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LSU outside linebacker K'Lavon Chaisson (4) is tended to by team medical personnel in the fourth quarter of the AdvoCare Classic against Miami, Sunday, September 2, 2018, at AT&T Stadium in Arlington, Texas. LSU won 33-17.

The knee was normal, and that was the news.

Tight end Jamal Pettigrew stepped through footwork drills, blocked dummies, pivoted and cut through routes in the LSU indoor practice facility — standard stuff, except for one thing: Pettigrew had only surgically repaired his torn anterior cruciate ligament (ACL) four months before, which, according to experts, meant he’d returned to football activities nearly twice as fast as the average athlete.

No brace. No problem.

A few days later, outside linebacker K’Lavon Chaisson wore sweats as he tossed around a football during pregame warmups at Kyle Field in College Station, Texas. He’d suffered a torn ACL against Miami on Sept. 2, tweeted a picture post-surgery Sept. 20, and less than two months later, tweeted a video of himself sprinting across LSU’s outdoor practice facility.

Plenty of torn ACLs with high-profile NFL athletes have played out publicly. Tom Brady. Jamaal Charles. Adrian Peterson famously returned to the Minnesota Vikings from a 2012 ACL tear in nine months — and that was widely considered unthinkable.

What was going on at LSU?

Back at Tiger Stadium, athletic training director Jack Marucci leaned forward in a stadium-seat chair in his office to explain: For nearly two decades, LSU has been practicing an ACL surgery that the consensus of sports organizations considers far too risky.

The results, Marucci said, have shown that LSU’s decision was both innovative and safe.

Over 17 years, LSU has repaired the ACLs of 39 football players, and only one player suffered a re-tear — a success rate (97 percent) that equals or exceeds the success rates that have been reported from the nation’s standard method of surgery.

Here’s what sets LSU apart: Marucci said the average time that it takes for an LSU player to return to practice from surgery is 4.8 months — a timeline several sports physicians consider impressive.

Now the LSU athletic training staff is collecting data from those former players to produce an official report, which could persuade other collegiate and professional football organizations to buck the standard surgery and advance sports medicine into a new era.

The report, Marucci said, could be published three months from now.

But this is no new battle between scientific ideologies. The standard has been set for decades.

“Everyone is afraid to go against the establishment,” Marucci said. “That’s why we’re going to publish … this is a big deal.”

The alternative

The story begins in April 2002, when LSU’s backup quarterback, Marcus Randall, tore his ACL during the spring game.

The ACL, one of the ligaments that connects the femur and the tibia, is located on the inside of the knee joint. It essentially stabilizes the knee and helps someone pivot and cut. When the ACL tears, it cannot regenerate. So the ligament must be replaced with other muscle tissue.

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LSU: ACL

The ACL is pointed out by Dr. Brent Bankston, an orthopedic surgeon at Baton Rouge Orthopaedic Clinic and LSU's team physician. The ACL is located on the inside of the knee joint, and it stabilizes the knee when someone pivots and cuts.

By the 1990s, physicians across the United States had standardized cutting out the middle third of the patellar tendon — which stretches from the kneecap to the tibia — and using it to replace the ACL.

Dr. Brent Bankston, LSU’s team physician, was prepared to perform the patella surgery on Randall, which would require a recovery time of at least nine months — likely cancelling out Randall’s chances of playing in the upcoming season.

But Bankston said then-LSU coach Nick Saban suggested an alternative.

Saban remembered that when he was at Michigan State, a player had recovered much quicker because the surgeon had used hamstring tendons to replace the ACL instead.

Bankston had performed the hamstring surgery on LSU basketball players before. The hamstring surgery, Bankston said, was actually preferred in basketball because players jump more often, and the surgery does less damage to the knee.

But it hadn’t been adopted in football because physicians knew the patellar tendon was stiffer than hamstring tissue, and there was a concern that a football player’s knee wouldn’t hold up long-term.

“Saban pushed to go the other way,” said Bankston, LSU’s team physician since 1995. “We said, ‘It’s a recognized surgery; it’s a good surgery; and we’ll see how it goes.’ ”

Bankston performed the hamstring surgery on Randall, who recovered by the beginning of the season and played in the final seven games, after starter Matt Mauck suffered a season-ending Lisfranc injury.

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Marcus Randall

Advocate staff photo by Travis Spradling. Photo shot on 11/26/04. LSU vs Arkansas football. Marcus Randall

Randall played in 20 more games during his LSU career, throwing for 1,672 yards, 11 touchdowns and seven interceptions.

“He did great,” Bankston said. “And so we did another (hamstring surgery). And another one. And every (ACL injury) since, we’ve done a hamstring.”

Perhaps you’ve noticed the results: Former LSU quarterback Zach Mettenberger tore his ACL in the 2013 regular-season finale against Arkansas, then returned three months later to participate in the university’s pro day. Tigers running back Nick Brossette tore his ACL in 2015, and he leads LSU in rushing this season with 922 yards and 14 touchdowns.

Dozens of autographed pictures from healed athletes hang on Bankston’s office walls.

So why hasn’t the hamstring surgery caught on?

It takes some historical context to understand, said Dr. Steve Jordan, an orthopedic surgeon at the Andrews Institute in Gulf Breeze, Florida.

The patella surgery — referred to as “bone-tendon-bone” in medical circles — had established staying power because it was reliable, and the hamstring surgery had early failures because physicians were using ineffective techniques that would later be improved upon.

“In the ’80s and ’90s, the bone-tendon-bone was a big player,” said Jordan, who was the team physician at Florida State from 1991-2015. “That was the only thing I did. That was the only thing sports surgeons did.”

The patella surgery, Jordan said, has its own issues.

When physicians cut out the middle third of the tendon, they also cut out a piece of the bone where both ends of the tendon are attached. Then, when physicians put the tendon where the ACL used to be, they graft the bone ends to the femur and the tibia (thus the name “bone-tendon-bone”).

This technique heals rapidly, Bankston said, because the body quickly recognizes the bone ends and restores blood flow to the tendon — an essential part of the healing process. It's like a puzzle that recognizes the correct piece has been appropriately placed.

The problem is, Bankston said, some studies have shown that up to 30 percent of patients experience some form of chronic pain in the spots where the bone was cut. In some extreme cases, the kneecap will fracture. That's what happened to Hall of Fame wide receiver Jerry Rice when he played for the San Francisco 49ers in 1997.

“I’ll give you many, many cases of athletes who have taken (the patellar tendon) from their good knee and it still aches today,” Marucci said. “(It) becomes the bad knee. That tells you alone, we’ve created a problem here. We know that creates a problem. So why do we keep doing that?”

Jordan said the majority of physicians and sports organizations are still biased against the hamstring surgery because of its early failures.

The earliest hamstring surgeries in the ’80s and ’90s, Bankston said, replaced the ACL with a strand from one hamstring tendon: the semitendinosus, which is not as stiff as the patellar tendon. Studies showed, Jordan said, that this method had a re-tear rate that was 1½ times higher than the patella surgery.

But over time, physicians started combining the semitendinosus with another tendon near the hamstring — the gracilis — and that made the graft just as sturdy as the patella tendon surgery.

In fact, Jordan noted, a study was published in The American Journal of Sports Medicine in 2016, which conducted a long-term, randomized trial to identify which surgery was better.

“Only minor and mostly insignificant differences were found,” concluded the study, which was written by Dr. Haukur Bjornsson.

But football organizations are stuck in their routines, Bankston said — especially in the NFL.

Why wouldn’t agents send their high-profile clients to established physicians like Dr. James Andrews? Andrews, an LSU alumnus and the team physician for the Washington Redskins, has performed patella surgeries on dozens of notable players, including former Tigers tailback Derrius Guice.

“I have a good friend, the president of an NFL team,” said Jordan, who kept the president nameless. “And he says, ‘I like the hamstring graft, but since it’s the NFL, I do patella.’ I go, ‘Why?’ ‘Well, they’re just judged by bias. If it’s not bone-tendon-bone, it may not be good.’ 

“But if it hurts less and heals faster and is just as strong, it’s too hard to ignore, right?” Jordan added. “Now, to make it gospel, it would take a lot of other programs doing the same thing and getting the same results.”

The LSU athletic training staff believes their upcoming study will give those programs the persuasion they need.

“They’ll always come back, ‘Where’s the hard evidence?’ ” said Derek Calvert, an associate athletic trainer at LSU. “Now we can say, ‘We have that paper that shows 17 years of a Division I college and what they’re doing.’ ”

'It could wake people up'

It was a rainy day, Stevan Ridley recalled — a slick day out on the second session of LSU spring practice in 2009.

It was a run play — 35 zone or something — to the left, and Ridley bounced the run to the outside. A safety closed in to attempt a tackle, and Ridley tried to slow down so he could plant and cut.

His cleats dug in the ground. Slid forward. His right knee jerked.

Ridley never forgot the strange feeling knee as he jogged back to the huddle.

“The best way I can explain it to people is, if you could imagine being upside down and trying to balance all your body weight on your pointer finger,” said Ridley. “You just put one finger down and press it real hard. You just feel like you have no stability at all.”

Ridley remembers the MRI with Marucci; Bankston counting backward from 10 in the surgery room; then emerging from unconsciousness to hear Bankston say just do what the trainers say to do and you’ll be fine.

“Of course, telling somebody that who just tore their ACL is kind of hard to believe,” Ridley said.

Nearly a month into rehab, Ridley said he was running with a brace on his knee and asked Marucci how long he’d have to wear the brace.

“You can take it off right now if you want to,” Marucci said.

Ridley blinked: What?

“There was one point and time when I thought Jack Marucci was nuts, like really crazy,” Ridley said. “But I was right back in it and rolling by the next year.”

Ridley played in all 13 games in 2009, and he was named first-team All-Southeastern Conference in 2010, when he rushed for 1,147 yards and 15 touchdowns as a junior. He declared for the NFL draft and was selected in the third round by the New England Patriots.

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Stevan Ridley, Russell Allen

New England Patriots running back Stevan Ridley (22) high-steps toward the end zone for a touchdown after catching a pass and getting by Jacksonville Jaguars linebacker Russell Allen (50) during the third quarter of an NFL preseason football game in Foxborough, Mass., Thursday night, Aug. 11, 2011. (AP Photo/Elise Amendola)

Ridley led the Patriots in rushing in 2012 (1,263 yards, 12 touchdowns) and 2013 (773 yards, seven touchdowns). Then, six games into the 2014 season, a Buffalo Bills defender caved in Ridley’s right knee during a tackle — a blow that Bankston said would have re-torn any repair.

And when the Patriots coaching staff asked Ridley where he was going to get surgery, he told them he would return to Baton Rouge.

This time, Bankston performed the patella surgery because Ridley didn’t have enough hamstring tissue left in the right knee, and Bankston didn’t want to remove hamstring tissue from Ridley’s fully healthy left knee.

“If Dr. Bankston told me he wanted to take an ear lobe, I’d have let him clip it,” said Ridley, now with the Pittsburgh Steelers. “It didn’t matter. Everything they said to be true was exactly how they said.”

But what about Ridley’s low production in the past four seasons with four separate teams? The 19 games with 261 yards and one touchdown?

It has nothing to do with the knee, said Ridley, who added he has never received a negative test from an NFL inspection, and he doesn’t suffer from any knee pain other than when he squats for several minutes to play catch with his friend’s sons — but who doesn’t?

“Every time I go somewhere, what is the first thing they want to check out on Stevan Ridley?” he said. “My knee. And every time they put it up on the table, they yank on it. They pull it. ‘The knee feels solid. The knee feels good. Who did your surgery?’ And I tell them.”

Former LSU linebacker Lamin Barrow said Ridley was the first person he called when he tore his ACL during 2017 preseason camp with the Miami Dolphins.

“No question,” Ridley told Barrow. “Go home. Just go back to LSU.”

And Ridley said he’s told other NFL players, too, including Patriots wide receiver Julian Edelman, who suffered a torn ACL in the 2017 preseason.

But as Ridley put it, players have relationships with their own doctors.

“I would not lie and send someone in the wrong direction,” Ridley said. “I would want somebody to overcome and do exactly as I have done.”

Ridley’s case history will be published in LSU’s report. Joined with the stories of the 38 other football players, the report could have enough proof to be a catalyst in sports medicine.

“I think it could definitely wake (people) up,” Marucci said. “I think it can change the way they view ACL injuries in the future. And it should.”