When should an athlete undergo surgery for a torn ACL? Is it safe to wait until the end of the season? Or does the extra time for rehab of the knee benefit a player returning to contact and collision sports? All of those questions have come up recently Patellar tendon ACL graftwith a star athlete, and they apply to any athlete preparing for ACL surgery.

The possible timing of surgery for Clemson’s Deshaun Watson

Earlier this week, Aaron Brenner reported that Clemson is considering ACL surgery for quarterback Deshaun Watson now rather than after playing in a bowl game a few weeks later.

According to reports from the team, Watson sprained his lateral collateral ligament in a loss to Georgia Tech on November 15. After the Tigers’ decisive win over South Carolina, head coach Dabo Swinney acknowledged that Watson played the game with a partial tear of his ACL. “Basically, that (knee) brace was (Watson’s) ACL,” Swinney told reporters.

Initially Swinney announced that the standout freshman would undergo surgery after the bowl game, which would have meant the procedure would take place after Clemson faces Oklahoma in the Russell Athletic Bowl on December 29. Now he says the team is weighing the option of giving him extra time to recover from surgery and be ready to go next season.

Also read:
When is an athlete ready for sports after ACL surgery?
ACL reconstructions in college football players

“At this point we may go ahead and do surgery, try and get him a three-week headstart on his rehab,” Swinney said. “Really want him to get all the skills and drills done this summer.”

Further damage with an unstable knee

The risk of further damage to the knee after tearing the ACL is one of the main reasons athletes of all ages and skill levels undergo surgery. With most ACL tears, the knee is unstable. If the knee buckles when he lands from a jump or changes directions, he risks injuring the meniscus or articular cartilage in the knee, damage that can shorten an athlete’s career and lead to long-term arthritis.

As Gene Sapakoff pointed out in a recent column, knee braces do not provide enough stability to prevent this damage in an athlete with an unstable knee.

Not being involved in Watson’s care, I don’t know the extent of his injury – the severity of his ACL or LCL injury or the presence of meniscal or articular cartilage damage – so I can’t speculate on his risk for doing further damage to his knee.ACL knee brace soccer

The timing of Watson’s surgery, however, does help illustrate an important point for any athlete with a torn ACL – whether it is a high school football player or an adult recreation league soccer player.

Return to play after ACL surgery

As I discussed in a column last year, many factors affect the decision to clear an athlete to return to play after ACL reconstruction, such as the return of full knee motion and symmetrical quadriceps and hamstring strength. The absolute length of time from surgery is a factor, but by itself, it is probably the least important.

Also read:
Three risk factors for a second ACL injury
Young athletes risk further damage by delaying treatment for ACL injuries

What matters most is the athlete regaining full sport-specific function. He must work to restore power with sprinting, balance when landing from jumps, and appropriate joint position sense to quickly cut and change direction. That process usually takes an athlete 9 to 12 months, although occasionally some return in as little as 5 to 6 months from surgery.

A best-case example

A best-case example of this return to play process is New England Patriots tight end Rob Gronkowski. He suffered a torn ACL December 8 last season and underwent surgery on January 9. While he practiced with his team throughout training camp, he looked like a shell of his former self. It wasn’t until week 5 that Gronkowski looked like the player he was before his knee injury, according to Boston Globe reporter Ben Volin.

Volin notes that Gronkowski’s return is exceptional, as most NFL players struggle with confidence in the knee and the fear of reinjury. Former New England Patriots safety and current NBC Sports analyst Rodney Harrison admitted Gronkowski’s recovery has been surprising.

“I tell you, that’s been something that’s really impressed me, because I’ve gone through the same injury and it took me two years to really feel comfortable,” Harrison recalled to Volin. “A lot of times I was afraid when guys were falling around myACL rehab knees, and I’m like, ‘Oh, my God, I’m protecting my knee.’ But you don’t see that with Rob, no sense of hesitancy. He’s just out there playing football, and he looks so comfortable.”

Week 5 for the Patriots was October 5, almost exactly 9 months after Gronkowski went under the knife.

The benefit of extra rehab time

The benefit of earlier surgery then comes from the extra time regaining strength, cutting ability and explosiveness. It offers a few more weeks for an athlete to feel more comfortable doing his job on the field and overcoming the fear of hurting his knee again.

Also read:
3 less known reasons athletes don’t return after ACL injuries
Ask Dr. Geier: Nonoperative treatment of ACL tears

Team doctors at the professional and college levels face these decisions with their athletes frequently. Athletes of all ages should keep these factors in mind when deciding if and when to have ACL surgery.

Note: A modified version of this post appears as my sports medicine column in the December 9, 2014 issue of The Post and Courier.