Sports Rehab Write-Up: QB Daniel Jones, Phases 2 & 3
Anddd we’re talking ACLs again!
New York Giants QB Daniel Jones recently underwent a successful ACL repair surgery & his rehab journey is officially well on its way!
We spoke here about the Prehab phase of his recovery a few weeks ago – check it out!
In his first interview since the surgery, Jones laid out his expected timeline for a return to play:
“Long term, it’s definitely the goal to be back by training camp.”
Considering he had his repair around Thanksgiving, that means he’s planning to be back out there just 8 months after surgery!
We know that’s doable, but is it ideal?
Let’s look to the literature!
Firstly, it’s interesting that Jones decided to go with the ACL repair as opposed to an ACL reconstruction. Reconstruction has typically been looked at as the gold standard surgical procedure for an ACL tear.
Due to the anatomy of the knee joint & lack of blood flow to the ACL, primary repairs have generally been seen as a riskier surgical option. Until relatively recently, they’d also been believed to have consistently worse outcomes & higher failure rates. All that coupled with the relative difficulty of the procedure, led to repairs falling out of favor in the medical community. But, due to the most recent research, ACL repairs are quickly regaining popularity!
In their 2022 study, Vermeijden et. al followed a group of subjects that had undergone an ACL repair in one limb & an ACL reconstruction in the other. They found that the two procedures lead to similar functional outcomes & that subjects generally reported better outcomes in the primary repair limb!
“Of all patients without failure, 78% indicated that their repaired knee was less painful during rehabilitation versus 22% of the reconstructed knees. In addition, 83% of patients reported that their repaired knee had earlier ROM return, as opposed to 0% of the reconstructed knees. Eighty-three percent of patients indicated that the rehabilitation following repair was advanced more rapidly than their reconstructed knee, as opposed to 11% who reported better function and progression during rehabilitation following their ACL reconstruction, and 6% did not note a difference. Finally, when asked which knee was their better knee, 33% of patients preferred the repaired knee, 11% the reconstructed knee, and 56% had no preferences”
With the constant advancements in medical techniques & technologies, it’s probably safe to assume Danny Dimes went and got the latest & greatest! So, maybe Jones’ ortho was onto something!
Diagram Highlighting the Steps of the BEAR ACL repair technique (Murray et. al; 2016). An example of the advancements made in ACL repairs.
One of the newer surgical techniques is the bridge-enhanced ACL repair (BEAR) which is meant to optimize the biological environment for ACL healing & to prevent failure due to poor blood supply. Mansour et. al published a meta-analysis earlier this year that compared functional outcomes in subjects that had undergone the BEAR technique to those in subjects who had an ACL reconstruction. Mansour’s team found that there was generally no significant difference in outcomes between the BEAR technique & ACL reconstruction, but that the subjects that underwent the BEAR technique came out with better hamstring strength, a shorter length of symptoms, and a quicker return to sport!
An eight month return to sport isn’t too unreasonable; all things considered!
With newer repair techniques being proven to get guys back on the field more quickly & with a solid Prehab phase behind him, 8 months might actually be a generous timeline for Jones!
When we add in that Danny won’t play a meaningful snap, let alone take a hit, for an additional 2 months; it’s probably best that he makes his return for training camp to get some genuine sport-specific training!
With all that being said, Jones still has to focus on his rehab! Let’s take a look at what he can expect for these next two phases of the process!
Filbay & Grindem put together a review in 2019 & recommended five distinct phases of ACL rehab. We’ve already covered the Preoperative or Prehab phase; next is the Acute phase, followed by the Intermediate phase.
The Acute phase is pretty straightforward, with a bunch of similarities to the Preoperative phase -- we’re reducing pain & swelling, maximizing range of motion, and getting the quads firing!
The Acute phase starts right after surgery with the goals being to reach full passive knee extension and to build back quad strength & control! This is right after surgery, so clinicians should be extremely cognizant of pain & weakness when prescribing exercises here!
Since his surgery, Jones has probably done at least a million SAQs & quad sets – and counting!
After about 2 weeks post-op, if all is going according to plan, Jones should be heading into the Intermediate phase.
This 3rd phase of ACL rehab focuses on maximizing the strength, proprioception, & motor control of the knee’s dynamic stabilizers. Sessions should consist of strength & balance training that begins to implement sports-specific skills.
The primary goal of the Intermediate phase is to implement a muscle strengthening program that will genuinely restore Jones’ strength & power to the level necessary to play football at the highest level.
The Intermediate phase is typically from around week 3 to week 6 post-op, but the patient should probably stay in this phase until they’ve made the appropriate strength & functional progressions! As opposed to a time-based criteria, we should be sure that our patients have full extension range of motion, near-normal flexion range of motion, and at least 80% quad symmetry with adequate movement quality!
Daniel Jones walking through the NY Giants locker room wearing his post-op ACL orthotic.
“I mean, it’s a long road. I think it depends, kind of how I do with each stage of it and, and how it progresses. I’m going to try to focus on what’s right in front of me during each stage and do as well as I can with each of those…”
Looks like Jones has the right idea!
As he’s likely just entering the Intermediate phase, there’s still plenty of work to be done! But Giants fans can rest assured, things are going exactly as planned!
Training camp will be here before you know it; it’s just a matter of time & effort before you’re seeing your franchise QB back on the field!
Works Cited & Further Reading
Vermeijden, H. D., Monaco, E., Marzilli, F., Yang, X. A., van der List, J. P., Ferretti, A., & DiFelice, G. S. (2022). Primary Repair versus Reconstruction in Patients with Bilateral Anterior Cruciate Ligament Injuries: What Do Patients Prefer?. Advances in orthopedics, 2022, 3558311. https://doi.org/10.1155/2022/3558311
Mansour, J., Ghanimeh, J., Ghoul, A., Estephan, M., Khoury, A., & Daher, M. (2023). Bridge enhanced ACL repair vs. ACL reconstruction for ACL tears: A systematic review and meta-analysis of comparative studies. SICOT-J, 9, 8. https://doi.org/10.1051/sicotj/2023007
Murray, M. M., Flutie, B. M., Kalish, L. A., Ecklund, K., Fleming, B. C., Proffen, B. L., & Micheli, L. J. (2016). The Bridge-Enhanced Anterior Cruciate Ligament Repair (BEAR) Procedure: An Early Feasibility Cohort Study. Orthopaedic journal of sports medicine, 4(11), 2325967116672176. https://doi.org/10.1177/2325967116672176
Filbay, S. R., & Grindem, H. (2019). Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture. Best practice & research. Clinical rheumatology, 33(1), 33–47. https://doi.org/10.1016/j.berh.2019.01.018
Brinlee, A. W., Dickenson, S. B., Hunter-Giordano, A., & Snyder-Mackler, L. (2022). ACL Reconstruction Rehabilitation: Clinical Data, Biologic Healing, and Criterion-Based Milestones to Inform a Return-to-Sport Guideline. Sports health, 14(5), 770–779. https://doi.org/10.1177/19417381211056873
Grindem, H., Snyder-Mackler, L., Moksnes, H., Engebretsen, L., & Risberg, M. A. (2016). Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. British journal of sports medicine, 50(13), 804–808. https://doi.org/10.1136/bjsports-2016-096031
