A case report Mirjana Djurica Vermezovic, handball player
– Written by Celeste Geertsema and Nebojsa Popovic, Qatar
An ex-Olympic gold medalist in handball presented to clinic with a history of untreated knee ligament injury. At 56 years old, she denied any significant knee symptoms, although she mentioned occasional swelling and some discomfort with squatting and climbing stairs. She remains very active and has a BMI of 21.7.
She had suffered bilateral anterior cruciate ligament ruptures (the first one in her left knee in 1981 and the second in her right knee in 1982), which were not diagnosed until 1988. Throughout the following 2 years she continued to experience instability – now present in both knees. However, she described this as ‘irritating’, rather than ‘debilitating’ and did not notice any decrease in performance. In 1984 she won a Gold medal at the Olympic Games in Los Angeles, scoring 18 goals in total. She continued playing elite level handball in the following 3 years, whilst experiencing frequent episodes of instability in both knees, occasionally resulting in pain and swelling. She managed these episodes symptomatically, occasionally requiring sessions out of training, but did not require any prolonged absence from training or playing.
Two months prior to the Olympic Games in Seoul 1988, she suffered a bucket handle tear of the medial meniscus in her right knee. This was the first time she received the diagnosis of ACL rupture in either knee. After a long discussion regarding treatment options, and in view of the upcoming Olympic Games, the doctor and patient reached a shared decision to perform a partial meniscectomy and no ACL reconstruction in the right knee. She received physical therapy and achieved fourth place with her team at the Olympic Games four months later. She played in all matches.
She retired from professional handball after a further four years (at the age of 31), but continued to play as a veteran until the age of 50.
Clinical examination of both knees this year revealed mildly painful squat, minimal effusion in the right knee and bilaterally ACL deficient knees. She had neutral knee alignment and full, pain-free range of movement. The rest of the clinical examination was unremarkable – specifically, there were no signs of significant joint line tenderness or pain with rotational manoeuvres.
X-rays revealed mild to moderate osteoarthritis of both knees, most significantly in the medial compartment of both knees.
Mirjana agreed to share her story with us. It is best told in her words in the accompanying interview.
When we saw Mirjana, she mentioned that, in the end, she had decided not to have the cruciate ligaments reconstructed and continued playing veteran handball until the age of 50. Today her knees are not perfect – she has mild to moderate arthritis. However, she arguably is no worse off than someone her age who had meniscal surgery in the 1980s, without any ACL deficiency. It is not clear if this athlete would have been any better served if she was seen with this presentation in 2017. Even though the diagnosis almost certainly would not have been missed, and the surgical management of ACL rupture has seen some remarkable progress in the intervening 30 years, it is difficult to imagine how here outcome could have been improved with surgery. There is no better colour in the Olympics than gold. As far as the mild to moderate osteoarthritis of her knees are concerned, we now know that she almost certainly would have developed degenerative changes in the knees post ACL rupture, even with surgery. What we do not know is how symptomatic she would have been, but her condition would be difficult to improve in any ‘normal’ 56 year old.
This case is interesting, because it highlights several concepts we need to consider when treating elite level athletes. This is not a commentary on ACL surgery in general. This is about the exceptional nature of elite (Olympic level) athletes.
This case raises a number of points we should consider:
We may have very few chances to treat elite athletes and, when we do, they may be able to teach us a lot about their particular sport, as well as their coping mechanisms for extreme challenges. We cannot treat elite athletes successfully without their input and a good understanding of what environment they need to function in.
Olympic level athletes are not our normal ‘study group’ population and may present and respond differently from recreational or even professional athletes – they may be ‘outliers’ on the normal distribution curve, with very high pain tolerance and excellent adaptive responses to certain disabilities.
For elite athletes, the imminent Olympic Games may be far more important than their long-term health outcomes (as may be the case with recreational athletes), or even their professional longevity (as may be the case with professional athletes). This should be considered when agreeing on a treatment plan with them – as long as they remain fully informed about the possible consequences of their decisions.
Even with elite athletes, we should follow the principles of ‘First, Do No Harm’ and not use them as trial subjects for unproven new treatments. If this athlete was correctly diagnosed with ACL deficiency in 1980, she may have ended up with a new surgical procedure which was later associated with debilitating knee extension loss in patients who received it, or an artificial ACL replacement graft, which eventually proved disastrous with a 98% failure rate.
Olympic level athletes present a classic sports medicine dilemma. The question of the indications for surgery in these athletes nicely demonstrates the fact that sports medicine is an art form, rather than a straight science. There are many aspects which have to be taken into consideration, including the coping strategies of the athlete, the timing of the season and the Olympic calendar. Even in today’s world of superb technological advances, we cannot apply an evidence-based ‘one size-fits-all’ solution to every elite athlete. We should also never forget that we are dealing with complex human beings who play their sports with their head, not just with their body.
The reality is that most athletes in this position (elite or otherwise) will do better with reconstruction than without, at least as far as return to play is concerned. However, it can be argued that those who fail to return to play (on a previously injured) knee may have a better long term outcome – this may be important for some athletes, especially those who are at the end of their career, and should be included in any conversation about ACL reconstruction.
In the end, it is important to have the same conversation about ‘copers’ and ‘non-copers’ with elite athletes as we have with recreational athletes – even when it may seem obvious that their type of sport is very demanding on the ACL. We should never make decisions on behalf of the athlete. Our role is to inform and to guide – but the ultimate decision regarding treatment rests with them.
Mirjana still vividly recalls the simple advice the surgeon gave her in 1988, and she has been following it ever since:
Never gain weight
Never stop exercising – focus on strengthening the leg muscles
Use analgaesia as necessary
The advice given by the surgeon, and which this athlete took to heart in 1988, was not exactly ‘cutting edge’ advice. However, it might be a major reason for her paucity of current symptoms. Ironically, weight control and regular exercise is now considered one of the few proven treatments (preventative and therapeutic) of osteoarthritis of the knee.
Finally, we should remember that the human knee is not a toy, and there is no orthopaedic condition that cannot be aggravated by surgery!
Celeste Geertsema M.D.
Sports Medicine Physician
Nebojsa Popovic M.D., Ph.D.
Senior Medical Advisor
Aspetar – Orthopaedic and Sports Medicine Hospital