Experts break down Mathieu's knee surgery

TEMPE, Ariz. – There are worse knee injuries to have than the one Cardinals safety Tyrann Mathieu suffered Sunday against the St. Louis Rams. Then again, there are better ones.

Mathieu tore his ACL and LCL in a gruesome hit while returning a free kick. He initially knew something was wrong with his left knee, but the severity of the injury wasn’t clear until he began walking off the field and it buckled, the result of his LCL being injured.

He underwent surgery Friday performed by team doctors Doug Freedburg and Gary Waslewski in Arizona.

While details of Mathieu’s specific injury are unknown, the surgery to repair both ligaments can be complex because of the LCL, according to doctors.

“When you have those combination of ligament injuries, you have a markedly unstable situation in the knee,” said Dr. Neal Elattrache, an orthopedic surgeon at Kerlan-Jobe Orthopedic Clinic in Los Angeles and the team physician for the Los Angeles Dodgers. “This does increase the complexity of the problem.”

Elattrache has operated on the likes of Kobe Bryant and Blake Griffin, and worked on New England quarterback Tom Brady’s knee, which was also a multi-ligament injury.

If all goes well, Elattrache said the type of surgery Mathieu had lasts about two hours. But depending on what condition the LCL is in can dictate if Mathieu will have at least one or two surgeries. There are three primary options for how the LCL could look when doctors began surgery on Friday. It was either shredded, torn off the femur or severed in the middle.

Ideally, Elattrache added, the ligament disconnects as one piece of tissue and the whole sleeve of tissue can be replaced with grafts. But “often times that’s not the case,” he added, and ligaments are reconstructed with tissue.

The lateral ligament, Elattrache said, is a “complex of several different bands” which stabilize the knee. The LCL is essentially responsible for the elasticity of the knee when it bows out or rotates.

Initial reports, even one by Cardinals coach Bruce Arians on Monday, put Mathieu’s timetable for surgery at eight to 10 days. But Elattrache said ACL and LCL surgeries are typically moved up – Mathiue had his at five days – so doctors can get into the knee before scarring begins and so they can see the knee in its natural state.

Ideally, Elattrache said, doctors want to repair the LCL with “native tissue” instead of having to graft a ligament from either a cadaver or other areas of the body such as the hamstring. Typically, if doctors opt for two surgeries, the LCL is repaired first because it needs to be immobilized after being repaired then the ACL is repaired.

“The lateral side is a little bit more tenuous,” Elattrache said. “If you allow those lateral tissues to stretch out too early, then as the body regrows the tissue, they’ll heal in a slack fashion.”

The LCL is very unlike the ACL, which is immediately stable and able to have weight-bearing pressure on it after surgery. But also unlike post-LCL surgery, ACL recovery begins with mobilizing the knee, extending it as straight as possible.

That’s why athletes, including Minnesota running back Adrian Peterson, can come back so quickly from ACL injuries. That’s not the case with LCLs.

If Mathieu has to have two surgeries, they’re usually about six to 12 weeks apart, which gives the LCL enough time to heal.

In his experience, Elattrache said it’s possible for football players to return to their previous performance level after this type of surgery. But contrary to popular belief, he said, when football players undergo ACL injuries, only about 70 percent return to their prior level. With LCL injuries, that injury drops to about 50 percent. However, in Mathieu’s case, it helps that he’s 21, said Stephania Bell, ESPN's injury analyst and physical therapist.

Mathieu didn’t have to look far to see an example of a player who returned from this severe of a knee injury.

Teammate Jim Dray, a Cardinals tight end, blew out his ACL and LCL, among a litany of other ligaments, while he was at Stanford University. Through a brutal rehab after multiple surgeries, Dray put in long hours, usually going for two sessions a day, including Christmas and Thanksgiving, in order to return to the field.

Four years into an NFL career, his knee is holding up.

“Everybody has a rehab process and it’s more up to the person, how mentally tough they are,” said Dray, whose rehab took about 10 months. “Invest the time because no one’s watching you. You’re doing it yourself.

“The things that he’s been through already in terms of overcoming obstacles off the field, he already has the mental toughness so I don’t think it’s going to be an issue at all for him to go through the rehab.”

Mathieu may have handled Dray’s advice in stride, but he doesn’t know what’s in store. Mathieu said Wednesday that he’ll sit down with team doctors and trainers to establish a rehab plan.

But, Elattrache said, rehab doesn’t usually start until about four to six weeks after surgery, which is all spent on crutches to immobilize the knee.

Bell said how the knee responds in the immediate aftermath of LCL surgery depends on if the ligament was repaired or reconstructed. The first goal, she said, is to reduce the swelling and that’s mainly done by staying off the knee.

“The first couple months are really boring,” she said.

While the knee is immobilized, rehab usually begins by working on “small muscles,” which includes keeping the ankle loose so Mathieu’s gait doesn’t become compromised, and core and hip exercises to remain stable.

“Athletes will often say that it’s like they had to learn to walk all over again,” Bell said. “That’s not something they expect. They figure they’re going to do some exercises, and do some walking and running and [they’re] really learning how to walk again.”

After spending a few months waiting for the LCL to heal enough to start motion exercises, it becomes like other rehabs in terms of the progression.

Mathieu will most likely start small, with leg strengthening and balance exercises. Bell calls it “functional training.”

She said a large part of LCL rehab is working on coordination. And once the athlete is cleared, she said, they usually start jogging then running then agility training for their sport.

But how long that takes can vary from person to person. It’s a slow process and the first few months are crucial to making sure the rest of the rehab goes smoothly. Pain is typically gone within a few weeks, Bell said, and then swelling is the next major concern.

Any time the knee is overworked or a slight tweak here or twist there can cause the knee to swell which sets back rehab a few days while the swelling goes down. And the athlete can’t usually progress until the knee doesn’t swell.

There will be things in his rehab that Mathieu can’t control, like how strong his ligaments are or how clean his joints are. Then there are things he can control.

“What you can control is how hard you work,” Bell said. “That’s being committed to the rehab. That’s also respecting the restrictions. If they tell you you can’t put X amount of weight on it, the player needs to be really respectful of that, because pushing too hard can make you go in the wrong direction.”

Mathieu’s heard from Dray and others about what it’ll take to regain his form that led him to the top of the defensive rookie of the year list.

There have been estimations on how long it’ll take for him to return to the field. Eight months. Nine months. Not until after training camp.

No one can accurately make that prediction -- except Mathieu.

“Just take it one day at a time,” he said. “Just do everything the trainers and [head Cardinals trainer] Tom [Reed] tells you to do and just do it. They said the more work you put into it the better results you get. Hopefully I can dedicate rehab and my knee like I do football and hopefully everything will be alright.”