor and how tight is the rehab program.

Sechrest: So to summarize, look for a surgeon who does these a lot and does them well. Look for a surgeon that has good outcomes, if you can find outcomes for the surgeon, if he does a lot and the outcomes are good then that's the surgeon you want to go with and then the third thing is his don't underestimate the importance of rehabilitation and pick a surgeon who really focuses on paying attention to rehabilitation both before surgery and after surgery. Is that accurate?

Schutte: That's correct.

Sechrest: Well thank you, thanks for joining us today.

Schutte: Well, I'm glad to be here.

Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopedic topic, be sure to visit eOrthopod.com and if you're an orthopedic surgeon or health care provider interested in participating as a guest on eOrthopodTV, you'll also find instructions on how to apply to become a guest on the eOrthopodTV. Thanks for watching.