Our own Dr. Komenda joined Shannon O’Kelley on KOMO to discuss the all too common injury, a torn ACL. They review the anatomy of the knee and exactly how our ACL works. They also discuss the signs and symptoms of ACL tears,  what to expect if you experience one, and how to get back to your activities after.




It’s a Northwest Lifestyle Weekend on KOMO News. IRG’s Health Talk continues.

IRG Physical & Hand Therapy’s Health Talk. The first guest, Greg Komenda, doctor of sports medicine and orthopedic surgeon for Proliance Orthopaedics and Sports Medicine in Issaquah, Redmond, and Bellevue. Jordan Morris, Sounder star out of Mercer Island went to Stanford and is not playing this season because of an ACL issue which is what our topic is going to be. Obviously, it takes a long time to recover.

That is a surgery that takes time. It’s a biological thing. You know, when they put that new graft in there, it’s got to heal down, but the reality of this injury is if you look at Jordan Morris’ injury, it’s a non-contact. It’s a deceleration-type injury that can happen to anybody, right?

All right. Let’s hear what Dr. Komenda has to say, along with Shannon O’Kelley on IRG Physical and Hand Therapy Health Talk.

Shannon O’Kelley: Dr. Komenda, welcome, welcome, welcome, welcome. How are you?

Dr. Komenda: I’m doing great this morning. Thank you for having me.

Shannon O’Kelley: Well, and we’re lucky and glad that you’re here because we’re going to talk about a topic that is in the news regularly, and particularly in athletics and people that are active in their life, and that’s ACL tears and the reconstruction aspect, and return to play or return to recreation, but before we do that, tell us and our listeners about your specialty and your area of practice.

Dr. Komenda: Well, I’ve been in the Seattle area since 1974, and I went to some different cities for medical training, to St. Louis and Baltimore, but I’ve been back here for the last 21 years, sports fellowship trained, so I’m part of Proliance Surgeons, and particularly our group is Proliance Orthopaedics & Sports Medicine. We’re located on the east side. We’re in Bellevue, Issaquah, and Redmond. I personally do sports medicine, so take care of ACL tears, meniscal tear, do a lot of rotator cuff injuries and labral tears, so I deal with athletes and pitchers and football players, lacrosse players, and then also the weekend warriors like us.

Shannon O’Kelley: Like us, exactly, and I just got back from skiing, and every time I go skiing, I look around and you know, you’re in the airport at these big resorts, and people are in knee braces, and you’re going, “Oh, I bet that’s an ACL,” because that’s a real common tear in skiing is that ACL. Tell our listeners about the anatomy of the knee, and let’s particularly talk about the ACL and how it’s so important for stability.

Dr. Komenda: Well, if you look at the knee joint, there are four things that make up a knee joint. Probably one of the most important things is that articular cartilage. The articular cartilage is what caps the bone, and that is a kind of springy, cushiony substances there that protects the knee joint. When that articular cartilage wears out, that’s what happens with arthritis, and so the goal of the meniscus and all the ligaments is to protect that articular cartilage.

So we have two structures called the meniscus, and that’s a different type of cartilage. It’s a fibrous, real flexible cartilage that protects the inside and outside of the joint, so you frequently hear about people tearing their meniscus. The other structures in the knee, of course, you have your ACL which is the anterior cruciate ligament. We also have the posterior cruciate ligament, and then we have collateral ligaments on either side, so we have the medial collateral ligament or the MCL, and then we also have a ligament on the outside, sometimes known as the lateral collateral ligament or also called the fibular collateral ligament. There are a bunch of other little obscure ligaments in the knee joint that are also as important, but I think for our listeners, starting with those first four ligaments is important.

The last thing we have inside a joint is the synovium. The synovium is what lines the joint. It makes fluid, and that’s a structure that frequently in people like rheumatoid arthritis or psoriatic arthritis will have an inflammatory reaction with this that actually attacks the knee joint.

Shannon O’Kelley: And you can actually, that synovium, you can actually irritate that, and in the old days, they probably called it, “Oh, you have water on your knee,” and that’s just an irritation of that synovial lining that gets kind of hyperactive and produces too much fluid?

Dr. Komenda: That’s right.

Shannon O’Kelley: But that’s a common thing in ACL tears. I mean, let’s talk about the ACL. So we look at the knee and we look at it as a box. The ACL prevents the tibia from moving forward, it stabilizes the anterior, maybe the medial portion of the knee, and most tears in the ACL situation are … They’re not contact tears. They’re slowing down tears or what we call eccentric loading. Maybe you can describe that because you see an athlete running down the field, and all of a sudden they go to cut and they collapse, and you’re going, “Oh wow, what happened there?” No one hit him, right?

Dr. Komenda:  Right, right. That’s exactly right. So looking at the ACL, it does control translation of the moving back and forth, but it also gives rotational stability to the knee, and you’re absolutely right. You’ll see that an athlete, nobody touches them and they go down, and frequently what that is it’s loading up the knee, so you have to have pressure on it. It’s frequently doing it, extended or non-flexed, and sometimes hyperextended, and then we’ll also see a valgus injury, which is the knee going inward, and at the same time you get external rotation of the tibia, and it’s the combination of those forces in that that can lead to a rupture of the ACL.

Shannon O’Kelley: Dr. Komenda, we have talked and have been talking about ACL tears, and we described and you described the anatomy, the mechanism of injury. Tell us about signs and symptoms. How would an athlete or a parent know, hey, this might be an ACL tear, because there are some classic signs, right?

Dr. Komenda: Well, there is, and I think the first thing oftentimes someone will feel a big pop in the knee. Typically they’ll get quite a bit of swelling in the knee joint where that can happen right away. What they’re wondering is, “Gosh, did I tear my ACL? Is it just an MCL? Did I tear my meniscus?” but usually with quite a bit of swelling, they know they did something.

Shannon O’Kelley: Usually if there’s a pop and some instability where they can’t weight bear and there’s some immediate swelling, there’s something going on in that knee.

Dr. Komenda: That’s right, and hopefully it’s just an MCL, maybe a grade one or two MCL that they can recover with a brace, but sometimes, unfortunately, it is that ACL tear.

Shannon O’Kelley: And as a sports medicine physician, and obviously your goal is to take typically a young athlete or someone who’s very active and get them back to activity, you tear your ACL, and there is a loss. You go through a period of kind of denial and anger, and it’s almost like losing something, particularly for the young athlete that’s worried about getting back.

Dr. Komenda: Well, that’s absolutely right, and I tell all my patients that they’re going to go through those stages, but the important thing is that the bottom line, they’re going to be okay, and the large majority of them are able to get back to their sport. The studies out there show that about two-thirds get back to their competitive sport, and about two-thirds of those get back to their high level of play that they had before.

Shannon O’Kelley: And technology and minimally invasive surgery today, particularly in ACL reconstruction is advanced so much from 20 years ago possibly that the return to play is pretty quick compared to the days gone by when it was a nine-month, 12 month. Tell us about return to play. Tell us about the surgical intervention and what your techniques are.

Dr. Komenda: Well, I think that … Actually, I always tell my patients you can’t beat the biology, so those cells still have to heal, and they’ve got to do their thing, and the reality is it takes nine to 18 months for that tissue to completely heal up. Now, we can get them moving pretty quick. We can get them going day two, day three. We get them into physical therapy pretty quickly and get their knees moving, but we do it in a very controlled and protected fashion.

Shannon O’Kelley: And what kind of technique are you using? Are you using a hamstring graft or a patellar tendon? What is your area of interest or what do you believe in?

Dr. Komenda: Well, I think those are both great grafts. Either bone-patellar tendon-bone is a great graft today. Hamstring autograft is a great graft, and those I think should be utilized for young people and competitive athletes and that because they’re strong grafts, and they’re going to allow for return to play. Their re-rupture rates are fairly low. I think we need to be careful with allografts and who we are using those on.

Shannon O’Kelley: And the reality is, as a result of the technique and improved rehab, you can get these patients moving quicker, you’re mobilizing them quicker, so it still takes about nine to 12 months to get back to play.

Dr. Komenda: Well, that’s right, and I actually went through that as a parent. My son was 17 years old, recruited for lacrosse and he tore his ACL his junior year. He, fortunately, had it repaired. He had a great senior year and was able to walk onto the University of Denver and make a team where he was previously recruited, and the year he walked on, they won the national championship, so just for all those parents out there that are going through this, they do get back … their lives get back to normal and they can achieve their dreams.

Shannon O’Kelley: Absolutely. Great stuff, Dr. Komenda. Thank you for your time.

Speaker 2: We’ve been talking about the ACL. www.POSM.com, that’s Proliance Orthopaedics & Sports Medicine. Visit us if you’d like to get more information. Shannon, the ACL, you hear about it a lot, and it certainly has felled many an athlete.

Shannon O’Kelley: It’s a really important ligament for stability of the knee, so yeah, you need an ACL to be active and cut, stop, twist, and turn.