POP: When Sport Brings Us to Our Knees

Produced by the Slattery Media Group Pty Ltd for Jess Cunningham

JESS CUNNINGHAM

www.jesscunningham.com.au

Slattery Media Group Pty Ltd

902/31 Spring Street, Melbourne, 3000

slatterymedia.com

Text © Jess Cunningham 2022

First published by Jess Cunningham 2022

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means without the prior written permission of the copyright owner. Inquiries should be made to the publisher.

ISBN: 978-0-6454913-1-9

Group Publisher: Geoff Slattery

Cover design: Alice Beattie

Typeset: Kate Slattery

Printed and bound in Australia by Ingram Spark Publishers

Written on Dharawal Country with acknowledgement and respect to the traditional owners of the lands and waterways upon which Australian sport is played

DEDICATION

To my clients and their knees

POP /pop/

Noun/verb - the sound or sensation often felt in the

knee when an ACL injury occurs

Abbreviation of popularise – to make a scientific or academic subject accessible to the

general public by presenting it in an understandable or relatable form

Contents

Part 1

ABOUT THIS BOOK

We have an ACL problem

What is the ACL?

The knee

ACL injury

Diagnosis of an ACL injury

What is an ACL reconstruction?

How to use this book

A note from the author

Part 2

Athletes’ stories

Aerial skiing - Lydia Lassila

American football - Adam Gotsis

Football (soccer) - Lydia Williams

Netball - Kim Green

Rugby Union - Mitch Short

Freestyle skiing - Anna Segal

Australian Football - Daniel Menzel

Snowboard cross - Belle Brockhoff

Rugby Union - Damien Fitzpatrick

Cricket - Callum Ferguson

Freestyle skiing - Russ Henshaw

Sailing - Eliza Solly

Ice Hockey - Nathan Walker

Part 3

Afterword

Listen and learn

ACL Cheat Sheet

Setting yourself up for success

Prevent, perform, recover, & reflect

Sport specific programs for injury prevention

Learn, connect & share

Acknowledgements

Glossary

Endnotes

Introduction

We have an ACL problem

There’s no denying that Australia is a sports-loving nation.

We punch well above our weight on the international stage and have a rich sporting culture. Whether playing, watching, or talking about sport, we really can’t seem to get enough.

But our love of sport also seems to be bringing us to our knees.

Research has shown that in Australia we have the highest rate of anterior cruciate ligament reconstruction (ACLR) in the world.¹ Between 2000-2015, a total of 197,557 primary ACLRs were performed in Australia. During this time, the average incidence of ACLR increased by 43 per cent, and more alarmingly by 75 per cent in those under 25 years of age. Revision surgery also increased by 5.6 per cent per year. Direct hospital costs of ACLR surgery in 2014-2015 were estimated to be $142 million. We also know that females are up to six times more likely to injure their anterior cruciate ligament (ACL) compared to males due to differences in hormones, biomechanics, neuromuscular control,² and gendered social and cultural factors such as training access and training age. With stats like these, it is clear we need to look closely at how we approach the way we are managing and working to prevent ACL injuries.

Of course, prevention is always better than a cure. The first step in reducing our alarmingly high rates of ACLR surgery is to simply stop the injury from occurring in the first place. There are many evidence-based sports-specific ACL injury prevention programs that have been shown to reduce the likelihood of ACL and lower limb injury by around half in all athletes, and up to two-thirds in females³,⁴,⁵ (see Part 3 for a full list of sport specific programs). As well as reducing injuries, these programs have the added benefit of improving performance and require only 10-15 minutes to complete—either before or after training and games, or at home.⁶ For the programs to be effective they need to be completed routinely, and in an ideal world at all levels of sport. Yet a huge gap continues to exist between this knowledge and it's implementation. Increased public awareness as to the existence of these programs is required.

For those who suffer an ACL rupture, the automatic assumption and narrative surrounding the injury has historically been that surgery is required (it was thought that the torn ACL could not heal) and that the athlete’s sporting season is over. But emerging research suggests we may need to rethink this approach⁷ with spontaneous ACL healing shown to occur⁸,⁹,¹⁰ in nearly two-thirds of full ACL ruptures¹¹. Good results have also been obtained from non-surgical management and thorough rehabilitation.¹²

The sports medicine world has long known it is possible to manage without an ACL, and those who cope with its absence are not limited to leading sedentary lives as was often traditionally thought. There are growing examples of athletes returning to pivoting and high impact sports without an intact ACL;¹³,¹⁴,¹⁵,¹⁶,¹⁷ who are not just surviving but thriving in their sport, as well as maintaining good knee function into the future.¹⁸,¹⁹,²⁰

Despite these research findings, it must be stressed that not everyone is a ‘coper’, and that for some, ACLR remains the best option. ACL injury management must always be considered on an individual basis, with patients made aware of the surgical and non-surgical treatment options available and their similar outcomes regarding the risk of future meniscal tears and osteoarthritis.²¹,²²,²³

Regardless of which management option is sought, there can be no denying that ACL injury is a significant interruption to anyone’s physical life and requires an involved period of rehabilitation if optimal physical performance is to be achieved. Although the timeframe for returning to sport is anything but exact, realistic expectations and the achievement of functional strength and ability milestones throughout the rehabilitation process is vital. However, unfortunately for many this is not always the case. Research shows that returning to sport before nine months post-ACLR is associated with up to a seven-times increased risk of re-rupture,²⁴ and worryingly most adolescents expect to return in six months or less,²⁵ with fewer than 15 per cent passing their return-to-sport clearance testing criteria at eight to nine months after surgery.²⁶,²⁷ Obviously it is important to increase awareness around setting realistic expectations for return-to-sport timeframes, and the successful completion of end-stage rehab cannot be overlooked if the increasing rate of re-ruptures is to be reduced.

No matter how telling these research findings are, the fact is that most of us don’t respond well to such data. And so there will be no further discussion in this book about statistics and numerical research findings. Instead, the pages are filled with what we respond to best—stories and emotions, all told by successful athletes from their lived experiences with ACL injury and rehabilitation.

The purpose of this book is not to argue whether conservative or surgical management is the better option, but rather to provide a valuable resource offering inspiration and education around the rehabilitation journey ahead for those who have suffered an ACL injury.

The common phrase heard from all the athletes interviewed for this book was, I wish something like that had existed when I was going through it all.

Now it does.

What is the ACL?

The ACL is one of the four main ligaments (a strong band of fibrous connective tissue connecting bone to bone) that connects the thigh bone (femur) to the shin bone (tibia). It runs diagonally—deep within the knee joint connecting the back of the femur to the front of the tibia—and forms a cross with the posterior cruciate ligament (PCL) which runs in the opposite direction, hence its name (cruciate is from the Latin word for cross). The ACL and the PCL work together to stabilise the knee during impact and rotational forces. The two other main ligaments—the medial collateral ligament (MCL) and lateral collateral ligament (LCL) run vertically on either side of the knee to support side to side movements.

ACL injury

Rupturing the ACL is one of the most common knee sporting injuries and can occur from direct trauma (contact to the outside of the knee in a tackle), as a result of twisting force through the knee (cutting or pivoting movements to avoid an opponent), or from awkward landings (landing off-balance with more weight on one leg). Other structures such as the medial and lateral meniscus (shock absorbing crescents of cartilage between the tibia and femur) may or may not also be injured in the same movement.

Diagnosis of an ACL injury

A tell-tale ‘pop’ is often felt or heard as the ligament fails. Swelling is usually immediate and significant. The integrity of the ACL is assessed most commonly using two main tests performed by clinicians—the Lachman’s test and pivot shift test. Magnetic Resonance Imaging (MRI) is usually utilised to confirm the diagnosis.

What is an ACL reconstruction (ACLR)?

Management of an ACL rupture can either be surgical or conservative. When surgery is performed it aims to reconstruct the damaged ligament using a graft to restore the internal stability of the knee. The surgery is performed using a minimally invasive arthroscopic approach where surgical tools and a small camera are inserted into small incisions on either side of the knee.

The graft can be:

an autograft (tissue from the person’s own body—using the hamstring, patella tendon, quadriceps tendon);

an allograft (tissue from a donor—cadaver Achilles);

synthetic (a Ligament Augmentation and Reconstruction System (LARS) graft—note these are no longer commonly used due to poor outcomes).

How to use this book

The intended purpose of this book is to share the journeys of athletes (both with, and without their ACLs) who have successfully returned to sport after an ACL injury, and to inspire and motivate individuals who are currently in rehab. I hope it can be a helpful tool that therapists and surgeons—and friends and family—can offer to the injured, whether they be professional or aspiring athletes, weekend warriors, or those unfortunate enough to be on the receiving end of dance floor antics gone wrong!

It is designed to be easily picked up and put down—ideal reading during knee-icing sessions for anyone with a freshly injured knee! After reading the introduction section (Part 1), the athlete chapters (Part 2) can be read chronologically or in any order depending on personal interests in particular sports or individual athletes. These chapters comprise two sections—the nuts and bolts of each athlete’s ACL story, and their reflections on their journey through it all. Explanations of technical terms can be found in the glossary at the end. The concluding section (Part 3) can also be read at any stage, and is not to be missed as it contains important practical advice for anyone going through their own ACL injury journey.

The stories in this book will also assist in improving the conversations that need to take place when an ACL injury is sustained. We can all benefit from a greater awareness of what options exist, and what our bodies can achieve with sound management and the hard work required during rehabilitation.

The aim of this book is not to suggest the perfect way to manage, rehabilitate or recover from ACL injury; nor does it intend to be a ‘how to’ text on ACL rehab and return to sport protocols (these are readily available elsewhere).

Athletes from a variety of sports have been selected, including sports where ACL injuries are not often thought of as common (sailing, cricket), with a cross-section of international approaches to surgical management and/or rehabilitation.

A diverse selection of athletes has been chosen whose stories demonstrate a variety of rehabilitation support and experiences, different graft types, optimal or less-than-optimal outcomes, and conservative versus surgical experiences.

With the focus on the athletes and their stories, the names of all medical and rehabilitation professionals involved have been omitted. The goal is not to point fingers or lay blame where outcomes weren’t optimal, but to simply tell each athlete’s story in their words, warts and all, so that we can all learn from their experiences—both good and bad.

A NOTE FROM the author

I have always had a love of sport, and an interest in the mechanics of the body, and I have been lucky to combine the two successfully throughout my career. As an Australian-trained Sports and Exercise Physiotherapist I have been fortunate to work alongside some of the world’s best athletes and sports medicine teams in Australia and overseas. With such work comes the immense satisfaction of helping athletes achieve their highest of highs—successful Olympic campaigns, World Championships, Grand Finals, and personal bests.

But the biggest sense of fulfilment comes when helping an athlete back from their lowest of lows, as devastating injuries are never far away when you are pushing the limits of physical performance. In my job, that’s what it is all about.

From the often dramatic and gut-wrenching buckling of the knee and traumatic ‘pop’ sensation at the time of the ACL injury, to the usually long and involved rehab required and their time out of sport, no athlete goes through an ACL rupture without having their life upended. But as they say, you need resistance to fly. In my experience the learnings that come from being forced to take time out and change the way you once approached your sport are always immense.

I wasn’t always interested in knees and can’t say I ever imagined I would create a book solely about ACL injuries. But knees seem to have followed me through my career, particularly from the start of my involvement in winter sports. I worked nomadically through a decade of winter seasons, basing myself in Wanaka, on New Zealand’s South Island, during the southern hemisphere winter, and travelling with national teams and athletes (Australia, New Zealand, United States) during the northern winters. In winter sports, ACLs pop like candy. During those years, I assessed and treated more ACL injuries than at any other time in my career.

There are two ACL-injured athletes in particular—Anna Segal and Russ Henshaw, both Australian Olympic Slopestyle skiers, whose scenarios personally and professionally challenged me, and made me rethink what could be possible with the management of ACL injuries. As their physiotherapist I was involved in helping each of them to compete successfully at the 2014 Sochi Winter Olympics with only one intact ACL between them! Their stories are included in the pages that follow; their experiences are what planted the seed for me to write this book.

As well as working in elite sport, I have also consulted in a variety of private-practice settings treating many amateur athletes, weekend warriors, and everyday clients who have sustained ACL injuries. The challenges faced by all who sustain an ACL injury—professional athlete or not—are very often the same.

Physiotherapists are well-positioned to counsel and educate attitudes to ACL injuries, to outline available options (conservative versus surgical), to describe the rehab process, and to motivate and encourage rehab to the end stages. I always tell my athletes and clients that successfully travelling through their ACL journey, although lengthy and often frustrating, will make them the best athlete they’ve ever been. Over the years I have realised that the stories of others who have travelled this path successfully are louder than any words I or other clinicians could utter. Sharing the ACL journey of a relatable athlete is more powerful and inspiring to a client ‘buying-in’ to their rehabilitation than any amount of discussion and explanation surrounding the latest ACL research findings or rehabilitation protocols.

I hope that by sharing the ACL journeys of these Australian athletes who have not only rehabbed successfully, but achieved amazing things along the way (with a few tricky moments thrown in), this book will provide an emotional road map on how to work through the injury, to motivate those who have injured their ACL to complete their rehab and not just return to their previous level, but to go beyond, and thus reduce the likelihood of sustaining a recurrent injury.

Jess Cunningham — June 2022

Aerial skiing

Lydia Lassila

Lydia Lassila is an Olympic champion in aerial skiing who sustained two left-knee ACL ruptures during her career. She underwent reconstructive surgery in Australia for both injuries—utilising an Achilles allograft for the first, and a hamstring graft for the second—and undertook the early stages of her rehabilitations in Australia before progressing to water ramp and on-snow rehabilitations in North America and Europe.

I competed as an aerial skier for Australia over five Winter Olympics. I won gold at Vancouver in 2010, and bronze at Sochi in 2014. As well as winning the medals, I am proud to have pushed the boundaries of my sport and helped bridge the gap between male and female aerial skiers by being the first female to perform a quad-twisting triple somersault—a mission of mine since beginning the sport in 2000. I achieved this while also being a mum to my two sons on tour during my last two Olympic cycles (Sochi and PyeongChang). These days I wear a lot of different hats: retired athlete, mum, wife, business owner, mentor, yoga lover and surfing enthusiast. I love surfing and I love being in the ocean. Like aerial skiing, it allows me to be 100 per cent present whilst filling my void and need for thrill and adrenaline.

It had always been my dream from when I was young to go to the Olympics. Before skiing, I was a national stream gymnast, winning multiple national championships. I showed talent at a young age and was asked to join the elite program, but my parents wouldn’t allow it as training was too far from home. It wasn’t until I was asked a second time as a 15-year-old, that they finally agreed. But I injured my ankle, and then wrist and as a result wasn’t able to make the team for the 1998 Commonwealth Games nor 2000 Olympic Games. I then heard about a program that was turning ex-elite gymnasts into aerial skiers—it was literally a case of one door closing and another door opening. My Olympic goal was still the same, it was just my sport that changed.

I didn’t think I could like another sport as much as l loved gymnastics, but I quickly became obsessed with aerial skiing. I was desperate to progress quickly and bypass the beginner stage and go straight to the World Cup level; and that’s not far off what happened. Eighteen months after not being able to ski at all I finished eighth at my first Winter Olympics in 2002 in Salt Lake City.

Looking back, it was all a bit nuts to progress that quickly. It was pretty full on. But I was really driven and trained like a work horse. And I was competitive. I had all the makings of what was needed to be a really good athlete. I was as tough as they come. But I was also reckless. At that stage there was no structure within the program, no physios and I overtrained with no objection from my coaches. I jumped with injuries. I did tricks I wasn’t ready for. And I guess that behaviour was fed by the fact I was doing well and was progressing, even though my body was getting quite injured.

The injuries started right from the beginning. At the Salt Lake Olympics, I had a torn medial ligament (MCL) in my knee, and I required a shoulder reconstruction soon after. Because I couldn’t hold my arm up, I’d started to go crooked off the jump and landing heavily on one leg. As a result, I ended up with a cyst in one of the small joints (L4/5 facet joint) in my lumbar spine. I really wasn’t in great shape after those Olympics!

It took me a good few years to start to feel normal again. I kept reinjuring my shoulder each season, and my back was really twisted after all of the punishment I kept putting it through. It was like I needed complete rewiring on my right side. When I think back, I was really quite messed up. At one point I also had a stress fracture in my thoracic spine, bruised ribs, and multiple concussions.

At that stage we didn’t have consistent physio for the team. We only had coverage at World Cup events and not at training camps. By that stage, I was already injured and trying to self-manage and cope with ice and Ibuprofen. It wasn’t good. My early injury management was all a little too late and reactive. I was constantly pounding myself and wasn’t able to get on top of niggles and injuries and improve. It was very difficult.

When I blew my knee the first time, I was on the water ramps in Lake Placid. It was day two of summer training. On my second jump I caught an edge and my knee twisted as I went up the jump. I didn’t feel a pop, I just felt a really strong twist on the outside of my knee. I thought I’d just done the lateral ligament. But there was a lot of pain, and it puffed up straight away.

It took a while to diagnose exactly what was wrong. We didn’t have a physio with us. I