Road to recovery: Tracking Antone Exum's ACL rehabilitation
BLACKSBURG, Va. -- The scene was almost perfect: 73 degrees and sunny, with only a few wispy clouds in the sky. Last Saturday, as a crowd of more than 65,000 settled into Lane Stadium, Virginia Tech prepared to host its homecoming game against North Carolina.
About five minutes before kickoff, the first note of Metallica's Enter Sandman came blaring through the speakers. By the time the main guitar riffs came in, the fans were whipped into a frenzy. Virginia Tech players sprinted out of the tunnel, buoyed by the bobbing sea of maroon and orange around them.
Twenty seconds later, redshirt senior cornerback Antone Exum emerged. He wasn't wearing a jersey. He donned a Hokies T-shirt, gray basketball shorts and -- to add a distinct sense of flair -- Versace sunglasses and a pair of American-flag Toms shoes. He walked alone through the path formed by the marching band, slowly making his way to join his teammates.
"I miss that part of it," Exum said of Virginia Tech's famed entrance routine. "I'm definitely looking forward to that."
Exum had missed the first five games of the season after tearing the ACL in his right knee in January. But on Sept. 30, doctors had medically cleared him to play. Exum passed the requisite tests and was set to make his much-anticipated return.
Only he wasn't ready, and he knew it. The day before the Tar Heels game, Virginia Tech announced the second-team All-ACC selection would not make his 2013 debut.
"I had literally already packed my backpack," Exum said. "I had my suit. I had my playlist ready on my iPod. But after further reflection, I just felt like it was the best decision not for me to play. It was definitely not the decision I wanted to make."
Of all the difficult moments in Exum's recovery, this was one of the toughest. The end was so close. This was supposed to be the game he had dreamed about since he first went down in pain.
But ACL injuries aren't that simple. If Exum had learned anything over the past eight months, it's that coming back from one doesn't always stick to a script.
When Barbara Exum got the call on Jan. 26, she felt numb. James Gayle, Virginia Tech's standout redshirt senior defensive end, had phoned her to deliver the news. Several Hokies were playing pick-up basketball at McComas Hall on campus, and Barbara's son, Antone, had just collapsed on the court.
Moments earlier, Antone had knifed toward the basket for a layup. The lane was crowded, so he tried to contort his body into an angle that would avoid landing on anyone's feet. Instead, he landed flat-footed and felt a snap. Within seconds, he was on the ground clutching his knee, unable to get up.
"I knew that it was serious 'cause I had a little bit of knee trouble before, but I had never felt that snap before," said Exum. "I knew that it was something different than my knee just going out for a couple seconds."
Less than a month earlier, Exum had informed coaches that he would bypass the NFL draft to return to school for his senior season. After switching from safety to cornerback in 2012, he had racked up an ACC-high 16 pass breakups, a team-high five interceptions and 48 tackles. He was named the Russell Athletic Bowl MVP after making a critical fourth-quarter pick to spark Virginia Tech's 13-10 overtime win over Rutgers on Dec. 28.
But everything changed as Exum lay sprawled across the hardwood. Barbara and Antone's father, Antone Sr., drove to Blacksburg from their home in Richmond, Va., while Antone met with Virginia Tech head athletic trainer Mike Goforth, who summoned a physician to check Antone out.
Everyone tried to stay positive. But they prepared for the worst.
"I wanted to think maybe he just twisted it," said Antone Sr. "Maybe he strained a ligament. Maybe something that's not going to require surgery. That was the mindset that I had. In the back of my mind, you're thinking, OK, if this is something serious, what do we do?"
An MRI confirmed their worst fears. Antone Jr. had torn the ACL in his right knee. He needed surgery and was out indefinitely.
After discussing the situation as a family, the Exums decided to set up an appointment with Dr. James Andrews at the Andrews Institute in Pensacola, Fla. They flew down to meet with doctors and therapists on Feb. 4, and after completing some preliminary range of motion exercises, Exum underwent surgery on Feb. 5. That's when doctors found out he had not only torn his ACL, but he had also torn his lateral and medial meniscus and suffered a microfracture.
ACL tears are ubiquitous in sports, and Exum's thoughts naturally gravitated to recent high-profile cases involving Adrian Peterson, Marcus Lattimore and Robert Griffin III. As Exum quickly found out, however, no two ACL injuries are exactly alike.
For someone who had never been seriously hurt -- he had never missed a game in any sport through his junior year of college, according to his parents -- working his way back to the field presented an entirely new challenge.
"I was there the night of his surgery and got him in the car and took him home," said Barbara. "I know neither Antone Jr. nor myself even imagined that this would be so painful and so difficult. We had nothing to base it on, so I think for us the initial aftermath of the surgery was most surprising. The pain, the difficulty, it was just incredible."
The initial questions are always the same: How soon will I be back? When can I expect to play again? For Exum, it was even more specific. As soon as he was diagnosed, he wanted to know if he would be ready to take the field by Aug. 31, the date of Virginia Tech's season-opening showdown with defending BCS champion Alabama.
There were no immediate answers. The journey from the operating room to the locker room is nonlinear, a track filled with ups and downs, advances and unforeseen setbacks. Before he could run, Exum had to relearn to walk. Before he could walk, he needed to be able to extend his knee and bear weight on his right leg again.
On Feb. 6, Exum met with Albi Gilmer, a physical therapist and clinic manager at the Andrews Institute, to go over his rehab plan. He began a program that consisted of quadriceps-setting exercises, heel slides, gastroc stretches and patellar mobilizations -- low-impact routines that would help Exum gradually improve his extremely restricted range of motion and limited strength.
The most painful periods in the early part of his recovery were the approximately 45 to 60 minutes each day in which therapists would stretch Exum's knee into flexion and extension, manually attempting to break through scar tissue.
"It sounds pretty cruel, but it's a guy pushing on his knee until it starts breaking loose," said Ben Graff, a clinical athletic trainer at the Andrews Institute who works closely with Gilmer. "We got to get that range manually. It's probably pretty gruesome to watch, but a guy pushing on another kid's ankle trying to bend his heel toward his butt and manually loosening it."
Added Barbara Exum, who accompanied her son to his sessions and sat in a chair beside the training table: "Sometimes it was like watching someone trying to bend metal. It's just a brutal recovery."
Things became even more difficult once Exum returned to campus. Not only was he unable to compete athletically, but he also had trouble with day-to-day activities. Simple everyday routines, like putting on socks or a pair of pants, were immensely challenging. At that point, a month or so removed from surgery, the thought of playing football -- of running and cutting and jumping at an elite physical level -- seemed like a distant dream.
"I live by myself in my apartment, so I was on crutches having to [get] to the kitchen and bring food back and forth," said Exum. "It was tough taking showers and stuff like that."
This was also the point in Exum's recovery when it became essential for him to fully grasp the nature of ACL injuries. Coming back requires patience. Coming back requires dedication. And coming back requires an understanding that each situation -- as with most medical conditions -- is unique.
"It's not one size fits all," said Graff. "It's the sport, it's the situation, it's the person. And some people have to be able to get their expectations more realistic. ... People hear the letters ACL and they assume we'll see him in a few months, he'll be 100 percent."
Given Exum's meniscus tears and his microfracture, he was particularly limited in the early stages of rehab. He couldn't develop strength or explosiveness until he increased his knee flexion, a grueling and gradual process that only comes with time. Gilmer estimates that meniscus tears and microfractures typically add a month to six months to ACL recovery, though every case is different.
"You can't compare Adrian Peterson to RGIII -- those are totally different injuries," said Gilmer. "They may both be successful, but I think it is dangerous to compare those, especially psychologically to the athlete because they may not understand why they're not healing as quickly as another person when their injuries are totally different. The ACL injury is so prominent in sports that it is all anybody hears. They don't ever hear anything about the meniscus being repaired, the TCL (tibial collateral ligament) or the posterolateral corner. And all those things can complicate a rehab quite a bit. I think that it's very dangerous psychologically for an athlete to compare themselves to somebody, especially if they have a different injury."
Recovering from a serious injury requires a different type of commitment than weightlifting or studying film. Rehab not only produces pain, it's predicated on it. Doing the things that once came more readily than anything else now hurts. No matter how commonplace ACL tears in sports seem, the process of coming back is nearly impossible to internalize until it's felt.
"Rehab is every day you walk in there you know you're going to be in pain," said Antone Sr. "You know that this whole process is going to be painful, it's gonna hurt. I'm gonna have to see what I'm made of, that kind of thing. And I was concerned because Antone had never gone through that."
Many young athletes exude an air of invincibility, and Exum was no different. Everything had always come so naturally; as a senior at Deep Run High in Glen Allen, Va., he had accounted for 2,357 yards and 30 touchdowns, including six on returns.
To be stripped of that ability often leads to confusion -- and anger.
"When you've never been hurt, you kind of think you're bulletproof," said Antone Sr. "You think it'll never happen to you. And when it does, it's pretty devastating."
This is where mental approach comes into play. Patients can elect to dwell on their situation or move forward, a choice that's much simpler in theory than in practice. Yet according to testimonies from his parents, therapists at the Andrews Institute and trainers at Virginia Tech, Exum fell squarely into the latter camp.
"He's a well-mannered, bright kid who's not afraid to challenge you, but in the good sense," said Keith Doolan, an athletic trainer at Virginia Tech. "He's not rude or disrespectful, but he wants the best out of you. If I come to rehab and I'm expecting the best out of him, well, he wants that back from me."
In the first few months after surgery, Exum worked with Marianne Harman Zolman, the owner of Blacksburg Pilates and Fitness Studio, to strengthen his core. He progressed from the AlterG machine (an anti-gravity treadmill that uses air pressure to control how much weight a user supports) to calf raises to an underwater treadmill. He would set attainable goals -- however arbitrary -- and push himself until he met them. Five more degrees of knee flexion. Ten more calf raises.
"I think with Antone, we would kind of pick a range," said Graff. "'Today, we're gonna try to get five more.' And if we stopped at four, he says, 'C'mon, let's work a little longer. Let's get that one more.'"
For the most part, Exum was relentlessly optimistic, an attitude that's difficult to maintain in a potentially career-jeopardizing situation. Gilmer goes so far as to characterize it as something that "makes or breaks" a player's recovery.
But patience is equally vital. For all that a positive outlook expedites rehab, and for all that Exum was set on returning against Alabama, sometimes an athlete's body has other plans.
"You can do everything you're supposed to do and you still might be that 12-month guy," said Goforth. "It's not gonna be about your toughness, it's not gonna be about your drive. It's gonna be about how your tissues heal."
The first time Exum ran after his injury was on June 21 in Phoenix. After traveling back and forth between Blacksburg and Pensacola for much of the spring, he flew to Arizona on May 20 and spent six weeks training with Brett Fischer, the owner and head therapist at the Fischer Institute. Fischer worked with Tampa Bay Buccaneers cornerback Darrelle Revis during his ACL recovery this offseason.
While there, Exum was exposed to ASTYM, a treatment set for soft tissue therapy. He was treated with joint mobilization and completed active range of motion exercises. He picked up recovery tips from Revis and film-room tips from Will Sullivan, a well-known defensive backs and wide receivers coach who has previously worked with Revis, Anquan Boldin and Vincent Jackson, among others. Exum was approaching the five-month mark since his procedure. He was ready to enter the next phase.
After being given approval from the staff at the Andrews Institute, Exum and Fischer took to the turf on a Friday afternoon. Exum ran 10 60-yard striders. He was far from perfect, but his knee handled the weight, stabilized and kept going.
"He was running for the first time, he had a little bit of that Bambi effect," said Fischer. "When Bambi first gets born, the legs are kind of all over the place. But he got better. And every day he's gotten better."
Exum began running three times a week while improving the range of motion in both his hip and his ankle, something Fischer says can make a tremendous difference in getting the knee to function properly. Three weeks after sprinting for the first time, he started to run more fluidly and resemble the player who NFL scouts pegged as a likely second- to third-round draft pick last December.
"The body becomes a neuromuscular idiot after surgery," said Fischer. "It just does. It short-wires itself and it has to learn how to walk, it has to learn how to run. But it comes back. The human body is an amazing thing."
Despite recent medical advances, returning from an ACL injury is not guaranteed. According to a 2010 study co-authored by Andrews in the American Journal of Sports Medicine, only 63 percent of NFL athletes who had an ACL reconstruction returned to play another game, with an average recovery time of 10.8 months. Part of that total includes fringe players who were barely hanging on in the league, but another part is made up of athletes who simply never made it back.
Rehab can become even more complicated when, in cases like Exum's, multiple sets of trainers and therapists are involved. Communication -- from sending weekly progress reports to text messages to videos -- is essential to making sure every stage of a recovery stays safely planned out.
"I think that that has played a huge role in his recovery," said Barbara, "because each of [the trainers and therapists] played a different role and they were at different places in his recovery."
Exum left Phoenix on July 6 with the goal of suiting up against Alabama in the Georgia Dome less than two months later. As he'd soon discover, however, the end of the rehab process poses a very different set of challenges than the start.
When Virginia Tech opened fall camp in August, Exum felt encouraged. He'd been in Blacksburg for nearly a month at that point. He'd passed his conditioning test by running 16 100-yard dashes in less than 15 seconds each. As a veteran, he took on a leadership role, helping defensive backs coach Torrian Gray get true freshmen cornerbacks Brandon Facyson and Kendall Fuller acclimated.
Exum set up an appointment with Dr. Andrews for Aug. 5, with the hope of getting cleared to play. His knee, however, wasn't ready.
"They told me I had about two more months left until I could play again," said Exum of his trip to Pensacola. "They told me [that what] I had to work on was just my quad strength. I needed to get some power back in my knee. Also I needed to come a ways in my mental state, just trusting me knee and [making sure] it is strong enough to handle certain things."
When most fans think of the mental toll involved with ACL injuries, they think of the process of learning to trust a knee. There's no set amount of time it takes before someone is able to regain faith in his body, particularly when speeding up or slowing down, jumping or landing -- doing the types of things that made a player special in the first place.
Still, there is arguably an even greater mental hurdle. For athletes who have spent the majority of their lives being pushed to the limit, it's tough to dial things back. One more rep can be a bad thing. Rest is a crucial component of recovery.
"I always equate it to when you're listening to an opera, sometimes the quiet parts of the opera are just as important as the loud parts," said Graff. "You gotta have that pause in the middle to kind of set up the next step. I think these guys can kind of relate to that. They know you can't work chest five days straight. You can't just run sprints five days straight. So why would you pound a joint five days straight?"
This was perhaps the most difficult piece of the puzzle for Exum. He has always taken pride in his work ethic. In fact, he considers it one of his defining attributes. In the moments after he came out from under the anesthesia following his surgery in February, Exum told Andrews, a consultant to Alabama's medical staff, that Virginia Tech would beat the Crimson Tide. He talks the talk -- he refers to his man-to-man coverage of wide receivers as Exum Island Daycare -- and he works tirelessly to back it up.
However, it's one thing for a player to have patience when he can barely walk. It's another when the finish line is seemingly in sight, but issues such as favoring one leg over the other still need to be corrected. Goforth and Doolan label patients as "push-me" or "pull-me" guys, who either require motivation or require monitoring to make sure they don't overdo it. Doolan says Exum fell into the second group.
"You can't always listen to them, 'cause they're gonna try to fool you," said Doolan. "They're trying to do everything in their mind to convince you that they're exactly ready. But you gotta go by your numbers. You gotta go by history. You gotta go by what research tends to show."
Echoed Gilmer: "There has to be a balance when you rehabbing these guys. If they overtrain, they're gonna end up setting themselves back. They've always been taught 'no pain, no gain.' And that can work in their favor, and it can also work against them if they're not recuperating, if they're getting tendonitis or something like that because they're overdoing it. Those can be huge setbacks."
There's one other aspect to keep in mind in all of this. Even when someone comes back from a serious injury, it's unknown if he'll be the same player he was before he went down. Not everyone is Adrian Peterson. Not everyone straps on pads and a helmet and instantly regains All-America form. For all of the attention paid to accelerated medical timetables, an inherent level of doubt will always exist.
"If [a player] runs a 4.4  and now all of a sudden we get him back out there and he's a 4.49 or a 4.5, the guy behind him is probably better than him," said Goforth. "So you've gotta take that Mercedes that's been wrecked and actually make it better than it was before it wrecked. And that's a fine line. If he's a 37-inch vertical, he needs to be [at the same level] to be the player that he was before he got hurt.
"It's a fine line between what a Division I guy does and a Division II guy. Or it's a fine line between an NFL guy and a Division I guy. So we really gotta get him better than he was before, and that's tough to do."
Sitting on the bench after Virginia Tech's 27-17 win over North Carolina last Saturday, Exum reflected on his journey. He talked about where it started, and how his rehab has evolved. He expressed his desire not only to come back, but to quickly establish himself as the top cornerback in the country. (In an earlier phone interview, Gray said Exum would start immediately upon his return, though Gray noted it may take some time to give Exum full reps and to establish chemistry with the rest of the defensive backs.)
Exum also explained his decision to delay his comeback, emphasizing his internal struggle between the temptation to play and the understanding that he wasn't yet in game shape.
"The whole process I've had that mindset of waiting to do what is best for me as far as right now and for the future," said Exum. "But once I got cleared I kind of lost the future and was just solely thinking about the present because I was so excited. I kind of got caught into that."
Exum hopes to make his debut this Saturday against Pittsburgh, but he's done setting dates. He'll take the field when he's ready.
Rehab is long. It's incredibly painful. Three letters that are often uttered without second thought can allude to a highly individualized recovery process that asks for everything and guarantees nothing.
Exum's greatest achievement won't be his return. It will be how he got there.
"It's watching your child that would run around the house on Friday night when he was about to play on Saturday in full equipment, full gear, helmet, shoulder pads, you name it," said Antone Sr. "To follow that all the way to high school, the excitement. To watch a kid that's always been either one of the best athletes or the best athlete wherever he is, to watch him be grounded. To watch him lose, temporarily, the gift that was given him.
"To see him lay in bed, which I know he would never admit to, but be in tears trying to sleep and being up all night because he was in pain, to actually being on the field running now and making cuts -- it's nothing short of amazing."