Dr. John O'Neil, DPT meets with renowned orthopedic surgeon, Dr. Andrew Bishop, MD to discuss ACL injuries
As a former NFL team doctor for the Atlanta Falcons from 1992-2004, Dr. Andrew Bishop has performed thousands of ACL reconstructions among many other orthopedic surgeries. He now practices out of Middleburg, VA in a quiet, more individualized setting, where he is able to spend much longer with his patients than he was previously able to. I had the opportunity to sit down with him and talk about the ins and outs of this surgeon's view of the ACL reconstruction process.
The ACL (anterior cruciate ligament) is an important stabilizing ligament in the knee that attaches from the back of the femur (thigh) to the front of the tibia (lower leg). It resists forward motion of the tibia on the femur and inward rotation of the tibia, as well as playing an important stabilizing role in athletics.
In the United States, there are approximately 200,000 ACL injuries each year – or 1 in every 3,000 people. These injuries can range from a strain to a full thickness tear, with approximately 95,000 full thickness tears per year. Women are four to eight times more likely than men to suffer an ACL injury with anatomical, biomechanical and neuromuscular differences that are believed to be behind the gender disparity. They tend to occur during contact sports, cutting and twisting movements, or even just stepping in a small rut.
Depending on the severity of the injury, and the stability of the knee after the injury, surgery may be required. With or without surgery, physical therapy plays a vital role in recovery from this knee injury.
Are there any programs that work for ACL prevention?
ACL Injury prevention programs have been in existence for more than 15 years, but few have been tested for efficiency. A recent review noted that few of these programs had been assessed both for their effect on ACL injury rates and for athlete performance. The review determined that only two programs "had a positive influence" on both injury reduction and athletic performance among athletes.
The programs that had a successful reduction in ACL injuries were ones that made the chief focus of using drills to encourage proper form for jumping and landing during athletic participation, and ones that address the potential deficits in the strength and coordination of the dynamic stabilizing muscles around the knee, hip, and ankle joints.
When does he choose to surgically reconstruct the ACL?
The greatest rationale of whether or not to surgically reconstruct the ACL is not MRI results, but functional instability. He will generally only choose to reconstruct the ACL if functional instability is present. Also, the more active the patient is the more likely he will opt for a surgical approach, with the desired level of functioning being another chief concern for electing to partake in the surgery.
The younger the patient the more aggressively he will choose to perform a surgery, and with ages 40-60 usually going with a more conservative care approach. This again is all depending upon the desired level of function for the patient. With higher level plyometric/cutting activities requiring a more stable knee. While lower level activities just as walking and lighter activities of daily living can function with an ACL deficient knee.
Choice in type of graft? Hamstring, quadriceps tendon, or from a cadaver?
He has noticed that in previous years there was a switch to hamstring graft, when previously quad tendon was the standard, but now there is a switch back to quad grafts.
Dr. Bishop has always preferred quad grafts over hamstring, but says they both have good outcomes, and if the patient has his or her heart set on a particular graft, he will utilize it. In the younger population though, he strongly prefers either hamstring or quad tendon over cadaver. Quads or hamstrings typically have much greater tensile strength compared to taking a graft from a cadaver, and they tend to stretch much less in time, increasing stability. Typically for the larger male athlete he will go with quad, and for females he will choose hamstring for the smaller scar, without any other extenuating circumstances.
What does Dr. Bishop recommend doing prior to the surgery?
Dr. Bishop made it very clear that it very important to reduce the swelling to as close to baseline as possible, and improve the range of motion to full, especially extension.
If multiple structures were damaged in the ACL injury, he often requires waiting for the other injuries to heal or become stable prior to performing the ACL reconstruction, such as the medial collateral ligament. Also of great importance is having the knee as stable as possible prior to the surgery as it optimizes surgical outcome. The first few months after an ACL reconstruction are difficult, and this is made easier and results in a better surgical outcome if the knee is more stable prior to the surgery.
He reports that although strength is important, it is not as vital as range of motion and swelling to be returned to as close to baseline as possible prior to the surgery. The time it takes to accomplish this can take anywhere from a week to a few months, but needs to occur prior to optimize surgical outcome.
Physical therapists use sound, scientifically proven principles of human anatomy, physiology, movement and psychology to help patients lead healthy, pain-free lives.
The therapist will conduct an initial evaluation followed by several progress notes to document progress over time. A comprehensive analysis establishes a 'clinical baseline' and identifies muscle imbalances, causes of pain and joint alignments. This is the foundation for short and long-term goals designed to help individuals recover completely. In fact, physical therapy can address every aspect of recovery including:
- Gait
- Biomechanical aspects like spine/hip/foot alignments
- Lower back strength
- Pain levels
- Functional capability
107 W Federal St # 6, Middleburg, VA 20117
Phone: (540) 687-3390
- Board certification: American Board of Orthopaedic Surgery, 1991 Recertified, 2001, 2011
- Medical: Emory University School of Medicine, Atlanta,Ga 1982
- Internship: Medical College of Virginia, Richmond, Va, General Surgery 1982-1984
- Residency: Emory University School of Medicine, Orthopaedic Surgery 1984-1987
- Society memberships: American Medical Association, State Medical Society, State Orthopedic Society
- Additional Society Memberships: National Football League Team Physicians Society 1992-2004
Purcellville Orthopedic Physical Therapy
850 E Main St, Purcellville, VA 20132
Phone: (540) 751-1970
