Woods's ACL Injury Seen As a Rarity in Pro Golfers
By David Brown
Washington Post Staff Writer
Thursday, June 19, 2008
Experts on knee injuries were puzzled yesterday over the announcement that Tiger Woods suffered an injury -- rupture of an anterior cruciate ligament -- almost always associated with fast-paced, quick-cutting sports such as football, basketball and lacrosse, but almost never with golf.
They speculated that there is more to know about the events leading to Woods's decision to have the ligament surgically replaced, ending his season on the PGA Tour. However, they did not rule out that this was a rare consequence of Woods's play -- and one more example of the limit-breaking athleticism he has brought to his sport.
Woods's Web site, which announced the injury and the golfer's plans, said he ruptured his left ACL in 2007 "when he was running at his home in Orlando." At the time, he elected to forgo surgery "and instead attempted to play through the pain," according to the announcement.
"I don't know we have all these pieces of the puzzle," said Nicholas DiNubile, an orthopedic surgeon in the Philadelphia area and consultant to the Philadelphia 76ers. "You don't have to be tackled, but you do have to be moving pretty quickly to tear an ACL. It is not a wear-and-tear injury."
William N. Levine, an orthopedic surgeon and director of sports medicine at New York-Presbyterian Hospital, agreed.
"It is not usual in straight-ahead running or jogging to tear ACLs. Until we have more information from the surgeon or the athlete, it is going to be very difficult to understand," he said.
Woods has undergone three previous operations on his left knee, the last one in April to, as his Web site statement put it, "clean out cartilage damage." Two previous operations -- one in 1994 and another in 2002 -- were done to remove a benign tumor, and later to remove fluid inside and outside the anterior cruciate ligament and to remove benign cysts.
Whether those growths weakened the ligament is unknown, but one expert said yesterday that was possible.
"If you think about the torque that Tiger generates and the speed with which he swings, you don't have to go too far out on a limb to say that was the nature of the injury -- especially if the cyst may have compromised the integrity of the ligament somehow," Levine said. "Otherwise, it is hard to understand exactly how this occurred."
Whatever the exact cause of the injury, experts predicted that with the much-improved modern surgery for ACL ruptures, Woods probably will regain full function.
"This used to be a career-ending injury for athletes. Now we say it is a season-ending injury," DiNubile said.
The anterior cruciate ligament runs inside the knee joint in a diagonal direction, connecting the lower end of the thigh bone to the upper end of the main bone of the lower leg. It prevents the thigh bone from moving backward, and prevents the entire knee joint from straightening too much (also known as hyperextension).
A second ligament, the posterior cruciate, crosses the ACL and stabilizes the knee in the opposite way. The ACL is slightly weaker, however, and more often is injured.
The announcement yesterday also revealed that Woods has a "double stress fracture of his left tibia," the large bone of the lower leg. The fractures were discovered last month and "were attributed to Woods' intense rehabilitation and preparation for the U.S. Open," which Woods won this week in a dramatic sudden-death playoff.
Stress fractures generally are injuries of chronic overuse. They are most commonly associated with distance runners who increase their mileage too quickly, causing constant, low-impact stress on a weight-bearing bone.
"Rehab exercises are usually low impact. It would be very rare to get that [injury] in the physical therapy room. I have never seen it," DiNubile said.
What relationship the stress fractures may have to the ACL tear -- and what either may have on the unspecified cartilage damage that surgeons treated in the arthroscopic surgery in April -- is unknown.
The surgery Woods is likely to undergo will require getting a replacement ligament from elsewhere in his body or from a cadaver. If the former strategy is chosen, surgeons could use part of the patellar ligament, which attaches the kneecap to the lower leg. An alternative would be to use part of the tendon of the hamstring muscles at the back of the thigh.
The new tendon is attached to the bones at both ends using screws or staples. Cadaver tendons, unlike other organ transplants, do not require a patient to take immune-suppressing drugs. However, they do take somewhat longer to heal.
The operation usually is done with fiber-optic arthroscopes. A small incision is made below the kneecap, through which the surgeon tunnels into the joint.
"The procedure is light years from what it was when I was training," said DiNubile, who is 55. "This has gone from being a disastrous surgery with a huge incision to something that is usually done with an overnight stay."
Whatever strategy is used, a main issue after the operation is that the patient usually feels ready to fully use the knee well before it is ready to bear the stress of high-level athletic activity. The grafted tendon does not reach full strength for 18 months.
The failure rate for first-time ACL repair is about 5 percent. If a second operation is required, the failure rate rises to about 25 percent.
"Our goal is for the athlete to be back playing their sport at the six-month point," Levine said. He speculated that Woods could be putting three months after the surgery and chipping at four, but not swinging hard until after that.
Staff researcher Madonna Lebling contributed to this report.
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