Dr. Richard Lehman, who is with the U.S. Sports Center for Medicine in St. Louis, has served as a team physician for three different NHL teams and has worked with professional athletes at all levels. Now that Robert Griffin III’s surgery on his lateral collateral ligament and anterior cruciate ligament is over, here’s what Lehman says the Redskins quarterback faces. The top part was added in case Griffin only needed to have his ACL repaired and not reconstructed. It makes a huge difference.
Q: If they just tightened the ACL, as some reports say, how much does that change things?
A: It tends much more towards just a lateral collateral so if you put some arthroscopic stitches in and you don’t have to reconstruct the ligament completely as opposed to let’s say 10 months or nine months or 11 months, whatever, it probably goes back to four to five months. He’ll have a much easier ride if he doesn’t have to have full reconstruction.
Q: If that’s case realistic to expect him to be ready for the season?
A: Yes. Because if it was an isolated lateral collateral ligament tear you have to figure three months, four months, the outside is six months. But it’s usually about three or four months. If you do an ACL repair and not do a reconstruction it’s usually about six weeks. If you just put some stitches in there and tighten it, which is something we do not infrequently, the healing time will fall under the window of the healing time of the lateral collateral. It would have to be beyond four to six months healing time to tack on and it doesn’t add problems with motion like a full reconstruction would. There’s not as many issues as far as quad atrophy. So it’s a much easier rehab.
Q: Would you still be concerned for issues down the road like arthritis? Or does that change it too?
A: No, I would be concerned. You still have the same issues in play. … Virtually everybody the clock starts ticking and there are degenerative changes in the joint so every time you re-injure that joint you re-up that a little bit and the breakdown in joint damage gets worse so you still have similar issues.
Q: Anything else we need to know?
A: The one thing that would be of interest is what did for lateral collateral. Did they graft it, did they repair it. That’s a key question.
Q: How does that change it?
A: If you repair the ligament your down time is less than if you have to reconstruct it so if you put some type of graft vs. just putting stitches in the ligament, then you’re probably looking at two months or three months vs. three months to four months. So you’ll knock off a month if you can just put stitches in the ligament and repair it. That will answer some questions in terms of down time.
Q: What’s the best case scenario for what they did?
A: That he had a repair of the lateral collateral so you actually sutured it back to the bone and repaired the ligament and you repaired the ACL. If you have a ligament graft, each ligament graft is bad. IF you have an LCL graft the downtime is longer than if you had a lateral collateral ligament repair. The same thing with an ACL, it’s better repair it time wise than reconstruct it.
Q: Either way, if they just repaired the ACL and did a graft on the LCL, would he be ready for the season?
A: I believe he’d be ready to rock.
Now, here’s what Griffin faces if he had full reconstruction:
Q: Robert has already had an ACL tear so from your perspective, what difficulties does he face recovering from another type of surgery to reconstruct his ACL?
A: He’s had a previous ACL injury and basically you may be able to compensate for a small amount of anterior instability. So you have some damage to your ACL. Then you tear your lateral collateral ligament so what ends up happening is … your tibia, or lower part of your leg rotates; it doesn’t just go front and back or side to side. So if you plant your foot, you don’t have rotational stability because one ligament is torn that goes back and forth and one ligament’s torn that goes side to side. What ends up happing is you’re almost obligated to fix the ACL. If you just fix the LCL then the knee will continue to be unstable. It’s a much harder rehab fixing both ligaments and the problem we run into is … the rehab is tougher because the knee tends to get stiffer. It’s harder to get your motion back. You have to protect the knee from rotation post-op so the rehab is slower or quite a bit slower and what happens is instead of taking three or four months – which an LCL is probably three months and an isolated ACL might take three or four months – you combine them and because of the problems of motion it could take a year, 14 months. It could take longer to get it rehabbed and rehabbed appropriately.
Q: How much is it complicated because of the first ACL injury?
A: The problem with the first ACL tear is you tear it in 2009, then you play at Baylor [for two more years], then you get ready for the combine and you go through the whole process and all that stuff creates damage in the knee. When you get in the joint, you won’t be looking at a beautiful, perfect knee that is pristine. When you have breakdown in the joint, which you’re going to have when you have old ACL problems, you see pieces chipped off, you see loose pieces floating around. So all of a sudden instead of having this beautiful 22-year old knee, you have this degenerated knee that has joint surface arthritis and breakdown and that makes it much harder to rehab so it makes it longer until you get to this mecca where you need to be able to play NFL football. The problem is, you’ve got all this ancillary stuff going on in the joint and a breakdown in the joint from three years of ACL deficiency so the joint has other issues other than a garden variety ligament tear. You’ll have other components and breakdowns in the joints. It’s also tougher to come back. A breakdown in the joint creates swelling and irritation. It’s harder to get your motion back so that little bit of arthritis in the knee makes it tougher to get your strength back and to get your swelling down. That’s why everyone keeps harping on the old ACL because the joint will be jacked up from his previous injury and all those things really slow down and make it tougher to come back.
Q: If it goes the way we hear, would you say he probably won’t play next year?
A: If I were a betting man, I would bet that they’ll reconstruct his ACL and lateral collateral because if you leave him a little unstable that’s like being a little bit pregnant, that doesn’t work. I would say there’s probably a 50-50 or 60-40 chance he doesn’t play next year just because even though he’ll be pretty good he won’t be pretty good enough. He’ll have decent stability but he his strength won’t be back. He’ll have rotational issues. You’re talking about a guy who you could see immediately when he couldn’t plant his foot or take that first step…His game is made in one step; if that corner comes in he keeps the ball and goes. His whole career is pushing off one step, two steps and if he doesn’t have that he’s like he was [against Seattle], he can’t plant and he can’t throw the ball.
Q: Knowing that, I wonder how much stress having to plant and pivot will put on that knee if he comes back too soon.
A: That gets back to, you can’t send him back at 75 percent. The NFL is a different deal. In college plays develop slower so you have time, especially if you’re a great athlete. Vince Young, RG3, Andrew Luck, they see the play develop and they can control the play. Great quarterbacks can control the play. In the pros the play develops so fast you can’t control the play if you’re not 100 percent. That’s why these guys get destroyed when they’re a little injured and so ineffective. It’s not that if you took them in the middle of the field by himself and you put a couple receivers out there that he couldn’t get the ball to them. He could. But when you watch an NFL play develop, the play develops so fast because the linebackers are so fast and the linemen are so fast and the stunts are so quick, if you don’t have any reserve you’re going to get killed. You won’t tear an ACL, you’ll get a concussion or a dislocated shoulder. The problem is you’re making that decision and it’s so fast and the play develops so fast that if you don’t have time to get set, so if you lose a little ability to plant in the NFL, you’re dead. In college you can get away with it.
Q: I assume you think he’ll need to do PRP injections?
A: He needs stem cell injections, PRP injections. Give him the whole enchilada. It should be part of the rehab anyway and it all enhances the ability to heal the joints. It’s about making sure the joint service is treated appropriately so he doesn’t have any breakdown. If it gets arthritic, the breakdown will really limit not only the number of years he’ll play but the effectiveness of his play.
Q: If he comes back too soon, what is your concern?
A: You break the joint down and usually you don’t re-tear cells as much as the joint breaks down. You hear about guys getting their knee drained, knee drained, knee drained. That’s what happens. The joint service breaks down because you haven’t recreated all your strength and your verticals aren’t there and your 40 time is down. What ends up happening is you’re chipping off pieces of joint so you’re creating arthritis. The reason to get rehabbed completely is to make sure the joint is safe going forward.
In my opinion it’s never as good as a virgin reconstruction. You definitely lose something in the second ACL. There’s damage in the joint so what happens is you’re not just reconstructing the ligament, you’re also fixing he stuff that happened in the interim from not having an ACL.