The painful truth

The helmet slammed into Joe Marinaro's right knee like a torpedo.

"I'll never forget the moment," he said. "All my friends tell me how much I was screaming."

University of Michigan spring practice had just begun. Marinaro, an offensive tackle from Andover, lined up to run what should've been a routine goal-line drill. But blocking for big Tyrone Wheatley, the future NFL running back, meant your legs were always at risk.

"No one," Marinaro said, "wanted to tackle Tyrone high."

Sure enough, a blitzing safety went low, inadvertently hitting Marinaro.

"Square in the knee cap," he said. "My foot was in the turf and it just bent the other way."

In addition to dislocating his knee, which led to bleeding in his lower leg, he damaged his anterior, posterior and lateral collateral ligaments.

"They ended up cutting me here and cutting me here," he said, running a finger along two scars on either side of his shin, "just to let it bleed for a couple days."

Fourteen years later, the injury still stings. When he saw Tom Brady, his Michigan teammate, go down with a left ACL tear two weeks ago, Marinaro winced.

"The mental aspect is hard to deal with," Marinaro, now an Andover High assistant coach, said this week. "Especially a guy like him. He's a leader. You want to be involved."

Marinaro only missed three games in 1994, but they were big ones: Boston College, Notre Dame and Colorado. Like many injured athletes, Marinaro felt like he was in exile.

"The process of rehab is a lonely one," he said. "No one really knows that you're working hard to get back on the field. They just know you're gone. When you're out of sight, you're out of their minds."

Marinaro returned to the lineup in Week 4 against Iowa. In hindsight, it was a poor decision.

"I definitely wasn't at full strength," he said. "I probably shouldn't have played. But I did."

Brady, who according to reports, may also have a torn medial collateral ligament, is on injured reserve. At the earliest, he'll be back next summer. But the excruciating journey, from surgery to recovery to rehab, is already underway.

"You have Type-A, aggressive, driven personalities. If they're not playing they feel like they're going backwards," said former NFL linebacker Alex Lincoln, the director of performance at Athletes' Performance Florida. "That's amplified if there's an injury. There's this underlying sense of urgency. It can be a bad mindset. It's, 'If I'm not pushing myself to the max, then I must not be getting better.'"

The better way

Long before Dr. Lonnie Paulos was a surgeon, he was a strong safety at the University of Utah. In 1968, the Utes played Nebraska.

"They were kicking our butt, of course," he said.

His one highlight - an interception - was ruined when a teammate fell into his knee during the return. He sprained his MCL and was in a cast for eight weeks. His senior season was lost.

"That got me thinking," Paulos said, "there's got to be a better way."

Thus began his quest to help change the way injured knees are repaired.

While treating athletes over the past three decades, he's become intimately familiar with the ACL, which connects the underside of the thigh bone (femur) to the top of the shin bone (tibia), and the MCL, which connects the thigh bone and the shin bone on the inner knee. (A torn ACL is actually not repaired but replaced, usually with a patellar or hamstring tendon.)

Surgical procedures have come a long way since Paulos' career began. Twenty-five years ago, Paulos said, an ACL graph was sometimes secured with a large metal pin. Afterward, the patient was forced to wear a cast for six weeks.

"There was an incredible amount of recovery," said Paulos, who has treated the United States Ski Team, Utah Jazz and Cincinnati Bengals, including quarterback Carson Palmer. "And a lot of stiff knees."

Marinaro had his knee repaired only 14 years ago. His third surgical scar, this one on the inside of his knee, is 16 inches long.

"Now," Marinaro said, "it's a little incision, get in there and do what they have to do."

University of Oregon team physician Dr. Kenneth Singer said as recently as the early 1980s, surgical success was far from a sure thing. If you tore your ACL or MCL back then, he said, you had about a 25 percent chance of a full recovery.

"It took months to get motion back," said Singer, who treated the Ducks' All-American quarterback Dennis Dixon's ACL tear last fall. "Some might never get it back. They may lose a step and some stability. There was a magnitude of difference."

Now, he said, the percentage is in the 90s. Even the most severe injuries aren't necessarily career ending. Palmer is the most recent example. On Jan. 8, 2006, Pittsburgh Steelers defensive lineman Kimo von Oelhoffen dove at the QB's left leg. The collision, which looked similar to Bernard Pollard's sack of Brady two weeks ago, left Palmer with cartilage and meniscus damage in addition to tears of his MCL and ACL.

Paulos operated on him on Jan. 10 in Houston. Nine months later, Palmer started the Bengals' season opener. He hasn't missed a game since.

Dr. Frank Noyes, president of the Cincinnati Sportsmedicine and Orthopaedic Center and former Cincinnati Bengals team physician, said that if Palmer had suffered similar injuries 20 years ago, the odds of him playing football again would've been significantly less.

"By many multiples," Noyes said.

But what about Brady? Noyes is confident he'll be back. Patriots team physician Dr. Thomas Gill will likely perform No. 12's surgery. Noyes said he's one of the best in the business.

A high force environment

NFL football defies physics more and more every year. Players run faster, jump higher and hit harder than ever before. And they're much bigger than they were in the past.

"They're playing in a high force environment, absolutely," Noyes said.

The ACL, Noyes said, fails at 400-500 pounds of pressure. Pollard may "only" weigh 224 pounds, but the speed at which he was traveling was so great, Brady's knee didn't have a chance.

Even non-contact movements, such as running or cutting, can be disastrous. Two weeks ago, Seattle Seahawks receiver Nate Burleson tore his left ACL during a pass route. He simply planted his foot on the artificial turf at Buffalo's Ralph Wilson Stadium and boom, down he went.

The ACL attaches to a notch on the femur. If the notch is narrow, which Paulos said is the case with some people, particularly females.

"it'll act like a pair of scissors," he said.

If you extend your knee too far, too fast, look out.

"Anecdotally," said Lincoln, who played two seasons for the San Francisco 49ers, "the majority of ACL injuries I see are just guys running on the field and falling, like somebody shot them from the stands with a rifle."

The nature of Burleson's position may make it more difficult for him to fully recover. Brady is fortunate he's a quarterback, a pocket passer at that. He has to run and jump - both actions the ACL facilitates - far less frequently than a receiver.

Basketball point guards with injured knees, Noyes said, face "the ultimate test of recovery."

Shaun Livingston of the Los Angeles Clippers tore multiple ligaments and dislocated his knee in February 2007. He hasn't played an NBA game since.

All athletes take risks when they compete. Especially females. They face 5-10 times greater risk of ACL injury than their male counterparts.

"It's an epidemic," Paulos said.

It can also run in families. Singer has treated five sets of twins in which both siblings have torn ACLs.

The outlook isn't totally grim. Knee surgeries are highly successful. Say you tear your right ACL and have surgery. Singer said you're more likely to tear your left ACL than the one that was just repaired.

Still, positive statistics often do little in terms of comforting athletes. "Why me?" is sometimes too complicated a question to answer.

"You want to be able to put it in a box," Lincoln said. "Unfortunately, with an injury, it's very difficult to do."

'What do I do now?'

Alex Lincoln's neck ached. His hands and feet were numb.

"I felt totally helpless," he said, "I was a rookie coming into the league, trying to make a name for myself. I didn't want to tell anybody I was hurt."

Selected by San Francisco in the seventh round of the 2001 draft, the All-Southeastern Conference linebacker had high expectations. He struggled to play through pain.

Lincoln can still hear assistant coach Tom Rathman's words loud and clear. The former fullback, who won two Super Bowls with the 49ers, often repeated a phrase that has become an NFL locker room clichÃ©.

"You can't make the club in the tub."

Lincoln said he faced a moral dilemma. Get treatment or tough it out. What made it worse, he said, is that his injury wasn't visible to the naked eye. He was standing upright, seemingly intact. Teammates asked, "What's wrong with you?"

Cracked neck and all, he survived two NFL seasons before San Francisco cut him. His injury was just too much overcome.

"I went through a grieving process," said Lincoln, who roomed with Patriots fullback Heath Evans at Auburn. "From (age) 8-22 I was a linebacker."

Then he asked himself a question: "What do I do now?"

A health care education major in college, he decided to help people avoid some of the problems he faced. At Athletes' Performance Florida — which is affiliated with the famed Dr. James Andrews Institute — he oversees programs designed to aid injured athletes.

Rehab technology has evolved in recent years. Advances like underwater treadmills and specialized weight training have quickened recovery time.

But as high as the odds are of coming back strong, accepting an injury's consequences is never fun — or easy.

"It's a devastating event in their lives," Singer said. "It's a big mental thing. Once the shock wears off, most athletes face it. They're used to facing adversity in their sport."

Dennis Dixon, who tore his ACL last November, appears to be back at full strength. In April, the 2007 Pacific-10 Offensive Player of the Year was selected by Pittsburgh in the fifth round of the NFL draft. He's currently on the Steelers' active roster.

"Dennis is a very optimistic guy," Singer said. "He worked incredibly hard. He was incredibly diligent."

But being upbeat can only take you so far. ACL replacement is not a fail-proof substitute for the real thing.

"One of the things people forget, is what you put back still isn't the same," Paulos said. "It's never a person's good knee again. The (replacement) ligament isn't the finely tuned and twisted ACL God put in."

As time passes, Paulos said, it flattens out and loses flexibility. Sure, players return to the field, but, "How many of those people are playing 3-5 years later?" Paulos said. "Very few."

And not everyone is a professional athlete. Teenagers especially, Noyes said, shouldn't rush back from ACL and MCL surgery.

"You want 100,000 miles out of that tire," he said. "You don't want to burn it all in five years."

Fourteen years after his surgery, Marinaro said his knee is feeling good. It doesn't bend quite the way it used to, but it works.

He feels for Brady, whose knee will remain a public concern until he returns next season. Will he come back at full strength? Or will he lose a little physically?

Unfortunately, science may point to the latter.

"I don't think," Singer said, "we can totally match nature."

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