Q&A: Could knee surgery change Tiger's game?

Doctor: Woods may fully recover despite torn ligament, stress fractures

MSNBC.com—June 18, 2008

Tiger Woods will miss the rest of the 2008 golf season due to knee surgery to repair a torn ligament in his left knee.

Woods, who also suffered a double stress fracture of his left tibia shortly before playing the U.S. Open, was obviously in pain when he won the tournament and was last seen late Monday walking with a limp.

Msnbc.com asked Hospital for Special Surgery orthopedic surgeon Dr. Edward V. Craig about the ramifications of Woods' injury.

Q. How do these knee and leg injuries affect a golfer compared to an athlete in a sport who runs and is more active?
A. The main chronic injury to Tiger is a tear of the Anterior Cruciate Ligament (ACL), which he says he tore while jogging some 10 months ago. The ACL is a primary ligament that stabilizes the knee. If this is torn, secondary knee stabilizers such as the meniscus cartilage inside the joint take over. These are then subject to stresses and can tear.

It is also reported that Woods has stress fractures on the inside of his knee. Stress fractures can occur in many bones and are common in people training for marathons. Essentially, the constant pounding puts so much stress on the strength of the bone that the bone "fails" and develops a crack. His doctors apparently advised him to rest so he wouldn't put weight on the bone.

This injury could be particularly bad for Tiger, or any golfer, because there is tremendous twisting motion to the knee during backswing and follow-through. With an ACL injury, this twisting can produce knee instability, and a type of dislocation which can be very painful. This may not occur with running sports such as jogging that don't require twisting.

Q. How could this injury change Woods' game?
A. The injuries are all to Tiger's left leg, which he puts his weight on when he swings. If he has a painful knee and cannot transfer load from left to right, the mechanics of the swing are disrupted, the coordinated activity of energy transfer from leg and trunk to arms is disrupted, and — at least in theory — distance and accuracy would be affected. He may be able to make up for some of that with club selection, for example, but distance and accuracy depend on balanced transfer of body weight from one leg to another.

But I think he can completely recover and be back to normal, although it can take a long time. ACL reconstruction is a predictable operation to stabilize the knee. Once that is done and after a long rehabilitation, the knee can be stable and secure and painless. It's a common injury among women athletes such as WNBA players. A lot of people live very normal and very athletic lives after the surgery.

Q. What kind of pain do you think he was in when he played the U.S. Open?
A. I think he was in tremendous pain, particularly on tee shots. The toughest, most focused, most disciplined golfer in the world winced and actually bent over in pain on every drive, the time when he was putting the most stress on his left leg.

Q. How long will Woods be out after ACL surgery?
A.
It will probably take several months to rehabilitate the leg muscles while the ACL graft matures and gets strong enough to withstand the loads he will put on it.

Q. What are the long-term ramifications of these kinds of injuries?
A.
With a torn ACL, the main stabilizer of the knee is gone. The rest of the knee then undergoes considerable stress from excess motion. The main joint cartilage can then wear out prematurely, which is what arthritis is. In a young, active person, reconstructive surgery to rebuild the ACL is done in part to avoid possible degenerative arthritis in the knee.

Q. What kinds of injuries affect golfers most often?
A. Golfers seem uniquely prone to back injuries because of the twisting and torque that occurs in the spine during the golf swing. Back injuries happen when the legs are firmly planted, while the upper body twists severely during the backswing. This twisting puts a tremendous stress on the thoracic and lumbar spine area.

Golfers are also susceptible to elbow and shoulder injuries because of the mechanics of the golf swing. There is a condition of the elbow called "golfer's elbow" because of its frequency in golfers. It is an injury to the tendons on the inside half of the elbow.

ACL is not a typical golf injury, but the twisting that occurs through the knee, and, particularly all the bending and squatting that can occur, may injure the meniscus cartilage.

Shoulder injuries can occur during mishits and when an accelerating swing is interrupted.

Q. Are recreational golfers also vulnerable to these kinds of injuries?
A.
Recreational golfers are vulnerable to spine, elbow and shoulder injuries. ACL injuries tend to occur with significant knee trauma, but anyone can tear the ACL. It's among the most common of knee injuries.

Stress fractures tend to occur in bones subject to repeated stress over a long period of time in distance training. That's why it is seen in leg bones of distance runners.

Dr. Edward V. Craig is Attending Surgeon at the Hospital for Special Surgery in New York City and Professor of Clinical Orthopedic Surgery at Cornell Medical School.

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