April 29, 1991
One False Move
That's all it takes for a player to suffer the NBA's most feared injuryâ€”a torn anterior cruciate ligament
On one side of the Los Angeles clippers' locker room, Danny Manning picks up a blue-and-black neoprene kneepad and tosses it to his teammate Ron Harper. Harper snatches it out of the air. He daintily points his right foot toward the floor and starts to slide the rubbery sleeve up to his knee. "That's inside out," Manning says, scolding Harper like a big brother.
"I know how it goes," Harper snaps back, easing the kneepad into place. Harper knows how it goes. It has been 15 months since his career ended and three months since it started again. Manning knows how it goes, too. It has been two years and four months since his career ended and 17 months since it started again.
This kneepad, which looks like a toeless sock from a wet suit, is worn by players who have torn their anterior cruciate ligaments (ACLs) and returned to the NBA. The kneepad and the metal brace worn with it have become the emblems of membership for the league's ACL union.
Over the last three seasons the membership has multiplied with elite players: Manning went down on Jan. 4, 1989; the Milwaukee Bucks' Larry Krystkowiak, on May 14, 1989; the Seattle SuperSonics' Dave Corzine, on Nov. 8, 1989; Harper, on Jan. 16, 1990; the Philadelphia 76ers' Johnny Dawkins, on Nov. 8,1990 (box, page 56); the Dallas Mavericks' Roy Tarpley, on Nov. 9, 1990; the Cleveland Cavaliers' Mark Price, on Nov. 30, 1990. Before 1988 the membership roll included Toby Knight (Sept. 23, 1980), Campy Russell (Aug. 13, 1982) and Eddie Lee Wilkins (Aug. 2, 1985), all of whom played for the New York Knicks; Bernard King (March 23, 1985), who was also with the Knicks when he got hurt and is now starring for the Washington Bullets; and Mitch Kupchak (Dec. 19, 1981), who played for the Los Angeles Lakers. "It's like some fraternity nowâ€”the ACL frat," says Krystkowiak. "But it's not the kind of club anyone wants to be a member of."
The club has grown so renowned around the league that players who wouldn't know their cerebral cortex from a pick-and-roll have become fluent in the pronunciation of "anterior cruciate ligament" and experts about its function. A tear of the ACL has become the most feared injury in the sport. "The hardest thing is the mind," says Clipper trainer Keith Jones, who has worked with Manning and Harper. "They hear they tore their ACL; they know what that means. They think [their careers are] over. You can tell them success stories like Bernard's, but it doesn't mean anything to them. They think they're done."
The ACL ruptures suddenlyâ€”the injury is not the result of years of getting banged under the boards. In a fraction of a second this 1Â½-inch-long ribbon of tissue, upon which a player's career hinges, can be ripped apart. Corzine, who was playing center for the Orlando Magicâ€”an expansion team in its first season in the league-when he tore the ACL in his left knee, says, "I remember that I took a pass at the top of the key about five minutes into the game. Then I took a couple of dribbles down the lane and went to plant. It was the exact same thing I'd done hundreds of thousands of times before."
That one move in a hundred thousand cost Corzine, like other ACL club members, at least a year of his basketball life. While recovering, players work out alone every day as their teams make do without them and talented rookies come into the league. "The nightmare is that all of a sudden you're not part of it anymore," Krystkowiak says.
Until about 20 years ago a knee injury often ended an athlete's career. Even if he or she did come back, the player was rarely the same. The clichÃ© is that the knee was not designed for sports. But for 2Â½ million years it worked fine; it has only been in the past 100 or so, since athletes started collidingâ€”often quite violentlyâ€”at high speeds on the football field, that we have noticed it could be improved.
The reason the knee can twist and flex is that the strongest thing connecting the femur (the thighbone) to the tibia (the shinbone) is a series of ligaments. The ACL is one of two ligaments (the other is the posterior cruciate ligament) that cross between the femur and the tibia, preventing the two bones from slipping forward or backward out of joint.
When the tibia juts too far forward, the ACL can rip. Except in the case of Priceâ€”who tore his ACL when he collided with a courtside signâ€”all of the ACL injuries in the NBA during the last few years have occurred when a player pushed off or planted his foot. "It happens when you want to jump with maximum force and speed," says Krystkowiak.
Given how often a basketball player puts himself into a position that strains his ACL, one would think that ACL injuries have always occurred in the NBA, and of course they have. But Elgin Baylor, who played in the NBA for 14 years for the Minneapolis and Los Angeles Lakers and is now the general manager of the ACL-injury-plagued Clippers, says, "We never heard of it when I was playing. Torn cartilage, yes, but never this ACL."
Players, however, did suffer ACL injuries before 1980. We just didn't hear much about them because the injury usually ended the players' careers. Neither Hall of Famer Billy Cunningham, who ruptured his ACL in December 1975, nor Doug Collins, the four-time All-Star with the 76ers, who tore his in March 1980, returned successfully from those injuries. Who knows how many cases of "bad knees" or "severe knee sprains" were really ACL injuries? When a player "blew out" his knee, team officials were more concerned with if and when he might return to action than with which ligament he had shredded.
Nobody knows if NBA players suffer more ACL injuries today than five, 10 or 20 years ago. According to John Robinson, director of sports research at Nike, "There are a lot of questions. And we're not attacking them in a very scientific manner."
Stephen Lombardo, who is a team doctor for the Lakers, says, "I'm not sure that there are more. There are a lot of apparent epidemics: We had three broken fingers on the Lakers in one year, three hand injuries on the [L.A.] Kings, seven knee-ligament injuries on the Rams. It may only look like there's a rash of ACL injuries."
Not until he was hurt did Corzine notice that ACLs were being ruptured all around the league. While doctors may not agree, players, coaches and general managers are convinced that more NBA players are tearing their ACLs than in the past. They offer the following theories to account for the injuries:
â€¢Shoes are too good. The most common fracture in skiing used to be the boot-top break, so called because the tibia would snap just above the top of the ski boot when a skier fell. Now, however, ski boots come up higher on the leg; it's as if skiers wear casts from the toes to the middle of the shin. Some doctors have said the higher boots put more pressure on the knee ligaments, and that in turn has increased the incidence of ACL ruptures on the slopes.
So what does skiing have to do with professional basketball players? Almost everyone in the NBA now wears hightops. If high ski boots put more pressure on the ACL than low boots, then maybe hightop sneakers put more pressure on the ACL than low-cut sneakersâ€”even though hightop sneakers don't come as high on the leg as ski boots. NBA players have taped their ankles for decades, and some players say that, too, increases pressure on the knee. But tape loosens up during a game; hightop sneakers don't. Says one general manager, "It must be the shoes. Everything else is the same. Maybe they're not giving enough?"
â€¢Players are bigger, stronger and faster. Although ACL injuries are not caused by behemoths' bounding into one another, big, strong, fast players do exert more force on their knee ligaments than small, weak, slow ones do on theirs.
â€¢The season is too long. With the combination of the interminable regular-season NBA schedule, the playoffs and summer leagues, some players are on the court year-round. Krystkowiak was hurt during a Sunday playoff game. "I was so tired by then that I didn't have enough energy to work out the Saturday before the game," he says. "I wonder to this day if I had gone into the weight room on Saturday to use the leg-lift machine, whether that little bit would have been enough to protect me from what happened."
For such a devastating injury, an ACL tear sometimes seems less than serious initially. Harper, who tore not only his ACL but cartilage as well, asked to return to the game a few minutes after he got hurt. The team doctor said no. Manning thought that he had simply hyperextend-ed his knee. "It wasn't that bad," he says. "It was an 'Oh, hell' feeling. You never think it's something all that serious. You never think you have an injury of that magnitude."
Because players often have to wait a day before an arthroscopy or MRI can be performed and a diagnosis confirmed, they have some time to hope for the best. No player imagines the worst. "My first reaction when they told me what it was, was shock," says Price. "I thought, This is the worst thing you can have."
After a player hears the worst, he's left with two questions: Can the ACL be fixed? and, Will I ever be the same player again? The answers are usually yes and no, respectively.
Most of the body's ligaments can be sewn together after they've been torn. Tears in the collateral ligaments, which run along the sides of the knee, can be repaired this way. The ACL, however, is wedged between the tibia and the femur, within the joint, where it's bathed in a lubricant called synovial fluid. If an ACL were sutured together, some doctors believe the synovial fluid would prevent it from healing. Also because of its confined position, a stitched-together ACL would never fully regain its blood supply.
Thus, because the surgeons can't sew the ACL back together, they must find something to replace itâ€”usually a strip of tissue from somewhere else in the body. In King's case, Dr. Norman Scott, the Knicks' team physician, used a stretch of the tough sheath that runs from the hip to the tibia along the outside of the thigh muscles. Although it was astonishingly successful for King, that technique isn't used very often anymore.
Besides Dawkins, whose knee was repaired using a technique similar to the one used on King, virtually every NBA player who has had an ACL reconstruction in the last three years has had a patellar-tendon graft. The patellar tendon connects the kneecap (the patella) to the tibia below. (Another tendon connects the patella to a thigh muscle above.) Through a 3-inch incision in the knee, the surgeon removes a bandâ€”about 3Â½ inches long and⅜ of an inch wideâ€”from the patellar tendon. Then, while peering through an arthroscope, he places the tendon between the tibia and the femur and screws it into place, replacing the ACL. Says Lombardo, who performed a patellar-tendon graft on Manning and Krystkowiak, "What we put in there is similar to the ACL, but it's not exactly the same. It simulates, but it doesn't duplicate."
In time, one study has found, the body mysteriously transforms the tissue of the grafted tendon into ligamentlike cells. And in another example of anatomical wonder, until blood supply returns to the area, the synovial fluid that normally retards healing nourishes the graft.
When performed on young people-most of the members of the ACL club fit into this categoryâ€”the patellar-graft procedure is successful more than 90% of the time. Its most common side effect is patellar tendinitis, or "jumper's knee." Because the patellar tendon that remains in its original place after the surgery is only three quarters of its normal width, it sometimes becomes irritated. So the drawback of the patellar-graft procedure is that it may leave players with two injuries to recover fromâ€”one suffered on the basketball floor, the other on the operating table.
Doctors have tried many other ACL-reconstruction techniques. In one the damaged ACL is replaced by a ligament or tendon from a cadaver. The risks are that the body will reject the foreign tissue or that the transplant could transmit an infection from the dead donor to the living recipient.
In another procedure, artificial ligaments made of Gore-Tex have been implanted. But they loosen up a few years after surgery or, worse, they break, as often happens with pro athletes. Says Lombardo, "There was a rash of enthusiasm for these techniques. But the best tissue is your own."
A damaged ACL doesn't have to be fixedâ€”players are now competing successfully in the NBA with damaged ACLs. Anthony Daly, the Clippers' team physician, says, "You can lead a normal life without an ACL, but you can't play a cutting sport like basketball." San Antonio Spur forward Sean Elliott tore part of his ACL when he was only 14. Surgical reconstruction wasn't done at the time because it would have interfered with the growth of the bones in his knee. He still has more play in his knee than normal, but why correct that and take away a year of his promising career when he performs as well as he does?
Krystkowiak tried to play on a damaged ACL. After he chipped cartilage and ripped both his anterior cruciate and medial collateral ligaments during the '89 playoffs, surgeons fixed the cartilage and the collateral ligament. They didn't repair the ACL, however, because recovery from collateral ligament repair usually requires the knee to be immobile for four weeks; rehabilitation from ACL surgery requires constant movement of the knee as soon as possible. Krystkowiak tried to come back without ACL reconstruction. He played 16 games for Milwaukee toward the end of last season. "I thought I was back, but little things kept coming up," he says. "Then in the summer league [in Los Angeles] I knew something was wrong. I went to test the knee. I flunked the test. It kept popping and grinding."
Because he didn't have a sound ACL, Krystkowiak's tibia and femur were slipping out of place, mashing his cartilage to bits. On Aug. 28 he underwent a second operation, this one to reconstruct his ACL. Says Krystkowiak, "I didn't know what I was missing. Now I have an ACL and my knee feels much more stable." (Not incidentally, when Krystkowiak, 26, decided to have the ACL repaired, he had three years left on a four-year guaranteed contract and could thus afford to take another year off for rehabilitation.)
ACL rehabilitation starts immediately after surgery. A player wakes up after the patellar-tendon procedure in an anesthetized stupor, with his knee buckled into a bracelike contraption that flexes and extends his knee once a minute. The motion prevents the surgically weakened tendon from sticking to the tibia as it heals. After three to six weeks the player can pedal a stationary bicycle. A few months after that he can jog on a treadmill and start shooting set shots.
"When they start shooting, they think they're back," says Jones. "That's when they get lazy. You have to get on them. You have to call them names. You tell them you've had it, that you're leaving. Eventually they give in and say, 'O.K., I'll do the exercises.' "
Says Price, "My physical therapist told me that the main thing is that you're the one who has to do the rehabilitation. You're the only one who can get you back."
The most frustrating thing about the rehabilitation process is that for nearly a year, the knee seems to feel no better one day than it did the day before. The recovery is long and the progress is subtle because the graft and the muscles in the leg don't regain their strength for several months. Says Manning, "Sometimes I think it would be best if you could be hypnotized for a year."
One Thursday in December, Clive Brewster, Krystkowiak's physical therapist, promoted him to that thrilling stage of rehabilitation in which he would be allowed to grunt, groan and sweat aboard a hamstring-quadriceps machine. "It was like I had climbed a mountain," says Krystkowiak. "It's great to be able to get tired again."
Brewster, the director of physical therapy at the Kerlan-Jobe Orthopaedic Clinic in Los Angeles, says, "You have to give them little victories. Larry was heading for the dumps, so we put him on the machine and his whole spirit changed."
It's during the lonely year of rehab that membership in the ACL club pays off. "I've called other players just to let them know that it's something they can overcome," says King. "I talked to Larry Krystkowiak when [the Bullets] were in Milwaukee earlier in the season. He indicated that it's given him a lot of confidence just watching me, during those moments when it might be tough for him." In 1989 King called Manning to "let Danny know that it could be done." Manning, in turn, advised Harper. "I told him to be patient," says Manning. "I didn't know what he was going through, but I had a good idea."
If the ACL club had a slogan, it would be, Stop asking me that question. Other players recovering from ACL are the only ones who don't ask, "When are you coming back?" and "How's the knee?" A few weeks before he returned to the lineup, Harper said, "I want to get a shirt that Says WHEN I COME BACK, YOU'LL BE THE FIRST TO KNOW."