Anterior cruciate ligament injuries – are they becoming more common?

by Anne O’Donoghue for The Irish Times on Friday 8th July.

ACL Surgery at UPMC Sports Surgery Clinic

‘It doesn’t take great force to do it. A certain amount of bend, a certain amount of what we call valgus – inward bend at the knee – and a certain amount of rotation.” Put that all together and you have the “perfect storm”; a recipe for disaster described by Mr Ray Moran. The result? A ruptured anterior cruciate ligament, also known as ACL.
Moran is an orthopaedic surgeon, based at the UPMC Sports Surgery Clinic in Santry, Dublin. He reconstructs hundreds of ACLs every year.
The ACL is located in the knee, joining the tibia and femur. The injury does not occur through wear and tear; the rupture is a traumatic incident, specific and acute. In its simplest form, the ACL ruptures due to a twisting of the knee. A tear may be partial or complete.
When the athlete lands and their foot comes in contact with the ground during a change of direction, the force can hit the knee a certain way which twists it. The quadriceps muscles pull and the twisting motion overloads the knee, causing the ACL to rupture.
An ACL rupture is particularly devastating to athletes because of its long recovery time, which can be anywhere between six to 12 months.
Studies show women are three to four times more likely to rupture their ACL than men. There is no single reason for this and experts are not entirely sure why injuries are more common in women. However, some theories include the fact that women have a naturally wider pelvis, causing the knee to fall towards the centre more. Women also tend to be more supple than their male counterparts and have a smaller bone surface area.

Real-life ramifications

One woman who can explain the real-life ramifications of an ACL injury far better than any scientific term is Galway camogie player Therese Manton. Manton was a late bloomer when it came to camogie, only taking up the sport at the age of 11, but since then she has flourished.
The Mullagh club woman won two Ashbourne cups during her time at University College Dublin and a senior All-Ireland camogie final with Galway in 2013. In 2015, Manton contested two All-Ireland finals, first a club All-Ireland final against Wexford’s Oulart The Ballagh and the senior All-Ireland camogie final against Cork.
They were fruitful in neither challenge, but the 28-year-old returned at the start of this season hoping to right the wrongs of last year. However, that perfect storm occurred.
It was a challenge match against NUIG in Ballinasloe – a minor match, just a chance to give the whole panel a run and test different combinations of players.
Manton was beginning what would have been her 10th year playing camogie with Galway, a seasoned hand at this stage. Towards the end of the match, she was driving forward from the full-back line and went to dodge the player in front of her. That movement caused her to fall to the ground.
“I actually don’t remember much. The girls told me I screamed when I went down, but what really made me nervous, what I can remember, the most horrifying thing was that I could hear the crack in my knee and I think that is what frightened me most.”
At this stage, Manton was unaware that she had just ruptured her ACL. In the days and weeks afterwards, she did not experience much pain, just soreness and tenderness. She worked on getting the swelling down in her knee and thought she had not done much damage.
Manton, a nurse, thought it was a little excessive when a physician suggested she go for an MRI, but she took the advice anyway. “Even the morning I was going for the MRI I felt like a bit of a fraud, that I didn’t have a genuine injury. I thought the MRI was a bit excessive, but I went and had it done.”
Sure enough, the rupture was discovered. A visit to Moran ensued and then surgery. Manton underwent the surgery at the end of March and is in the third month of her rehabilitation programme. She is not alone or even in an exclusive group of sportspeople who have ruptured their ACLs – many athletes have done it and there have been a lot of high profile cases.

More common?

The question, discussed in serious tones on sidelines and debated in dressing rooms after matches, is are ACL injuries becoming more common? There is no definitive answer, says Moran, because there is no concrete data from yesteryear from which we can use to draw a comparison.
“If you go back 20 or 30 years you have a situation where the MRI scan was only coming into its own. If you go back about 40 years and you got a rotational injury to a knee and players had any sense of giving, it was assumed to be cartilage. I still see patients today in their 50s and 60s who have ruptured their ACL and don’t know it.”
Enda King, a physiotherapist and head of performance rehabilitation at the UPMC Sports Surgery Clinic, says ACL injuries are more common among those who play field sports, because the movements required are riskier to the knee.
“A runner can [injure their ACL], but it is all about risk. The high-risk positions are single leg landing and single leg change of direction. So, cyclists, swimmers and track and field athletes are moving straight ahead; I can’t remember the last person I saw doing their ACL like that.”
King, currently doing a PHD in rehabilitation and return to play after ACL injury, says prevention is possible.
There will always be a certain amount of ACL injuries which are contact – they cannot be prevented – but non-contact injuries, which have to do with the way an athlete moves, can be reduced through improving movement and lower body strength.
Manton is very passionate about injury prevention and it is something she says she will push for when she finishes her recovery. “Obviously going through this myself, I wouldn’t want anyone else going through it and if we can try prevent it I think we should. We need to start working on it now rather than later.”
ACL rehabilitation can take anywhere between six to 12 months, but King is quick to warn that there is no one-size-fits-all scenario for returning to sport. Your return should be guided by how well you move, not how many months you have been in rehabilitation, he says.
Manton has a very positive outlook on her injury. She is progressing well in her rehabilitation programme, which she does five to six days a week with her husband, who is also recovering from an ACL injury.
“The programme really helped me in that I am progressing very well, but it also helps keep your mental health in check, knowing that you are doing all you can to get back to the game you love.”
King’s advice to those who may be dejected because they are injured is that “every injury is an opportunity” to come back a better athlete then you were before.
“If you ruptured your ACL and it wasn’t a direct hit to the knee, that is clearly a sign that athletically speaking or from a movement competency point of view, you weren’t really moving as well as you could.
“Obviously no one wants to take six to 12 months out to try to improve their movement, but it is an opportunity to come back stronger and fitter.”
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