The physical demands of football put enormous stress on the knee leaving the knee particularly vulnerable to injury. While tears of the anterior cruciate ligament are among the most serious of all knee injuries, recovery and full return to play are common. Not so for the articular cartilage that covers the surfaces of the bones.
On June 29-30, 2007, the first FIFA Medical Centre, the Schulthess Clinic, Zurich, was host to the first International Cartilage Repair Society Rehabilitation Consensus meeting. About 120 scientists and rehabilitation specialists from around the word discussed the many details of the injury, its treatment and rehabilitation. The FIFA-Medical Assessment and Research Centre (F-MARC) was a contributing sponsor of the meeting.
Treating articular cartilage injuries is a developing science with evolving techniques for treatment and rehabilitation. The process of rehabilitation is complex because of the nature of the lesion (size, location, and number of lesions), how the lesion is treated and the various details of rehabilitation. The important process of rehabilitation has to consider such critical topics as how long should the player be non or partial weight-bearing, when to begin movement of the joint, the necessity of a brace or passive motion, when to begin strengthening exercises, how fast to progress in strengthening, when to allow the player to start - and progress through - functional exercises that will eventually bring the player back to the playing field. The rehabilitation process is far longer and more arduous than most patients realize.
Over 2 million new articular cartilage defects are diagnosed each year and football is far from immune. Those without access to the newest technologies and techniques face a difficult road. Most patients begin with modifying their lifestyle to reduce the forces across the knee that lead to pain.... But a change in lifestyle most players are unwilling to consider.
The treatment protocols have shifted from repair and replacement to regeneration of cartilage. One of the most widely used techniques is arthroscopic microfracture where the surgeon pokes numerous small holes into the defect to stimulate the underlying bone to grow new cartilage that will fill in the defect. Think of the defect as a pothole in a street.
The problem is the replacement tissue is not normal cartilage and does not possess the features of normal cartilage. While there is relief of symptoms and return to normal activities, it is unlikely that the replacement tissue will be a permanent solution.
Regeneration of the normal cartilage is the new direction of treatment and research. There are a number of techniques that require a biopsy of the knee cartilage so that cells may grow in a laboratory prior to being reinserted. These regenerative techniques seem to be pretty good at getting normal cartilage to grow in the defect for a longer-term solution.
With such novel advances in surgical techniques, rehabilitation also must advance. Current rehabilitation protocols vary widely based on the age, size and location of the defect, expectations for recovery, type of surgery performed and so much more. An important question under discussion was "What is successful rehabilitation?" This will differ based on the patient because the needs of a 50-year-old office worker are dramatically different from the young athlete.
The conference concluded with a special segment entitled "FIFA-Cartilage Rehabilitation for Football Players" where F-MARC members and research partners discussed current practices. The football player is unique because they only have one question: "When can I return to play?" Just because some procedures are done through an arthroscope does not mean recovery is swift and players need to know recovery will be lengthy.
This special session included Mario Bizzini, PT, who was also the module chair for the session entitled Procedure-Specific Marrow Stimulation Techniques in which he spoke on the main rehabilitation issues for these novel procedures. Prof. Jiri Dvorak, MD, Chairman of F-MARC and FIFA Chief Medical Officer, joined Mr. Bizzini as chair for the special event. Presenters included F-MARC research partners Prof. Lars Petersen, MD, Sweden, Bert Mandelbaum, MD, and Holly Silvers, PT, Santa Monica (US) and Stephan Meyer, PT, from the Swiss Olympic Medical Centre in Magglingen.
After the conference, the speakers met in an attempt to minimize the differences in rehabilitation protocols in order to come to a consensus. A key question is whether rehabilitation for articular cartilage lesions can be accelerated in a manner similar to the rehabilitation programs for anterior cruciate ligament rupture. Their conclusions will be the subject of a future statement of consensus.