Jan 29, 2015D.J. Gnader
Northwest Missouri State University
It was the first series of the first game of the 2010 football season and Northwest Missouri State University middle linebacker D.J. Gnader was already getting comfortable. Gnader was playing his first college game after redshirting as a freshman and was making plays all over the field–and it felt great.
Then, on the Bearcats’ second defensive series, everything changed. With the offense lined up in a shotgun spread formation, the opposing quarterback took the snap and began running an option play. Gnader honed in on him and readied to make the tackle. But before that could happen, the quarterback pitched the ball to a running back. Gnader quickly planted his left foot, changed direction, and took two hard steps toward the new ball carrier. That’s when he felt a pop in his left hip and stumbled to the ground.
“It felt like I was running and my upper body gave way while my legs kept going,” recalls Gnader. “I laid there for a second and thought to myself, ‘That didn’t feel right.'”
Still, Gnader picked himself up off the turf and lined up for the next play. “I think my adrenaline was running so high at that point that my hip didn’t really hurt,” he says. “Plus, I was having too much fun and wanted to stay in the game.”
On the next play, the quarterback dropped back to pass. Gnader picked up the coverage on a running back who was executing a go route. As the back came up the middle and started down the field, Gnader rotated his hips and planted his left leg in preparation to follow him. “That’s when I really felt it,” says Gnader, who again found himself on the turf. “It was like my hip had jumped up and hit me in the rib, then popped back into the socket. I stood up and could barely put my foot on the ground it was so painful.”
Gnader hobbled off the field and was met on the sideline by Jeff Smith, MS, LAT, ATC, Athletic Trainer for Football at Northwest Missouri State. Smith performed internal and external rotations on Gnader’s left hip, which caused him tremendous pain. At halftime, the team physician examined Gnader and told him he may have suffered a hip flexor or groin injury and that he was done for the game.
Four days later, Gnader had both an MRI and magnetic resonance arthogram (MRA), which revealed a torn hip labrum. He met with the team physician, who told Gnader that his career could be over. “Our team orthopedist and athletic training staff were worried that a hip subluxation had taken place,” says Smith. “Because the MRI showed a labrum tear and some bony involvement, our doctors knew it was a more complex injury than they were used to seeing and recommended that he get a second opinion.”
Gnader traveled a couple of hours north to his hometown of Omaha, Neb., to meet with an orthopedic surgeon. The surgeon confirmed the labral tear and told Gnader he could perform the surgery and have him in and out of the hospital in a day.
As he left the surgeon’s office, Gnader received a call from The Steadman Clinic in Vail, Colo. Before Gnader left for Omaha, Smith had contacted a former NWMSU graduate student who worked at Steadman and asked if Marc Philippon, MD, a world-renowned hip specialist and partner at the clinic, could look at Gnader’s MRI and MRA results. Philippon, who has performed hip surgeries on a number of professional athletes, including Alex Rodriguez and Mario Lemieux, examined the images and found that in addition to the labral tear, Gnader had cartilage damage and a femoral acetabular impingement.
“Once I heard the diagnosis from The Steadman Clinic, I knew right then and there I would have to go out to Colorado to have the surgery,” says Gnader. “Dr. Philippon’s resume spoke for itself. Plus, he saw stuff the other doctors missed.”
Philippon is in high demand, though, and Gnader had to wait six weeks for surgery. He spent that time on crutches applying ice and e-stim for pain management and doing continuous range of motion exercises. “The first week the pain was excruciating, but the more I iced and stimmed, the better it felt,” he says. “Still, that six weeks was a rough patch for me. It was my first serious injury and I was pretty depressed about it.”
On Oct. 11, Gnader underwent what turned out to be a very complex surgery. His labrum was reattached with four anchors, and the impingement was repaired via osteoplasty and rim trimming. To address the chondral damage, Gnader underwent microfracture, chondroplasty, and thermal treatments on his femur. The acetabullum was also treated with microfracture and chondroplasty procedures. Plication, or folding, was used to close the capsule. He also received a platelet-rich plasma injection during the procedure.
After waking from anesthesia, Gnader was visited by Philippon. “He said it was one of the worst he had ever seen of that type of injury and that I had completely destroyed the labrum and the cartilage around it,” Gnader says. “But he told me he had fixed me up and there was a good chance I could be back on the field in 10 months for the start of the 2011 season.”
Philippon also explained that the impingement had predisposed Gnader to the injury. “Basically, I had an extra piece of bone in my left hip,” says Gnader. “He said the injury could have occurred that day or 10 years from now, but it would have happened eventually.”
The next day, Gnader transferred to Howard Head Sports Medicine, a nearby rehab facility where he would begin a week-long rehab stint. When he checked in, Gnader was warned that the first session would not be pleasant.
“At 5:30 the next morning they were taking me by wheelchair to physical therapy,” Gnader says. “They put me on the table to do some manual exercises on my hip and it was by far the most intense pain I had ever felt–much worse than the injury itself. I actually questioned whether playing football again was worth going through that type of pain.
“It was tough to stay positive that week,” he continues. “My mom had to help me do simple things like shower and sit on the toilet the whole time I was in Colorado.”
When they left Vail for the long drive home, the Gnader family did so in a vehicle packed with rehab equipment. The payload included a Game Ready ice and compression system to combat swelling and inflammation, a sequential compression device (SCD) pneumatic pump Gnader would use for four weeks to prevent blood clots in his leg, a continuous passive motion device to aid the healing process, rotational boots that would lock his legs in place and prevent external rotation while he slept, crutches so he could remain non-weight bearing for the next 12 weeks, and a hip brace that he wore while ambulating for the next three weeks. Gnader was also given a binder packed full of physical therapy information that was to be shared with Smith and the rest of his rehab team.
After spending a couple of days at home–and demonstrating to his mother that he could operate all of his rehab equipment independently–Gnader returned to campus. “When I got back to school, the athletic trainers, strength coaches, and football coaches were all really excited to see me back,” he says. “They made me feel wanted, which motivated me. I felt like they hadn’t written me off and that I still had a purpose.”
Meanwhile, Smith readied for a very unique rehab. “I had conducted a few labral rehabs before, but they weren’t as complex as D.J.’s,” Smith says. “With the labrum tear plus microfracture surgery, we were in uncharted waters. The Steadman people understood this and told us that even for them it was a very unique injury–one of the more severe and complex that Dr. Philippon had worked on.”
So Smith immersed himself in the rehab manual provided by The Steadman Clinic. “The binder was amazing,” says Smith. “It contained a ton of information, including a timeline and progressions for D.J. based on how he was feeling and performing.
“It also helped that we had open lines of communication with the Steadman people throughout the process,” Smith adds. “During the 10-month rehab, we were on the phone with them four or five times and sent a bunch of e-mails back and forth. They were always following up to see how D.J. was doing.”
For the first 10 weeks, the chondral repair dictated that Gnader’s rehab consist mainly of manual therapy range of motion, hip rotation, pendulum, and circumduction exercises. “Near the end of that period we introduced more passive-assisted exercises,” says Smith, who worked with Gnader daily in one- or two-hour sessions. “At that point, we were doing some gait training work by walking heel to toe. He was also doing hydrotherapy in the pool and cold whirlpools with our Head Athletic Trainer Kelly Quinlin [ATC] and using the Game Ready system for pain management.”
Gnader says spending time in the pool was his favorite part of this phase. “I was in the pool two days a week,” he says. “And even though I was doing very simple non-weight bearing workouts like running in the deep end while wearing floaties, I liked those days the best because I could move my arms and legs and feel like myself again.
“I also spent a lot of time pedaling a stationary bike with zero resistance,” he continues. “My friends started calling me Lance Armstrong because I was always on the bike when they came into the athletic training room.”
The next phase of Gnader’s rehab continued with more passive-assisted table exercises and saw the introduction of leg lifts and extensions to work his quad and hip area. Isometric core work and flexibility training were also big components of this stage. As he progressed and grew stronger, seated exercises transitioned into standing work and double-leg exercises such as very light squats and other closed kinetic chain exercises. Toward the end of the phase, step-ups and single-leg squats were added.
Around this time, Smith began sharing the rehab load with Joe Quinlin, MS, SCCC, CSCS, the school’s Head Strength and Conditioning Coach (and Kelly Quinlin’s husband). “We identified early that we were going to defer to the experts in Vail, so Joe and I met all the time to talk about what we were going to do with D.J.,” says Smith, who was a roommate and fraternity brother of Joe Quinlin’s when the two were students at NWMSU. “Joe is a big fan of doing dynamic work in the weightroom, which fit with the rest of D.J.’s program. While Joe worked with D.J. on strengthening his upper body and opposite leg, the athletic training staff worked on D.J.’s injured leg and hip.”
With the spring semester winding down, Gnader entered the final phase of his rehab. “We started to incorporate more functional exercises–more running, jogging, biking, and pool work,” says Smith. “We tried to keep a balance of all that stuff and took a cross-training approach by doing multiple exercises and not overworking one particular motion.”
But late in that third phase, Gnader did overdo it. As he grew stronger and more confident in what his hip could do, he began going heavier and deeper with his squat workouts. His hip responded by becoming tight and sore. Smith immediately pulled Gnader out of his weightroom routines and contacted Philippon’s office.
“They reviewed his charts and notes and decided that based on his injury and anatomical makeup–the impingement history–deep heavy squats weren’t in his future,” Smith says. “So we remodeled his lifting program and replaced the squats with more single-leg work. He’s done really well since that change and it’s something he’ll probably have to adhere to for the rest of his career.”
The timing of the setback coincided with the end of the spring semester. Recognizing that Gnader needed more individualized care than he could provide at that time, Smith recommended he return to his hometown and work with Travis Manners, PT, an Omaha-based physical therapist. Manners, who was a fraternity brother of Smith and Joe Quinlin at NWMSU, helped Gnader rebound from his speed bump.
“Travis spent a month with D.J. in a one-on-one setting and really fine-tuned him,” says Smith. “He taught D.J. a lot of single-leg isolation work that stressed range of motion and hip mobility while reinforcing proper biomechanics.”
“Working with Travis was the best thing for me at that time because if I had stayed on campus for the summer I probably would have done a lot on my own and I might have pushed myself too hard,” Gnader says. “Travis allowed me to accelerate my rehab in a safe and controlled setting.”
Manners began his sessions with Gnader by having him start from scratch. “We spent the first few days doing very basic things like stretching and mobility work,” Gnader says. “Then he gave me a functional movement screen test, which revealed an asymmetry in my left side around the hip area. Based on that test, we started a program that incorporated a combination of stretching and isolation strength exercises.”
Smith and Gnader both agree that the communication between Smith and Manners was instrumental to Gnader’s successful summer. “If I was five minutes late to PT, Jeff would call me from Missouri saying, ‘Where you at?'” recalls Gnader. “He and Travis were all about taking care of my injury.”
Manners ended his work with Gnader by administering the return-to-play test required by The Steadman Clinic. Gnader passed, and on Aug. 6, he was cleared to participate in the Bearcats’ preseason camp, which began three days later.
“As soon as Travis told me I passed, I called Jeff and all of the coaches to tell them the news,” says Gnader. “The last full game I had played was in high school more than two years earlier, so I was super excited.”
That excitement carried over into camp and the season. Gnader started each of the team’s 14 games and never missed a practice. He tallied 100 tackles and helped lead the Bearcats to an 11-3 record and a spot in the NCAA Division II quarterfinals, where they lost to the eventual national champion, Pittsburg State University.
“Throughout the season, D.J. got better and better,” Smith says. “By the time we got to the playoffs, he was really excelling and leading the team in tackles. He was one of our top players.
“He would get sore or tight from time to time, but D.J. is a good communicator and would tell us how he was feeling and we would limit his reps in practice if necessary,” Smith continues. “He’s regained most, if not all, of his athletic ability. When you watch him play, you can’t tell that he was ever injured.”
While Smith credits Gnader’s work ethic and personality for the successful rehab, Gnader knows he couldn’t have done it alone. “Jeff did everything he possibly could to help me,” says Gnader, who has three years of eligibility remaining. “We spent a lot of time together and I put a lot of trust in him. He, Joe, and Travis went above and beyond what they had to and really showed how much they cared for me as a person and an athlete.