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.


There is a growing momentum in sports medicine to encourage athletes and their coaches to warm up in more effective ways. Born partly out of the Santa Monica Sports Medicine Foundation’s PEP program, and spurred on by success stories such as this one, these new exercises are widely touted as simple and powerful, reducing knee surgery numbers by a substantial percentage:

These programs, formally known as neuromuscular training, use a series of exercises to teach athletes how to land, cut, shift directions, plant their legs, and otherwise move during play so that they are less likely to injure themselves. Studies have found that the programs can reduce the number of A.C.L. tears per season by 50 percent or more, particularly among girls, who tear their A.C.L.s at a higher rate than boys do (although, numerically, far more boys are affected).

The good news: these are easy-to-perform and familiar exercises which resemble the calisthenics we all learned growing up. Educating yourself or your local sports team is as simple as watching a few online videos. Yet the savings in medical care costs can be staggering, especially as you diminish the likelihood of ACL tears and their attendant recovery measures.

While a warm up run to get the juices flowing and proper stretching prior to the main work out helps to prevent muscle strains, neuromuscular training is an entirely different concept.  Neuromuscular training is really nothing more than a functional core workout.  Yup, that’s it!  What you do in martial arts, or yoga, or pilates….these strengthening activities helps the young female soccer athlete avoid that infamous ACL tear.  The muscles in the torso, abdominal wall, pelvis, and proximal thigh help the athlete to properly position the knee, which minimizes risk of ACL tear.  It has been proven!!!

For some mature athletes, in addition to neuromuscular training, further measures to maximize knee longevity and function include oral supplements (glucosamine, chondroitin, MSM), platelet rich plasma (PRP) or stem cell injections, and hyluronic acid (HA) injections.

I specialize in knee surgery and orthopedic surgery in San Diego, and encourage all my patients to take every precaution they can to stay active and nimble. Please call my offices today to learn more about how you can prevent knee surgery.

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