ACL injuries or Knee ligament injuries are seen commonly by the best orthopedists in town, as these injuries often times occur in aggressive or elite level San Diego athletes that yearn to return to play.


Anterior Cruciate Ligament or ACL injuries happen to hundreds of thousands of people every year. This knee ligament injury usually ends play and can be extraordinarily painful. Although debilitating, they are treatable. You just have to make sure you know how severe your injury is and what you can do to treat the problem.

ACL injuries are actually quite common among people who participate in high action cutting sports, such as:

  • Soccer
  • Football
  • Basketball
  • Lacrosse

Levels of Severity with ACL Injuries

There are three categories of injuries based on what kind of damage has been done to the ACL:

  1. Grade 1: This is the easiest ACL injury to heal. A grade one ACL injury is the result of the ligament stretching slightly. It does not cause the knee joint to become unstable.
  2. Grade 2: This grade of injury is in the middle, and the least common of all knee injuries. A grade two type of injury happens when the ligament stretches to the point where it is unstable. It is more commonly known as a partial tear.
  3. Grade 3: This ACL injury is the most severe. A grade three injury is labeled when the ligament is completely torn in half. This can cause the knee to become extremely unstable. Severe knee pain and an almost impossible time walking are common symptoms.

At the end of the day, the grade doesn’t really matter.  To an orthopedist this injury boils down to those athletes that are able to compensate (ie, their knee is functionally stable) and those that can’t (ie, their knee is functionally unstable). Having a functionally stable knee means that that athlete is able to return to his/her level of customary play in cutting sports without the knee giving out.  Generally speaking, one third of athletes will be able to return to play despite their injury with little to no intervention; one third of athletes will be able to return to play after engaging in directed physical therapy; one third will require surgery in order to return to play due to continued knee instability.

Treatments for ACL injuries

Non-Severe ACL Injuries

If you only have a mild injury, you can, usually, use physical therapy to treat your injuries. Your physical therapist will have you go through a series of exercises and motions to help you regain full control of your knee again. It can take some time to heal completely, depending on the injury type.

Since this is so common with sports athletes, there are specialists who work specifically with athletes. The goal is to help them get back into their sport of choice as quickly as possible.


Severe ACL Injuries (ie, unstable knee)

One third of the athletes will require surgery to regain a stable knee, despite having engaged in physical therapy.  With a physical examination and an MRI scan, a well-trained sports medicine surgeon can anticipate the need for treatment of various concomitant injuries: cartilage damage, meniscus tears, etc.

ACL reconstruction can be done in a variety of ways.  First decision to be made is whether a patient chooses to use their own tissue or donor tissue to reconstruct the ligament.  If a patient chooses their own tissue, the options are bone-patellar tendon-bone, or hamstring tendon, or quadriceps tendon.  Although some surgeons may argue that one type of tissue is superior to the other, many studies have looked at this and there is little to no clinical difference.

If you have been told that you have an ACL tear or are concerned about a knee injury, contact our award winning sports medicine doctors at San Diego Orthopedic Surgery Clinic.


Orthopedic surgeons commonly talk about knee osteoarthritis occurring after major trauma or ACL tears; we solve this problem by performing a total knee arthroplasty or knee replacement surgery.  However, there does not exist a similar replacement for the traumatic brain injuries or brain damage we see in athletes years after the stadium lights have dimmed.

One doesn’t need a medical degree, or data, or even a television to believe that players of a rough contact sport, such as football, will probably suffer long term brain damage and cognitive impairment from repeated head trauma.   In fact, locker room speak for the neurologic changes that boxers and gladiators such as UFC fighters undergo is commonly known as ‘punch drunk’.

brain traumatic injuries

The NFL, however, disagreed this to be the case and convinced its players the dangers were minimal.  However, after being recently sued by 5,000 former players, they were forced to rethink their stance. After hiring actuaries to compile the data, they came to the conclusion that approximately 33% of retired football players will develop long-term issues like degenerative brain disease at a much earlier age than those of us that do not play football.

If knowing that 1 in 3 football players will be affected isn’t bad enough news, Chris Nowinski, from the Sports Legacy Institute states: “… that total does not even include former players who develop mood and behavior disorders and die prior to developing the cognitive symptoms associated with C.T.E.”

The lawyers for the NFL maintain that the findings were an overestimate and the number is likely to be smaller since it was based only on those involved in the lawsuit. Their sole purpose for the data, however, was to ensure there would be enough funds to pay any settlements to the players that were affected.  In the case there is a higher number of players with long term brain damage, there will be money to cover their settlements, too.

brain traumatic injury

The NFL originally agreed to around $1 billion in compensation, but amended that to an unlimited amount over 65 years. Most players who file claims to the NFL regarding this work-related injury, if it could simply be referred to as that, are those who are diagnosed with advanced dementia or Alzheimer’s disease. This amounts to around $800 million in compensation settlements. Those who are diagnosed with Parkinson’s disease, chronic traumatic encephalopathy, or amyotrophic lateral sclerosis will receive up to $5 million.

The NFL calculated that players younger than 50 have about a 0.8 chance of a diagnosis of dementia or Alzheimer’s (compared to less than 0.1 percent for the rest of us), and those ages 50-54 have a chance of 1.4 percent (compared with less than 0.1 percent for the rest of us). Chances increase with age.

While the amount of money sounds like fair compensation, it will take 20 years to receive the first half and 45 years to receive the rest. If a player is diagnosed at say, age 45 with Alzheimer’s disease, he will have his total compensation at age 110. That sounds fair.

Many will argue that the players knew the risks involved when they signed up to play and shouldn’t receive any more compensation than other professions. While this may be true to an extent, every job has risks, even innocuous ones. Librarians can develop carpal tunnel syndrome, preschool teachers can get bulging disks, or a mom finds herself with osteoarthritis. All painful, but some possibly more deserving of a larger compensation than others.


Our young athletes in Carlsbad and North County San Diego, especially soccer and football players, are particularly vulnerable to concussion.  This issue is particularly important to me; my daughter sustained a Grade 2 concussion as a result of a skiing injury.  I feel parental education regarding concussion awareness is tremendously important.  Middle school sports are more rigorous and ambitious than ever before. More physical demands, practice times, and pressures are placed on athletes and the path to perfection is often paved with injuries.concussion-football

One of the most popular sports, globally, is soccer. Children can begin playing as early as Kindergarten. While the sport is fun, good exercise, and a foundation for learning sportsmanship, it can also be damaging to young bodies.

Soccer injuries can range from something as mild as a small bruise to something as major as a concussion. Knee pain, calf pain, and ankle pain are commonly associated with soccer players. Some injuries, like a torn ACL (anterior cruciate ligament) or torn meniscus requires a visit to an orthopedic surgeon for knee pain treatment and possible knee surgery.  These types of injuries that occur in younger athletes may affect them their entire lives. Shin splints, which occur from overuse, stress and bone fractures, wrist sprains and fractures, and even painful shoulder dislocations can occur due to playing soccer.

One especially serious injury from playing soccer is a concussion. A concussion is a traumatic brain injury that occurs when a person is hit hard enough for the brain to shake inside the skull.  This can happen during a sport, a fall, or other types of hard hits. Many people assume a loss of consciousness is needed for a concussion, but this is not true. Symptoms of a concussion include confusion, dizziness, headaches, nausea, vomiting, changed sleep patterns, change of emotional state, and sensitivity to light. Any symptoms of a concussion should be discussed with a doctor as soon as possible.concussion-anatomy

Of all the sports for female middle school athletes, soccer causes the most concussions. High school female athletes have double the amount of concussions per year than male high school athletes.  A study was conducted from 2008 to 2012 that focused on 351 advanced female soccer players between the ages of 11 and 14. During this study, there were 59 concussion reported, which is about 17% of the players.

Because of the high amount of concussions, a class action lawsuit was filed against FIFA (Fédération Internationale de Football Association), along with U.S. Soccer Organization and the American Youth Soccer Organization. This lawsuit, as reported by The New York Times (8/28, Strauss), The Washington Post (8/27, Payne) and the Los Angeles Times (8/28, Baxter) among others, states that the groups have not acted responsibly in terms of monitoring concussions and head injuries.

The lawsuit was filed by parents and players and are asking for a change in the soccer rules. They ask that children under 17 be limited to the number of times to head a ball, and to allow substitutions for anyone being examined for a possible head injury, rather than limiting the number of substitutions in a game. While some are skeptical that new rules will make a difference, we can only wait and see.  As an orthopedic surgeon and sports medicine specialist, I back such legislation and policy change.

If you have questions or concerns about your child and their sports preparedness, feel free to reach out to our top notch Orthopedic Surgery San Diego sports medicine specialists.


At least one time in our sports-watching lifetimes we have seen a player go down hard, wrenching a gut reaction of “Oooh! That’s not good!” from the fans. We wait breathlessly to see if the player can stand on his own or if he needs help from a stretcher. Once the player leaves the field for concussion and broken bone tests, we, the armchair doctors, debate the medical condition, and what it could mean for the team. Each team has their own doctor that determines the extent of the injury, healing time, and when the player can return to the game. Sometimes, a player returns to the field earlier than expected which leads one to wonder if it is safe for him to do so.  Unfortunately, with the objective of winning games, if a star player is injured, it affects the team, the owners, and the fans, and it’s imperative to hear a good prognosis for the injured player, as fast as possible. Pressure from outside influences, on professional sports teams, in particular, can lead to a player being released back into the field too early. We have all heard stories of sports doctors threatened with firing if a player isn’t returning quick enough, but is this ethical, fair, or expected? Sports teams hire their own doctors which is beneficial and at the same time potentially harmful. The sports doctor gets to know the players history. He learns over time what each player can handle, and can assess that what might seem like a bad injury to others may only be minor and release the player back into the field sooner, rather than later.  The drawbacks to having a more personal relationship are pressures from the player, himself, on the doctor, insisting he is “fine” or well enough to go back in. Allowing this could cause even worse injury down the road. Pressures from the coach and the owners on the doctor may also allow a player to be hurt in the long run. An alternative to having a personal doctor for the team would be for the leagues to hire a doctor for them.  He would be a neutral, non-partisan employee. This doctor would be on the league medical staff, rather than a personal team doctor. This doctor would not be required to report to the coach or owners, but to higher up medical personnel in the league itself.  With appointing league doctors, however, it could prove difficult to have one medical standard for all to follow. Will the doctors rotate teams to avoid partiality? If Doctor A thinks Player 1 can go back to the field, but Doctor B does not, who is right? Will a third doctor need to weigh in? Will the players have any say in their recovery? Both scenarios have positive benefits and negative aspects that need addressed.  The only thing that should matter is the health and safety of all the team members. I don’t advocate for or against the present day situation.  My goal is to shed light on a potential  situation that may present with  perceived conflict of interest.

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