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Tuesday, February 3, 2009
Pain shouldn't trouble Tiger's return

By Stephania Bell
ESPN.com

Many in the world of golf are wondering how Tiger Woods will feel physically when he makes his first post-surgery start on the PGA Tour.

Will the world's No. 1 golfer be pain-free when he comes back in 2009?

Does he face any risk of reinjury when he does ultimately return?

Can we expect changes to his swing?

Perhaps most importantly, once he's back, how long can he and his knee last in this sport?

One of the things we can be fairly confident about is that Tiger will not be concerned with pain in his knee when he returns to competition. The truly painful phase postoperatively is typically within the first three to four months. The pain lingers until the swelling has subsided, the wound has healed and the muscles have recovered enough to control the leg during everyday activities. Once those targets have been met -- and barring any major setbacks -- pain is no longer a real issue.

Woods, speaking at the Chevron World Challenge in December, described the early stages after the surgery as "brutal."

"The first three weeks, the swelling in the leg and the pain … it's hard to describe the pain. I didn't start feeling pretty good until probably three months after post-op, 3½ months where I felt like I could do most activities. And then about four months out, I felt pretty normal. And now I feel great."

So with the pain no longer an issue, shouldn't Woods be on the brink of returning? Not necessarily. It may come as somewhat of a surprise that pain, often thought of as the precursor to limiting an athlete's function, may not be the primary factor in determining his return.

In fact, the absence of pain can be deceiving, often leading athletes to think they are ready for competition when they might still have a long way to go. Certainly other athletes have rushed to return to their sports after similar injuries, including golfers, and the results have not always been pretty. ESPN's Bob Harig described the case of PGA Tour veteran Brad Faxon, who ultimately required a second ACL surgery when his knee problems persisted after he returned to the game.

Since golf is not a running sport, the general perception is that the load on the knees is minimal. Certainly from a direct-impact perspective, repetitive pounding is not a primary issue. But it is important to respect the forces on both knees that result from torque created during swing rotation, with the lead leg being particularly susceptible.

Tiger Woods
Tiger Woods hasn't played a competitive round of golf since June. When he returns to action, the world's No. 1 player might make a few changes to his swing and routine.

If the muscular strength is not adequate following surgery, subtle increases in shear forces across the joint can result during a swing, leading to deformation of the still-healing graft over time. If the graft stretches out too much, it no longer serves its purpose of providing stability, and a second surgery might be necessary. Although this is not a common occurrence, it most certainly is not desirable.

Weakness of the muscles is not simply a factor in an isolated swing of the club, either. A round of golf takes a considerable amount of time so muscular endurance, and not just strength, must also be restored. Subtle indications of decreased endurance can show up postoperatively as decreased weight bearing over the surgical leg. In the case of a golfer, one might see him placing less weight on the leg while standing, or leaning on a club intermittently for support. During a golf swing, this deficit shows up as an inability to transfer weight over the surgical leg.

For instance, at the end of a swing, the golfer should normally have about 60 to 70 percent body weight over the lead leg. A weak or fatigued leg, however, may only tolerate 50 to 60 percent body weight.

Not only can this weakness harm the knee itself, but the golfer's mechanics can become compromised. The failure to transfer body weight properly can translate into a loss of power that occurs with a deceleration of the club on the ball through impact as opposed to the intended goal of acceleration at the same point in the swing. The end result is decreased accuracy when the ball does not travel as the golfer expects it should.

Woods has been adamant that he is not pushing himself to take any chances as far as coming back too quickly. In addition to his disciplined physical rehabilitation and fitness regimen, he has been steadfast in his mental approach of maintaining a slow and steady pace. When asked in December if he was tempted to come back sooner than he should, Woods' answer was clear.

"No, because … one, I don't want to go through this process again; and two, I'm not ready yet."

It sounds as if Tiger has taken the risk of reinjury out of the equation.

So far, so good. But what about the concerns related to Tiger's swing and his longevity in the sport? It turns out that those two items are probably intimately related.

The golf world can collectively exhale; Tiger is positioned to have a very nice next phase of his career. With all the attention to his fitness and leg strengthening, expect a stronger, sturdier Tiger after this surgery and subsequent rehab. After all, it was just a few weeks ago that we were discussing why Woods may actually emerge even better after this process. But Tiger will still likely need to make some changes.

The fiercely competitive Woods will be forced to take a kinder, gentler approach to his knee. And that starts with his swing.

There is no denying the force to which he subjected his left (lead) leg with the mechanics of his original swing. Woods himself was aware of the stress he placed on it, particularly during his follow-through, but explained he had a hard time controlling the snapping of his leg without a functioning ACL.

Tiger recently acknowledged on his Web site that he started to hit longer irons and his driver in January. He also stated that controlling the terminal part of his swing so that he does not snap his knee into hyperextension/rotation is likely part of the plan.

Why is this so important? When Tiger revealed that he had undergone an arthroscopic procedure on his left knee in April 2008 following his second-place finish in the Masters, we learned he had some cartilage damage in that knee. Ligamentous instability leads to increased shear forces within the knee joint, so it is safe to assume that as Tiger's knee became even less stable with the failure of his ACL, the cartilage surfaces (which when healthy are smooth and shiny and protect the ends of the bones) were potentially subject to increased wear and tear. Although that cartilage surface can be resurfaced and buffed, it can never truly be replaced. Protecting the existing cartilage surface within that left knee becomes a top priority for Woods going forward.

Translation: He has to examine his swing.

Kyle Yamashiro, a physical therapist and owner of Results Physical Therapy in Sacramento, Calif., works extensively with golfers of all levels and spent several years providing physical therapy services for the LPGA Tour. He has seen golfers who have a similar knee extension/rotation thrust at the terminal point of their swing (although none perhaps as vigorous as Tiger's), and has worked with them to control that movement and decrease stress on the knee.

"Just like a pitcher's shoulder breaks down due to the repetitive nature of throwing over and over, a golfer will get cartilage wear within his knee, especially on his lead leg, with repetitive swings," Yamashiro said. "That's why we often see golfer's [lead] knees begin to break down in their 40s and 50s."

Breakdown of cartilage within a joint is more commonly referred to as arthritis.

Yamashiro also pointed out that faulty mechanics, such as excessive torque or hyperextension at the end of the swing, can accelerate arthritic changes in the knee. Ultimately, precision-tuned muscular control of all of the muscles that cross the knee joint -- primarily the hamstrings, quadriceps and calf muscles -- is responsible for controlling knee position. Muscular strength and coordination have to be retrained after ligamentous reconstructive surgery as the muscles are often weak and inefficient to some degree, not only as a result of surgery but also from compensating for instability for a period of time.

knee brace
Note how the brace provides reinforcement to help limit hyperextension at the end of the golfer's swing.

Sometimes external bracing will be used to help control knee hyperextension as an interim measure while the athlete is training, especially if that athlete has a natural tendency toward laxity or "looseness" in his or her joints. Such a brace has a "stop" on the back side that serves to prevent the athlete from extending the knee beyond a predetermined range.

Braces are often used as transitional measures following ACL surgery when an athlete is returning to higher levels of activity. The reason? Athletes may exhibit solid muscular control of the knee during various lower extremity exercises. But when the brain is required to multitask -- throw a ball, catch a pass or swing a club -- all while maintaining precision control over the knee, the challenge is much greater initially, and this is when setbacks can occur.

Not all athletes will require a brace. Some view the brace as a hindrance because of its somewhat bulky nature and the fact it alters the natural feel of the leg. The ultimate goal for an athlete, depending on the sport, may be to perform those tasks without a brace and allow the muscles to provide that support independently. Whether Tiger will use a brace is unknown, but given his perfection-driven approach to both his golf game and his rehabilitation, it seems unlikely that he will use one. If that is indeed the case, it becomes even more important he achieve peak control of the knee during his swing before he returns to competition, both for his short-term and long-term health.

In addition to ensuring Tiger's readiness to return to play before he resumes competition, Yamashiro suggested Woods will likely make some permanent changes to his training and practice regimen to protect his knee for the long haul. For instance, less running during the week will decrease the impact on Tiger's knee. More low to non-impact cross-training -- such as riding a bike, swimming in a pool or working out on an elliptical machine -- will likely occur in its place. As Yamashiro pointed out, "Tiger is so far ahead of the demands of golf already in terms of his physical fitness that adapting to a modified routine should not affect his conditioning for the sport."

Yamashiro said Woods may cut back a bit on his practice schedule, especially the number of swings he takes at any one time with his driver, in an effort to protect his knee.

"You may only take 15 swings with a driver in a round of golf," Yamashiro said, "but it's the repetition of training and practice that can ultimately lead to breakdown."

Tiger has already said he's dedicated himself to his rehabilitation and is preparing for a return to competition that will be dictated by his readiness, not by an artificial deadline. That readiness no doubt includes a plan that will encourage the maintenance of the health of his knee and ensure his longevity in the sport.

Patience, Tiger fans. He may take his time returning to competition, but it's safe to assume that once he comes back, he's not planning on going anywhere for a long, long time.

Stephania Bell is the injury expert for ESPN.com fantasy.