Infection slows Brady's rehab

More complications can't be ruled out

Tom Brady returned to Boston recently for a checkup on his surgically repaired left knee by team doctors, according to NFL sources. Those same sources also confirmed that the Patriots quarterback suffered a postoperative staph infection and remains on antibiotics. Staph is the most common kind of postoperative infection.

In all likelihood, the patella tendon graft inserted to replace his torn ACL during surgery Oct. 6 will be kept, and not replaced in a second operation. But in cases involving a septic joint, doctors wait until the patient finishes the antibiotics treatment to see if the infection recurs and whether a new graft is needed.

When news surfaced almost four weeks ago that Brady had developed a postoperative infection, the sports medicine community shuddered. Doctors fear nothing more than the development of infections and blood clots. If not caught quickly and treated properly, such complications can threaten a patient's life, never mind the success of a surgery. In Brady's case, the infection was caught early and treated aggressively with wash-out procedures and IV antibiotics.

But it still constitutes a major setback, since infection delays rehab, increases the risk of scar tissue buildup, and leaves the patient more susceptible to long-term pain and stiffness. Restoring range of motion is the most important aspect of initial post-op rehab from ACL reconstruction, and there is a limited window of opportunity to work on it.

While Brady undoubtedly is trying to restore some range of motion, he is nowhere near the point where a patient without complications would typically be five weeks after surgery - doing squats, stability work, coordination drills, stationary bicycling, and stair-stepping.

Once the infection clears, he will essentially start physical therapy from the first post-op phase.

"Basically, you have to start over a little bit and restore motion," said Russ Paine, who is director of rehabilitation for the Houston-based Memorial Hermann Sports Medicine Center and physical therapist for the Houston Rockets. "You basically have to rewind the clock."

As Brady aims to return for next season, the next several months of rehab are critical. But with training camp starting in July, it is unnecessary to rush.

"I've seen great surgeries go bad, go horrible with bad rehab," said Dr. Lonnie Paulos, who performed knee reconstruction on Cincinnati Bengals quarterback Carson Palmer. "I've seen marginal surgeries salvaged with great rehab. Rehab is probably every bit as important as the surgery itself. The whole surgical technique is designed to enhance rehab."

ACL rehab follows what doctors and physical therapists refer to as a "criteria-based protocol," meaning patients advance from one phase to the next based on how they feel, how the knee looks, and how the joint responds to various range-of-motion and strengthening exercises. Typically, the rehab takes six to nine months, from the day after surgery to the day the athlete returns to play. Most NFL quarterbacks who have required ACL surgery in recent years - such as Palmer, Donovan McNabb, and Trent Green - have been ready for action roughly within that time frame, though the length of rehab programs varies depending on whether other ligaments and cartilage were damaged and on other complications.

Brady's infection added one more variable to an already unpredictable and evolving process. When coming back from ACL tears, it is not unusual for athletes to break new ground because they enter surgery stronger and fitter than the average patient, have more time to devote to rehab, and often face pressure to come back quicker. In part because of athletes pushing the envelope, accelerated ACL rehab protocols have been developed.

"There was a period of time where it would definitely be a year before they got back," said Sue Falsone, director of physical therapy at Athletes' Performance, an institute devoted to training elite athletes. "We went through a little phase of accelerated rehab where people were coming back from ACL surgeries at eight weeks, 12 weeks, four months. We were finding that extreme wasn't ideal, either.

"We've kind of gone back to somewhere in the middle where it's going to take six months to a year. Physiology is physiology. That's why ACL rehab is incredible variable, depending on the graft, any complications, the doctor's comfort with return to certain activities, and what the patient's sport requires."

With Brady, Dr. Neal ElAttrache repaired the quarterback's torn MCL through a separate incision, in addition to reconstructing the ACL. The MCL repair plus the infection will add time to the rehab schedule. Still, when Brady was spotted in a wheelchair at the Kerlan-Jobe Clinic in Los Angeles more than a week after surgery, it was a bad sign.

After ACL reconstruction, the first several days of rehab set the tone for the months ahead. Immediately following surgery, patients focus on regaining range of motion and strength. Some patients can discontinue the use of crutches within a week, while the general goal is approximately 10 days.

The precaution of having Brady use a wheelchair, however briefly, was an indication that there had been complications. Brady confirmed that a few days later when he revealed the infection on his website. Instead of moving from the first post-operative phase of rehab to the second, Brady was focused on knocking the infection out of his system and maintaining the health of his knee cartilage. The infection also increases the odds of further complications later in the process.

"Some of the damage to the knee comes from the fact that you have to hold it still when the infection is there," said Paine. "Any time you immobilize a joint and you don't move it and it's got all this bad stuff going on inside of it, then the articular cartilage gets sort of sick."

Knowing that "sick" articular cartilage can lead to arthritis, Paine added, "Arthritis can end your career just as quickly as instability in your knee."

Reestablishing range of motion is a key early component of rehab because it prevents the buildup of scar tissue and, again, protects the cartilage. The infection and resulting slow start of rehab place Brady at risk of developing more scar tissue.

"The infection alone increases the ability of scar tissue to form," said Diane English, a team physician for Boston College athletics. "That's the biggest fear. If you get an infected knee, it can just turn to a wad of scar because infection builds up all sort of adhesions and things like that.

"One of the things about infection is you want to rest the knee and let the antibiotics work and not have swelling. There are no options. You really just have to wait for the infection to clear up, then start on the physical therapy. That's why it's delayed and that's why there's such a question of a time frame for someone like him."

A month after surgery, patients often can do the leg presses, lunges, calf raises, stationary bicycling, and stair stepping. Functional activities generally begin at the eight- to 10-week mark with running. Jumping follows at 10-14 weeks. Cutting comes last, at 12-16 weeks. Around the six-month mark, athletes can return to full participation in sports.

But even then, there remains work to be done.

"When the other guys get to hang it up and take a shower and go home, you're going to be on the bike," said Paulos. "You're going to do leg presses. You're going to maintain your muscle strength and the lifting program, the progressive resistive exercise program, the whole time you're staying sports-active.

"If you don't, you'll find that that leg will stay slightly smaller than the normal leg. When you don't use it, it will get weaker at twice the rate of a normal leg. So you have to have a maintenance program designed to keep those muscles comparable to the other leg."

In the short and long term, Brady has both time and constant medical attention (if needed) working in his favor.

"If someone wanted to bet me today if Brady makes it back, I would not bet against him, no way," said Kevin Wilk, who as associate clinical director of Birmingham, Ala.,-based Champion Sports Medicine works closely with Dr. James Andrews and who has helped more than 500 NFL players recover from ACL surgery. "He'll make it back because he's a smart guy, a pro athlete with the best of medical care.

"They're not going to let him fail. They're going to do everything humanly possible. Unless something goes really weird, something that was a 1 in 2 million shot, he's going to make it back and back at the same level."

Shira Springer can be reached at springer@globe.com