One of the most common sports related injuries is a torn ACL (Anterior Cruciate Ligament). Many people think that ACL injuries happen mostly in contact sports but the truth is that a majority of ACL injuries occur without contact. One example of a non-contact ACL injury was during a recent major league baseball game. Los Angeles Dodgers pitcher Paul Maholm ran to cover first base on a relatively routine ground ball. Maholm arrived at first, planted the toes of his right foot on the edge of the bag and then went down riving in pain and reaching for his right knee. After watching the replay about a dozen times it is still hard to say that anything even truly happened. However, within a day it was confirmed that Maholm had a complete ACL tear. A simple misstep and his whole season is over.

The ACL is one of four major ligaments that help to align and stabilize the knee. The knee is the point at which thighbone (femur), shinbone (tibia), and kneecap (patella) meet. The ACL attaches the center of the kneecap to the front of the shinbone. The function of the ACL is to assure proper alignment of the shinbone and thighbone. In addition, the ACL provides very important rotational stability. Like many other ligament injuries, ACL injuries can be diagnosed by severity. Grade 1 ACL sprains are considered mild and involve the ACL being stretched but not detached. With grade 1 ACL sprains, the ACL is still capable of stabilizing the knee joint. Grade 2 ACL sprains are moderate or partial tears and occurs when the ACL is stretched to the point of becoming loose. Grade 3 ACL sprains are the most severe of the ACL injuries. Grade 3 ACL sprains occur when the ACL is completely torn into two separate pieces making the knee joint very unstable.

Grade 1 and some grade 2 ACL sprains can often be treated without surgery as long as instability symptoms are at a minimum. The process of healing involves a heavy regimen of progressive physical therapy but can often restore the ACL close to its pre-injury form. For a more severe tear or what is called a ‘complete tear’, surgical reconstruction is the only way to achieve pre-injury form if there are symptoms of instability. Instability is when the knee gives away or buckles. The ACL is replaced using a tendon graft typically from the patient’s patellar tendon, hamstring tendon, quadriceps tendon, or from various cadaver tendons. The success rate of ACL replacement is tremendous and many athletes come back after surgery and rehabilitation to perform similar to their pre-injury performance. One such example of this was Minnesota Vikings running back Adrian Peterson. Peterson nearly broke the NFL rushing record just one year after suffering a complete tear of his ACL and MCL.

As for the case of Paul Maholm, his surgery has not yet been scheduled, but should be scheduled soon. Given the recent success of professional athletes on surgically replaced ACLs, I have no doubt that we will see Paul Maholm on the mound for the start of the 2015 season.


ACL tears that undergo delayed intervention can lead to further cartilage and meniscus damage. Although many such injuries eventually earn a referral for orthopedic knee surgery, it’s not unusual for kids and their parents to wait several weeks to see how the healing process is going on its own.  ACL tears don’t heal.  The inflammation that is caused by an injury may improve.  But the athlete remains indefinitely vulnerable to recurrent episodes of knee instability.  The knee repeatedly giving out puts the young athlete at risk of further damage with meniscus tears and cartilage loss.

Now researchers think too much caution may be unwise:

Compared to children who had surgery within six weeks, those who had surgery six to 12 weeks after their ACL injury were 45 percent more likely to have a lateral meniscus injury – on the outside of the knee – and those waiting more than 12 weeks were almost three times more likely to have a lateral meniscus tear.

Children who waited at least six weeks for surgery were about four times more likely to have a medial meniscus tear – on the inside of the knee – than those who had prompt treatment, Anderson said.

It is a stark finding, but one which makes sense on its surface: when trauma occurs, often the best chance to reverse its potentially ongoing damage is to hasten the repair process right away.

If you or your child has suffered an ACL tear, I recommend seeing an expert San Diego orthopedic surgeon sooner rather than later.  The longevity of your knee may be at risk.


It has long been a topic of some debate in the world of sports medicine whether partial orthopedic knee replacement surgery is safer than a complete knee replacement procedure.

Now a new epidemiological study published in the Lancet found that complications were far more common in total knee replacements than in partial procedures:

Researchers at the University of Oxford analyzed the outcomes of over 100,000 knee replacement surgeries and found that – while the risk of serious complications is small — TKR patients are twice as likely to have a blood clot, heart attack or deep infection, three times as likely to have a stroke, and four times as likely to need blood transfusions, compared to those having partial knee replacement.

It is an interesting finding that will almost certainly inspire more detailed research, including, one hopes, a randomized study which should yield better data. But this remains a strong signal that doing less can be more effective than doing more, especially in cases where the orthopedic injury doesn’t necessitate a full replacement.  The advantage of consulting with a sports medicine orthopedic surgeon is that we can treat the particular knee condition with an appropriate intervention (i.e., we have more tricks in our bags than simply doing a total knee replacement on every patient that walks in the door).

If you have suffered with knee pain in San Diego for some time, I urge you to see a  sports specialist. Please contact my orthopedic knee surgery offices in San Diego today.


Shoulder injury is common in the NFL, as any diehard sports fans can testify.  The video showing such injuries may be so graphic that many fans even wonder if the player will ever return to form, especially for NFL quarterbacks.

A new study has found encouraging news. Orthopedic shoulder surgery shows an overwhelming success rate among professional athletes:

The new study included 60 players who had shoulder stabilization surgery. Ninety percent of those who had this procedure successfully returned to play, defined as playing in at least one regular season game. The return rate was 82 percent for those who had open surgery and 92 percent for those who had minimally invasive (arthroscopic) surgery

These are numbers which should please anyone who plays, or is invested in, football on a competitive level. They also serve as a reminder that shoulder surgery is a safe and effective way to relieve pain and reclaim movement, no matter if you are a weekend warrior or a professional linebacker.

To learn more about shoulder surgery in San Diego, contact my practice today.


Frozen shoulder is such a painful condition that patients in the past have equated to being tormented by a medieval torture rack. Because it tends to arise, progress, and ultimately dissipate without any particular cause or warning, many patients find themselves mystified by the condition.

This article helps to demystify the various stages and remedies associated with frozen shoulder, covering everything from the freeze to the thaw. Although restricted movement and steroid injections remain common prescriptions, some cases will require more aggressive intervention:

In certain severe case a manipulation under general anaesthesia maybe necessary though stringent exercise following this is essential for a good outcome. Resistant case[s] may need an Arthroscopic Capsular release surgery. Open releases have become obsolete with the advent of Arthroscopic Surgeries (key hole surgeries) which are definitely less morbid and have a faster recovery period.

If you are dealing with the immobility and distress of frozen shoulder, please contact a San Diego orthopedic surgeon today.


This interesting piece caught my eye recently: a first-person account of an orthopedic surgeon’s visit to China. Its author relays a great deal about how the sports medicine specialists there accommodate the nation’s high volume of patients and occasionally insufficient supply of tissue:

When it comes to performing biologic orthopedic procedures using human donor tissue, the situation is challenging. Donor tissues are in short supply and the supply chain is not trusted. This has led to high doses of irradiation being used to sterilize the tissues. Unfortunately, the radiation also ruins the quality of the tissue by cooking it. This is possibly one area where we may be able to help by providing an off-the-shelf device solution.

Some feel that using animal tissues might represent at least one solution, although there is no question that improving the medical infrastructure overall would offer some essential relief throughout the nation.

What stands out from the piece is the singular dedication physicians and surgeons around the world bring to their practice, even when limitations render certain best practices difficult to follow.

I am grateful to serve my orthopedic surgery patients in San Diego, and to offer the gold standard in knee surgery and rehabilitation. To learn more about some ways you can relieve knee pain today, please contact a San Diego orthopedic surgeon.


Knee injury while at rest.  Seemingly contradictory.   It has long been suspected that an active life and daily movement represent good ways to reduce your likelihood of getting arthritis. Now some researchers have finally looked at the numbers to see if this popular notion withstood statistical scrutiny. Their conclusion?

When they analyzed the step data from the pedometers, they found a strong link between participants’ activity level and knee health. Their results suggest 6,000 steps marks an important threshold: 70% of participants who developed knee impairments walked less than this amount while 70% of those who remained healthy walked more.

Using nothing more advanced than off-the-shelf fitness trackers, these researchers were able to study and control for a variety of factors in a population of about 2,000 people. Sure enough, the more active participants seemed considerably less likely to develop knee pain and other symptoms associated with this progressive disorder.  From a scientific standpoint, this makes sense.  Cartilage and the locomotion machine (i.e., body) function better when the ‘engine’ is kept warm.  Not turned off and allowed to collect dust; and not when the engine is ‘revved’ too high, wherein the parts fall into disrepair.  For example, the fascinating thing about cartilage is that cartilage requires, as a part of its normal maintenance, it’s use (such as with walking) to deliver the nutrients from the joint fluid into the cartilage structure.  It’s use actually prolongs it’s longevity!

Of course a cohort study like this cannot officially separate causation from correlation; it is possible, for instance, that people who walk fewer steps do so because they already have bad knees. Yet this study remains a tantalizing clue in support of the idea that sedentary lives can be injurious lives, and that we would all do better to move around more during our active years.


It’s always exciting to work at the forefront of a field defined by so much innovation. I have written before about the many ways technology is changing orthopedic medicine. Now doctors and entrepreneurs are finding new paths to intuitive medical designs via 3D printing.

No two bodies are the same. This fact has long bedeviled designers and specialists looking to create braces that cover a variety of shapes and ranges of movement. Scoliosis in particular has been infamous in this regard, which is why it is encouraging that some people are finally creating ways to design utterly customized, one-of-a-kind braces:

The 3D printing and design company on Monday released its plans for a scoliosis brace that is devised to be sleek and comfortable. Dubbed “Bespoke,” the 3D-printed brace can be personalized to the backs of children and young adults who have the condition.

It is yet another sign that medical devices are finally catching up to other wearable technologies in terms of versatility and comfort. To learn more about how to relieve and treat back pain, please contact a San Diego orthopedic surgeon today.


Shoulder Pain and knee discomfort plague tons of active ‘regular Joes and Joannes’.  Pain relief is an evergreen topic in the field of orthopedic medicine. Most patients come to my practice only when the pain reaches a fever pitch, and by then it is often too acute to treat with ‘the more gentler’ methods.

But there are a number of good ways you can relieve chronic pain before it reaches the boiling point, including herbs, changes of diet, and exercise. Stretching remains the simplest of all and the most portable, which is why I am always on the lookout for easy stretches to help my patients on the go.

This article includes some of the easiest I have seen, including one easy variation on a knee bend:

1. Stand with feet wider than hip-width. Deeply bend both knees and shift your hips back. Place hands on your thighs with fingers pointed inward.
2. Drop right shoulder to the midline of your body pressing into your thigh for leverage. Come back to center and drop left shoulder to the midline of your body. Maintain a strong core and keep glutes engaged the entire time for additional support.
3. Continue to alternate for 30 seconds to one minute.

For more great tips and expert medical care, contact San Diego’s orthopedic surgery experts today.

© 2023 Dr. Robert Afra – San Diego Orthopedic Surgery Shoulder – Knee – Elbow