Having an ACL tear can be hard on a young athlete. Recent studies estimate that nearly 250,000 ACL injuries occur annually in the United States. If reconstruction is indicated, a reconstructed ACL is as strong and sometimes even stronger than the original anterior cruciate ligament. But some of the risk factors, including movement patterns, that caused the original injury are still present, and for that reason a thorough rehab program is vital after surgery.
Here to discuss recovery from ACL Injury, how young athletes can protect themselves from sustaining injury again and what young athletes can do now to prevent ACL injuries from occurring is Jeffrey Nepple, MD. He is a Washington University pediatric orthopedic surgeon at St. Louis Children’s Hospital and director of the St. Louis Children’s and Washington University Young Athlete Center.
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Coming Back From ACL Injury
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Learn more about Jeffrey Nepple, MD
Jeffrey Nepple, MD
Jeffrey Nepple, MD is an orthopedic surgeon who focuses on treating pediatric sports medicine including knee injuries, osteochondritis dissecans, anterior cruciate ligament tear or ACL tear, meniscal tear, patellar instability and dislocation, clavicle fractures, adolescent and young adult hip disorders such as femoroacetabular impingement, labral tears, and slipped capital femoral epiphysis, with a specific focus on minimally invasive arthroscopic techniques for the treatment of hip disorders.Learn more about Jeffrey Nepple, MD
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Coming Back From ACL Injury
Melanie Cole (Host): Having an ACL tear, can be hard on a young athlete. Recent studies estimate that nearly 250,000 ACL injuries occur annually in the United States. My guest today is Dr. Jeffrey Nepple. He’s a Washington University Pediatric Orthopedic surgeon at St. Louis Children’s Hospital and the director of the St. Louis Children’s and Washington University Young Athletes Center. Welcome to the show Dr. Nepple. So, explain a little bit about ACL injury. How common is it and how does it happen?
Dr. Jeffrey Nepple, MD (Guest): Sure, well thanks again for having me. ACL injuries I think are one of the more common serious knee injuries that we see in our young athletes; high school age athletes, junior high even down into grade school. So, these are injuries that often happen with sporting activities where a sporting movement, cutting, pivoting, landing, jumping, they tear their ACL. Most of these injuries are non-contact. Some of them happen with contact where they run into another athlete, but a lot of them are just the athlete controlling their body and they have enough stress it that they tear this ligament. And ACL tears are a big injury in a young athlete’s career and take a lot to come back from.
Melanie: Do we know why they seem to be more common in girls?
Dr. Nepple: Yeah, I think it’s a combination of things. I think we understand more and more about neuromuscular control, how the athlete’s body is controlling their movement has a lot to do with things and females have certain things, the way that they cut, land, pivot that are a little different than males and that seem to be playing a role in those at-risk behaviors where they may put themselves in a position to tear their ACL as well as a variety of other things. Females tend to be a little more loose jointed than males, hormones, those kinds of things can play a role as well as their bony structure. So, it is kind of the perfect storm of things, but clearly girls especially in certain sports like soccer are at the highest risk.
Melanie: Does it always necessitate a surgical intervention?
Dr. Nepple: So, in general for athletes who want to return back to playing cutting and pivoting sports and have a complete tear of their ACL; surgery is going to be the safest way for them to prevent injury. Occasionally, athletes will try to play with a torn ACL and you really risk the knee giving out and causing further damage to the meniscus and cartilage structures in the knee. And those are injuries that we can’t always put back. So, protecting those key structures in the knee is really important for the long-term health of the athlete. There are situations where the ACL is not completely torn, a partial tear that are less common where an athlete may be able to get by without a surgery, but those are relatively unique scenarios.
Melanie: So, if you do surgery, then is this ACL now stronger? Is the scar tissue make it at an increased risk? And what’s the difference between returning to play versus you telling a young athlete that they can’t play that sport anymore?
Dr. Nepple: Yeah, so I think in general, our treatments nowadays are pretty good in efforts to kind of put them back as good as they started. So, we can’t sew the ACL back together, so we reconstruct the ACL or replace it with other tissue. In general, those tissues are stronger than their ACL was to begin with, but they have to also undergo a process where they kind of become that patient’s live tissue getting blood supply and maturing, and that process is really what slows the recovery from these injuries. So, a broken bone is fairly simple and a couple months back and they are back out on the court. ACL recovery is really a long process of kind of a six to 12-month process for them to safely be back on the field. In general, nowadays, the risk of reinjury to ACLs is still significant. So, the athletes with an ACL tear are often those who have at risk movement patterns where there is significant risk of them tearing their other ACL down the road while they are playing sports or re-tearing their reconstructed ACL. We think the risk in that reconstructed knee is about back to the baseline what they started with or sort of probably making them as good as they were to start with Mother Nature, but that risk never goes away.
Melanie: As the director of the St. Louis Children’s and Washington University Young Athletes Center; what else do you consider maybe some barriers to recovery for these young athletes? Is there a psychological component now maybe they are afraid to take the risk or to push as hard as they might have done before?
Dr. Nepple: Yeah and I think that there are definitely are psychological aspects of this that we probably underrecognize. So, for a lot of these athletes, sports is a major part of their life at this point and you take that away for a period of six months and that can be very hard on them kind of in all aspects of their life. As they are getting back to sports, I think it really depends on the athlete. Some athletes have no fear and may be the ones at most risk for reinjury and some athletes clearly have a – some mental hurdles to get over to get back to doing the things they want to do, and some athletes may choose that they were never really that interested in the sport and they have been through all this that they don’t want to go through it again. So, it is really we see a big spectrum of responses by our young athletes and kind of how they view their knee and the future for their knee and what – how much they are worried about another injury down the road.
Melanie: So, what can a pediatrician do to encourage prevention and to assist in recovery?
Dr. Nepple: Yeah, so I think maybe assisting in recovery first, so I think it’s important for everybody surrounding that athlete, their family, their parents, coaches, the other athletes and the pediatrician to kind of understand the process. So, this is a long process. This is not an easy fix and they are right back on the field. This athlete is going to be dealing with a number of things through this six to nine-month period that they really need support on all aspects to best deal with all the stresses that come along with that. As far as preventing other injuries; I think it comes back down to making sure that these athletes are moving in ways as optimized as possible, so we put athletes through a very detailed return to play assessment looking at their strength, looking at their balance, their explosiveness to really make sure that that knee is as ready as it is ever going to be to return back to sports. There are good programs out there nowadays that we have really bought into and try to push out into the community on ACL prevention. So, if the highest risk group we are ever going to find is kids who have already torn one ACL so those are athletes who we want to be doing everything for through these neuromuscular education programs and dynamic warm up to make sure they are doing everything they can so that we can feel like if they do come back with another injury, we really gave them the best chance to prevent those injuries in the long run.
Melanie: Do you feel that coaches are involved enough I this prevention and in learning the neuromuscular training techniques and proper warm up and being able to teach their athletes? What would you like to see coaches doing?
Dr. Nepple: Yeah, I think nowadays, especially as you get into the high school age; coaches are very aware of ACL injuries and that they happen and certainly it’s a big deal when they lose one of their athletes for a season or a year from these injuries. So, I think people realize these injuries are out there, but I think very few people realize this is potentially a preventable injury so, there are great prevention programs with good science behind them that would suggest maybe we can prevent 30-50% of these major knee injuries and also prevent some of the other nagging injuries through programs that are freely available, fairly simple to do. I think most parents and coaches aren’t aware of those things even existing out there. We look at the benefits of those programs, certainly we have to have a number of athletes do them to prevent an ACL tear but preventing one ACL tear in one of your athletes is a huge success if we can get these programs more implemented across our region.
Melanie: And the programs you can Google them and find plyometric programs and things that can help the coaches along the line but another thing; tell us about the Young Athletes Center at St. Louis Children’s Hospital and what are you doing there?
Dr. Nepple: Sure, the Young Athletes Center at Washington University and St. Louis Children’s Hospital really has the goal to provide comprehensive care for our athletes. So, to take not only our injured athletes but to be really pushing out injury prevention and what is the science behind that and then other things that are sometimes hard to find like sports psychology for our younger athletes. So, the Young Athletes Center as far as ACL prevention, we utilize the FIFA 11+ Program. So, this is a program with 10 or 20 years of research behind it. Some done in the US, some done in Europe that really has the science behind it. If you Google ACL prevention, I think you get maybe some good programs and some programs that really don’t have any scientific basis that they truly work. These are programs that have been implemented across entire nations in soccer programs in Europe as well as a number of studies in the US showing that we can prevent injury. So, we are really trying to work with our local area clubs to help implement them. Again, I said they are free, but they do take some expertise to get up and running, so we are trying to help our area athletes by teaching them how they do the program, teaching the coaches, teaching trainers to understand these programs and giving them the resources to keep them running long after we are there.
Melanie: In summary, Dr. Nepple, tell other physicians what you would like them to know about ACL injury, recovery, prevention and when to refer.
Dr. Nepple: Sure, so I think ACL tears are extremely common and any athlete you encounter going through the recovery of these injuries really needs support through this process and understanding of how long this process is and that hopefully any athletes around are being educated on the risk of ACL tears and the availability of some of these programs to decrease their risk would be good. For many of our athletes, it can be a big change in their pathway for how they view sports, whether they get that college scholarship, all kinds of things that have big time long-term effects that we want to keep our athletes healthy and hopefully avoid injuries at the forefront as much as possible.
Melanie: We certainly do and thank you so much Dr. Nepple, for joining us again today. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP. That’s 1-800-678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital you can go to www.stlouischildrens.org , that’s www.stlouischildrens.org . This is Melanie Cole. Thanks so much for listening.
Coming Back From ACL Injury
Melanie Cole (Host): Having an ACL tear, can be hard on a young athlete. Recent studies estimate that nearly 250,000 ACL injuries occur annually in the United States. My guest today is Dr. Jeffrey Nepple. He’s a Washington University Pediatric Orthopedic surgeon at St. Louis Children’s Hospital and the director of the St. Louis Children’s and Washington University Young Athletes Center. Welcome to the show Dr. Nepple. So, explain a little bit about ACL injury. How common is it and how does it happen?
Dr. Jeffrey Nepple, MD (Guest): Sure, well thanks again for having me. ACL injuries I think are one of the more common serious knee injuries that we see in our young athletes; high school age athletes, junior high even down into grade school. So, these are injuries that often happen with sporting activities where a sporting movement, cutting, pivoting, landing, jumping, they tear their ACL. Most of these injuries are non-contact. Some of them happen with contact where they run into another athlete, but a lot of them are just the athlete controlling their body and they have enough stress it that they tear this ligament. And ACL tears are a big injury in a young athlete’s career and take a lot to come back from.
Melanie: Do we know why they seem to be more common in girls?
Dr. Nepple: Yeah, I think it’s a combination of things. I think we understand more and more about neuromuscular control, how the athlete’s body is controlling their movement has a lot to do with things and females have certain things, the way that they cut, land, pivot that are a little different than males and that seem to be playing a role in those at-risk behaviors where they may put themselves in a position to tear their ACL as well as a variety of other things. Females tend to be a little more loose jointed than males, hormones, those kinds of things can play a role as well as their bony structure. So, it is kind of the perfect storm of things, but clearly girls especially in certain sports like soccer are at the highest risk.
Melanie: Does it always necessitate a surgical intervention?
Dr. Nepple: So, in general for athletes who want to return back to playing cutting and pivoting sports and have a complete tear of their ACL; surgery is going to be the safest way for them to prevent injury. Occasionally, athletes will try to play with a torn ACL and you really risk the knee giving out and causing further damage to the meniscus and cartilage structures in the knee. And those are injuries that we can’t always put back. So, protecting those key structures in the knee is really important for the long-term health of the athlete. There are situations where the ACL is not completely torn, a partial tear that are less common where an athlete may be able to get by without a surgery, but those are relatively unique scenarios.
Melanie: So, if you do surgery, then is this ACL now stronger? Is the scar tissue make it at an increased risk? And what’s the difference between returning to play versus you telling a young athlete that they can’t play that sport anymore?
Dr. Nepple: Yeah, so I think in general, our treatments nowadays are pretty good in efforts to kind of put them back as good as they started. So, we can’t sew the ACL back together, so we reconstruct the ACL or replace it with other tissue. In general, those tissues are stronger than their ACL was to begin with, but they have to also undergo a process where they kind of become that patient’s live tissue getting blood supply and maturing, and that process is really what slows the recovery from these injuries. So, a broken bone is fairly simple and a couple months back and they are back out on the court. ACL recovery is really a long process of kind of a six to 12-month process for them to safely be back on the field. In general, nowadays, the risk of reinjury to ACLs is still significant. So, the athletes with an ACL tear are often those who have at risk movement patterns where there is significant risk of them tearing their other ACL down the road while they are playing sports or re-tearing their reconstructed ACL. We think the risk in that reconstructed knee is about back to the baseline what they started with or sort of probably making them as good as they were to start with Mother Nature, but that risk never goes away.
Melanie: As the director of the St. Louis Children’s and Washington University Young Athletes Center; what else do you consider maybe some barriers to recovery for these young athletes? Is there a psychological component now maybe they are afraid to take the risk or to push as hard as they might have done before?
Dr. Nepple: Yeah and I think that there are definitely are psychological aspects of this that we probably underrecognize. So, for a lot of these athletes, sports is a major part of their life at this point and you take that away for a period of six months and that can be very hard on them kind of in all aspects of their life. As they are getting back to sports, I think it really depends on the athlete. Some athletes have no fear and may be the ones at most risk for reinjury and some athletes clearly have a – some mental hurdles to get over to get back to doing the things they want to do, and some athletes may choose that they were never really that interested in the sport and they have been through all this that they don’t want to go through it again. So, it is really we see a big spectrum of responses by our young athletes and kind of how they view their knee and the future for their knee and what – how much they are worried about another injury down the road.
Melanie: So, what can a pediatrician do to encourage prevention and to assist in recovery?
Dr. Nepple: Yeah, so I think maybe assisting in recovery first, so I think it’s important for everybody surrounding that athlete, their family, their parents, coaches, the other athletes and the pediatrician to kind of understand the process. So, this is a long process. This is not an easy fix and they are right back on the field. This athlete is going to be dealing with a number of things through this six to nine-month period that they really need support on all aspects to best deal with all the stresses that come along with that. As far as preventing other injuries; I think it comes back down to making sure that these athletes are moving in ways as optimized as possible, so we put athletes through a very detailed return to play assessment looking at their strength, looking at their balance, their explosiveness to really make sure that that knee is as ready as it is ever going to be to return back to sports. There are good programs out there nowadays that we have really bought into and try to push out into the community on ACL prevention. So, if the highest risk group we are ever going to find is kids who have already torn one ACL so those are athletes who we want to be doing everything for through these neuromuscular education programs and dynamic warm up to make sure they are doing everything they can so that we can feel like if they do come back with another injury, we really gave them the best chance to prevent those injuries in the long run.
Melanie: Do you feel that coaches are involved enough I this prevention and in learning the neuromuscular training techniques and proper warm up and being able to teach their athletes? What would you like to see coaches doing?
Dr. Nepple: Yeah, I think nowadays, especially as you get into the high school age; coaches are very aware of ACL injuries and that they happen and certainly it’s a big deal when they lose one of their athletes for a season or a year from these injuries. So, I think people realize these injuries are out there, but I think very few people realize this is potentially a preventable injury so, there are great prevention programs with good science behind them that would suggest maybe we can prevent 30-50% of these major knee injuries and also prevent some of the other nagging injuries through programs that are freely available, fairly simple to do. I think most parents and coaches aren’t aware of those things even existing out there. We look at the benefits of those programs, certainly we have to have a number of athletes do them to prevent an ACL tear but preventing one ACL tear in one of your athletes is a huge success if we can get these programs more implemented across our region.
Melanie: And the programs you can Google them and find plyometric programs and things that can help the coaches along the line but another thing; tell us about the Young Athletes Center at St. Louis Children’s Hospital and what are you doing there?
Dr. Nepple: Sure, the Young Athletes Center at Washington University and St. Louis Children’s Hospital really has the goal to provide comprehensive care for our athletes. So, to take not only our injured athletes but to be really pushing out injury prevention and what is the science behind that and then other things that are sometimes hard to find like sports psychology for our younger athletes. So, the Young Athletes Center as far as ACL prevention, we utilize the FIFA 11+ Program. So, this is a program with 10 or 20 years of research behind it. Some done in the US, some done in Europe that really has the science behind it. If you Google ACL prevention, I think you get maybe some good programs and some programs that really don’t have any scientific basis that they truly work. These are programs that have been implemented across entire nations in soccer programs in Europe as well as a number of studies in the US showing that we can prevent injury. So, we are really trying to work with our local area clubs to help implement them. Again, I said they are free, but they do take some expertise to get up and running, so we are trying to help our area athletes by teaching them how they do the program, teaching the coaches, teaching trainers to understand these programs and giving them the resources to keep them running long after we are there.
Melanie: In summary, Dr. Nepple, tell other physicians what you would like them to know about ACL injury, recovery, prevention and when to refer.
Dr. Nepple: Sure, so I think ACL tears are extremely common and any athlete you encounter going through the recovery of these injuries really needs support through this process and understanding of how long this process is and that hopefully any athletes around are being educated on the risk of ACL tears and the availability of some of these programs to decrease their risk would be good. For many of our athletes, it can be a big change in their pathway for how they view sports, whether they get that college scholarship, all kinds of things that have big time long-term effects that we want to keep our athletes healthy and hopefully avoid injuries at the forefront as much as possible.
Melanie: We certainly do and thank you so much Dr. Nepple, for joining us again today. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP. That’s 1-800-678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital you can go to www.stlouischildrens.org , that’s www.stlouischildrens.org . This is Melanie Cole. Thanks so much for listening.