By Sapna Pathak
Staff Writer

"Couch potatoes don't get these injuries." — Dr. Gregory Soghikian

It hinges on this The anterior cruciate ligament (ACL) is a stabilizer of the knee in terms of front-to-back and rotational motion, said Gregory Soghikian, M.D., a local sports medicine and trauma specialist focusing on knee and shoulder reconstruction. The knee joint, positioned between the femur, or thigh bone, and tibia, or shin bone, allows these bones to move. The ACL, Soghikian said, prevents the knee from shifting too far forward from the shin bone. “Think of the ACL as a hinge,” Soghikian said. “But it's really much more complex.” Suffering an ACL injury creates instability in the knee, Soghikian added, which makes it difficult to make quick, precise pivots. According to About.com contributor Jonathan Cluett M.D., an orthopedic surgery fellow in sports medicine and arthroscopy in California, “When the knee is unstable, patients often complain of a sensation that the knee will ‘give out' from under them. When this giving way sensation is because of an ACL injury, the knee joint is sliding too much. “... Each episode of instability can cause damage to the knee cartilage,” he added. “Therefore an ACL injury makes patients more prone to developing arthritis and meniscus tears.” – Marc Thaler

Options available ACL reconstruction is still optional, said Dr. Gregory Soghikian, a sports medicine and trauma specialist. The decision to undergo surgery is largely based upon the degree of daily instability in the individual's knee. However, most injured athletes hoping to return to form opt to repair the damage. During surgery, the patient's torn ACL is replaced with “a similar ligament from somewhere else around your knee ...,” according to information on ACLSolutions.com. “... The grafts that are currently used today are the central part of the patellar tendon, some of the hamstring tendons, or an ‘allograft' from a cadaver.” The patellar tendon graft requires removal of the middle third of the patellar tendon – which extends from the bottom of the patella to the front of the tibia – and small blocks of bone at the ends of the ligament. Tara Mounsey said she opted for this procedure, favored by some surgeons for its history of success and relatively quick healing time. Hamstring tendon grafts, according to ACLSolutions. com, are easier to harvest than patellar tendons and require smaller drill holes in the femur and the tibia for fixation. Beth McAloon's allograft used a frozen portion of a tissue donor's patellar tendon, which avoids harvesting the patient's own patellar or hamstring tendons. Of course, each of these options, according to the Web site, has advantages and drawbacks. Still, the long-term success rate of ACL reconstruction is between 75 and 95 percent, New York's John D. Hubbell M.D. wrote in his article, “Anterior Cruciate Ligament Injury,” for eMedicine.com. “The current failure rate is eight percent, which may be attributed to recurrent instability, graft failure, or arthrofibrosis (internal scarring of the knee joint),” he wrote. — Marc Thaler

It occurred more than three years ago in September 2002. Yet Beth McAloon remembers the instant she suffered the injury with perfect clarity.

Competing in a preseason soccer scrimmage for American International College, the Manchester West graduate, attempting to score on a breakaway, was greeted by the netminder, who was trying to stop the AIC 18-year-old in the open field.

“When it happened, I honestly didn't know how bad it was,” McAloon said. “The girl hit me hard, but I didn't think it was as bad as it turned out to be. I thought I'd be out a few days.”

She missed four months of play. An MRI confirmed extensive damage to her right knee, including injuries to the anterior cruciate ligament (ACL), medial collateral ligament (MCL) and meniscus, or cartilage.

“I did the ‘terrible triad.' Yeah, I did it well,” said McAloon, who re-injured her right ACL two years later after transferring to Plymouth State University. “... Everyone heard the pop but me. I was worried because I was a scholarship athlete for two sports, soccer and lacrosse, at AIC.”

While McAloon completed the nasty knee-injury trifecta, she's hardly the only young, local athlete to rupture the ACL.

A numbers game

The number of people sustaining ACL injuries has increased in the last 15 to 20 years, said Gregory Soghikian M.D., a sports medicine and trauma specialist in Manchester, whose focus is knee and shoulder reconstruction.

“There are a lot more kids playing sports, in particular a lot more women,” he said.

Likewise, more middleaged individuals are remaining in high-level athletic activities available in over-30 leagues, according to Soghikian.

“Couch potatoes don't get these injuries,” he said.

Roughly 200,000 injuries related to the ACL take place every year in the United States, with reconstruction performed approximately half the time, John D. Hubbell M.D. wrote in an eMedicine.com article titled “Anterior Cruciate Ligament Injury.”

“The incidence of ACL injury is higher in people who participate in high-risk sports such as basketball, football, skiing and soccer,” said Hubbell, a consulting surgeon for the department of orthopedic surgery at Southampton Hospital in Southampton, N.Y.

Other high-risk sports associated with the injury include gymnastics, field and ice hockey, lacrosse, rugby and wrestling, according to Dr. Jonathan Cluett, an orthopedic surgeon who writes for About.com.

ACL injuries were traditionally believed to result from contact sports such as football, Soghikian said.

The classic example involved a player who was “clipped,” or hit from the side, while running forward.

However, Soghikian and Salem-based physical therapist John Toth said non-contact sports have proven to be the true culprit.

“The vast majority (of ACL injuries) are from non-contact sports,” said Core Physical Therapy and Sports Medicine's Toth. “In general, non-contact injuries outnumber contact injuries.”

In non-contact competition, an athlete is often required to make sudden directional changes, increasing the likelihood, for example, a ski tip catches in snow or a foot lands awkwardly on a playing surface.

Another startling statistic relating to ACL injuries deals with an athlete's gender.

“When the frequency of participation is considered,” Hubbell's article said, “a higher prevalence of injury is observed in females over males, at a rate 2.4 to 9.7 times greater for females.”

Despite many studies, the reason hasn't been determined, Soghikian said.

But theories exist.

“Factors for females may include pelvic shape and alignment, abs and pelvic strength, how women jump and land, hormonal differences that may make their ligaments weaker, knee anatomy (notch shape), or a whole variety of things we haven't thought of, or haven't figured out how to study yet,” Soghikian said. “The challenge is to identify what the risk factors are that make any athlete susceptible to injury, and then figure out how to protect them.”

Arduous jouney back

In his 11 years of outpatient physical therapy, Toth said the patient's postoperative pain typically lasts two to three weeks. Furthermore, a minimum of eight to 12 weeks are needed for any soft tissue to heal.

Then, Toth added, the individual begins the process of dealing with the symptoms of muscle atrophy.

“Patients need to understand they aren't going to overcome the injury with harder work early to get them back (on the field sooner),” Toth said. “Pushing harder might not get them back faster.”

Typically, the healing and strengthening process lasts four to six months; a return to the playing field is six months to a year, depending on the athlete's condition at the time of the injury.

Toth also said there are groups of core exercises used to rehabilitate just about any type of ACL injury. His patients participate in formal workouts for 60 to 90 minutes every-other day, and at-home exercise routines for 30 to 45 minutes daily.

Injured athletes must be able to tolerate running, jumping and cutting in rehab before Toth will clear them to return to action. “I'm looking for a lack of joint pain and a lack of instability in the knee with those activities,” he said.

Once the pain and inflammation subside, recovering from an ACL injury isn't only difficult on the physical front, several local athletes said. Overcoming mental obstacles is very tough, too.

Now 27, U.S. Olympic hockey gold medalist Tara Mounsey said the benefit of a mature mindset taught her the injury, while heartbreaking, “isn't that bad in the grand scheme of things.”

In high school, however, maintaining an upbeat attitude was a tremendous challenge for Mounsey, injured her sophomore year as a member of Concord's boys team; and it didn't happen without the help of a solid support system, she said.

“Both of my recoveries took over a year due to complications,” said Mounsey, who injured her right ACL in college playing women's hockey for Brown University. “... I learned a lot about perseverance and patience that have helped me to this day.”

McAloon echoed Mounsey's message. She said fewer tasks are tougher for high-level athletes than accepting they'll be sidelined for a substantial amount of time while teammates take the field. It's critical, McAloon added, to find that silver lining, no matter how thin.

“There are so many people who've had (ACL surgery) done; it helps to have somebody that's going through it, too, to talk to,” McAloon said. “It's important to stay involved with the team. Don't let yourself drift away.”

Beating the fear of reinjury

It would be understandable if these injured athletes hesitated upon returning to competition. Nonetheless, most return to the field prepared to compete as if their injuries never occurred.

McAloon broke three knee braces showing her PSU coach she could still perform at a high level.

“If you let up on the field, you could get hurt worse than if you give 100 percent,” she said. “You can't really think (another injury) is going to happen. Otherwise, you won't be fully focused on what's (taking place) around you.”

Mounsey, while “not 100 percent in Salt Lake City“ for the '02 Winter Olympics, said she didn't allow herself to succumb to fear either.

“The rehabilitation process is designed so when athletes are released to sports, the knee is ready to go back to the level of activity they left at,” Toth said. “They're just dying to get back ... Most don't have any fear when they're given the green light.”