Are instances of knee injuries increasing?
Down player Barry O’Hagan’s cruciate injury hit the headlines earlier this year and led some to question if these knee injuries are happening more often. In this feature, two local physiotherapists give their views.
EARLIER this year, Down GAA was hit with a blow when star forward Barry O’Hagan was ruled out for the rest of the season, following the news he had damaged his cruciate knee ligament.
The news was disappointing for a Down team who appeared to be in good form ahead of the league campaign, as O’Hagan was expected to be a key player. On the night in question he had scored 0-3 against Antrim.
The injury prompted Mourne Observer GAA writer Peter McGrath Jnr to ask why we hear of repeated instances of cruciate injuries in Gaelic football.
A man very well placed to answer the question is former Down and Mayobridge player, Michael Walsh.
He suffered a cruciate injury as a player, and it was knee injuries that ended his playing career.
He is also well-informed about knee injuries because he has a physiotherapy practice in Mayobridge which specialises in injury treatment and reconditioning, building injury resilience and overall performance levels of athletes.
“ACL is a common injury, but it has always been there,” Michael said.
“Any team sports that involve a lot of cutting manoeuvres, and changes of direction and sudden decelerations from landing and sprinting you are always going to be putting the knee at risk.
“I suppose now everyone hears about people doing their ACL because it is more public and in the media, but years ago you might not have heard it about it.
“They might not even have had it diagnosed, and maybe didn’t know what to do with treatment.”
One reason why cruciate injuries happen is cutting and twisting and the pressure that places on players’ joints. That happens in games, but Michael said that if it happens in training as well, then the risk is increased.
“The more small-sided game scenarios you put players into then the more twisting and more demand and risk you put them under.”
The force they put on their knees is one reason for strain, but the surface might also play its part.
Michael said: “Researchers point to proof of more knee and ankle and soft tissue injury from playing on 3G and 4G surfaces. There are different ground reaction forces that are created through these surfaces.”
So, what can players do to try to reduce the risk of suffering such knee injuries?
Michael said: “You have to improve your ability to absorb load, not produce load. Most times when players are going to the gym they want to see how much they can push in a squat, for example, but that is producing force, but ACL injuries happen the opposite way.
“They happen when a player is applying the brakes. If they come out of a sprint they are absorbing load. So, they have to train for that. The more you can train yourself to tolerate load, the less risk you will have of these types of injuries.
“In a simple way there is no point in building horsepower if you can’t apply the brakes. If you have a fast car but if you don’t have the brakes then you are not going to be able to take the corners.
“If a player has speed but he can’t decelerate well then he is more likely to have an ACL injury.”
For Michael, he felt that education was so important.
“I try to educate the people I am rehabbing. I feel it is a good thing the more they know. I would say there is a lack of education.
“It is never a straightforward thing. People think all ACL injuries are the same, but they are not.
“There could be other ligaments injured. The medial ligament. The lateral ligament. There can also be cartilage tears. That can make things different, if you have a cartilage involved.
“That is what put me out of my sport.”
The time it takes to recover is also important to take seriously.
Michael said: “Everyone has this notion that it is a nine-month injury, but research shows that 12 months is a safer time (to take before returning).
“There are too many people coming back too early with strength deficits, power deficits and limb asymmetry. They have not rehabbed fully.
“Anyone who comes back in nine months or less is at a higher risk of reinjuring and not only the same side, but the other side.
“But they develop patterns that are over-compensating. They overload and become vulnerable on the other side.”
He felt that younger players getting ACL injuries should be a concern.
He says it happens more often than we think and coaches need to know how to protect against it.
“You have to take into account other factors, such as growth spikes. When young lads go through a growth spurt, they become awkward in themselves.
“They are not as in control of their body. It is called adolescent awkwardness.
“GAA clubs need more awareness of that. If we were monitoring growth spurts among children through the year, say quarterly, if you have more than 7.2 cm of a growth spurt in a year that child’s training should be monitored, altered and reduced to allow them to go through that phase. We are probably losing a lot of talented sports people through not having an awareness of what they go through at that age.”
Michael said that his own club, Mayobridge, are currently monitoring the growth spurts and development of their U-15 and U-17 players.
They advise coaches when to reduce training when it happens.
What about Barry O’Hagan?
Michael reckons that Barry will make it back, but he has to take his time.
“It is a really hard injury to come back from.
“But I know that Barry is very diligent in everything that he does.
“Barry is very diligent and he will put the work in. He just has to approach it correctly.”
Francis Quinn is a physiotherapist who runs a practice, along with Kieran Murray, called the Physio Group, which has sites in Newcastle and Newry.
Francis has experience of working with athletes throughout the world of sports, including many Gaelic footballers.
Francis has also worked as a physiotherapist with Sunderland AFC, when they played in the Premier League and Championship.
He explained that knee injuries are a costly business, and perhaps that’s why they get so much attention.
“Following injury studies by FIFA clubs were saying that the cost of injuries is a big drain on resources. Arsenal, eight to ten years ago, produced a report to say that
every injury costs their club £320,000, based on lost wages and lost player time.
“FIFA then decided to abolish the tackle from behind.”
He explained that knee injuries are the second most common injury in the GAA, behind thigh injuries, which includes hamstrings, and they too are costly to the amateur clubs who have to deal with them.
“The GAA injury insurance is capped at £5,000. Surgeries have become more complex. That has led to other issues. ACL reconstruction used to cost £4,500 but the basic one has gone up and is close to £6,000. The cost isn’t covered by the insurance scheme anymore.
“There is guilt for the players costing the club money.”
A lot of research has ensured a much greater understanding of these serious knee injuries.
Frank said: “They know that two thirds happen during games. They know that 80 percent of them are first time, the rest are repeat.
“They know that females are eight times more likely to do their cruciate than males.
“They still haven’t pinned down whether that is bio-mechanic. In females the angle that the femur leaves the hip at is a different angle to the male.
“They are investigating whether the menstrual cycle and hormonal changes (is a reason for a higher ratio). We know it does around the pelvis but does it happen for other joints?”
When it comes to working out why it happens, there are some pointers to take from the GAA.
“A big part of the problem I think in Gaelic sports is how the athletes prepare,” Frank said.
“It is a running, twisting, turning game yet a lot of the off-season training is very linear.
“I think flexibility and agility are two athletic components that have been nudged aside in Gaelic Games.
“They have been replaced by strength and conditioning. A lot of coaches go for strength and power.
“Very simple agility exercises have been lost in the GAA, for example, like running left hand down, right hand down.
“They might have been lost because they seem simplistic.”
He explained that the GAA’s focus on strength and conditioning might have led to more knee injuries.
“I think GAA players have tried to chase muscle mass and power as a holy grail for improving athleticism, but they have forgotten that the joints that carry those loads and provide the fulcrum of the force have not changed their structure.
“But if the ligaments hold the bones in place but allow guided movement, if they can’t withstand the force that the muscle put through the joint then you are in trouble.
“You never see GAA players do exercises to train the lower leg. It is always hip and thigh. Whatever forces the hip and thigh produce that force has to be passed on to the ankle joint in a controlled manner. So there is an imbalance with the upper part of the leg to the lower part of the leg that can create these problems.”
So, with GAA players focused on strength and conditioning, how much could it be that the problem is being exacerbated by a lack of education?
Frank said most people know someone who has had a cruciate injury, but the in-depth knowledge may not exist.
“I don’t think they are aware of how they can protect themselves from that type of injury.
“At the end of the day players are at the mercy of what is dictated to them from the trainers and their coaches.
“If the message being delivered is leading to them being vulnerable, and it has to be because so many injuries are non-contact, then it has to do with preparation. That could be long-term or short-term preparation.”
Frank explained some of the preparation that players should be doing to reduce risk.
“The first prevention advice I give people is ‘Can you lift your own body weight in multiple directions? Can you do that in a coordinated manner?’
“Have you got flexibility and variability of movement that can allow for an awkward twisting action that might lead to an injury?
“In the warm up pre-training, have you got muscles switched on and are you doing movements that you are going to perform at high speed in a game?”
With injuries happening in the GAA, players can make an effort to protect themselves. But is there anything the GAA could do to reduce the instances of knee injuries?
Frank felt that there isn’t.
“From an overall GAA point of view, because of a lot of them are non-contact, there is not a lot that they can do rule-wise.
“I’m not sure how Gaelic could, from a rules point of view, reduce match-related ACL injuries, because two thirds happen in matches, because they are non-contact.
“Injury prevention across the board is an ongoing battle.
“Clubs at this time of the year would say that they are doing pre-season exercise so to keep the injuries down. But it is a long-term plan.
“But have we devoted enough time to flexibility and strength maintenance? Are we fatiguing them, so they are not able to protect themselves in high-speed match scenarios?
“Have you covered agility, endurance, plus the ability to execute the skill at high speed