WTLC Interview with Dr. David Geier on Russell Westbrook, knee injuries, and athlete recovery

We have the distinct privilege today to bring you an exclusive interview with Dr. David Geier. Dr. Geier is an orthopedic surgeon at the Medical University of South Carolina. Dr. Geier was gracious enough to talk to WTLC at length about Russell Westbrook's injury, rehabilitation, and the issues that recovering athletes face in today's sports landscape.

(Update: A point of clarification - Dr. Geier was not the surgeon who performed the procedure on Westbrook. Rather, he is a surgeon who is an expert in the area of meniscus repair and wanted to share his insights.)

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WTLC: Dr. Geier, please tell us a bit about yourself.

Dr. Geier: I'm an orthopedic surgeon here in Charlestown, South Carolina. I specialize in sports medicine and I'm the director at the University of South Carolina's sports medicine program. I look at athletes from high school, college, and the pro level, as well as adults, the weekend warrior types that suffer these types of injuries.

WTLC: How did you get interested in this type of sports medicine?

Dr. Geier: It's interesting. You'd think it is more related to cool surgeries or hanging out with athletes or things like that. But actually, what I like about it is getting people back and able to play. If the high school athlete plays soccer, it's about fixing whatever their injury is and getting them back to play and that kind of thing. It's about people having one sport, one activity that they like to do and the injury is keeping them from that. I like helping with that. If it's surgery to fix it, identifying the problem or getting them to rehab, a cast or walking boot, whatever it is, getting them back to play. And hopefully not just to play at all, but to the same or higher level, there's something really gratifying about that.

WTLC: What was your general reaction when you saw that Westbrook had gotten hurt?

Dr. Geier: I'm a huge NBA fan, and the fan side of me was disappointed as I'm sure most people were, he is one of the stars in the league and stars in the playoffs. From a physician's standpoint, watching the play and the injury, it doesn't surprise me at all. It wasn't a surprise when I heard that diagnosis.

The meniscus is a c-shaped shock absorber in the knee. There's one on the inside, the medial side, and there's one on the outside, the lateral side. They're involved in and commonly injured through twisting motions. You plant your foot and you twist your knee, or you land awkwardly and twist it. You can tear that shock absorbing cartilage, the meniscus.

So what happened when Patrick Beverley went for the steal, Westbrook tried to get around him and Beverley kind of bumped

around him, that twisted Westbrook's knee. So that injury didn't surprise me. What they found on the MRI was not all that surprising. I was kind of suspicious at the time that that was going to be a surgery that involved repairing the meniscus rather than trimming it out by the way they said he was out indefinitely and that they would know more when they got in there. I think they were suspicious that it was the type of meniscus tear that was going to be repaired and clearly it turned out when he had surgery on Saturday that this was the case.

There are certain types of meniscus tears that you sew back together if you can to get it to heal and preserve that entire meniscus rather than trimming a part of it out. Clearly that's what they found and that will take longer rehab.

WTLC: Could you explain the difference between the cleaning out of a meniscus and the repairing of a meniscus?

Dr.Geier: Let me explain what's involved and then we can talk about what types can be repaired and what types can't. The majority of meniscus tears are of the type where you go in and trim part of it out. What that it entails is an arthroscopic surgery through about 2-3 small incisions. You look in the knee with a scope and you run a lot of fluids through it to see. Then you use tiny arthroscopic scissors and a shaver to trim out the inner part of the meniscus that is torn. What that does is eliminate the piece of the meniscus that is torn from catching between the bone and causing pain. So you take that out and leave the majority of the meniscus as a shock absorber. That's an outpatient surgery, it takes about 15 minutes to do. Then you work on getting the motion back and getting the swelling down. You're able to put your weight on it right away. And then you can go back to playing. That is about 2-4 weeks although most athletes tell you they will continue to improve over 3-4 months. But you can do things on it right away. I've had athletes get back into it in a couple weeks.

If it's a repair, meaning you put stitches and anchors to sew it back together, that's a very different proposition. You have to protect the repair. If you go in and pound on it running and twisting on it, jumping on it, you might break the stitches and completely disrupt all the work the surgeon did. You protect it and different people protect it differently. Most often, it's non-weight bearing for 2-4 weeks, a brace for about 4 weeks, and then you start weight-bearing. You start jogging to get your strength back. That whole process takes about 3-4 months.

You go through all that lengthy period to get that meniscus tear to heal so that you have the entire structure to be there down the road. When you take part of the meniscus out, you leave 75% or 60% or whatever amount you have to take out, if a meniscal repair heals, potentially you will have the entire meniscus still there to act as the shock absorber. So it's potentially better for his career long-term. The ones you trim out it's not that you don't want to trim them out, but they're not the type that you can repair.

WTLC: It doesn't regenerate right? Once it's gone, it's gone forever?

Dr. Geier: Correct. That tissue doesn't magically fill in with new tissue. Which is not to say that it guarantees that it will give you arthritis or anything like that. A lot of the time you're not taking a huge amount out. You're taking out enough to eliminate the catching of the tissue between the bones and eliminate pain. There is thought that if you take some of that meniscus out that could lead to more wear and tear on the cartilage lining of the ends of the bone, the articular cartilage. And yeah, it could take its toll over the years, but the player and surgeon really don't have any decision of repair over trimming part of it out. The decision is made based on the location of the tear, the orientation of the tear, whether or not it is repairable and whether the repair will heal. Neither the surgeon or player has any control over that.

WTLC: Could you compare/contrast Westbrook's injury with some other players like Metta World Peace, who infamously returned 12 days after his, and Brandon Roy, who has had numerous knee injuries?

Dr. Geier: Metta World Peace, all the media reports said, 'repair,' but I don't think it is likely that it was a true repair. That's one of the things that teams will say, 'repair,' without medical background, and they won't have the doctors speak. You'd have to ask his doctors, but I don't think he had a meniscal repair to be back in 12 days. If he had a partial meniscectomy that would make sense and it would be certainly possible to play 12-14 days with part of it trimmed out. That would be highly unusual to have a repair and be back that fast.

Brandon Roy is a little bit different. He may have had meniscus surgery at some point but his injury was articular cartilage injury. The cartilage lining on the end of the bones, so he had multiple surgeries to perform a microfracture, where surgeons basically take like a fancy ice pick and you poke holes in the bones. When the cartilage lining starts to break down you have exposed bones. So the surgeon who worked on Roy poked holes in the bones to stimulate blood flow into the area and get it to fill in what we call fibrocartilage. The problem is that it is not very durable and does not have good long term success. He had multiple surgeries and now has bone-on-bone arthritis as the cartilage keeps breaking down.

WTLC: For athletes who are hypercompetitive, how do they manage the rehab process so that his situation does not turn into something like Roy's?

Dr. Geier: That's a good question. That's one of the things that the surgeon at Westbrook's surgery will look at, to see if he has any cartilage damage that happened at the time of the injury. I haven't seen any mention of that, but the surgeon will look at it. As far as protecting for that, the biggest factor is to get the meniscus to heal. Most cartilage damage, yes it can occur as wear and tear over time as you lose some of the meniscus, but some of it is traumatic, you get a twisting injury that damages the cartilage lining. I don't know if there's anything different you make about the rehab other than everything you have to do to get the meniscus repaired to heal.

Could he develop articular cartilage damage down the road? No question, just like anybody in the NBA could. But I don't know if there's anything that can be done differently. If they can get that meniscus repaired to heal then you would expect that he would have good, long-term function of his knee.

WTLC: What is Westbrook's ceiling? Can he get back to 100%? Is it going to be something less than that?

Dr. Geier: I think the goal is to get the stitches to heal to create a completely normal meniscus. The goal is a normal knee. That's going to be one of the questions going forward - did the meniscus actually heal? We know that when you do surgery and put the stitches in, to get it to heal, that's got good success rates, but it's not 100%. The goal is to make it a completely solid meniscus. But they will follow it over the next 4-6 months. Different studies have the fail rate of the meniscus repair at different numbers, but some studies have it at 25% or even higher. That's where a lot of the restrictions come from, trying to minimize the chance that you've done that surgery to sew it back together and the stitches don't hold. The meniscus has very little blood supply, that's why they don't heal in the first place without surgery. But it's thought to be a reason why meniscal repairs don't heal. So that's something to keep an eye on over the next 3-6 months.

WTLC: What are some of the most important things for an athlete like Westbrook in order to make sure his rehab goes according to best possible case scenario? Is it psychological, is it just listening to the doctors?

Dr. Geier: It's kind of both, but different elements at different points in the rehabilitation. Early on, it's to be absolutely in compliant with whatever the restrictions that the surgeon placed on him. Some of that depends on where the tear was and things like that. But if the doctor says 'no weight-bearing,' then there is no weight bearing. If it is limiting the motion to 90 degrees and not bending past that. It would be things like that, and not doing too much too soon. You would not try to rush back through this. You would make sure you follow all the protocols. Because the restrictions are going to be based on whatever is most likely to get the meniscus repair to heal. But then you get further on and the doctor is more comfortable that the repair is going well then it's working really hard to get motion and strength back, and getting back to basketball shape.

In my case, meniscus repair, I could get back to daily exercise and activity and it wouldn't be a big deal, but I'm not trying to the NBA, so getting the strength back at an elite level to be able to cut and pivot is quite a different thing.

WTLC: When Westbrook is finally cleared to get back into game shape, what is the most important thing for him to do to get back to the level he wants to be at?

Dr. Geier: I think working really aggressively on strength and functional training, they'll work a long time in physical therapy on balance and high level jumping ability, landing on one foot. But then a lot of it is just the status of his knee and what the surgeons found. Some of it is under Westbrook's control, some of it is not. If all goes well though, you'd expect him to be back to the same level he was before he got hurt.

WTLC: Are you seeing any increase in athlete knee injuries We seem to have a rash of them lately, with Ricky Rubio, Derrick Rose, and now Westbrook. Is there a trend?

Dr. Geier: I think there is an increase overall simply because of more people playing, especially youth athletes. I think you have to be leery of saying there is a trend in any one sport because we tend to be too close to it to see if there is a sudden rise in a specific type of injury for 5-6 years when you can compare the data over long periods of time. Two years ago there was a huge spike in Achilles tendon ruptures in the NFL during pre-season, but really it was just a blip on the radar in the grand scheme of things. I don't think there is anything worrisome going on.

In the NBA though, these guys are as big and fast and strong as they ever have been plus defenses are getting much more physical. What they put their bodies through is as strenuous as it ever has been. With the physical defenses you start to worry it could have an effect, not just on knee injuries but injuries in general. You might see more overuse injuries and hamstring strain injuries, and overuse muscle injuries, things like that. It could lead to more traumatic events as well. That's something we're not going to know for a while though when we can see at a distance the statistics year to year. It's a more physical sport than it used to be, but I don't know that I would look at the last 12 months and say that there's any reason for concern. These guys are getting hurt with different types of injuries with different motions. I would caution to say this is some sort of epidemic. Could it be a gradual increase with the changes in defenses over time and the physicality of the sport? Definitely.

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Many thanks to Dr. Geier for his thorough explanation of Westbrook's injury, what his recovery will look like, and what similar athletes may face in the future as they deal with knee injuries.

Dr. Geier can be followed at:

www.drdavidgeier.com

Twitter: @DrDavidGeier

Facebook: facebook.com/DrDavidGeier

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First meniscus image via www.aurorahealthcare.org

Image of suture and meniscal anchor via www.drdavidgeier.com