Medical practices give boost to athletes

Art Nadler

Saturday, Feb. 22, 1997 | 11:59 a.m.

In January 1996, Cheyenne High School basketball player Amanda Koval went up for a layup, came down straight on her right leg and felt the knee pop.

Like many people active in sports and recreational activities such as skiing, Koval injured her anterior cruciate ligament. Located beneath the kneecap, it is one of the most common injuries.

The excruciating pain, coupled with her desire to continue playing basketball, prompted Koval, 16, to have surgery in June. Dr. Timothy Sutherland, an orthopaedic surgeon specializing in sports medicine, did the operation.

Sutherland took a third of Koval's patellar tendon from her injured leg and used it to refashion a new anterior cruciate ligament, which he reattached to the bone with screws.

Years ago, Koval's leg would have been wrapped in a plaster cast, and she would be told to stay off it for several months. That was standard medical practice.

Sports medicine has pretty much slam dunked that kind of treatment.

Getting physical

Within two weeks, Koval was grunting and sweating on weight machines in Columbia Sunrise Hospital and Medical Center's rehabilitation clinic two hours a day, three times a week. Daily, she struggled through the pain and tedious routine of performing bending exercises at home.

Eventually, Koval's physical therapist incorporated basketball into her rehabilitation. This month Koval, a junior at Cheyenne High, returned to the basketball court once again. She's performing at about 95 percent strength and confident of continuing to play through her senior year.

The SUN has tracked Koval's recovery since July in an effort to illustrate how sports medicine has elevated the importance of rehabilitation following surgery. As a result, athletic-minded individuals are recovering faster from their injuries and continuing to enjoy many years of sports activities.

Controlling muscle loss

Koval underwent surgery June 14. Seven days later, she was sitting on a workout table in Sunrise's Doctors Pavilion rehabilitation center. Jeff Deets, clinical director of sports medicine and rehabilitation, was telling her to try to push her leg down flat on the table.

Koval's knee was still swollen and couldn't lay completely flat. To stretch the muscles and new ligament, Deets told her to wrap a towel around her foot and pull back with both hands, while the leg was extended.

"By getting a person's knee moving early, you have much less muscle and movement loss," Sutherland said. "In any kind of sports medicine, the therapy after surgery is as important as the surgery itself."

While pain is the body's natural reaction to an injury, stretching and moving the area actually helps it heal faster, Sutherland said.

"You can be aggressive with therapy and not damage the graft," Sutherland said. "We have done 150 anterior cruciate ligament reconstructions. The re-injury risk would be the same as injuring the other knee."

Sutherland said it is a myth that a previously injured part of the body, if proper therapy was done, would be more susceptible to injury.

Besides strengthening the new ligament, Deets said it was important to also strengthen Koval's quadriceps and hamstring muscles. This she did using weight machines.

In the past, Deets said Koval wouldn't be putting weight on her leg for six weeks. She would have worn a cast during this period. Muscle mass would have been lost, and stiffness common.

"Her leg should be 50 to 60 percent straight after six months," Deets said of his aggressive rehabilitation. "We want her to have full range of motion in six to seven weeks. We hope to have her back playing basketball in seven months."

To help reduce swelling, Deets wrapped a direct-current cuff around Koval's knee. Operating on negative-polarity, the wrap gently massaged the knee in a milking fashion to disperse fluid buildup.

"After this, Amanda will do some bending exercises," Deets said. "She must do them five times a day for a half hour each."

"I like the therapy," Koval said a little halfheartedly. "I know I have to work at this, or I won't get anywhere."

After two hours of therapy, Koval wrapped a full-leg brace on and walked with a slight limp to her mother's car. She admitted to experiencing some slight pain.

Walking again

By the end of July, Koval was doing mini-squats to stabilize the knee and strengthen the hamstring and quadricep muscles. In a side room, a portable wood floor, similar to a basketball court, was laid down.

With her leg brace off, Koval practiced walking up to Styrofoam cups lined up in a row and stepping over them. She would concentrate on putting her heel down, rolling off the flat of her foot and slowly pushing off with her toes. Besides being a basic step in basketball, this exercise also puts emphasis on walking.

"As early as the mid-'80s, therapists were very, very conservative," Deets said. "In most cases, a patient would still be wearing a brace and doing very little. The fear was that you would tear the graft. But now graft fixtures are stronger, and they are hooked directly into the knee."

In conjunction with stepping over the cups, Koval balanced herself on her injured leg only, and slowly did a mini-squat.

"This is a pre-cursor to jumping in basketball," Deets explained. "This also strengthens the inside leg muscles that Amanda would need for stopping and turning."

Reducing pressure

After four weeks of therapy, Koval was doing stepping exercises in the rehabilitation center's swimming pool. Using a submerged staircase, she practiced stepping up and down.

The swimming pool reduced Koval's body weight by about 50 percent, which made it easier to do full-range-of-motion exercises.

"Amanda doesn't put a lot of weight on her leg because of the water, so she can normalize her gate and do heel-to-toe stepping easier," Deets said. "She also doesn't limp in the water, so the memory of the muscle as it worked before the injury sets in (in her mind again.) She also gets some cardiovascular benefit from exercising in the pool."

"It feels good to be doing something active," Koval said in reference to her month-long routine of weight exercises. "This seems easier in the water, and it doesn't hurt. I just want to know when will I get to move toward a more exciting exercise routine?"

Like many athletes, Koval was eager to speed up her therapy after experiencing some initial progress. But Deets knew he had to hold her back because the graft wasn't completely healed.

He forced her to maintain a routine of using weight machines, doing simple floor stepping exercises, walking and stepping in the water and bending and squatting.

Getting more aggressive

In September, Amanda Koval discarded her leg brace. She was step climbing on a Stairmaster machine and running in place on a trampoline.

"I'm running on the trampoline, but my leg still hurts," Koval said. "I still can't jump or run unless I'm on the trampoline."

Deets uses a trampoline because it retrains Koval to maintain balance and increase lateral movement abilities for changing directions.

"This re-educates Amanda's body to respond to things she would need to do on the basketball court," Deets explained. "If we hadn't done what we did before this, she wouldn't have the strength, and her muscles would have shrunk in the cast.

"Amanda is at 95 percent of motion now and 65 percent of normality. She should get back 99 percent of both when we are done."

It has been 3 1/2 months since Koval's surgery. She's been in therapy 11 weeks. Deets has started to pass a basketball to Koval on the small wooden floor, engaging her sometimes in light one-on-one basketball play.

"Exercise is the best medicine," Deets said. "She shouldn't be jumping or running at full speed, but jumping on the trampoline and dribbling on the floor is fine. She should be ready for basketball in January."

On the court finally

Koval did begin practicing with her Cheyenne High team in January of this year. Deets estimates she has about 90 percent strength back in her injured leg.

"Initially, I felt that I might injure myself, but I got over that fear quickly," Koval said. "I couldn't be playing basketball as aggressively as I do now if I hadn't had the operation. I could have played without the operation, but my bones would have kept popping out."

Wearing only a knee sleave for protection, Koval played in eight games this season and started in five. In the game with Western High School, she scored 17 points.

As long as she follows some safeguards Deets taught her, Koval expects to be playing basketball through her senior year.

There are three common situations Koval must avoid when playing basketball, Deets said. These include sudden stops, planting the feet and suddenly cutting to one side and straight-leg landings.

"Amanda has been doing drills to avoid these positions," Deets said. Instead of suddenly stopping, she's been taking one step before planting her feet. Suddenly, turning to one side is never done.

"I don't feel like I'm at 100 percent yet," the young point guard said. "I still go to therapy every two weeks to use the weight machines and to do balancing exercises. It (therapy) was fun at times towards the end, but it also was depressing because I couldn't do anything active."

Fortunately, Koval had medical insurance to cover the cost of her operation and physician's fees, which were more than $14,000. Rehabilitation was another $9,000 and added expenses such as X-rays, emergency room fees and braces brought total expenses to around $26,000.

The Kovals paid 20 percent of the bills, plus the added costs of driving their daughter 75 miles to therapy three times a week.

If Amanda Koval would have been treated with traditional therapy from the 1980s, Deets believes she would only be walking a year after her operation. Whether she would have range of motion, let alone be playing basketball, would be a tossup.

"We do things fairly aggressive today, but don't put the surgery at risk," Deets said of his mission as a rehabilitation therapist. "The first six weeks you do what's necessary to protect the bone plugs, and the following six weeks you protect the ligaments. After that, it's important to get your strength and balance back.

"I think people have to remain active, even when injured. Inactivity causes problems. The human body was made to move."

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