Note: The names in these email inquiries have been changed for privacy purposes. By posting their questions and Dr. Sanders' response to them, we hope to help others searching for answers to similar problems.

Clarion, Pennsylvania

We would like your opinion about our son.

Our son John is 21 and plays Division II Football at Clarion University in Clarion Pennsylvania. He hurt his leg the other day during spring football and the trainers thought he had torn his ACL. He had torn his ACL in his left leg at a football camp the summer before his junior year of high school. He made a tremendous recovery and was able to play basketball the second half of the season of his junior year. He has since done very well with that leg.

He was seen by his doctor at the UPMC Sports Medicine Clinic in Pittsburgh and had an MRI this morning. They are saying the ACL is torn but they think it is an old injury as there is no swelling or fluid on the MRI. Everything else looks good, but the LCL looks a little stretched which could be causing the pain. They wrote a prescription for 2 weeks of therapy and then want to see him.

They are telling us he may not need surgery, as many athletes don't have their ACL including 4 Steelers. Since they think this is an old injury, he is able to tolerate this. What are your thoughts on this? Could not having surgery cause more severe problems if were to hurt it again? Joe is a junior, but has 2 years of eligibility left as he was red shirted his freshman year due to a shoulder injury. We want to do what is in his best interests.

We appreciate your response,
Joe and Jan

From Dr. Sanders

Thanks for your email. What's most important is not the MRI but whether or not the knee is loose. That can be best measured on the KT-1000 machine. It's something that we have in the Clinic and don't even charge for. If his knee is loose then it may be best to reconstruct the ACL that is a problem now. If he has been playing without an ACL and his knee is not giving way, then only a crazy person would have it fixed. If it continues to cause him problems then it should be fixed.

We are the only center that can reliably get an athlete back in three months, but we only operate when necessary. Let's see how he does. If his knee gives way over the summer, then it is best fixed ASAP.

Kind regards,
Mark Sanders MD

Reply from Joe and Jan

Thank you Dr. Sanders for replying so quickly. When our son John was examined by his doctor at UPMC on Thursday, before the MRI, they did not think the ACL was torn. They were getting a response. They thought the LCL might have some damage, but were getting a response there too. This KT-1000 machine you said, do they have those everywhere, or just at your clinic? Also, you say you can get an athlete back in 3 months. When he tore his other ACL in 2000, it took him 6 months to recover before he could play, but he said it still took him about 18 months before he felt he was back at the level he had been before. How are you able to accomplish this in 3 months? We are very interested. I called your clinic yesterday and left a message.

Anxiously awaiting your response,
Joe and Jan

From Dr. Sanders

Dear Janet,
Thanks for your email. The kt-1000 is not a laser beam or rocket science. It is a measuring device that measures anterior or posterior excursion of the tibia on the femur. FYI, it costs about $3500 to buy the machine (a tiny amount in today's healthcare world). It is the best measurement of knee instability as it tells you how stable or unstable the knee actually is. The MRI is just a snapshot. It doesn't show laxity, also known as excursion. I thought that all serious sports medicine clinics used one. I am rather shocked that they don't.

All our athletes return to sports is three months. Again, it's not rocket science or laser beams. I, in conjunction with my trainer, Ed, personally supervise their rehab - starting with a 150-300 foot walk without crutches, braces, or casts in their hospital room the night of the procedure.

From there, kids do exercises in bed for the first week, although I let them up for bathroom and one hour on the bicycle usually by the fifth day.

By the eighth day, they go home, walking like regular people while continuing on the program by themselves, - emphasizing one hour per day on the bike, and then adding sport-specific exercises over the next few months, which we will tailor to his needs. By this time, guys can all ready do a deep squat.

It is important to remember that the bone plugs heal inside of one month. The ligaments graft is strong, and since it is his own tendon, the cells keep alive in their new position. All we have to work on is getting over from the surgery. With the Sanders Clinic rehab plan, that's easy!

I don't use any special machines, techniques or lasers. Any ortho can do this stuff if he/she just pays extreme attention to details both in the operating room and, more importantly, after. Unfortunately most guys are locked in by tradition. Or, as they say it, "It was the way I was trained." I have always looked for better than the traditional answers to the same questions!

I have a few questions for you: What tissue did they use for his other knee? When do you want to come down? Expect to stay one week. The local La Quinta Inn gives a $49/per night rate for our patients. Please let me know about the graft source for the opposite leg's surgery.

Kind regards,
Mark Sanders MD

Whitman, Massachusetts

I had an ACL repair last July -- 8 mos. ago. I am 57 and active working every day with Kindergarten children.

I was told by my ortho. surg. that my knee would "be as good as new."

My problems have been knee swelling and pain. There are days that I wear a brace in order to feel more comfortable walking around all day.

My knee is constantly warm to the touch. I use ice a lot and try to rest it at the end of the day.

The incision under the knee feels numb -- no feeling. I'm thinking nerve damage.

I spent 3 months post-op. in therapy, 3 times a week - and did well and got back to my job quickly.

I have sacs of fluid that can be felt around the patella. Dr. says "soft tissue."

Can fluid be drained from the knee??? I find myself limping, and I now use an asper cream product for relief.

Jenny

From Dr. Sanders

Dear Jenny,
Thanks for your email.
I would love to help you but I first need to know what tissue was used for repair or reconstruct you ACL.
Is your knee able to fully straighten out, equal to the other one?Does it feel loose or give way?
Or does it just hurt and stay swollen?
Also please let me know if your leg bows in like you just got off a horse or whether you are knock kneed.
One thing I can tell you is that when a knee carries an effusion (water on the knee) draining it with a needle would just offer relief until the fluid re-accumulates again. Not worth your time.
Please let me know the answers to these questions and I will be able to advise you.
Also could you give me your name and address?

Kind regards,
Mark Sanders, MD

From Jenny

Thank you for replying--now lets see if I can answer all your questions, so you can better understand my problem. Here goes; from hospital operative report-

Operative procedure: Arthroscopy. arthroscopic partial medial meniscectomy and arthroscopically assisted anterior cruciate ligament reconstruction left knee using autogenous patellar tendon graft. Also reading from report, the central third of the patellar tendon was harvested together with a bone block from the distal patella and a bone block from the central aspect of the tibial tubercle. A 28 x 8 mm biointerference screw was used to secure the femoral bone block in the femoral tunnel.

My knee can straighten out like the other--full extension. Once in awhile it feels like it shifts--not too often--it does ache and is always swollen--feels like fluid around the patella --legs do not bow in and not knock-kneed.

After the surgery, I was in a Bledsoe brace for quite awhile--what a trip!! ROM is good---I pushed myself with therapy--have no patience with being down. My therapists were great--they really took their time and were very pleased with my progress. As I stated, my knee is always warm to the touch--when I sit, my leg is up with ice. I do take Gluc./Chond. everyday 1500/1200. I'm always rushing around--I guess hyper would be the term to describe me---bowling and gardening are my passions--haven't been able to kneel yet--tried but was too painful. Spring is coming and I need to get back to my outside working, including kneeling and planting. Any advice you can give me would be greatly appreciated. Also small area of arthritis in this knee and bakers' cyst.

Thank you so much---have enjoyed the info. on this site. Take care.

Jenny

P.S. I'm 30 miles outside of Boston--have been told I should have gone into New Eng. Baptist Hosp. for this repair instead of the local hosp.

From Dr. Sanders

Thanks for all this information.
Try using the stationery bike one hour per day, with the seat in a reasonable middle of the road position with minimal to light resistance. Try that for a week and let me know how you feel. Do you have a step box as noted on our Website? You should be doing step-ups 25x/session, several sessions/day. You should be able to step up 4 inches not 6 or 8 inches. This will improve your strength and should make your patella less painful over time. Next time you hurt yourself, come to Houston.

Kind regards,
Mark Sanders

Fort Worth, Texas

Our daughter just tore her ACL. She is a basketball player at Texas Christian University. They are suggesting surgery for her by doctor here. I was wondering if you are familiar with the doctors here. We live in California, and as parents we are very concerned regarding her future. Any advice would be welcomed. Henry

Thanks for your email. First of all, no surgery should be done until she regains all of her knee motion, is walking normal, and is finished with the semester's studies. By waiting, the chance of severe stiffness is decreased to just above zero.

An ACL tear is not important enough to have to take incompletes in her classes. Of course, I have a preference with regards to what graft to use and from what knee - in conjunction with our Accelerated Rehabilitation program. Still in all, she shouldn't have surgery now.

While I don't know of the doctors to whom you have referred, I would be very reluctant to use any MD, who is trying to rush the situation. Lots of your questions could be answered by clicking here: www.sandersclinic.net/faq acl.html

Houston is a short plane ride away. I would be delighted to see y'all. Let me know if you have any further questions. Regards, Mark Sanders

Thank you for your quick reply to my questions and concerns. How long should an athlete wait once knee motion and normal walking have returned? Henry

After an athlete has normal knee motion, especially hyperextension equal to her other knee, and walks normally, she should have her knee repaired. For a college athlete, this should be during the Christmas-New Year break.

At least in my hands, I want patients to be at restricted activities for the first week. By the second week they can return to all their school activities. I have them so busy with my athletic/rehabilitative activities that they don't miss theirs until they return to competitive sports at three months. It's not just passive. I require a partnership with my patients, if they want to continue to excel. Mark Sanders

Intense Rehabilitation Program

I saw your website and wanted to know the cost of a week-long program during December, if possible. My daughter will be having her ACL rebuilt tomorrow and I was hoping that December would be a good time to start an intense rehabilitation program. Are you covered by PPO Blue Cross/BlueShield insurance? Thank you, Nancy

Thanks for your email. This program is designed for my surgical patients. Not all surgeons adhere to the same principles as I, and as such would, I would be surprised if your surgeon would want your daughter to participate. If your daughter is having her ACL fixed tomorrow, she needs to follow her doctor's plans.

Should you care to see me before this for a second opinion/or a second type of surgical option, I would be delighted to see her. Sanders Clinic accepts most insurance. Good luck! Regards, Mark Sanders

Pocatello, Idaho

Hello,
Our son plays DI basketball for Idaho State University. He recently turned 21 years old. He had his left ACL repaired with the patella tendon/bone at 16 years. Last November 2003, he had his right ACL repaired the same way.

Last week it looks like his left ACL gave out while playing an outstanding game of basketball. He is the leader of the team. He is not giving up.

We want to help him in the best way possible. We are exploring options to give him the best possible experience to get him back to where he wants to be. His surgeries were successful in that he has progressed his athletic ability to great heights.

What options do we have? What is the best way to proceed? What do you have to offer?

We appreciate any information you can give us. Best thoughts, mom and dad

Thanks for your email. If he has ruptured his left ACL (previously reconstructed) and he wants to continue basketball, it needs to be reconstructed again.

More likely than not the right patella tendon has regenerated enough to allow a second graft harvest. Doing it this way, he will certainly have a much less unpleasant experience than he had with the previous two operations. An allograft, taken from a cadaver, is an option, but not one that I would take on a 21-year-old, who is a keen player.

A hamstring graft isn't strong enough for this high demand player, either. I would be happy to see you guys and probably proceed with an ACL reconstruction utilizing a contralateral graft. After completion of our accelerated rehabilitation program, he could get back by three or four months.

Kind regards, Mark Sanders

And thank you for responding so promptly! We do much appreciate that. Are you saying that the patella tendon on the right knee, which was done last year, would be able to supply the graft? What is the next step? How long do you feel is needed before surgery is performed - condition of knee - motion and swelling (which is nominal)? An MRI is being done this afternoon. The measurement was 6 mm on right knee and 14 mm on the left knee when they checked it this morning. Our son is sure it is his ACL. We don't know if anything else is wrong, though he doesn't seem to think so.

Can he rehab with your program as he is going to school in Idaho? How would this all be able to come together? He wants to go after it as aggressively as possible. We want him to heal as safely as possible (being parents!)

Looking forward to hearing from you soon. Best thoughts, mom

Yes, the patella tendon on the right knee would be able to supply the graft. An allograft (which is tissue from a cadaver) will rapidly, I repeat, rapidly fail in an elite athlete. The next step is to make sure that he gets full motion of his knee - emphasizing hyperextension equal to the other knee, normal gait, and good quad control. Then the knee is ready to be reconstructed.

Do not concern yourself about any other injured structure in the knee at this point. The ACL takes precedence. If his KT-1000 is 14mm versus 6mm, he didn't need the MRI.

Your son is welcome to rehab with our program. The rehabilitation is really easy. If he has normal motion now, you should give him to me for a week during the winter break. He will be able to return to all his normal school activities with a normal gait by the eighth day.

kind regards, Mark Sanders

Torn ACL

Dear Sir,
My 13-year-old son has a torn ACL. The MRI showed that the ACL is completely gone. We have done a bone scan to see at what age he is developing. His growth is the same as his age. He is very active in sports and we are looking to see at what age it is safe to do surgery. We would like for him to have surgery as soon as possible, but only when it is safe. Any information you could give me would be greatly appreciated.

Thanks, John

If this were my son, I would wait until he is at skeletal maturity. There are a million operations that can be done on a child of this age for knee instability, and absolutely all of them fail.

Certainly in your community there is someone who wants to do something. You can't do anything with the patella tendon until the growth plates are nearly closed. I am sure that he is not as tall as his dad, and has not started secondary sexual development.

It really is a no go until about age 15 or 16. Perhaps he can play in an ACL brace. If he has a meniscal tear, then that might need to be repaired, but do not subject him to an unnecessary and unrealistic operation to reconstruct the ACL or any extra-articular operation to buy time.

I did at least 30 of these before I realized that each youngster would come back for surgery at age 16. The only time you buy is the time the child is in the cast. Waste of time!

When he is 15, come and see me in Houston, and we can reconstruct his ACL and have him back to sports in three months with a stable and pain-free knee.

Regards, Mark Sanders