An example of an acute ACL tear (sagittal T1-weighted MRI scan). Reproduced from Fagelman M, Freedman B: Failed ACL reconstruction: Evaluation for revision ACL reconstruction, in Freedman KB (ed): Complications in Orthopaedics: Anterior Cruciate Ligament Surgery. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 49-59.


Published 7/1/2008
Ann Kepler

A lesson for golfers

Anyone who watched the 2008 U.S. Open knew that Tiger Woods was playing in pain. Two days after winning his 14th major championship, he announced that he would miss the rest of the PGA Tour season and have reconstructive surgery for a damaged anterior cruciate ligament (ACL) in his left knee. The surgery was performed on Tuesday, June 24, as this issue of AAOS Now went to press.

Woods has a distinctive, powerful swing that puts unusual stress on his left knee. He elected to undergo arthroscopic surgery in April to clean out debris and cartilage damage following the ACL rupture last year. He also hoped to delay reconstructive surgery until after the 2008 season. But while recovering from the arthroscopic procedure, Woods experienced a double stress fracture of the left tibia—just 2 weeks before the U.S. Open.

Rather than heed physicians’ advice to rest for 6 weeks to allow the stress fractures to heal, Woods endured increasing pain through the sudden-death playoff. Then came the announcement: “It is clear that the right thing to do is to listen to my doctors, follow through with this surgery, and focus my attention on rehabilitating my knee.”

Is the damage permanent?
Although sportscasters speculate that Woods may have returned to competition too soon after the arthroscopic procedure, thus leading to the tibial stress fractures, many doctors, including Frederick M. Azar, MD, think that the greater concern is the risk of permanent damage to the articular cartilage.

According to Dr. Azar, team physician for the National Basketball Association’s Memphis Grizzlies, “an athlete can play with an ACL deficit” but should take every precaution to prevent meniscal or articular cartilage damage. The arthroscopic surgery would not have addressed the basic instability of the knee caused by the ACL rupture. Correcting the unstable knee with ACL reconstruction will allow the tibial stress fractures to heal in the course of rehabilitation.

Woods’ surgeon, Thomas D. Rosenberg, MD, is confident that the long-term prognosis is good. “With the proper rehabilitation and training, it is highly unlikely that Mr. Woods will have any long-term effects as it relates to his career,” he announced after the surgery, which included “no surprises during the procedure.” He was assisted by Vernon J. Cooley, MD.

According to his Web site, Dr. Rosenberg prefers to use a single-bundle technique with a semitendinosus autograft, which is secured with an Endobutton (Smith & Nephew) proximally and a screw distally. Rehabilitation is carefully staged and planned, although a projected timetable for Woods’ return to competitive golf has yet to be determined.

“It was important to me to have the surgery as soon as possible so that I could begin the rehabilitation process,” said Woods in a statement released after the procedure. “I look forward to working through the necessary rehabilitation and training…over the coming months and returning to the PGA tour healthy next year.”

Rehabilitation is key
Dr. Azar believes Woods should have no long-term problems “if he is fully rehabbed” before he returns to competition. Although the suggested rehabilitation period after ACL reconstruction is 6 to 9 months, Dr. Azar thinks Woods may be able to start back sooner. Freddie H. Fu, MD, concurs, suggesting that Woods may be able to start work on his putting before the full rehabilitation period ends.

Woods’ reputation as an athlete and as a competitor is a crucial component of his rehabilitation.

Michael F. Schafer, MD, team doctor for the Chicago Cubs, says, “Tiger Woods works exceptionally hard to come back and will continue the same aggressive therapy to resume his professional schedule.” Dr. Schafer cautions, however, that Woods should adhere to the following specific adaptation to increased demand—or SAID—guidelines:

  • First phase: control swelling and restore range of motion
  • Second phase: perform strengthening exercises, including isometrics
  • Third phase: start sport-specific activities

Dr. Schafer recommends introducing sport-specific activities slowly, adding stress to the knee as it becomes stronger, to restore functionality more quickly and prevent setbacks or additional injury. He thinks a full year is needed to return to full functionality after ACL reconstruction, although Woods’ personal focus and the dedication of his coaches and trainers may reduce that to 9 months. “You can’t push biology,” says Dr. Schafer. “The ligaments need sufficient time for healing.”

Ann Kepler is a freelance writer who specializes in medical topics.