March 29, 2023
Inside the Stephanie Talbot journey back to basketball
Part I: The beginning of a 9+ month journey
(Editor’s note: Stephanie Talbot is going to detail her recovery period at The Next to talk about her injury, surgery, and the first two weeks of her recovery. And Abby Gordon, who has worked for multiple WNBA teams, most recently as physical therapist for the Seattle Storm, is here to interpret the medical details for us. This is the first part of a series about her return to basketball alongside common rehabilitation considerations following ACL reconstruction, known as ACLR.)
If you’re looking for Stephanie Talbot, she’s home, in Adelaide, Australia, spending quality time with her dog, Marley, with a new puppy on the way. On February 1, The Next announced the free agent sharp-shooter would sign with the Los Angeles Sparks. Unfortunately, three weeks later, The Next reported Talbot tore her anterior cruciate ligament (ACL) and would miss the 2023 WNBA season. Now she’s on a basketball hiatus as she begins her rigorous rehabilitation.
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The moment of injury
The 2022-2023 WNBL season was nearing completion when the Adelaide Lightning faced the UC Capitals in Canberra. Talbot injured her right knee during the third quarter. She said, “I had the ball. Can’t remember how I got it… rebound, steal or outlet pass… but I was going coast to coast, going pretty fast because I was overtaking someone, and as I went to elevate, it just buckled under me. I felt something go in my knee and my first instinct was ‘F*ck there goes my ACL’.”
Initially, the examination conducted by the on-site physio looked promising. He reassured her and even suggested she could return to the game if she didn’t have much pain. But Talbot had pain and could barely walk. She could already see her knee swelling. The next day, she returned to Adelaide, met with the team physician, and an MRI confirmed the injury. Talbot underwent surgery to reconstruct her ACL on March 1. Three days after surgery, the Adelaide Lightning held their annual awards ceremony where Talbot won team MVP and DPOY awards. She also won WNBL DPOY this season.
Once it’s determined surgery is indicated, the first important decision is the graft type the surgeon will use. A graft is like a bridge scaffold taken from a different part of the knee which will become the new ACL.
The most common ACL graft options, according to Buerba, are the patella tendon, quadriceps tendon, and hamstrings tendon. Talbot participated in the decision of which graft to use for her knee. She said, “My surgeon didn’t recommend the patella for a basketball player because we have so much knee loading, so that left me with quad or hammy, and the surgeon recommended the hamstring, so I told him that was fine with me.” If a surgeon has a preference, it may be the graft they use most frequently.
Buerba outlined the pros and cons for each graft type. The “L” in ACL is ligament, and most graft choices are tendons, which means they are structurally different. It’s like using wood and mortar to repair a hole in a brick house — the wood will likely remain in place and prevent the rain from entering, but the material is different and doesn’t become a brick over time. A hamstring graft like Talbot’s is much stronger, stiffer, and thicker than her native ACL. It has a slightly higher risk of re-tearing compared to a quad or patella tendon, however it comes with less pain and less risk of osteoarthritis after ten years. As Talbot is only 28 years old, taking long-term outcomes into consideration should have been essential for her surgeon.
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In Australia, the physiotherapist like combining the American Athletic Trainer and Physical Therapist. Talbot’s physio will design her rehabilitation and come to her home three times per week to implement it. She’s also going to the gym most days to work on her upper body and core strength while trying to keep her cardiovascular endurance intact. As a high level athlete, and as an Australian, she’ll have access to a different level of care than a typical American going to rehab.
In the United States, insurance companies impose visit limits for physical therapy. If a high school athlete attends PT twice per week for nine months, they would need 72 sessions. Many insurance plans do not allow for this level of coverage. Patients often have enough visits to return to running, around four months after surgery, but then need to progress sport activities independently. This could be a potential contributor to the high rate of recurrence of ACL injuries.
Professional and intercollegiate women’s basketball players who are injured in-season usually have access to their team athletic trainer and strength coach, sometimes a physical therapist, a dietician, a sports psychologist, and other medical professionals depending on the resources of the team. These athletes may have rehab daily in addition to workouts and time with their team. Talbot’s team has departed for their WNBL offseason, so she’ll be completing her workouts without them.
First month rehab priorities
In the first few weeks following surgery, pain management, infection prevention, and restoring full straight knee motion are the top goals. Talbot shared that she was no longer in need of pain medication and that she was feeling overall pretty good. She has been icing and using Power Dots, a gift from Breanna Stewart, for electric stimulation to help restore her quadriceps contraction. Her incisions remain covered and her physio will examine them to confirm proper healing.
Talbot has already weaned from using her knee brace and crutches while at home. Until her balance is restored and swelling resolves, she’ll use crutches when she’s out and about. In the United States, some surgeons do not use knee braces following ACLR, but some require them for many weeks. Talbot’s surgeon advised her to brace until she felt her quadriceps strength felt strong enough to walk without it.
Getting the knee as straight as the other leg is an essential early goal. Many athletes have enough flexibility that their knees go beyond a straight line — this is called hyperextension. It’s important that the leg can achieve full hyperextension, even if someone else moves it there for you. Talbot shared that when she uses her own muscles, she’s not quite there yet. When the physio is working on her knee, it does. This is excellent progress for early rehab and should be a key target for anyone going through this process.
The usual protocol for an athlete returning to sports following ACLR is at least nine months. There are some instances where athletes have returned to competition sooner. Nine months isn’t typically because the athlete can’t physically play their sport; it’s due to the high risk of re-injury. The 2016 Delaware-Oslo study concluded, “The reinjury rate was significantly reduced by 51% for each month RTS [Return to Sport] was delayed until 9 months after surgery…” Additional studies confirmed the benefit of a nine month recovery. Beischer et al studied the timeline in youth athletes and concluded, “Returning to knee-strenuous sport before 9 months after ACL reconstruction was associated with an approximately 7-fold increased rate of sustaining a second ACL injury.”
Nagelli and Hewitt searched to find how long it would take for the knee to return to normal. “The evidence in the literature indicates that the ACLR athletes do not regain baseline, or not significantly different from baseline, knee joint biological health and function until approximately two years after ACLR.” Athletes typically can’t — or won’t — delay their careers for two years. Thus, the 9 month cut-off has been more broadly used.
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ACL injury in the WNBA
Medical and scientific journals rarely report WNBA injuries, but recently more have been published. In 2022, Axelrod reported “ACL tears are the most common type of knee injury in the WNBA that resulted in loss of play, accounting for 37% of total knee injuries. In addition, ACL tears were found to have the longest RTP [return to play] length of all knee injuries at 375 days (including time during the offseason).” They also acknowledged the limited availability of WNBA injury data compared to the NBA.
If everything stays on track, nine months from March 1 puts Talbot back on the court around November 1. Until then, you can find her at the dog park, the gym, or at home. She’ll be spending quality time with her partner, Abraham “Heff” Helfand, her pups, and thrice-weekly visits with her physio.
Written by Dr. Abby Gordon
Abby Gordon is a Board-Certified Sports Physical Therapist at Seattle Children's Hospital. She was the Team Physical Therapist for the Seattle Storm from 2015 to 2022 and the Travel Coordinator and Equipment Manager for the Connecticut Sun from 2007 to 2010. After four seasons working as a team manager for the UConn Huskies Women's Basketball team, she graduated from the University of Connecticut in 2007 with a Bachelor's in Exercise Science and in 2014 with a Doctorate in Physical Therapy. She writes about WNBA Injuries and Sports Medicine Issues in Women's Basketball for The Next.
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