Commentary

Slow and steady will win this race

Originally Published: January 20, 2009
By Stephania Bell | ESPN.com

The speculation has already begun as to when Tiger Woods will make his much-anticipated return to the golf stage. But what about the question of how Tiger will perform when he makes his dramatic comeback?

Many wonder whether it is possible for Tiger to return to his pre-injury form. In reality, even his "injury" form was pretty darn good, considering he was functioning without an anterior cruciate ligament when he won the U.S. Open in June while playing through significant pain.

While everyone discusses the likeliest dates for Tiger's return to competition, we thought we'd take a gander at the issues he is facing during his rehabilitation process. After all, this in-between phase -- when he's not really injured but not yet ready for competition -- represents perhaps the most challenging time for an athlete such as Woods in terms of preparation.

Rehab is not nearly as much fun as playing your actual sport, especially when you're accustomed to dominating the field. Even putting practice sounds far more appealing than yet another trip to the physical therapy clinic, where, despite the therapist's encouragement of your progress, you are still reminded of your limitations. With all due respect and credit to Tiger's surgeon for laying the foundation of his knee's health, the rehabilitation path that Woods has been on since the day he emerged from surgery (and that he remains on until the day he returns to competition) might be the most important prologue to the next phase of his career.

With wise rehabilitation, Tiger has the potential to prolong his already storied career and raise it to an entirely new level. But approaching it as anything less than a full-time job could spell the beginning of a premature decline.

Returning to play after an ACL reconstruction can be daunting for any athlete, and some of the challenges an athlete faces are specific to his or her sport.

An NFL running back, a major league baseball player and a professional golfer all rely on the ACL to help control knee stability, but the demands each of them places on the knee are very different. Consequently, the rehabilitation process for each of these athletes is unique, fine-tuned to meet the needs of the individual.

[+] EnlargeTiger Woods
Ross Kinnaird/Getty ImagesEven with a torn ACL and two fractures in his leg, Tiger Woods was still able to play 91 holes to win his 14th major championship in June.
Bud Ferrante, a physical therapist based in Carmel, Calif., who has spent much of his career working with professional and amateur golfers, understands the unique mindset and physical demands of the elite competitor. He has worked with numerous tour players (including Tom Watson and Brad Faxon) and in 1991 developed BACKtoGOLF, a program designed to address specifically the fitness, performance and rehabilitation needs of golfers.

Ferrante explains that the world of golf often revolves around the question of what's new, what's next. Perhaps it's a new club design or the next-generation ball that is going to be the necessity du jour for the pro. He is quick to emphasize, however, that when it comes to rehabilitation, the clear-cut, straightforward approach is critical, simply because "It works."

"I tell the golfers, we [physical therapists] are not here to entertain you," Ferrante said. "We're here to help you focus on the basics and what is specific to your sport."

To that end, certain mechanical elements in rehab are emphasized post-ACL reconstruction.

Core fitness is essential to train the muscles that support the pelvis and spine, in particular the abdominal and hip muscles, which are essential for the golfer's frame. Additionally, a stronger core serves to enhance the strength of the limbs; the legs and arms move easier and with less effort as an extension of a solid central base.

The good news in Tiger's case is that he already had figured this out before his injury. Regarded by many in the golf world as perhaps the most physically fit player on tour, Woods is known for his intense level of cardiovascular training and core strengthening, and his athletic physique is apparent. As his competitors try to emulate his success, Tiger has inspired a new philosophy of total body training among a group not previously known for doing squats and crunches or hitting the exercise bike.

Although he no doubt had some catching up to do after his time off for surgery, Tiger did not have to be sold on the importance of this element of his rehab. In fact, Tiger's reconstructed knee is making it easier for him to tolerate this element of his training.

"I'm starting to do a lot more cardio than I did before because I couldn't do it -- the leg would swell too much," Woods said at a news conference in December, when he played host to the Chevron World Challenge. "As far as physical fitness, I'm so much better than I was in June."

[+] EnlargeTiger Woods
Ross Kinnaird/Getty ImagesTiger Woods was often seen clutching his left knee during his miraculous 2008 U.S. Open victory at Torrey Pines. It wasn't until after the win that the true nature of his injury was revealed.
That's a scary prospect for his competition.

In addition to the core elements of fitness retraining that have to take place post-surgery, there are the golf-specific motions the knee must relearn after this type of procedure.

Rotation is a key element throughout a golfer's swing. Consequently, rotation must be addressed in rehab. But there's a timing issue, as well. Early in the rehab process, straight plane movements are emphasized, meaning the body moves in one direction (forward, backward or sideways). These actions produce less force on the graft (the "new" ACL) in the earlier stages of tissue healing, and simpler movements make it easier for the body and the brain to adapt as the athlete relearns how to move properly.

Tiger said in his interview with ESPN.com's Jason Sobel in October that he felt good doing everyday activities and could do everything "except rotation," adding that he was working only on straight plane motions and wasn't "allowed" to rotate yet. Tiger also acknowledged then that he was not yet swinging a golf club. No rotation in therapy, no rotation in practice. It's that simple.

Once the muscles are strong enough and the ligament is mature enough that it can begin to be subjected to torsional forces, rotational movements are incorporated into the exercise program -- small ones at first (small range, low loads) to ease the knee into absorbing the stress, then progressively larger (increased range, heavier loads) as the athlete demonstrates increased skill and ability.

Ferrante uses drills such as ball tosses with a weighted (medicine) ball to get the athlete accustomed to turning on the knee. Drills are done with the feet in various positions, initially with minimal rotational forces through the lower extremity joints, but with gradual increases in that load as the body allows.

Ferrante also uses an exercise device called a Swing Fan, which has a shaft like a club but is outfitted with plastic fins to create resistance. This allows the athlete, as he progresses in rehab, to simulate a golf swing (with resistance) while still in a controlled environment. Ferrante points out that in Tiger's case, his lead leg is the one in which the ACL was reconstructed, and it is this leg that undergoes significantly more torsion during a golf swing.

As a result, it is important for Tiger to train his left leg to adapt to torsional stress, yet he must do so at a slow enough pace to allow the ligament to accommodate and not overload it. This is a very delicate balance -- it is precisely this type of training that helps stimulate the tissue to heal, but training too vigorously can result in stretching of the graft, which ultimately renders the knee less stable.

[+] EnlargeStephania Bell
Bud FerranteThe patient is working on resisted trunk rotation in the direction of his swing while the physical therapist observes for proper form. Note the rotation through his lead leg.
So how do you keep a competitive athlete such as Woods at bay and make sure he doesn't overdo it while still maintaining his motivation?

This is the ultimate challenge for a physical therapist working with elite athletes. Most athletes follow medical advice in the early stages after ACL reconstruction. They have significant pain and swelling in the knee, their range of motion is extremely limited, and the quadriceps muscle -- that large muscle on the front of the thigh that largely controls knee stability -- has withered into oblivion. They won't get too far without crutches, ice and anti-inflammatory medication. At that point, they're so uncomfortable that they're likely to follow whatever instructions are issued.

But what happens when they start feeling better? After a few weeks of following rehab instructions, they should have full range of motion and decent quadriceps strength, and not long thereafter, they're walking around with nary a limp.

The athlete's mentality is typically that if a little is good, a lot is better. Why not do 150 squats instead of 15? Why not run instead of walk?

Unfortunately, that philosophy is at odds with the goals of controlled rehab. The process must be gradual. It's tough for an elite athlete accustomed to thinking that if he just pushes harder, he can get back in the game faster than anyone else -- especially one who informed his doctors, after he was advised to sit out the U.S. Open, that he would not only play but also win … and did.

That athlete would have to believe rehab timelines are for sissies, right?

Ferrante's response is simple.

"Education," he said. "I explain to the athlete that how he handles the injury and his rehabilitation will affect his overall outcome. As he approaches a year out from surgery, the ligament is getting stronger, so I give him the analogy of walking on a frozen lake. He has to tread very carefully initially to avoid the weak spots; then later, as he progresses, he'll be able to walk on that lake with confidence."

And this is where Tiger continues to surprise and amaze.

As determined and defiant as Woods was in insisting that he would take the U.S. Open by storm despite his physical limitations, he has shown that same determination in making his return to the fairway a success. And for all his skill and acumen, Tiger did not get to the top of his game without also being extremely intelligent in his approach.

[+] EnlargeBud Ferrante
Bud FerranteThe patient is practicing his full swing motion while the physical therapist guides his position. Note how much torsion the lead leg is subject to at follow-through.
Tiger knew that he had nothing left in his knee and that he would require surgery almost as soon as he was done with the tournament, but he also knew there was no ligament left to tear. He now has a new ligament in place, one that will require more than a year to mature fully.

Tiger has taken to studying the process of how his body heals much as he would approach an alteration in his swing, and he will not take any chances now. Based on how he has described his rehabilitation experience thus far and how he is approaching his impending return, he has been an A-plus student.

Asked in December whether he was ahead of schedule, Tiger responded that indeed, his leg strength was better than it had ever been. But he quickly added: "You still have to understand the healing process of the ligament. The ligament is only going to heal so fast, and you've got to be responsible for your actions, and I can't stretch that out."

If only all patients were so disciplined.

As of December, Tiger had begun to incorporate that final phase of rotation into practice. He shared at the Chevron World Challenge that he recently had begun taking full swings, but only to work on his short game. In January, he added longer irons and his driver, although he is still not swinging with full power.

As with everything else, Tiger's swing will progress gradually. Much like a baseball pitcher returning from shoulder surgery who initially throws from a limited distance and is placed on a pitch count, Woods likely is given ball counts (a fixed number of shots to hit) and has progressed upward in club length, from short irons to woods and, most recently, a driver.

Ferrante says one of the biggest issues for Tiger in his recovery will be how he tolerates swings with his driver. These swings will place the biggest loads and torsional stresses on Tiger's reconstructed knee. Part of what made those swings so painful during the U.S. Open was a lack of stability. Woods acknowledged trying not to snap his left leg, but said he couldn't "hold it" and was forced to compensate.

With the graft in place, Tiger says the leg feels "stronger, more stable. It's not sliding all over the place." In addition to the stability provided by the new ligament, the focus on retraining his neuromuscular system as to how to work to support this remodeled joint will be what prepares him for his return to competition.

So far, everything Tiger is doing points toward his returning in superior physical condition from his golf hiatus.

Assuming that none of the elements of his game takes a step backward -- his mental focus, his competitive drive, his signature swing -- and given that he has had extra time to work on his chipping and putting, is it possible that he could not only return to his pre-injury form but also come back even better after surgery?

If you ask him, he'll say that this surgery is the best thing that could have happened, that his knee is "better than it's been in over a decade." And he doesn't want to come back the same. He wants to become better, and he believes the leg "will help [him] in that process."

After all, this is Tiger Woods. We should know by now that anything is possible.

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