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Tuesday, June 8, 2010
Welker looking good, but lots of work left


New England Patriots wide receiver Wes Welker generated a lot of buzz when he made his appearance at the team's organized team activities June 2. When most expected just an appearance, Welker took it a step -- actually, many steps -- further by showing just how well his post-surgical knee is doing.

According to ESPNBoston.com's Mike Reiss, Welker, who is four months removed from anterior cruciate ligament reconstruction, "went through agility drills with the team's receivers, stepping over bags at a rapid pace and navigating his way around orange cones placed on the ground." Reiss said Welker caught passes from quarterback Tom Brady, "at one point running about three-quarters speed, stopping abruptly, and then turning to make a reception." Six days later, Welker went through similar drills at another OTA.

Wes Welker
The fact that Wes Welker was already on the field doing drills just four months after knee surgery is a great sign.

With that news, many are wondering: Should we be shocked by what we saw? And how realistic is a Week 1 return now?

We should not be shocked by what Welker was able to do just four months after undergoing surgery (and five months after the noncontact injury to his left knee, which also resulted in a medial collateral ligament sprain). Advances in surgical technique and rehabilitation, combined with hard work and the absence of any setbacks, have shortened the timetable for return to activity.

According to Dr. Neal ElAttrache, Director of Sports Medicine at the Kerlan-Jobe Orthopaedic Clinic in Los Angeles, "It's a great sign that he can do the things that he's doing. He's obviously recovering very well from his injury and surgery." ElAttrache, who performed Brady's knee reconstruction surgery in 2008, said at this point Welker has met the biggest benchmarks following this type of procedure: full motion of the knee, no swelling and the ability to tolerate exercise.

ElAttrache appreciates the importance of early return to sports activity: "Whether it's the NBA, college basketball, soccer or football, the quicker that athletes who require high-level balance and agility can get back to sport-specific activities, the better off they're going to be."

Shawn Hunt, a physical therapist and athletic trainer who teaches in the physical therapy program at the University of Miami and previously worked with the New York Giants, said Welker is doing the things he should be at this stage. Hunt said while the media may have been surprised by what they saw from Welker in the OTAs, "that was not the first day he went out and tested it." He credits Welker's progress to intensive management behind the scenes by the medical staff and a gradual daily progression of activity based on what his knee will tolerate.

It's natural to compare Welker's recovery to that of his teammate Brady, who missed most of the 2008 season with a similarly serious knee injury. While they damaged the same ligaments, their injuries were not identical.

Brady was injured when a defender rolled into his knee (on his lead leg) while his foot was planted, stepping up in the pocket to throw. Welker's knee buckled when he decelerated to make a directional change. There was no direct contact with an opponent. This noncontact mechanism of injury is the most common means by which NFL athletes suffer torn ACLs, especially running backs (for example, the Miami Dolphins' Ronnie Brown in 2007) and receivers (the Seattle Seahawks' Deion Branch in 2008).

Tom Brady
Tom Brady was pretty much back to normal in 2009 after missing most of the 2008 season with a serious knee injury.

Quarterbacks, however, are most vulnerable while in the pocket, and their major knee injuries tend to be the result of contact (Brady, the Cincinnati Bengals' Carson Palmer in 2006, the San Diego Chargers' Philip Rivers in 2008). Occasionally, a scrambling quarterback will have an injury of the noncontact variety, like the Philadelphia Eagles' Donovan McNabb in 2006, but that seems to be the exception.

The trauma resulting from a contact ACL injury is often quite different from noncontact. Along with the ACL tear, Palmer suffered a dislocated patella (kneecap) and an MCL tear. Brady also suffered a significant MCL tear along with his ACL injury. The nature of their injuries, in terms of the complexity of tissue damage, translated to more extensive surgical repair beyond the ACL alone. Both required longer rehabilitation times to accommodate their procedures, yet both returned for the start of the next season, a testament to their hard work.

In noncontact ACL injuries, there is still the potential for damage to other nearby structures, like the MCL, but the forces causing the injury are more a result of internal shear and torsion, not external force, which is delivered in a linear or straight-line manner, as is the case with a direct blow. The differences in these types of forces can translate to differences in how the tissue is injured. Specifically, the MCL may have a better chance of healing on its own in the noncontact injury, which is what happened with Welker. Remember, he was held from surgery for a month so the MCL would have an opportunity to heal on its own. That healing time was followed by a surgery dedicated to reconstruction of the ACL, enabling a more straightforward recovery.

There are different demands on athletes returning from this injury, depending on the position. Quarterbacks are not subject to sharp decelerations and cuts like receivers and running backs, but they need to have the confidence to step up in the pocket and have the strength to deliver the ball over that lead leg. They also need to have the ability to scramble to escape contact yet trust in the knee to absorb it when unavoidable. Running backs and receivers need confidence in the surgically reconstructed leg, both in contact and noncontact situations, but they need to restore far more speed and agility to be effective, which may mean more recovery time.

Thus, running backs and receivers coming back from this type of injury often do not immediately return to form. In a 2006 study published by the American Journal of Sports Medicine, investigators found that running backs and receivers suffered a drop-off in performance (according to a formula of total yards and touchdowns) of roughly one-third after ACL surgery.

As for Welker suiting up in Week 1, there is no definitive answer. More will be learned from his work over the next few months. The fact that he's already running, doing light agility drills and other early football activities puts him in a better position to return sooner rather than later. But there is still a long way to go.

Despite all the focus on range of motion, strength, balance and agility, perhaps the most challenging aspect of a player's recovery from this type of injury is regaining confidence that the leg will perform as expected and will tolerate the daily grind of the sport, and that a maneuver similar to the one that caused the injury will not be a problem. Welker's style of play calls for him to perform that stop-start-change of direction over and over again. The transition from thinking about the "play" without thinking about the "knee" takes time, no matter how many physical benchmarks he's achieved.

One reason Welker's activity tolerance is such a good sign, according to ElAttrache, is that now "he can concentrate on the steps necessary to regain confidence. Once these milestones have been crossed, there is more time available to work on the thing that takes the longest."

According to Hunt, there are several key steps for Welker to return to competition. The most critical aspect is staying ahead of any inflammation that occurs as his activity progresses. As the workouts become more aggressive and the knee joint absorbs the repeated pounding of running, cutting, turning and increasing speed, close monitoring for any signs of swelling, followed by backing off activity as necessary, will help protect against major setbacks.

The next component, says Hunt, will be for Welker to "get his explosiveness and release off the line." That top speed and agility, so critical to Welker's game in particular, will be one of the elements he has to work diligently to regain.

The final, and perhaps most obvious, event in Welker's healing process that will signal his true recovery is his ability to absorb contact. When eyeing OTAs as a potential predictor of return to competition, Hunt notes that they "don't represent contact and they don't represent collisions." And it's not just any type of contact that lets everyone know a player is truly back; it's how a player responds to that first blind hit.

Wes Welker
Wes Welker had 123 catches for 1,348 yards in 2009, despite missing two full games and being knocked out of the season finale early.

"We're not talking about the first hit you're prepared for; it's the one you didn't see coming, that knocks you off your feet and twists your knee, and you're able to get up and walk away," Hunt said.

Both ElAttrache and Hunt were enthusiastic about Welker's performance at this stage and that his display at OTAs is a good prognostic sign for his recovery. But no one, including Welker himself, is willing to set a timetable for his return, knowing that every day brings a re-evaluation of how he tolerated the previous day's work, which then influences what comes next. Hunt said, "You can't make a prediction off a snapshot. He's going to do what he can tolerate, day by day."

The Patriots have been conservative with players returning from injuries before. So even if Welker appears ready to compete, the team might ease him back into competition or delay his return. Remember, he started last season with a problem hamstring and performed well in Week 1, but was sidelined for the next couple of games after that.

However, many are optimistic that Welker will return sooner than later. As Brady said of him during a charity event last week, "He's such a hard worker. Wes has a chip on his shoulder." That's what many said about Brady at this time last year. Then he showed up at OTAs with fluid mobility on his surgically repaired knee, turned soft corners and made routine plays, much like Welker has this year so far. Still, everyone wondered how Brady would respond to competition, the threat of contact, the speed of the game. And we saw how he answered that.

Maybe that's why Welker has been spending so much of his recovery time with Brady this offseason. Two guys who have been told repeatedly what they could not do might just need each other around as proof of what they can do.