Bobby Orr: The Knee

Who is the best hockey player ever to have played the game? For some people, it is a relatively easy question to answer. Wayne Gretzky of course! The numbers (and records) speak for themselves! Or is it Mario Lemieux? Pure dominance, even after coming back from Hodgkins Lymphoma. Or is it the man who can be credited with revolutionizing his position? Defenceman Bobby Orr is the closest thing we have in Canada to a mythological figure. The hockey prodigy that comes from a small, remote town in Northern Ontario, and hones his craft skating on a frozen lake for hours on end. He has become the gold standard to which every defenceman is compared, “well he’s no Bobby Orr, but…”. I don’t really need to make the case for Orr’s greatness, it has been well documented and by now, it pretty much speaks for itself. However, it is difficult to look back on Orr’s career, and not wonder what could have been. What would have been possible had he not been forced to retire at age 30? Would the 72’ Canada/USSR Summit Series had been as close had he been able to play? Sadly, just as Orr’s accolades on the ice are well documented, so too are his many struggles with knee injuries. Had Orr played in today’s era, there is little doubt he would still be a generational talent. The intriguing part of that thought process however, is that he also would have had access to medical technology and treatments that would have allowed his career to continue well beyond age 30, and perhaps make his claim to the greatest player of all time much more difficult to challenge.

One of Orr’s greatest attributes was his straight-ahead tenacity. He left no doubt that he gave it his all when on the ice, and good luck trying to get him to take a shift off. But perhaps as much as his strong will was an asset, it may also have contributed to his never-ending struggles with injury. Orr suffered his first knee injury during his rookie season, twisting his left knee after sustaining a hip check. Still, Orr would go on to win the Calder trophy as the league’s best rookie. Then, during the following off-season, Orr would injure his right knee while playing in a charity hockey game in Winnipeg (unbeknownst to the Bruin’s front office, who were none too pleased upon finding out). Luckily, the right knee would not require surgery, the diagnosis being a “minor sprain of a minor ligament.” The problem however, was that instead of starting a rigorous physiotherapy program, Orr’s knee was immobilized with a cast, where it remained for five weeks. He didn’t even start skating again with the Bruins until October 1st (!). Think about that for a second. Your knee is immobilized completely for five weeks, which causes both loss of range of motion in the joint, as well as muscle atrophy. You miss most of training camp, and only start skating with your team on the first of October, with the season starting just over a week later! Mere mortals would struggle mightily, but Orr quickly returned to form, seemingly unaffected by the setback. However, Orr was not out of the woods for his sophomore season. He would go on to fracture his collar bone and separate his shoulder in December, returning to action in time to play in the All-Star Game in January. There he would begin to experience pain and stiffness in his left knee, missing the next five games after the All-Star break. Then in mid February, during a game against Detroit, Orr’s knee would lock up completely. There was no playing through the pain at this point. It was determined that Orr’s left knee would require surgery. Back to Boston, and under the knife Orr went. These being before the days of arthroscopic surgery (more on that later), the knee would be opened right up, and torn pieces of cartilage were removed. Based on the research I was able to do surrounding what actually happened, I would take this to mean that segments of the meniscus were removed. This would be the first in a series of surgeries on the left knee (more than a dozen in total) over the course of Orr’s career, each time a little more scar tissue created, and each time further altering the natural internal environment of the knee joint. In those days, standard procedure following open knee surgery was immobilization and rest immediately afterwards. And truth be told, Orr didn’t tend to spend much time undergoing time-consuming rehabilitation or physiotherapy programs. The sooner he could get back on the ice the better. Some blame the Bruins organization for rushing him back to action too soon, some think Orr himself insisted on expediting the process. Orr would still go on to win accolades most could only dream of: 8 Norris Trophies, 3 Hart Trophies, 2 Art Ross Trophies, 2 Con Smythe’s, and of course 2 Stanley Cups. Incredible considering he consistently played with one knee never really being close to one hundred percent. Understanding what Orr was able to play through (and accomplish) still leads us to contemplate what he could have been capable of if he had access to even half of the medical technologies and techniques that are available today.

Oh how times have changed! Let’s take a look at how a knee injury such as one of Orr’s would be handled today, right from the time player goes down on the ice, until the time they are deemed fit to return to action. First of all, if a player were to awkwardly twist their knee, and fall to the ice, unable to get up right away on their own, they would instantly be evaluated by a trainer, either on the ice (depending on the severity of the injury), or on the bench, or back in the trainer’s room. This trainer is usually either an Athletic Therapist, or a Physiotherapist (aka a Physical Therapist), which means they would have extensive training in evaluating sideline injuries like this. At this point, their job is to determine a couple of things. First, is there any sort of medical emergency that requires immediate transportation to the hospital for further testing/treatment. This is less common, but it does happen. Then, if the trainer decides the player isn’t in any immediate danger, the next step is to determine if they are well enough to return to play in that game. Certain factors will come into play here if the injury is borderline: whether it is a playoff game, whether it is one of the star players, etc. If the player has sustained a knee injury that will prevent them from returning to game action that night, they will most likely be referred for an MRI (link to MRI article) (magnetic resonance imaging) either the next morning, or if the team is on the road, they may wait until they return home. Taking these steps will help to understand what is going on structurally with the knee, and direct treatment from here on out, whether surgery may be required, or whether the player can move right into rehabilitating their injured knee.

In Orr’s case, MRI’s were not yet available, so knee injuries had to be assessed much differently. A Physiotherapist or an orthopaedic surgeon may perform some tests manually with the player on the treatment table, and attempt to make a diagnosis. No clinical test like this is perfect, so 100% accuracy can not be guaranteed. Current research on evaluating meniscus injuries of the knee suggests making decisions for treatment based on a cluster of several clinical tests. Individually the tests aren’t great, but used in combination, they can be useful for directing treatment. This unfortunately was not likely the way of thinking during the days of Orr’s knee injuries. What would have been more likely, would be to open the knee up, and see what was inside; exploratory surgery if you will. Then, with the knee opened up, simply remove any bits of torn cartilage or even bone fragments that didn’t look the greatest. In those days, it was also common practice to simply remove the entire meniscus, thinking this would allow the knee to function better.

This is probably a good time to have a brief discussion about what exactly the meniscus of the knee is, and what it does. Basically, the top of your shin bone, (your tibia) has two oval shaped platforms, one on the inside of the knee, and one on the outside. These two platforms accept the weight of the thigh bone (the femur). The end of the femur has two rounded, ball-like structures, that fit on top of those two platforms on the tibia. Both the ends of the tibia and femur are lined with smooth cartilage to cut down on friction in the joint (think of the smooth end of a chicken bone). To help this all fit together better, you have the meniscus. There are two in each knee joint, one sitting on each of the two platforms of the tibia. They are shaped like the letter “C”, and are made of soft cartilage. This provides shock absorption, and generally just makes the knee joint fit together better. If the meniscus gets torn, it can interfere with the normal movement and weight bearing function of the knee, almost like having a rock in your shoe. One unfortunate thing about the meniscus is that it doesn’t have a great blood supply, so if it gets torn, it often doesn’t heal that well. If there is a tear that requires surgery, the surgeon does their best nowadays to keep as much of the meniscus intact as possible while still allowing the knee to function properly. Doing as little as possible to change the natural internal environment of the knee is generally the accepted philosophy when it comes to treatment, as you don’t want to dramatically change how your body weight is distributed throughout the knee joint. This can lead to abnormal wearing of the cartilage on the end of the tibia or femur, and ultimately result in osteoarthritis of the knee joint. This is what ultimately happened in Orr’s case, and he would go on to have a total knee replacement after his playing career.

View of meniscus from back of knee

Today surgical repair of the meniscus is done with a technique called arthroscopy. As mentioned earlier, Orr played in an era when this technique was not readily available. Arthroscopic surgery, or “scoping” the knee, is much, much less invasive than simply cutting the knee joint open. It is a procedure that uses tiny instruments with lights, cameras, and tools on the ends of long, cord-like instruments. This allows the surgeon to make only the tiniest incisions necessary to access the area they would like to operate on. The images/video feed from the camera goes on a monitor in the operating room that the surgeon watches as he or she performs the surgery.

The minimally invasive nature of arthroscopic surgery means that a player has to rest the repaired knee for a much shorter period of time before starting to rehab it. They are generally allowed to put weight on it right away, and start working on their range of motion and light strengthening very shortly after surgery. This is where the Physiotherapist takes over, and it is the player’s job each day, to build strength and mobility in their knee. Whereas the average person rehabbing a knee injury has to fit in their treatment around the rest of their busy schedule, a professional athlete has it as their top priority, and has unlimited access to healthcare teams and top-notch facilities. Not to mention they are usually young, exceptionally healthy, well-oiled machines, their recovery time is usually much quicker than your average Joe. A player will gradually be transitioned back onto the ice, normally skating on their own at first before rejoining their team at practice, at which point they will normally wear a red jersey, indicating that they’re returning from injury, so you had better not hit them! They will use this time to not only test the knee and build functional strength, but also generally work on their conditioning before they are ready for the fast-pace of NHL game action. There is generally a hesitancy now to rush players back too soon to game action. Medical staffs have been given a great deal of autonomy in many organizations, as they have been given the respect of knowing what is best for the safety of the athlete and their bodies. Such was not the thinking in the days of Orr’s career. The coaching/management staff, and the player themselves were much more involved in decision-making process when it came to return to play. They would certainly take the advice of team doctors, but the medical-teams in general were much smaller, and didn’t have the benefit of the technologies and knowledge base they do today.

An interesting comparison from recent history when talking about Bobby Orr and meniscus injuries is the case of John Tavares. During the 2014 Olympics while playing for Team Canada, Tavares injured his knee, tearing his meniscus and spraining his MCL. Unfortunately for Tavares (and much to the chagrin of the New York Islanders), this would effectively end not only his Olympics, but also his season. This would have been undoubtably a disappointing turn of events for Tavares, but at no point was the thought process that it would limit his career, or even put the start of next season in jeopardy. In Orr’s day, he may have been looking at prolonged immobilization, or even, (gulp!) cutting the knee wide open just to see what the inside looked like, and taking out the nasty-looking bits. When you think about how in the case of Tavares, his knee didn’t even require surgery (he was able to treat the knee with Physiotherapy alone), it starts to become tragically clear how much of the treatment Orr received over the years for his legendary left knee, ended up doing more harm than good. It is difficult to place blame on anyone in particular when it comes to how Orr’s career and injury history played out. He was still able to string together enough greatness to be considered in the debate for the greatest player of all time. Still, what would a 20 year career or even 1000 games played have looked like? Pretty fun to think about.

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