Jordan Burroughs, former NCAA wrestling champion from Nebraska and 2012 Olympic gold medalist in freestyle wrestling for the USA, was preparing for the 2013 world championships in Budapest when he broke his ankle. Just four weeks later, after having a surgery to stabilize the fracture with a plate and screws, he won the world freestyle wrestling championship on an ankle that was still not completely healed. Paul Posluszny was a junior All-American linebacker at Penn State in 2005, had just won the Bednarik and Butkus awards for top collegiate defensive player and linebacker respectively, and was playing in the Orange Bowl against Florida State when he tore the PCL and MCL ligaments in his right knee, ending his game and season. Posluszny rehabbed his knee without surgery, came back for his senior year 6 months later, broke the school record for tackles, was a repeat All-American and Bednarik award winner, Academic All-American of the year 2006, and played 11 years in the NFL as an All-Pro linebacker for the Buffalo Bills and Jacksonville Jaguars – all without reconstructive knee surgery. Carson Wentz was the starting quarterback for the first place Philadelphia Eagles this past year, had led them to an 11-2 record with 33 TD passes, 7 interceptions, and a QB rating of 102, when he tore the anterior cruciate ligament (ACL) in his left knee, ending his season. He had this reconstructed on December 13, 2017, but had to cheer from the sidelines as backup QB Nick Foles led the Eagles to their first Super Bowl title 2 months later. Perhaps he knew about Jerry Rice, the Hall of Fame wide receiver who tore his ACL in 1997, had it reconstructed, and attempted a comeback just 3 months later, when he broke the knee cap of the same knee, ending his season. Rice was able to come back from these injuries the next year and played 6 more years in the NFL before retiring in 2004. These are interesting stories about the potential risks of athletics, the value of perseverance, and the rewards of determination and hard work. But how do they apply to myself, my family, or the players that I coach when they sustain an orthopaedic injury? How do orthopaedic surgeons determine when it is safe for an athlete to return to sports after surgical or non-surgical management of a musculoskeletal injury?
Return to play criteria are ultimately based on a risk-to-benefit assessment of an athlete’s injury and desired activity. The factors involved include the athlete’s age and health status, the sport involved and physical requirements thereof, the specific site of injury and demands of that body part in the desired sport, and the natural history of healing and long-term risks of excess activity versus quality of life considerations in the future. Simple, right? Not so much. Here are some basics that help inform these decisions.
Orthopaedic surgeons are primarily concerned with biomechanical stability and long-term function. In terms of musculoskeletal injury, this means how long it takes for an arm, leg, knee, etc. to be healed to the point where it can sustain contact forces without further injury, or what methods of surgical or non-surgical (bracing, casting, etc.) treatment are available to make these activities “safe” before complete healing has occurred. For fractures (broken bones), biomechanical healing usually takes at least 2-3 months in adults and 6-8 weeks in children. Fractures involving the ends of the bones and extending into a joint often involve cartilage injury, and healing in these locations usually takes longer then non-articular injuries. Return to sport prior to complete healing may be safe depending on the location involved, the sport demands, and what options are available to protect the injured area during activity. For example, a non-displaced distal radius fracture (wrist fracture) in the non-dominant arm (glove hand) of a 12-year-old baseball/softball player may be safely protected in a short arm cast, and return to play might be reasonable 3 weeks after injury in some cases, while a displaced wrist fracture in their dominant arm (throwing arm) could require surgical treatment and protection from play for 2-3 months. Minor hand fractures can often be protected with an appropriate brace or cast, or occasionally surgical fixation, with accelerated return to sports. Fractures of weight-bearing bones of the lower extremities usually require at least 2 months of healing, and sometimes significantly longer, before aggressive activities are reasonable. The goal here is to maximize healing, balancing the importance and risks/benefits of the present activities and sports with the knowledge of long-term functional consequences of the specific injury.
Injuries involving ligaments (soft tissues that connect bones), muscles, or tendons (attachments of muscles to bones) have healing times that vary based on the site of injury. Most muscular injuries (quadriceps, hamstring or calf strains, pec, deltoid, or biceps intramuscular strains) can be safely rehabbed aggressively with return to sport being based on symptoms (pain and functional ability) rather than some external guidelines. Intramuscular injuries rarely require surgery or prolonged immobilization. Tendon and ligament injuries generally take 6-12 weeks for biomechanical healing depending on the site and severity (partial or complete tear) of the injury. Some injuries like minor ankle sprains may be safely protected with a brace and return to play in minimal time. Others, such as MCL (medial collateral ligament) injuries of the knee, need at least 2 weeks of protection before return to sports in a brace may be reasonable, while more significant ligamentous injuries such as ACL sprains/reconstructions generally require at least 6 months of protection and aggressive rehabilitation before return to cutting and pivoting sports is appropriate. Tendon to bone healing, such as that which occurs after surgical repair of biceps, triceps, pec major, rotator cuff, quadriceps, patellar tendon, or Achilles’ tendon injuries, takes 10-12 weeks for biomechanical stability. This means for these injuries, which, unfortunately, are all commonly seen in adult athletes, aggressive rehabilitation in terms of strengthening needs to be delayed for at least 2-3 months, or re-rupture is possible. Thus, return to aggressive sports after these injuries in adults usually takes at least 4-6 months or longer.
Balancing the demands of sport, with the strong emotional, time, and financial investment that athletes and family members have devoted, with the understanding of long-term function and quality of life consequences with these injuries, can be a challenging task. If you or your family member are dealing with these types of injuries, seek advice from a well-trained orthopaedic surgeon, who should be able to give you appropriate science-based criteria for recovery and treatment for your injury. If we can be of assistance please call my office at 205-971-1750.
Robert S. Wolf MD