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Tiger is back...with a New ACL

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Tiger woods returned to the PGA Tour last week, less than a year after Anterior cruciate ligament (ACL) reconstruction. ACL tears don't typically occur in golfers, but then, Tiger Woods isn't the typical golfer. The ACL is one of four ligaments in the knee, and it functions to stabilize the knee during twisting motions. Tears of the ACL are relatively common injuries, but they usually occur in more high-demand sports, such as football. Though golf isn't usually thought of as a demanding sport on the same level as football or soccer, the fact that Tiger was able to win the US Open with a torn ACL and stress fractures is amazing.

The ACL is a ligament located in the center of the knee. When it tears, patients often describe a "pop," and the knee swells. After the acute event, the pain typically subsides however symptoms of instability and giving way persist. Doctors can often diagnose these tears with one of several physical exam tests, but an MRI remains the best test to definitively document an ACL tear. Additionally, an MRI scan allows for the assessment of other structures in the knee that may be injured at the same time as the ACL.

According to reports, Woods initially tore the ligament while running. At the time, the knee was probably swollen and painful, but those symptoms resolved. The initial decision to try to treat the ACL tear conservatively was a very reasonable option. Unfortunately for Tiger, the elements of his swing that have made him so successful (the speed and torque he generates) are probably the same factors that made the nonoperative treatment unsuccessful in his case.

Unlike many orthopedic procedures, such as rotator cuff repairs, in which a torn tendon is sewn back to its original position, the ACL does not respond well to being repaired. Instead, the torn ligament is removed, and a piece from the patient's patella tendon or hamstring tendons are used to reconstruct the ligament. Another option is to use a tendon from a cadaver donor. No matter which graft is used, the majority of the procedure is done arthroscopically. A small incision is typically made distal to the knee to pass the graft into the knee in the appropriate position. According to Dr. Answorth Allen, an orthopedic surgeon specializing in sports medicine at The Hospital for Special Surgery and orthopedic surgeon for the NY Knicks, "newer techniques allow for more anatomic placement and better fixation of the graft, which should improve the long term outcomes of ACL reconstruction."

After surgery, patients are often allowed to walk with a brace and crutches and range of motion exercises are started immediately. As motion improves, strength training is added to the therapy regimen. A golfer would probably be hitting balls by the 3-month mark after surgery. Athletes are typically allowed to return to sports when strength and motion are about equal to the opposite leg. A study of NFL running backs and wide receivers with ACL tears found that they returned to competition about a year after surgery, on average. Though we have less data on such injuries in golfers, clearly golf is less strenuous than football. Tiger returned this week, which was about 8 months after surgery.

Tiger Woods has never ceased to amaze us. Allen points out that "given the excellent physical condition that he is in, combined with his natural athletic ability, there is no reason to think that he won't get back to his previous level of play. Tiger Woods' surgery was done modern reconstructive techniques which should not only prevent the knee from buckling but provide better rotational control which is extremely important in golf. He should have more confidence in his knee and this will influence his swing."