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Obstacle Course

After reconstructive surgery, student-athletes face a grueling path to emotional and physical recovery

Watch Dr. Tracy Dierks, associate professor of physical therapy at the Indiana University School of Health and Rehabilitation Sciences, explain and demonstrate knee ligament functions and the long-term consequences of a severe knee injury.

The morning fog hangs thick and heavy in Stillwater, and Jean-Paul Olukemi is screaming.

Fellow Oklahoma State students amble to class wearing vacant stares framed by vibrant orange or sharp black cotton hoods that fight off the 10 a.m. chill.

On this mid-February day, Olukemi’s hoodie is already off. It sits in a heap on a black leather training table deep in the bowels of Boone Pickens Stadium, within an underground maze of steel and cinderblock. Olukemi’s growls and whimpers are inaudible to the students walking above, many of whom spent dozens of nights in Gallagher-Iba Arena marveling at the 36-inch vertical leap that helped earn him a basketball scholarship.

But now Olukemi sits in a devilish contraption devised from a plastic chair bolted to a board. His surgically repaired right leg stretches from the chair to the training table. An array of hooks screwed into the board holds thin black ropes as tight as cables on a suspension bridge. The ropes pull upon a pad that runs from his atrophied right quadriceps to his upper shin, forcing the leg to straighten against the will of its newest ligament.

Three and a half weeks earlier, Oklahoma State orthopedic surgeon Dr. Mark Pascale removed a sliver of muscle from Olukemi’s hamstring. He bored holes through Olukemi’s femur and tibia and strung the harvested muscle through the fresh tunnel. Screws that Pascale inserted will secure the slice of hamstring to Olukemi’s bones, hopefully, for the rest of the 23-year-old’s life.

A photographer’s lens captures the moment after Jean-Paul Olukemi was injured, and the start of the long journey back to the court.

After spending years helping Olukemi mystify defenders, that piece of hamstring has new obligations: replace his torn anterior cruciate ligament, keep his knee from buckling, get him back on the court and ensure that he keeps his scholarship. All are responsibilities seemingly too vital for a few inches of sinew, but the ACL Olukemi was born with betrayed him in the waning hours of 2011.

While strapped in the chair, Olukemi struggles to speak through the clenched muscles in his jaw. The agony digs wrinkles in his forehead. He holds his long, wiry fingers together in front of his face, tip to tip, as if negotiating with the pain.

After five minutes, John Stemm, one of the school’s athletic trainers, approaches Olukemi, offering a few casual barbs meant to simultaneously evoke laughter and toughness. Stemm reaches a hand down toward the ropes. As if he’s starting a stubborn chain saw, he pulls up on the top of the ropes, which tightens the ones anchored to the board. Stemm’s yank exerts more pressure on the knee and forces Olukemi’s new ACL to relent further.

Once more, Olukemi is screaming.

He has five more minutes – and several more weeks – in the chair.

“It looks like they used that back in medieval times, that chair,” Olukemi says. “It’s constant pain that won’t go away.”

Through his rehabilitation, Olukemi, a junior, spends up to four hours every day in that dungeon – battling against pain and uncertainty and fear – as his teammates relish the spotlight of nationally televised games and raucous crowds. In an instant, he was forced to adjust to a world in which the 6-foot-6-inch, 215-pound frame that paid his way to Oklahoma State was rendered useless by a failed inch-long ligament. He limped out of that spotlight, into a dark periphery where he battles the mental and physical strain of a year lost – a year spent learning how to bend and straighten his leg, how to walk, how to rebuild strength and trust in the failed joint … and in himself.

A YEARLONG BATTLE

EXPLORING THE ACL INJURY

The anterior cruciate ligament, or ACL, is one of four major ligaments that stabilize the knee. Running vertically through the middle of the joint, it helps keep the femur and tibia bones in place during stop-and-go motion. A torn ACL is illustrated below.

Click here to download a PDF showing how a torn ACL is reconstructed.

BY THE NUMBERS
15 NCAA sports are at high risk for producing ACL injuries.

More than 2,000 NCAA student-athletes will experience an ACL injury in a given year within those sports.

90% of athletes recover from a tear, most of whom reach pre-injury levels of athleticism.

ACL tears have risen 1.3% annually over a recent 16-year period, according to a study of NCAA injury data.

Six to eight months, fans hear, maybe a year.

Student-athletes like Olukemi crumple into a heap on a court or a field, clutching vainly at a knee. Slow-motion replays show the joint contorting, buckling, twisting. Questionable return, the announcers say. Torn ACL, the newspapers read. We’ll see him next season, fans think. Bring in the next player.

Then they turn the page.

But what is an ACL? Why does it matter? Why does it so frequently interject itself into discussions of college athletics? After all, it’s merely one of four major ligaments that stabilize the knee. But it runs vertically through the middle of the joint, serving as its backbone, keeping the femur and tibia in place as players cut, jump and accelerate through practice and competition. Though student-athletes are faster and stronger than they’ve ever been, a study of NCAA injury data revealed that ACL tears rose by 1.3 percent annually over a recent 16-year period.

“No matter how strong you are, you’re still at risk,” says Dr. Leland Winston, head physician for Rice athletics. “When the ACL tears, your muscles don’t have time to react quickly enough to protect it.”

Every year, more than 2,000 NCAA student-athletes across 15 high-risk sports will feel that bomb detonate inside their knee, hear the menacing echo reverberate through their body, endure a few minutes of misery in their final moments on the playing surface and eight or more of the most trying months of their lives off it. Next season isn’t assured.

But advances in surgical and rehab techniques have shifted the odds dramatically in their favor. Orthopedic surgeons note that roughly 90 percent of athletes recover from ACL tears, most of whom reach pre-injury levels of athleticism. The snap of a ligament and gasps of concerned fans are no longer the requiem for an athletics career.

After they’re stitched – sometimes stapled – together, student-athletes will spend many waking hours in forgotten training rooms where torment and tedium collide. As the graft and the screws settle into tunnels burrowed inside bone, they’ll rehabilitate shriveled muscles, performing endless repetitions of exercises that evoke a startling, unfamiliar brand of pain. They’ll watch the teammates they’ve sweated and bled with go to battle without them. They’ll miss classes in the mostly bedridden week that follows surgery. They’ll tackle homework with minds smothered by pain medication.

And when they’re cleared to play again? Most endure a yearlong battle with themselves, learning once again to trust the joint that’s caused so much strife.

“This is harder than anything you’ll do on the court,” says Oklahoma State basketball athletic trainer Jason Miller. “This is the hardest thing to get through. It’s painful. It hurts. It’s time consuming.”

And student-athletes will navigate the other parts of their lives, the parts not devoted to or defined by basketball or soccer or football, on crutches. Tasks once taken for granted – sleeping comfortably, getting off a toilet, opening a door, maneuvering into a car or comically small college desk, getting a meal in a cafeteria, or carrying a textbook-laden backpack across campus – become monumental obstacles. And stairs sap time and energy, evoking dread and sweat. They’re to be avoided. Except, in college, they seem to be unavoidable; Olukemi lives on the third floor.

“Stairs were the hardest part after surgery,” Olukemi says, more than three weeks into rehab. “They still are.”

 

DAILY HARDSHIPS

It’s 9:30 a.m., and Meredith Kussmaul’s arms are churning. They’re propelling her 6-foot-1-inch frame on a pair of crutches through a cold March morning a handful of miles from Lake Michigan. Her left leg dangles, locked in a black brace running from her upper thigh to her calf to keep the limb as straight as possible.

After an intricate dance with her crutches and the door at the DeVos Fieldhouse, the Hope College junior basketball player and team captain swings herself toward the training room. Three classes and hundreds of feet hobbling around campus await, but rehab comes first. A surgeon sliced open her left knee three weeks earlier.

Two months before that, in a December game against Ithaca, Kussmaul had taken advantage of a defender who’d wrongly assumed one of Hope’s tallest players to be slow. As the defender pressed her near the top of the key, Kussmaul sped by. She jump-stopped upon arrival at the basket, preparing to lay it in and perhaps absorb a foul, but the forward momentum of her femur surged away from a firmly planted tibia. Her ACL ripped apart as it struggled to make the stubborn bones work in concert.

Hope College's Meredith Kussmaul uses a stationary bike to force her surgically repaired knee to bend and straighten. Through the early stages of rehabilitation, she spent at least 10 minutes on the bike daily.

“I was crying because it was instant pain,” she says. “Just feeling that pop …”

She lets the thought hang, grimacing.

In the training room, Kussmaul lies on her back and digs her heel into a wall. It slides downward as she flexes her once-powerful hamstring with what’s left of her might. She’s teaching that muscle how to bend that leg again, teaching the graft how to settle any more disagreements between her tibia and femur.

One of the three incisions healing on her leg doesn’t match the others. All are covered in slim, white bandages hiding the vestiges of puncture wounds. But one above her knee is leaking fluid. Hope’s head athletic trainer, Brian Dykhuizen, says it could be a stitch that has failed, or worse – the beginnings of an infection. His voice tries to reassure Kussmaul – it’s even, without panic – though he can’t veil the concern in his eyes.

“It’s hard to tell, is it the normal drainage or is it something a little more than that?” he wonders as he rests his hand on the bloated joint, trying to detect if it’s a degree or two warmer than the rest of her – a signal for alarm.

He presses down on the knee; it won’t straighten. He presses down again; she grimaces. He pushes harder; her fists clench. It’s his job to get this swollen, discolored knee to extend perfectly straight – for now, three weeks after being dissected and rearranged, it’s rightfully stubborn. Getting a knee’s range of motion back is the first, and most important, step in rehabilitation. Failure here could severely hamper Kussmaul’s ability to play basketball or even walk properly.

“We’re kind of concerned about that,” he says. “It’s not where we would like that to be.”

When she goes to class later that day, she’ll implement the system she’s devised to get her long legs, one completely immobile, in and out of diminutive college desks and her Chevy Malibu.

“I have to leave so much earlier,” she says. “It takes me so much longer to do things.”

Her life is now a series of annoyances – constantly sore shoulders from the crutches, asking friends to put together a meal for her in the school cafeteria, rolling around her apartment in an office chair. But none of those hindrances compares with the first few moments after she was roused from three and a half hours under anesthesia.

“It was the worst pain I’d ever experienced,” Kussmaul says. “I remember waking up in recovery and I was crying because it hurt so bad. I’ve never felt anything like that.”

She didn’t spend the night in the hospital – nearly all ACL surgeries are now outpatient procedures – but lingered in a painkiller-induced stupor for several days. After a weekend spent in bed at home, she tried to venture downstairs with a concerned parent on either side. The handful of steps became a five-minute sojourn.

Crutches will be her means of transportation for six weeks because her surgeon opted to repair her torn meniscus rather than simply trim away the damaged portion. The meniscuses – medial and lateral – are part of the cartilage that separates the femur and the tibia, providing cushioning for the joint. In nearly every ACL tear, there is a contusion, or bone bruise – a sign of the two bones colliding when the ligament relented. In about 30 percent of cases, this collision is powerful enough to damage the meniscus, Winston says.

In the last decade, orthopedic surgeons have learned that the outer third of the meniscus has its own blood flow and can heal, says Dr. Michael Busch, surgical director of sports medicine at Children’s Healthcare of Atlanta. Rather than trimming off torn portions, they repair them, which is better for long-term knee health but more harrowing for patients in the short term. They’re not allowed to put any pressure on the cartilage as it heals … slowly.

Meredith Kussmaul averaged 10.1 points and 5.2 rebounds through 10 games as a junior before her ACL gave way.

Where is she now? Now a senior, Kussmaul is back in the starting lineup for the Flying Dutch.

Kussmaul’s injury didn’t shock her coach, Brian Morehouse, who has seen countless players writhe on the court in his 16 years as head coach at Hope. Women tear ACLs at a rate that far outpaces men. In a 16-year study of NCAA Injury Surveillance System data, for instance, the ACL tear rate among women’s basketball and soccer players was more than three times that of males. Some physicians suggest the rate is as much as eight times higher across all sports. According to the study, ACL tears accounted for nearly 5 percent of all injuries among female basketball players and nearly 4 percent of all injuries suffered by female soccer players. Women are more susceptible for various reasons – wider hips put more stress on the knees and women tend to land with their feet overpronated.

“ACL tears are a somewhat tragic aspect of women’s sports,” Morehouse says. “I’ve really learned how to deal with them. I used to be devastated. Now, without sounding too cavalier about it, it’s a little bit of the price of doing business.”

It doesn’t have to be, orthopedic surgeons say. Countless Division I programs, like Northwestern and Rice, have implemented ACL tear-prevention programs in the last half-decade to combat the steady climb of knee injuries. They put athletes through rigorous plyometric exercises and neuromuscular training. This array of complex jumping and agility drills teaches athletes how to leap, plant, pivot and land properly. Legs should be bent upon landing, toes shouldn’t be pointed out and cuts should made with hips square, for instance.

A 2000 study performed by Dr. Bert Mandelbaum, team physician at Pepperdine, indicated that neuromuscular training can prevent roughly three-quarters of ACL injuries. Mandelbaum put more than 1,000 female high school soccer players in California on neuromuscular training regimens while a control group practiced normally. Only 0.2 percent of those who engaged in neuromuscular training tore ACLs, while 1.7 percent of the control group suffered the injury, an 88 percent difference. A year later, the same study was performed, yielding a 74 percent injury gap between those with and without the training.

“Colleges are getting very good at working at some of that injury prevention, especially among women,” says Dr. Michael Terry, an assistant team physician for Northwestern athletics.

While these programs have permeated the ranks of Division I athletics, they are not as common in other divisions. Kussmaul, for instance, engaged in some jump and plyometric training, but never partook in a comprehensive prevention program.

“I understand why people say you can train to avoid it,” Morehouse, of Hope, says. “I respect that, but I also think I’ve seen the best-trained athletes that I’ve had go down.”

 

BATTLING DOUBT

Little more than a half-hour after the chair exercise, and immediately following an array of other stretches designed to improve his knee’s limited range of motion, Olukemi enjoys a moment’s respite. Though many muscles and ligaments are tight in the posh training room, the mood is loose. A few football players drift in and out and coarse banter fills the air. But one moment of ribbing catches Olukemi off-guard.

“You’ll lose your bounce,” Oklahoma State redshirt sophomore golfer Kevin Dougherty, rehabbing a stress fracture in his spine, says to Olukemi. It’s that bounce that brought him to Oklahoma State, that earned him a free education and that has him dreaming of a pro career.

“I’ll lay it up then,” Olukemi retorts defensively. “Two points is two points.”

Olukemi started 11 games as a junior, scoring double figures seven times, before tearing his ACL.

He pauses long enough for the conversation to drift away.

“I’m still going to jam it in,” he says softly and in no one’s direction, his bravado doing little to mask insecurity. The statement passes unacknowledged.

Seven minutes into the second half of a New Year’s Eve home game against Virginia Tech, and only moments after returning to the court after tweaking his knee, Olukemi jumped to throw a routine inbounds pass. His life wouldn’t be the same when gravity beckoned him back to the floor.

While he was in the air, it happened. The pop was accompanied by the feeling of a knife maliciously inserted into his joint. Miller knew – even before a battery of stability tests in the training room and an MRI the next day – that Olukemi’s season was over, and his career forever altered.

“That pain was crazy,” Olukemi says demonstratively, voice elevated. “It felt like my knee came out of the socket.”

That pain would abate within minutes, but more was coming. Trainers thrust a syringe into his bloated knee two weeks after his surgery to alleviate swelling. The needle penetrated deep into the joint and drew 46 CCs of fluid. At the sight of the needle working further into Olukemi’s leg, one of the trainers fainted.

“It felt like someone was poking their finger under your kneecap,” Olukemi says.

He does about 20 different workouts in a rehab session – leg presses, leg lifts and hamstring curls among them – in three sets of 15. For the next six to eight months he’ll be living his life three sets of 15 at a time, using the music in his headphones to drown out the monotony. He once regularly squatted 225 pounds. Now, he struggles to lift a 1-pound weight wrapped around his ankle.

Olukemi saw more of Oklahoma State athletic trainer Jason Miller than he did of his coaches during his rehab.

Where is he now? The senior returned to the starting lineup in Oklahoma State's second game of the 2012 season, but, sadly, tore the ACL in his left knee -- he injured his right knee last season -- against Akron in only his second game back. He is expected to miss the remainder of the season.

Later, he lies on his side with a round foam pad under his hip. It acts as a fulcrum as he pushes his body weight back and forth, trying to strengthen and stabilize the muscles in his upper thigh. The scars on Oklahoma State football player Deion Imade’s knee have had longer to heal than Olukemi’s, and he watches with knowing eyes as Olukemi works on the floor.

“That hurts,” he says solemnly, gazing down.

 

NO GIVING UP

Tim Abromaitis’ dreams are affixed, boldly, vibrantly to the wall.

The collage of jerseys and smiles and sweat reminds him every day of how close he is … how close he was. Six former Notre Dame players who have reached the NBA – the likes of Troy Murphy and Luke Harangody – are plastered to that wall in the players lounge outside the Fighting Irish locker room.

He sees them every day.

Abromaitis, a fifth-year senior with a bachelor’s degree and an MBA already in hand, sits on a leather couch in front of the mural, a dryer sheet clinging to his right sock. A foot north of that dryer sheet is a scar – bulbous and menacing, red nearly morphing into deep purple. That scar is the reason why, after he leaves Notre Dame in a few months, he likely won’t be on that wall wearing a jersey and the radiant smile evoked by an NBA signing bonus and the realization of a dream.

He plucks the dryer sheet off his ankle and tosses it aside. He can’t do the same with that scar.

It was born three months before, early in December of 2011, when a surgeon made a 6-inch incision below his knee. Unlike Kussmaul or Olukemi, Abromaitis would be replacing a torn ACL with the middle-third of his patellar tendon – the thick, prominent band below the kneecap. Along with the slice of tendon, two pieces of bone would be chipped away on either end – one from his lower kneecap, the other from his tibia – to anchor the graft in its new home.

While there’s much debate, it’s considered by many orthopedic surgeons to be the sturdiest graft. (Other common grafts come from a patient’s own hamstring or from a tendon in the ankle of a cadaver.) But there are drawbacks to that strength, sacrifices his body must make.

He will feel much more discomfort than Olukemi or Kussmaul. The front of his knee will throb and ache, longing for the missing pieces of bone and tendon stripped away. His quadriceps will grow weak, taking years to fully rebuild.

“My leg shriveled up,” Abromaitis says. “I was kind of like a stick figure after surgery.”

Tim Abromaitis played only two games before suffering a knee injury in his final season at Notre Dame. He averaged 13.7 points and 4.8 rebounds per game in his career.

Where is he now? Abromaitis signed with the French professional team ASVEL Lyon-Villeurbanne in July.

Through his entire life, Abromaitis has borne witness to the consequences of pushing through pain to keep playing. His father, Jim, had two knee injuries of his own during a collegiate career at Connecticut and a professional one in Europe. Jim would hobble around the driveway with Tim when he was a boy, helping his son hone his near-automatic jumper – Tim made 41 percent of his three-point attempts in his college career. Tim says he can already see himself, years in the future, in a driveway teaching his children how to shoot, limp be damned. Struggling to move as a middle-aged man is worth the chance of a professional career, worth grinding an already injured knee beyond its limits.

“My dad can’t begin to jog; it’s such a limp,” Abromaitis says. “I’m trying to do the rehab the best that I can so that hopefully the tendinitis and arthritis and all that are held off until later on.”

“Arthritis will happen no matter what,” says Winston, of Rice. “A lot of them have pain there forever.”

Two consecutive losses had drawn the ire of head coach Mike Brey, who pushed his players though an arduous workout the day after Thanksgiving in 2011. In a two-on-two drill, Abromaitis attacked the basket, planting his feet as he prepared to go up. His body and his left leg stopped, ready to spring, but his right leg lost its way.

“Right away I knew my knee isn’t supposed to go that way,” he says. “Then I was like, ‘Season is over; the year is done.’ ”

He was right. The ACL tore along with his medial and lateral meniscuses. Soon, the joint was swollen, misshapen, unrecognizable and his college career was snuffed out.

“All the guys on the team came in to say hi and sorry,” Abromaitis says. “Coach Brey came in and started talking about making decisions about my future. He was really good about being empathetic and trying to keep me upbeat. But at the same time, it hit me, ‘Who knows what the next step is now?’ I started to tear up a little bit. … ‘What’s going to happen in my career?’ ”

Three months after surgery, the 15 pounds he shed after being sliced open have returned to his powerful frame, thanks to a rigorous upper body weightlifting regimen that has him powering through bench-press repetitions of 255 pounds, refusing assistance and groaning through a painful last rep. He military presses 80-pound dumbbells above his head with relative ease.

But he hobbles on the short stroll from one workout station to the next. He can’t rush back to normalcy. He won’t be cleared to run, or even jog, for several months. Jumping and cutting, moves essential to basketball, won’t be allowed for many more.

“As people feel better faster and they feel like they can do more sooner, the graft just takes a fixed amount of time to heal,” says Terry, of Northwestern. “It’s biologically mandated and it doesn’t change.”

Abromaitis meanders into practice six minutes after his teammates have taken the floor. There’s a massive bag of ice on his knee, hampering his gait even further. It’s there to help his joint recover from a grueling 20 minutes on a rickety StairMaster in the cramped training room in Purcell Pavilion.

As his teammates prepare for the following night’s game against Providence, taking jump shots and weaving through complex pass and screen drills, Abromaitis’ gaze is directionless, sullen. His chin rests in his left hand. His eyes are dim.

“Rehab used to be the toughest part of the day,” he says. “Now, it’s still just going to practice every day and sitting there on the sidelines while everybody else plays.”

Abromaitis wears that same look nearly a month later, on national television, when the Irish succumb to Xavier in their first game of the NCAA tournament. He has on a dress shirt, not a uniform, and his slacks hide the scar. He doesn’t know the next time he’ll get to sit on a bench, whether his image, wearing a glistening new jersey and a seven-figure smile, will ever join the others on the Notre Dame locker room wall.

“This better not mean a desk job for me next year,” he says. “I don’t want to be working in an office yet.”

 

THE LONG CLIMB TO RECOVERY

After morning rehab, class. After class, two more hours of rehab. After rehab, Spanish homework. After Spanish homework, fatigue. But before it can take hold, Olukemi’s teammates take the court at 8 p.m. in Columbia, Mo., on ESPN2. His low-hanging eyelids bolt open. His tired, low speech morphs into a series of dejected shouts.

He watches from a bed in Stillwater, damaged leg propped up on a pillow, but incessantly shifting out of discomfort. He yells in frustration throughout the first half as Missouri’s fast pace demoralizes the Cowboys. At halftime, Missouri has amassed a 44-22 lead. Olukemi’s wild gesticulations and admonishments during the game are in vain. There’s nothing he can do; he’s 400 miles away.

“They’re just toying with us,” he says.

A month-and-a-half removed from his last moments in uniform and a seven-hour drive from the game, Olukemi still uses “us” and “we” when referring to the Cowboys. Those teammates on the television double as his closest friends. Olukemi admits it’s jarring when they venture to away games.

“I feel lonely,” he says. “I don’t like it. It’s like when your brothers and sisters are out of the house.”

As Missouri’s bench warmers play out the final minutes of the Tigers’ 83-65 win, Olukemi’s dejection fades into subtle grimaces and low sighs. Next season, his teammates won’t be pixels dancing on a flat screen. He will trade the worn sweatshirt for a trim jersey. The knee will bend freely and he’ll assume a low squat, arms wide, assigned to stifle the opponent’s most potent perimeter scorer. He will rebuild faith in his body every time he slashes to the basket. He will edge from the periphery back into the spotlight.

But, first, the long climb.

Olukemi returns to his apartment building. Before he can reach his door, his bed and well-earned sleep, he must confront those two flights of stairs. The journey is arduous, but Olukemi scales them deliberately, both feet on every step, one at a time.

As he ascends, the stars are vivid against a dark Stillwater sky. But the fog, thick and heavy, will soon return with the sun, the morning chill and the muffled screams.