Rondo's Going To Need a Helping Hand Again
"Rajon Rondo was diagnosed with an ACL sprain and is headed for surgery. He'll be out for eight to 12 months."
That's going to be the standard line you hear over the next few days with the Boston Celtics point guard. You might ask yourself "What is going on during that process? What will Rondo be doing?" In this slideshow, I'm going to explain the process of rehabbing an athlete's knee after ACL reconstruction.
The timings in this article are based on standard rehab protocol created by Kevin Wilk and Mike Reinold, two of the top physical therapists in sports. Wilk is based at Champions Sports Medicine in Birmingham and works closely with Dr. James Andrews. Reinold previously worked with Wilk at Champions and was recently an athletic trainer and rehab specialist with the Boston Red Sox.
A rehab can go very well and be "ahead of schedule" and there can be issues during the process that will be called "setbacks." Keep in mind that these are merely guidelines and that the medical team working with the athlete—or Rondo in this example—will adjust the process as needed. The timings here are based on the standard and should be considered an example.
Throughout the article, I will refer to the athlete with a male pronoun. The rehab is roughly the same for a male or female athlete, but since Rajon Rondo inspired this article, saying "he" helps me keep it straight in my head.
Will Carroll has been writing about sports injuries for 12 years. His work has appeared at SI.com, ESPN.com and Football Outsiders.
Phase I: Prehab
Timing: Pre-surgery, 1 to 10 days
In the days between diagnosis and surgery, the athlete will work with the team medical staff and physical therapists, as well as the surgeon, in order to get the area (in this case the knee) ready for surgery. The focus is on strengthening surrounding muscles, decreasing pain and inflammation, as well as preparing the athlete for the difficult phase of immediate post-operative rehab.
There are occasions where this phase will be much longer, such as the recent Alex Rodriguez surgery. Rodriguez needed significant strengthening in his hip before the surgery could have a good chance of success. The delay was nearly two months, cutting into part of the 2013 season, but was medically necessary.
The opposite can be true as well. Sometimes this phase is not needed and surgery can be nearly immediate. It is important to remember that while athletes do get preferential scheduling, travel and other scheduling concerns for the doctor and hospital do come into play here.
Phase II: Surgery
Timing: Day 0
Surgery will be handled by the orthopaedic surgeon, replacing the damaged ligament. Current best practice has shifted back to using a graft from the affected-side (same as damaged ligament) patellar tendon. The surgeon will cut a piece away from the tendon, then drill it into place using anchors into the bones.
During the process, the doctor will also clean out the joint space and correct any associated damage. ACL sprains often involve damage to the MCL and the meniscus. With a basketball player, the articular cartilage at the ends of the bones (femur and tibia) will also be checked and repaired if necessary.
Phase III: Post-Op
Timing: Week 1
In the week immediately following surgery, the focus is on reducing pain and swelling, while introducing motion and even some weight bearing in some cases.
Until the advent of arthroscopic surgery, the large scar and chance of infection made it impossible to do anything for the athlete for weeks or months. That lack of activity created muscle atrophy and slowed the process.
The last decade has seen great advances in technique and materials, allowing the therapies to begin much more quickly. The therapists will focus on passive motion—the therapist moving the knee through as much range of motion as possible without the athlete's involvement—and in keeping the muscles active, usually through electrical stimulation.
The other key in this phase is watching for any sign of infection. Even in the best hospitals, opening the body creates a risk of infection. Both Peyton Manning and Tom Brady had significant setbacks due to infection after procedures on their respective knees. Infection can be serious, even deadly, and can set the process back by months.
Phase IV: Early Physical Rehab
Timing: Week 2 to Week 4
In Phase IV, the pain and swelling from surgery should be completely gone. The athlete will begin to take more control and will begin some light active range of motion and light muscular activity. In some cases, an athlete will be able to stand or ride a stationary bicycle in this phase.
By Week 4, the athlete will have gained significant range, up to 115 degrees, and will begin not only weight bearing, but can begin using weights to help strengthen the knee. The grafted tendon will have "locked in" more significantly by this point and is beginning to offer stability to the knee. However, the athlete will not tax that ligament by any sort of lateral or rotational activity.
By the end of this phase, the athlete should be out of his immobilizer and off crutches. A brace or immobilizer may be used to protect the knee during sleep, but this varies from therapist to therapist.
This is the point where many athletes get back to their locker room and are seen by teammates and the press. Though walking is a great result by this point, there is a long journey ahead and should not be seen as being "ahead" of schedule.
Phase V: Continued Rehab
Timing: Week 5 to Week 8
This is where the hard work happens. This is also often where setbacks happen, not in the sense that something goes wrong, but there are significant tests in this phase. If an athlete does not pass those tests, such as showing full range of motion, passing strength tests or completing agility drills, the rehab phase must be repeated or changed to get to that necessary result.
About Week 6, the athlete begins to tax the ligament more, doing more agility and balance drills. He will also begin doing more weight-bearing exercises and using testing equipment like a KT2000, which will test the strength of the newly grafted tendon.
By Week 8, the athlete will begin to appear very normal. Their gait should not have any sign of limp or compensation. They should be able to make normal athletic movements and should have few proprioceptive deficits. Basically, they should be physically close to normal, with a bit less strength and stamina.
Phase VI: Advanced Activity
Timing: Week 11 to Week 16
Once the athlete has passed all the tests of the continued rehab phase, he will be ready to push the leg further. Instead of focusing on getting the knee back to healthy, the therapist will shift to making the knee functional. The addition of lateral and rotational activities comes here and offers a significant point of setback.
Some of this is often confidence. An athlete has to believe his knee is back to normal and a therapist will often have to change activities in order to find something the athlete is comfortable with. The athlete will regain confidence with success, as he sees his knee get better and hold up under tasks that he knows will be needed.
The addition of sport-specific activities usually happens here. For a point guard like Rondo, that will likely mean shifting to a basketball court rather than a therapist's clinic. Activities like a tilt board, agility cones and others can be done in Rondo's "natural setting" and can have things like dribbling or shooting added in.
Phase VII: Return to Activity
Timing: Week 17 to Week 22
This is the stage where you will hear phrases like "Rondo will be allowed to do basketball activities."
The focus goes from therapeutic to functional and the shift from therapy-specific exercise to basketball-specific exercise happens. While the team personnel is often involved throughout the rehab and may even have run the process, it is normally handed over to the team at this stage.
To enter this phase, the athlete must have full range of motion in the knee. He must have 80 percent strength compared to his other, healthy leg. His knee must be able to handle nearly the full weight of his body's torque, the rotational force that often created the injury. Finally, the doctor must clear the athlete and release him back to activity.
Being cleared to return doesn't make the athlete ready to go back into competition, but it is very significant. The therapist and the team's medical staff has to make it clear here that an athlete is still in the rehab phase and cannot overdo it.
Pushing too hard in this stage is the most common setback. The team doctor or athletic trainer is often going to have to "pull the reins" on an athlete if they are doing too much, in their professional opinion.
By Week 22, just shy of the six-month mark, an athlete should have made a complete physical recovery. The grafted tendon is fully healed, the leg is strong and flexible and a great part of the function has returned.
Phase VIII: Sport-Specific
Timing: Week 23 to Week 52
If you've ever wondered where the six-to-12 month timeline comes from regarding return to play, here it is. Rehab will continue during this phase and even after, focused on making sure that the repaired knee has normal strength and function. However, the goals move from the medical to the functional.
In the sport-specific phase, the control is handed over from the medical side to the coaching staff. The goal is to get the athlete back to his previous level. Time off the court and away from teammates often causes an athlete to feel "rusty" and integrating him back into the normal routine is key.
At some point, the coach will look at the athletic trainer and say "it's time." The athlete's recovery is complete and he will be ready to not only return to activity, but to return to play. The broad range on the timing of this is because no injury, no rehab and no athlete will go exactly the same. The athlete will do some final tests and get a clearance from the team doctor.
This almost never happens before the eight-month mark (Week 30). Simply put, an athlete needs six to eight weeks of training, and usually longer, before he is ready. This is not to say that one rehab is better or worse, or that there were setbacks. It is merely an individualized program and timeline.
Then, we'll get to hear the fans cheer and the announcers discussing a "miracle comeback." Now you'll know exactly what goes into the process. It's a lot of science and a lot of sweat.