Interview with the ACL Doctor Richard Cunningham MD
Dr. Nic Interviews leading ACL Orthopedic surgeon Dr. Richard Cunningham about various topics regarding orthopedics, ACL surgery, and ACL injury prevention.
Head over to Dr. Cunningham's website at https://theacldoctor.com/ to check out his great blogs and videos regarding all things ACL surgery and recovery. You can also find him on youtube at Vail Knee His main website address is https://drrichardcunningham.com/ for
FULL TRANSCRIPT:
Dr. Richard Cunningham Interview
Nic Hedges DC MS 00:00
Alright everybody, really exciting to have Doctor Richard Cunningham MD, actually, the ACL doc on the call today with us so, we're going to be interviewing him a little bit about some of his background and some of the – some information regarding ACL surgeries in particular so, doctor Cunningham you've been all over the country receiving medical training from Amherst College to University of Washington, Salt Lake City Utah and then the fellowship in Pittsburgh so can you tell us a little bit about some of your background? And then some of the things that separated you from the pack as far as ACL specialists.
Dr. Richard Cunningham 00:40
Sure – I'm – I was very happy to train at numerous locations and certainly happy that I landed here in Colorado, you know, I've been here now almost twenty years. I can't believe it, and I love Colorado, specially where we live and work but I went to medical school at the University of Washington in Seattle and then I did a residency as you mentioned at the University of Utah, which was great, I was there for five years and then and additional year of sports medicine, which is basically orthopedics. For those that don't know, it's basically arthroscopy on the knee and shoulder and I did that at the University of Pittsburgh medical center which – very strong sports medicine. A fellowship in – was fortunate enough to work with, you know, the Pittsburgh Steelers when I was there, the Pittsburgh Penguins and, you know, lot of great surgeons and medical teams that you’re exposed to, you know, in the university of Pittsburgh athletics and things like that so – and that was great and then – again, have been here in Colorado ever since so…
Nic Hedges DC MS 01:46
Very cool. What things specifically drove you to the knee and shoulder as an area of interest in specialization for you? I know that – I've looked at some of your background information, you had some of this orthopedic surgeries yourself right?
Dr. Richard Cunningham 02:00
Yes.
Nic Hedges DC MS 02:01
And one of the other things I kind of wanted to touch on was – we've seen a huge progression not only in the percentage of return to play but also the time to return to play in a lot of athletes receiving ACL, whether that be repair or reconstruction surgery so. Let's maybe talk about some of your experiences personally having this kind of surgeries and then, how have these things developed over time, and you highlighted some of this differences in some of your videos about how these surgeries used to be performed versus how they are now.
Dr. Richard Cunningham 02:32
Right. Just growing up – I grew up in Upstate New York actually and played a lot of sports. I won't say I was the best at anything but enjoyed playing sports and had my share of injuries and, you know, a lot of my uncles who I looked up to were primary care docs through family docs in Upstate New York and living in smaller towns and taking care of a community. My doctor John Cunningham, he was up in Warrensburg, New York, this small town and I used to stay with him before I'd go skiing at Gore Mountain in Upstate New York. But in any case, you know, when I was seventeen playing soccer I didn't – I have (Inaudible 03:10) my ACL actually So I pulled the ACL up with a chunk of bone, which at that age if you're going to choose is probably the better injury to have rather than a full ACL tear, but that threw me into the orthopedic world and it was funny, I really identified very much with my orthopedic surgeon in my hometown of Troy, New York. And he was a great guy and inspired me I would say. And then as things evolved I was actually an English Major in college but, you know, had always an interest in orthopedics and how do you get there and then also family medicine, I thought about that going through medical school as well, but orthopedics really appealed to me. Particularly managing sports injuries, just because, as you know, there's a lot of lifestyle disease in our country and I think if we all made better choices in our lifestyles we could avoid some of the, you know, high blood pressure and high cholesterol and cardiac disease, and maybe pulmonary disease in those that smoke and things like that. And orthopedics – I just going through my rotations really identified with those patients that just, you know, were active and trying to resume their sport and wanting to get back to all those things, so really gravitated toward that field in medical school, and then again the orthopedic surgeons that I met along the way, they were kind of, you know, in a way guys like me, you know, just – there's funny things they say in medical school and again, they're like: “If you can bench press your weight you're going to go into orthopedics.” Which I never could do by the way but somehow I ended up there anyways.
So, you know, because the orthopedist in medical school it's kind of like the jocks guys, you know, that used to play college sports or something, got hurt and now they're in orthopedics. There's some truth to that but I really enjoyed all those guys so – and then within orthopedics itself as you know, there is foot and ankle, there's ham, there's spine, there's hip, there's joint replacement, there's so many different fields but I just really loved arthroscopy and fixing things through minimally invasive techniques and getting people back after knee and shoulder injuries to all their activities so, that's what kind of led me down that road.
Nic Hedges DC MS 05:21
Awesome. I was doing some reading last night and it was pretty funny after looking at your really great blogs and, I'll provide in the show notes some of the things like links to your blogs and websites and some of the things that you talk about specially with concerns to graph locations, and utilizing the quad tendon graft and things like that. I was doing some reading and I saw a paper titled: “The quad tendon: The graft of the future.” But you've been doing this for well over a decade utilizing the quad tendon and also kind of pioneering the ACL repair surgery as well so, can we just touch on – I don't want to go, like, fully in depth but maybe touch on graft locations and different things associated with each one, maybe the reconstruction versus repair as well, which you have an excellent post on. So I'll lead people there but let's maybe touch on that a little bit right now.
Dr. Richard Cunningham 06:11
Yeah. You know, I think graft location is so critical and, honestly when I came out of my fellowship in 2003, like I worked with guys uh some of these names I'm sure people won't know but in orthopedics they're pretty big names like Freddie Fu was our chairman and orthopedist at Pittsburgh, and Chris Horner and Jim Bradley and the Steelers doc and guys like that, and we were doing what's called trans-tibial ACL reconstruction at the time, and really what that means is we're drilling sockets in the bone and with the trans-tibial technique you're drilling a socket up through the tibia bone, and through that socket you determine where you place the socket on the femoral side. Well, Freddie Flu actually was one of the – he actually published some very well received and well-regarded papers. Really starting in '03 to '05 during that time frame where it kind of questioned this whole trans-tibial technique and moreover he really started to look at the ACL once again and showed that it really was a double bundle structure, it has like two ligaments in one and so from that kind of came out this whole anatomic ACL reconstruction technique where we're really trying to reproduce what's called the footprints, so where the ACL is once attached in the knee. And at that time he started to do double bundle ACL reconstruction and I would keep in touch with him and I’d get back to Pittsburgh and learn some of his newer tricks and I started to do double bundle as well for a period of time but, you know, since I really don't do double bundle but out of that grew this whole anatomic ACL technique where we're basically placing grass exactly where they once lived in the knee which ,you know, when you hear it you think: “oh that makes perfect sense you know probably these guys are doing it all along.” But we really weren't, believe it or not, [coughing]. Excuse me, we're using these guides and placing the ACL through this trans-tibial tunnel technique which was not anatomic, it wouldn't – the graft would not be exactly where it once lived in your knee, and as a result of that honestly people weren't as stable, they re-tore the graphs at a higher rate and they just didn't do as well and so since doing these more anatomic ACL reconstructions that's evolved over time, so it kind of came out of this double bundle technique to then anatomic single bundle and, about 10 years ago there's a colleague of mine down at Emory in Atlanta, who was doing – starting to do quite a few quad tendon grafts and that really intrigued me and he made a very good argument as to why that was reasonable to consider namely that, you know, quad tendon is, it's about – you know, the other options would be patellar tendon graft or hamstring grafts and I had been doing hamstring grafts for many years and they worked well but a quad tendon graft is one big section of tendon, it's much more collagen than a patellar tendon graft for instance and a hamstring graft you can have the same amount of collagen but it's four or five individual strands of tendon woven together as one, whereas the quad is just one big piece of tendon. And that all ,you know, intrigued me and I thought it was the results, the early results particularly out of this surgeon in Emory but also the surgeon in Mississippi who had been doing it for years, were very encouraging and so after going down spending some time with those docs, I started to do this here in Colorado and I think I was the first in Colorado, if that makes any difference. But it certainly has been a great technique and I've stuck with it to this day, you know, as time marches on, and that's what is great about what you and I do Nic is that, you know, like techniques are always changing and it's a great way to continue learning and the implants we use today are different than the implants we use 10 years ago, they're smaller and stronger, and again all these things can be less invasive so it's been a journey when I look back on how things started almost 20 years ago to today and I think it's going to be different 10 years from now, that's what makes this so exciting I think.
Nic Hedges DC MS 09:58
One thing that I find particularly interesting that I really hadn't even heard of in my brief perusing of the literature was the repair surgery, and so if it's torn in a certain location then you can just tack that right back down to the femur as opposed to going in, taking out the whole thing and then completely replacing it, and that seems really interesting, especially with the recovery time literally cut in half.
Dr. Richard Cunningham 10:23
Right, absolutely. Yeah, that's really exciting and I think I’ve now done ACL repairs, primary repairs and certain types of tears and what they're called is: They're called type one tears or proximal tears so, where people literally are pulling the ligament directly off the bone or it's very close to its attachment on the femur, we can take that ACL and save it and just reattach it in that in – it's again, if you look back like, surgeons were doing ACL repairs in the seventies and the early eighties and they failed miserably, and the reason was a number of things:
First of all the surgeons were repairing all types of tears so even if you tore your ACL right in the middle of the ligament they were trying to stitch that ligament together and then, remember back then there was not arthroscopy so there'd be a big six inch opening of your knee joint and then the suture would be used to try to sew ligaments together in their mid portion which didn't work, and then the rehab was terrible back then. I mean, you know, you help people with accelerated rehab and back then it was like put people in a cast for eight or ten weeks and they got a very stiff knee so, it was written off years ago as: “Okay this does not work.” Which, for those indications does not work, amid substance terror, repairing it as of today does not work. But again there was a surge in New York and actually another in Europe that started to look at this again and say: “Hey you know, now we can do it arthroscopically, all our sutures are much stronger and we have these suture anchors now which we didn't have back then and what if we only did it for these tears that like peel off the bone.” And that again really intrigued me I thought: Gosh, that's something we should revisit and like so many things in medicine I think if you, I don't know if the term is, but if you stick your head in the sand and say: “Okay that didn't work, it's never going to work again.” I think as technology evolves we have to revisit all these things and say: “You know, based on what we know today should we look at this again?” And I think it's a great option particularly for kids. I mean, you know,
like someone, a kid that's ten or twelve that's torn their ACL, the risk of that surgery is very high because we're – often times, you know, they have open growth plates so for drilling across growth plates, we could cause a growth disturbance, we could cause them to have that leg not grow as long or grow with angular deformity and so, if we can repair an ACL particularly in a kid and not risk any injury to the growth plate it's a real win and so, in that patient definitely but even in adults. I mean, you know, if I had, you know ACL repairs I think one in the last two weeks, which is a bit of a run for me because they're not that common. I tell people they're like one in 50 ACL tears, they're not that common but you have to look for them, and if you're a candidate I think it's a great option, people do really well and as you said the recovery is about half as long, you save your normal anatomy, you know, if you ever tore that ACL down the road like five years from now skiing then it probably would be a normal reconstruction but it's almost as if you've never had surgery on that ACL before so, it really is exciting and a great option for certain types of tears in certain patients.
Nic Hedges DC MS 13:29
Awesome, yeah. I actually have a little bit of insight into – I heard about you through actually my roommate, who tore his ACL and then – so he lives here in Frisco and he actually got really lucky because he just searched for like the nearest orthopedic surgeon for like a knee, and then he just walked over to your Frisco location and he happened to get one of the best ACL surgeons in the world, so he's been really lucky in that he got you and his recovery has been going very, very well so, what are some of the things, let's say somebody can't come in to see you up here in Summit County, what are the things people should be looking for as far as an ACL doc to perform the surgery? So, you obviously have an orthopedic residency under your belt as well as a fellowship and a very, very high-end location so what things could people be looking for?
Dr. Richard Cunningham 14:23
Absolutely, yeah. I think, for sure, you know, you certainly want an orthopedic surgeon that has done a fellowship in sports medicine and that's again arthroscopy of the knee and shoulder, because that – within that fellowship, you know, you're not doing hand surgery, foot surgery, spine surgery, you're really concentrating on these sorts of injuries and in that year I tell people of fellowship is almost some doc's liking it to 10 years of experience in practice. You know, for a year you're really concentrating on just this one field and so I think someone having had a fellowship in sports medicine is important, and then certainly when you talk to the doc I think patients of course want to feel like they're going to be well looked after and taken care of and that the doc cares about their outcome, I think a reasonable question would be, you know, to a doc is ,you know: “How many do you do a year?” I think that's reasonable and I think, believe it or not, about eighty percent of ACLs done in this country are done by docs that do twenty or less per year. And so, not to say that some of those docs can't do a good job, but the studies would show us that you really need to be doing about fifty of a given surgery per year to have good results, so I would try to look for a doctor that does at least fifty ACLs a year, fifty ACL reconstructions a year. And then other questions to ask or be concerned about is, you know: “What graft you use?” You know, you can get a very good outcome with a patellar tendon graft or hamstring graft. I think quads have some slight advantages so I vote for that one but any of those three grafts would be a good option. However I wouldn't recommend donor tenant ACLS, particularly in an active patient and a young patient, if someone's ,you know, in their fifties and above, maybe a donor tenant can work fine, I do think that's the case but, unfortunately, you know, still in this country twenty year olds are getting donor tendon ACL reconstructions, and we know in that category in particular that they tear them at a much higher rate, like up to thirty percent re-tear rates. Which, you know, we don't want to ever have to put people through this a second time if we can avoid it, so I think those are some of the things I'd look for in a doc though.
Nic Hedges DC MS 16:27
Awesome, I think that's going to be really great information for people that are, you know, anxious or kind of scared about things and they don't really know what to look for because a lot of people, you know, see all docs is the same and like, everybody can do the same things but there really is a significant difference between people who specialize in certain things and then get those, you know, higher accreditations and higher training levels and things as well so, could you just ballpark for us? Maybe just how many ACL surgeries you've done over your career?
Dr. Richard Cunningham 16:57
Yeah, I mean it's definitely – it's probably up around 2000 or so I would say. Something like that, you know, just probably above over two thousand, I haven't actually, i got to sit down and think about that one, but I’m sure it's over about two thousand or so.
Nic Hedges DC MS 17:13
Well that's pretty awesome. So you’ve definitely got a decent amount of experience as far as going into the knee.
Dr. Richard Cunningham 17:20
Yeah, yeah. And it's, you know, what's funny is, you know, you're young in your career, for me as i get on it's nice to really focus down on a couple things, and really I just do ACL's meniscus surgery, rotator cuff repairs and instability surgery of the shoulder. Those four things comprise about eighty or ninety percent of what I do, and I'm okay with that.
I think when I first started out, you know, it was okay, you were trained in everything so you could do a lot of different things well, but as time marches on, you know, I think you realize: Hey, you can't be the best at everything, you better concentrate if you're going to really be a benefit to patients. And where I live and work to be able to do that so…
Nic Hedges DC MS 17:58
Yeah. You know, I’m not a big fan of like, the ten thousand hours rule because I think there are some things wrong with it but I mean, I think that you've literally spent ten thousand hours inside of someone's knee, which I think is absolutely an incredible thing.
Let's maybe change directions here and talk a little bit about something that I do a little bit more, which is trying to prevent ACL surgeries in individuals so, especially youth athletes have been trying to go around and do things like incorporating stuff like the FIFA eleven plus protocol, kind of taking some of that stuff and put out some information for individuals regarding things they can do for skiing that could potentially decrease their chances of an ACL injury, especially someone who isn't super active or something and just wants to go out on the hill for their vacation so, what are your thoughts and opinions on the current protocols and maybe where they could go in the future as well?
Dr. Richard Cunningham 18:54
Yeah. Nic I think that's great especially if, you know, you're spearheading that in Colorado, I think an adaption of the FIFA eleven plus program would be great and for those patients or people out there that maybe don't know it's, you know, the governing body of professional soccer came out with these recommendations on a 20-minute or so warm-up program that their athletes, professional soccer players, footballers, do every time before they train or play, and starting to get that information disseminated down to youth athletes around the world that play soccer, because that is like skiing that's is a high incidence of associated knee injuries particularly in our female athletes, and I think it's a great thing, you know, it doesn't require any equipment and these young athletes can do it, and I think you're absolutely right. Some of the very same predisposing factors to having a knee injury with soccer are there for our young skiers, again particularly in our young female athletes. So I think, you know, you leading that charge and getting our youth like, team Summit, team Breck athletes and others on this program, that would be great.
Nic Hedges DC MS 20:09
Yeah and luckily I spoke with one of the team Breck coaches last week in a kind of similar format to what we're doing now, and they seem to already be incorporating a lot of those strengthening things already so, I think that they're totally on board and we've been kind of chatting with them and as far as different things to do with those things so…
Dr. Richard Cunningham 20:28
Yeah one thing I find, you know, one thing I will say that I see that unfortunately again like all of those coaches can't know maybe the latest and greatest preventative exercises, but in our youth athletes I see a lot of quad strengthening exercises which are important but the things we do, you know, the skiing, the soccer, the running, the biking, the hiking, it's very – we tend to get very strong in our quads and our hip flexors but we get relatively weaker in our hamstrings and our glutes, so if anything I think our young athletes if they can focus on really strengthening that posterior chain like the hamstrings and the glutes more than anything in their core, you know, instead of going to the gym and busting out more lunges and squats and things like that, which they're usually already strong in those muscle groups and they tend to ignore the posterior chain I would say.
Nic Hedges DC MS 21:18
Yeah that nordic hamstring exercise is really going to be a big one, and biomechanically the hamstring can actually work almost like an accessory ACL, right?
Dr. Richard Cunningham 21:28
Exactly, you know, it does provide some stability to the knee because it's causing that posterior directed force. Yeah, whereas, believe it or not, when your quads are strong, you know, there is some anterior tibial translation that is pulling the tibia forward, not to say, I think you need to have all these muscle groups strong, but more often with weak glutes and weak hips muscles – we tend to get that valgus or knock kneed alignment, and that puts our knee at risk.
If our core is weak we tend to land in the back seat and, you know, those back seated landings on a snowboard or whatever it might be puts your ACL at risk and, you know, we've done studies looking at world cup skiers, you know, and we've done it with one of the docs of the US ski team where we looked at studies of how they tear their ACLs and it's usually, you know, let's say coming around a gate, being in the back seat, putting your downhill ski out to brace the snow and land it with the knee extended, with your knees straight. And that puts your – that mechanism is the one in which we see pro skiers tear their ACL the most, and I think it's true in our team Summit, team Breck athletes as well.
Nic Hedges DC MS 22:36
Yeah, I think I may have cited one of those studies in kind of creating that sort of blog post that I wrote on the topic so, really glad that you kind of had a bit of a part in the creation of that, that's really cool.
Do you have a – I know that you have some other stuff that you've got to go and do pretty soon so, do you have any final words or sage advice for anyone, whether it's looking for an ACL doc or potentially undergoing surgery or anyone that may want to try and prevent this surgery from ever having needed to take place?
Dr. Richard Cunningham 23:13
Yeah and I would say, you know, skiing in particular, just having a big lever arm attached to our foot has a high risk of knee injuries: ACLs and MCLs and even tibial plateau fractures, other things. So I think some of those things that we discussed, you know just, going into the season strong, strong in your core, strong glutes, strong hamstrings, rolling out the IT band, you know, seeing professionals like yourself to get some guidance there I think is important and then, you know, we, you know, you hear in the office all the time: “How did you hurt yourself?” And you usually again, as we know, it's a variety of things, it's you know, the flat light, it's a, you know, I had a flat landing off my snowboard, I landed in the back seat, you know, felt that pop, so I think, you know, be careful the conditions out there when it's flat light, I would say, you know, maybe shorten your day when you're fatigued, shorten your day and, collisions unfortunately.
We're seeing more and more people get hurt with collisions and I think on those really crowded days it may be worth to just pull the plug and get out of there honestly, and then I think, you know, looking for a doc if you've hurt your knee, you know, someone that I think has been in practice for a while, you know, at least a couple years I would say. Someone that's done that extra training and fellowship in sports medicine, deal with athletes. And it's not unreasonable to ask your doc, you know: “Hey, how do you do these?” “How many do you do a year?” “What type of graphs do you use?” I think going in with some knowledge is important and I think those are the highlights.
Nic Hedges DC MS 24:54
Awesome, so we'll be sure to point people in the direction of your blog and very insightful videos on the topic.
Thank you so much doctor Cunningham for talking with me today and hopefully this information goes out to a lot of people and helps a lot of people.
Dr. Richard Cunningham 25:08
Absolutely, thanks Nick and thanks for taking great care of patients in Summit County and yeah, looking forward to sharing working with more patients in the future.
Nic Hedges DC MS 25:17
Awesome, yeah. Same to you, I know you've been a part of the county for a lot of years and have been bringing great information and work to a lot of people here so.
Dr. Richard Cunningham 25:25
Perfect, all right.
