Limerick’s Mike Casey conquers ‘dark moments’ on long road to recovery from injury blows

This article was published on the Independent and written by Donnchadh Boyle.

Earlier this year, when Limerick were still searching for their first win in the National League, Mike Casey had his own little milestone success.

Limerick hadn’t managed a win in four attempts in the league at that point but after a most unfortunate series of events, Casey was about to start his first game for Limerick in two years.

Back in 2020, the All-Ireland-winning full-back was motoring well, playing four of the first five games in that year’s league. However, Covid hit and set in chain setback after setback that would see him out of action.

“In October 2020 we played a challenge against Galway and I did the cruciate then,” Casey explains, picking up the story.

“I had surgery in mid-November, and around July, after my nine months, I came back and played a club game and got through that okay – then the next training session I had a cartilage issue. I felt a pop in the knee and unfortunately my cartilage had given way.

“In July 2021, I got that surgery done by Ray Moran up in Santry; they were excellent.”


“Thankfully, I haven’t looked back since.”

Back in the thick of it, it’s easy to forget that the road back was a grind.

“There were definitely dark moments – my girlfriend, Jessica, I’ve been with her five or six years and she was excellent through it all. Any time I had a setback and needed someone to talk to she was there for me. And with the group, a lot of the lads have been through a lot of things, knee surgeries and things like that. And I never left the group.

“I was asked to come in and help with stats and that so I was part of everything that was going on, there was some small bit to contribute to the team.”

He missed plenty in his time out with Limerick sweeping the boards. And while he could help out with the analysis, he also found himself in the unwanted position of being able to advise his brother Peter on his own recovery. He damaged his ACL in last year’s All-Ireland final while in the midst of a tour de force and has just recently returned to full training.

“It was really unfortunate but he’s been able to bounce ideas off me and ask me questions. With an ACL they’re all different but Barry Murphy did his the week after in a club game but they’ve rehabbed unbelievably well under our medical team.”

In the wake of the Munster final win over Clare, a photo featuring Casey and a few of his team-mates celebrating shirtless emerged.

Their remarkable physiques served as a reminder that while they’ve led the way with their hurling, Limerick’s physical conditioning is top drawer too. “It (gym work) is such a fundamental to it. If you’re progressing there, it is definitely going to help you on the field.

“Yes, it’s not the be all and end all of it. You still have to put the ball over the bar. Your bicep curls aren’t going to do that for you.

“But we’re really, really competitive in there, and everyone takes massive pride in it.

“And it’s definitely something that if you are slacking, lads are going to let you know that you need to improve this aspect of where you’re coming at. A lot of lads have really bought in.”

Limerick face Galway this weekend, two wins from yet more silverware for this remarkable team. A third consecutive All-Ireland win would force them deeper into the ‘great teams’ conversation. But for Casey there’s no real secret to their success.

“It’s about getting down to the brass tacks and working and winning that ball. We love doing that.

“It doesn’t matter if we win the game by 20 points or by one point to no score – we love the battle and the intensity and working hard. I think we’ve put that stamp on our play – when people come and play us they know they have to match that.”

From Cavan to Qatar: The physio helping the world’s best athletes recover and improve

This article was written by Maurice Brosnan and published by The 42.

In the summer of 2018, Tipperary and Sydney Swans flyer Colin O’Riordan came crashing to a halt. He suffered from osteitis pubis as a teenager and in his third year of professional sport it started to flare up again.

O’Riordan persevered until one agonising day at the SCG against the Gold Coast. As he turned to race up the field, the pain became unbearable. At that moment he was convinced his hip was about to explode.

“I couldn’t play the last four games of the season at all,” O’Riordan explained last year.

“I went home and saw Enda King. He had me back running in two weeks. He just sees things differently. Not that he doesn’t believe in surgery but fix the problem before you do that. It was about running mechanics and technique.

“He is honestly incredible. His knowledge of the body. I don’t think he did any work on my groins. It was all hips and glutes. We were doing calf work. I was wondering how this influenced my ability to run. But it does. We’d do a squeeze test and there would be less pain. It is all related.

“He views your body as one. Your upper back is as important as your hips in running. It is all linked. It opened my mind to how the body works. It was like going to college for five weeks.”

This endorsement came to mind recently when reading Chloe Mustaki describe her remarkable recovery from Hodgkin’s lymphoma and an ACL injury. The physical and emotional toll was considerable. During her first visit with King, Mustaki broke down in tears of frustration. It was seven months since her surgery and the pain had not subsided. Fears about never recovering had started to creep in.

Last month she made her Ireland debut.

“This is one of the best parts of my job. It is nice to help good people,” says King.

He has been working as the Head of Performance Rehabilitation at the Sports Surgery Clinic in Santry, Dublin for the past decade. There he has worked with the likes of Johnny Sexton, Ruby Walsh and Dan Carter as well as a host of professional clubs across sports from the Premier League, NBA and the AFL.

“Going back to my own career and injuries, it can feel like a crater. When you are in it and you’re not sure if anyone can help you get out of it, you cling to any light at the end of the tunnel.

“My goal is to help them understand why they are where they are, but it is also to give them some direction and that they feel empowered to stick to it rather than wait for it to get better. I am not at the level of Chloe or Colin and never was, but any footballer knows what it is like to sit in that chair and wonder will I ever be right.

“Most chronic or recurrent injuries do not go away. You have to get rid of them. People are waiting for it to go away and naturally you become despondent. Whereas a broken bone has a defined recovery and timeline and it gets better. Having been through those experiences, from a research and biomechanics point of view, really opened my eyes.

“Moving attention away from where you are sore and focusing on why you are injured. Then trying to get that across to an athlete. Ultimately, they are doing all the work. I am just trying to show them the direction.”

King’s own playing days influenced his approach now. He still draws on it. He was moulded by it. After success with his club Cavan Gaels, the midfielder went into an intercounty squad with dreams of Ulster glory. Meanwhile, his hip and groins gave him nightmares.

The same thing that hindered him on the field allowed him to prosper professionally.

“At the time, you want it to be fixed rather than standing back and wondering why it is happening. Training load is naturally a massive factor in most overuse injuries. You want to contribute to every team, all the time, rather than focusing attention and saying, developmentally I want to play at this level.

“What can I do this year to achieve that? You try to be a servant to everyone and end up pleasing no one.

“When I look back, rather than looking for a fix or anti-inflammatories or surgery, the first question is why am I sore in this area? How can I optimise my training load and how I move on the field of play to give me the best chance of staying injury-free and optimise my athletic performance.

“Then it is about how do I do it as an athlete? For example, the idea of being in a gym is to make you a better athlete on the field. Not to be only better in the gym.”

Knowing what you want and the best way to attain it. That is his creed and the bedrock of his work. When athletes present with pain, the first step is not targeting the painful area alone but understanding why it is there.

His PhD research focused on the use of 3D biomechanical analysis to better understand how an athlete moves, how that is driving their injury and how to individualise their rehab based on their specific deficits.

Soreness is not just to be dismissed or suppressed with a short-term fix. King rarely uses injections or anti-inflammatory during groin rehab. Pain is a useful marker. A signal providing valuable information. It is about understanding the source rather than temporarily quelling it.

He recently published a research study on hip and groin pain prevalence and prediction in Elite Gaelic Games. It monitored 2703 male athletes across two seasons, the largest study in elite athletes relating to hip and groin pain internationally. The findings were presented at the IOC conference in Monaco last year.

Such research has led to a seismic shift in rehab strategies. Yet the injuries keep happening. How are we improving one crucial aspect while stagnating in the other?

“That paper shows at least 40% of every intercounty team male squad will have athletic hip and groin pain every season, which is a substantial amount,” he explains.

“When you look at why people develop groin pain, it is also about how they move, and the amount of load placed on the body.

“Our understanding of how it manifests in terms of how we move has greatly improved. It has certainly been a game-changer from a rehabilitation point of view.

“But the one thing that has remained constant is the high training loads. The body is meant to train hard. That is not the problem. It is the fact that some things changed tremendously, and some haven’t changed at all. Look at the window from December to March and the demands on young players across several different squads. It is a recipe for groin pain.

“Our ability to rehab these athletes is improving all the time, our understanding and focus on their anatomy, not sending everyone for surgery but fundamentally it is still underpinned by a need to have sufficient periods of recovery within the week and to have sufficient periods of recovery within the season.

“You can’t be a servant to multiple teams at one time.”

Much done, more to do. After 15 years in Santry, the Cavan native is about to bid farewell and take a new role as Head of Performance and Development for the Orthopaedic and Sports Medicine Hospital in Aspetar, Qatar.

The plan is to swap Dublin for Doha while continuing to work with visiting athletes and travel internationally to assist teams. The chance to work at a FIFA-accredited world-renowned centre of excellence was too good to pass up.

“My role is assisting in the rehabilitation of elite athletes. Both in Qatar and with international athletes visiting. Whether that is players from teams they are affiliated with, such as PSG, or injured athletes I work with, or teams coming for warm-weather training and preparation for the World Cup.

“Obviously, they are connected to PSG, so you have Neymar, Messi, Mbappé etc. I am looking forward to working with that type of athlete and bringing my experience from the SSC with me to contribute to clinical practice and research.

“I will also be assisting the development of their multidisciplinary team. As an international centre of excellence, they highly prioritise that clinical consistency. Trying to put structures and ongoing research pathways in place with a continuity of care at the highest level.

“My attraction to working with elite athletes has always been that it is a fantastic environment to develop yourself clinically. To work with one athlete for five or six hours a day, you can really get into a depth of analysis. Get them from A to B as quick as possible.

“It allows you to take that expertise and share it with colleagues. One of the fantastic things about the SSC was providing elite athlete care for all.

“Take the principles you are applying to a high-level athlete and use that to apply a precise but modified version to the general population. You develop clinically and can have the most impact in terms of pushing understanding.”

Mining the smallest details generates the greatest lessons. That is at the heart of everything King does. Small brushstrokes without ever losing sight of the big picture. The goal is to rehab athletes. If implemented correctly that should ensure they improve as athletes.

“That is the starting point. The day one conversation is where are you sore, why are you sore, what are we going to do about it?

“If you run this way and do this, your performance will also improve. Everyone is great at rehab when they are injured and terrible when they are not injured. How can you get the buy-in that athletes are constantly developing?

“Great athletes like Colin keep in touch not just when injured but because they want to get even better. That is the whole point. Giving you what you need to rehabilitate your injury but also make you a better athlete.”

Paul Mannion talks knee injury, life outside Dublin bubble and pain of missing All-Ireland final

This article was written by Kevin O’Brien and published by The 42 on friday 1st April.

PAUL MANNION IS content with life outside the inter-county bubble as he rehabs the knee injury that forced him to miss Kilmacud Crokes’ run to the All-Ireland club final.

Mannion suffered a torn lateral ligament in his left knee during the Leinster semi-final against Portarlington. It forced him to miss the provincial decider win against Naas and subsequent clashes against Padraig Pearses and Kilcoo in the All-Ireland series.

“I thought I might have gotten away with it without it being too serious but in the days that followed it was very painful and I wasn’t recovering at all and once I got a scan it confirmed the ligament had fully detached from the bone. And the only fix was surgery.

“I looked at the options, but once I had the surgery there was definitely no chance [of playing]. Without the surgery I’d left it about three weeks and it wasn’t recovering at all I couldn’t walk so there was no chance,” he adds.

“All kind of things go through your head, what if this happened or what if that happened but I have learned to park those thoughts because you drive yourself mad thinking about those what ifs, and not just what if I was around or what if something else happened.

“I spent the first week two weeks going through all that in my head and eventually you just need to move on and accept these kind of things happen in sport and that I have also been on the other side of those kind of results many times myself. So just accept it move on and hope for better days really.”

The 28-year-old says he’s nearing full fitness and if the All-Ireland had taken place in it’s traditional slot on St Patrick’s Day, he’d probably have made it back in time.

“The physio that’s working with me had said that if the final was on Paddy’s Day as it used to be…I was asking him would I be going for that and he said definitely.

“It mightn’t have been 100% but certainly by that time I felt like I could have done something on the pitch. It was unfortunate timing but now I’ve got plenty of time to recover and make sure I’m in full health for the championship this year.

“It’s flying, much better now, back running, squatting and doing everything in the gym. It’s been like that for the last few weeks and I’m close to 100pc I’ve been really, really lucky with the recovery and the surgeon Ray Moran is probably the best around, he did it out in Santry so I was fortunate to have him do that.

“There’s not a bit rush on it now because we’ve got league games coming up of course but I just want to make sure that the knee is more than 100% right before I go back training on it at all. I’ve been out running, kicking and it feels great from that point of view. The step into full competitive match play is a big one as well so I’ll take my time with that.”

He believes Kilmacud will react the right way to the heartbreaking extra-time defeat to Kilcoo.

“I don’t think it will have any kind of negative impact. In fact, I think it’s only made lads more hungry for an All-Ireland win. I know it’s definitely made me more hungry as well.

“Obviously the Dublin championship is the first big step on that road and that’s got all of our attention now. We had a meeting to regroup after that loss and discuss plans for the year and things we can improve on.

“Everyone was vocal about taking it to the next level and really, really pushing to get back to that stage again. I think it’s reinvigorated a lot of us.

“Management are all still fully bought in and there will be new younger lads that are coming into the team this year that will be pushing for places and adding to the team as well. I think everyone is really optimistic and excited for the year ahead.”

Mannion opted out of the Dublin panel at the end of the 2020 season and declined to answer any questions relating to Dessie Farrell’s squad.

The three-time All-Star picked up six All-Ireland medals during his inter-county career before stepping away due to the commitment levels involved.

Earlier this year Mannion confirmed he has no plan to return to the Sky Blues fold and he says he’s enjoying the freedom that came with his decision.

“It’s well-documented the commitment and time that goes into playing intercounty football and sometimes when you are in that it can be a bubble and I have enjoyed being outside that a bit and being able to spend more time and focus with the club and other things so it’s been a nice time.”

Mannion’s friend and former team-mate Jack McCaffrey is another high-profile absentee from the Dublin set-up.

“I think he’s off to Africa this summer for another few months there,” says Mannion. “He’s a bit of a free spirit, he just goes where the wind takes him.

“He seems to be doing well. I met him in Manchester a couple of weeks ago for the United-City game, it didn’t go too well. He’s in great form, loving life. ”

Legend of the club: Síle Nic Coitir is a prized jewel in the capital’s crown

This article was published in the Independent.IE on Monday, 21st March and written by Niall Scully.

Síle Nic Coitir (extreme left) at Ballyboden St Enda’s Sports Surgery Clinic Sponsorship launch along with (l-r) Fiachra O’Connor, Fiona Roche (both from Sports Surgery Clinic), Ciarán Maguire (Chairman) , Paschal Taggart (Chairman of the Board), Dr Ray Moran, Brian Keane (CEO SSC) and Shane Durkin

Síle Nic Coitir (extreme left) at Ballyboden St Enda’s Sports Surgery Clinic Sponsorship launch along with (l-r) Fiachra O’Connor, Fiona Roche (both from Sports Surgery Clinic), Ciarán Maguire (Chairman) , Paschal Taggart (Chairman of the Board), Dr Ray Moran, Brian Keane (CEO SSC) and Shane Durkin.

“It’s wonderful to see female athletes at the centre of things” says Ballyboden and county legend

A Big night at Boden. Billy Joel’s ‘Piano Man’ comes on the music system.

If the great man had been in Páirc Uí Mhurchú himself, he would have sung: ‘It’s 9 o’clock on a Tuesday. The regular crowd shuffles in.’

Soon, it’s standing room only. For the big sponsorship announcement. From the Sports Surgery Clinic, Santry, the club’s new sponsors.

Earlier in the day, Rachael Blackmore and Honeysuckle won the hearts at Cheltenham. This club has known Gold Cup days too.

In the corner of the Boden clubhouse, the Manchester United-Atletico Madrid match is on the tele. Stephanie Roche is on the RTÉ panel.

Síle Nic Coitir finds a quieter spot and reflects on her own role models .

She was a big fan of Paul Curran. And the Antrim hurling goalkeeper, Niall Patterson. Then there was Dublin’s hurling All-Star, Brian McMahon.

“All men,” she smiles now. “Thankfully, that has changed.

“There’s so many outstanding women in sport that young people can now look up to. That has been a brilliant development,” she notes.

“The 20×20 campaign was a big success. As it says, if you can’t see it, you can’t be it.

“It’s wonderful to see female athletes at the centre of things. At launches and on TV, and in the media in general. You have the likes of Katie Taylor and Kellie Harrington. It’s incredible what they have done.

“When I was growing up, it was different. Thankfully, the achievements of women in sport are being recognised, and that young people can see that, and can relate to it. Women in sport work just as hard as the fellas. So it’s only fair that they get the profile.”

She’s a pundit herself now. “I really enjoy that. You see the game from a totally different perspective. You are up on a height and you are focusing on things like tactics and all the rest of it.”

In the clubhouse, there are pictures the tell the Boden story. This is where Síle calls home.

She’s been coming here for over a quarter of a century. And she has a bagful of medals that stretch the length of the Firhouse Road.

She was born into the games. Her Dad, Don, was the Chairman of the Dublin County Board.

Síle recalls happy days at school in Scoil Naithí and Coláiste Íosagáin. And with Ballinteer St John’s and St Olaf’s. And then arriving down to Boden. Playing for the U14’s. “I felt so welcome from the first day.”

She became an acclaimed dual player, with club and county. With Boden, she won ten Dublin Senior Camogie Championships, plus one Leinster. “That Leinster win was one of my proudest days.”

In Ladies’ Football, she collected four Dublin Senior Championship crowns, three Leinster and one All-Ireland. Bill Daly lighting a spark that became a bonfire.

Then for the Dubs, there was a Leinster Senior Championship Ladies’ Football victory, and an All-Ireland Camogie Junior Championship success.

She has learned so much along the way. And one of the most important lessons of all – keep playing as long as you can.

She’s a coach herself now. Mentoring the Maynooth camogie team. “I’m really enjoying it. Coaching is such a completely different ball game. Just because you played, doesn’t mean you can coach.

“You have to listen and learn from other people. There’s so much emphasis on tactics and formations, etc. It’s fascinating. I feel fortunate that I have got the chance.”

She delights in how ladies football is prospering. Mick Bohan’s Dubs. “It’s so quick now. The play is constantly up and down. It’s a very attractive game to watch.”

She commends camogie’s journey. “The physicality has greatly added to the game. The rule changes have helped so much.”

She’d be thrilled to see the Dublin camogie team return to the big-time. “I hope things can keep progressing. It’s all about getting the grassroots and structures right. And building from there.”

Having the GAA family under one roof would be an initiative she’d welcome. A family that have been such an important part of her life.

There’s a growing hum coming from the Boden Bar now. Proceedings are about to begin. She tips her hat to the generosity of the new sponsors.

She has known the long, injury-filled days herself. A catalogue of cruciate and cartilage operations.

She overcame them all. A sharp, darting forward with big ball and small. And when the knees began to act up, she put on the goalkeeper’s cap.

It’s her composure, under pressure, that most stands out. The ability to think on those quick feet.

An attribute that will serve her well in the coaching department. And in the commentary box.

Chloe Mustaki thrilled to finally make Ireland debut after overcoming cancer and serious injury

This article was published on the 21st February 2022 on Extra. IE Sport. This article was written by Mark Gallagher.

The smile on Chloe Mustaki’s face said it all. On Saturday evening in La Manga, the Dubliner finally made her senior international debut, almost two years after tearing her ACL in an Ireland training camp.

As she spoke to journalists over zoom yesterday, there were times when she got a little emotional as she reflected on the path that led to Saturday night, and her Playerof-the Match performance in the 1-0 defeat to a fine Russian side.

Mustaki spoke of the support from her family, her boyfriend — Dundalk player Greg Sloggett — the staff at Shelbourne and the likes of Enda King at the Santry Sports Clinic. When the anthem started playing ahead of the Pinatar Cup semi-final is a moment Mustaki will never forget.

‘It was a day and night to remember for myself,’ she said.

‘The award could have went to a number of different players, the two other debutantes [Megan Walsh and Abbie Larkin] had a fantastic game as well, so I am probably sharing it with those two. It was a long time coming over the last two years. It was hard but I am very happy.’

The ACL tear hasn’t been the only setback which the former Irish under-age captain has had to overcome. At just 19, as her senior career was starting, she was diagnosed with lymphoma.

‘Something my auntie told me early in my diagnosis when I was going through the lymphoma is that everyone experiences setbacks in life. Unfortunately I had been hit with quite a bad one quite early. I had just turned 19 when I was diagnosed. But you need to keep perspective, everyone has road bumps along the way. I had two bad ones early on, but there are more to come and it is just about realising everyone has them at different stages. As long as you have the right people around you to keep going during the bad days, that’s all that matters,’ she said.

The journey back for Mustaki from the ACL was extra lonely as it was during lockdown.

For the first few months of her recovery, she had no face-to-face contact with physios and no gyms were open. So, she ended up doing too much and that significantly delayed her rehabilitation. She missed certain milestones, and seven months in, she still wasn’t able to run.

‘That did freak me out. That is when I went to Enda King in Santry. My first day with him, I just cried in front of him and he was probably wondering what he got himself into. But he set me right and now here I am.’

Mustaki was one of Ireland’s more impressive players on a windy night in La Manga, where Brighton keeper Walsh was an assured presence behind her.

Vera Pauw selected a fairly inexperienced side against a fine Russians – it was the first time in 46 Ireland matches that Katie McCabe didn’t start although both herself and Denise O’Sullivan came on in the second-half.

And Mustaki wants to become an established part of the squad. She accepts that will probably mean a move abroad at some point if she wants to become a mainstay in the international team.

‘When I came back last season, my body was trying to catch up, but now I was able to last 90 minutes in an international game. I was delighted to do that, and it is down to all the effort I put in over the last year and a half. I am committed to Shels but to keep my place in the Ireland team, I do think I need to move abroad.’

Mustaki’s senior debut made her the 11th player from the Ireland under-19 side – that reached the 2014 European Championships semi-final – to win a full senior cap.

‘Obviously that was a super team at the time, with a lot of talented players. And I think the more success you have at a younger age, the more ambition that breeds. I think part of it must be having so much success at a young age, we all wanted to continue to have it.’

ACL injury prevention strategies for any coach – Neil Welch

Lorem ipsum“ACL injury prevention strategies for any coach” by Neil Welch, Head of Rehabilitation at SSC Sports Medicine

This article was published by Sportsmith.

The Sports Surgery Clinic (SSC) in Dublin performs around 1,000 anterior cruciate ligaments (ACL) reconstructions per year. I lead SSC’s Lab services, which performs biomechanical and performance testing for the majority of these athletes throughout their rehabilitation. In my role, I interact with a large number of athletes who have undergone surgery, so I understand the massive physical and emotional challenges that are involved in the athlete’s rehabilitation process.

This perspective has shaped my thoughts around injury prevention concerning change of direction and agility training. Hopefully, this article will provide you some ideas of why and how you can implement strategies to reduce the risks of ACL injury that your athletes face during changes of direction.

Movements and positions that increase ACL risk

Before we try to implement injury prevention strategies, we should try to understand the mechanism of ACL injury and whether it relates to the sport we work in and the athletes we work with.

In invasion sports, ACL injury occurs most commonly during non-contact change of direction tasks in both attacking and defensive scenarios. ACL injuries result from excessive rotational loading through the joint causing strain and shear loading high enough for the ligament to rupture. The impact in the majority of circumstances is a year or more out of action.

Researchers have identified a number of biomechanical or technical factors that increase this rotational loading through the knee. To reduce these loads, we need to know what these factors are.

Wider foot plants, greater angles of hip abduction, greater foot external rotation, greater ipsilateral trunk sway and greater knee extension all relate to increased rotational knee loads. Away from the biomechanical factors, there are also performance factors that contribute to increased knee rotational loading during change of direction. These are greater velocities, greater ground reaction forces and greater angle of cut. Conversations regarding the performance-injury trade-off centre around these considerations.

What technical changes could lower an athlete’s risk of ACL injury?

The video below shows a rugby 7s player injuring her ACL. The player in red attempts to decelerate and cut immediately to her left using her right leg, and then step inside the #6 in white. She ruptures her ACL in this stride. Extended knee, ipsilateral trunk sway, large ground reaction forces, high velocity movement and large angle change. A mix between the technical and performance factors we mentioned above.

If we are to prevent this injury, we need to reduce the loading through the joint.

However, from a performance perspective, reducing velocities and ground reaction forces is not what we’re about. In fact, it’s the opposite. The sharp angle of cut is required to evade her marker and is an important attacking option, so that is also not something we’re going to change. Even if it were, can you imagine telling your athletes you are going to slow them down when they cut? Instead, we have to look at what technical factors we can influence.

Video 1: Deceleration example

In the example above, the technical changes we need the athlete to make are reducing trunk sway and using a strategy with more knee bend while decelerating. If we think of a technique change that would achieve both, lowering the centre of mass would fit the bill. The excess trunk sway that contributes to the rupture in this instance happens because the athlete creates an axis of rotation about a stiff limb out in front of her as she decelerates. Think of how a pole vaulter drives the pole into the box. Except in this instance, the pole (or the knee) gives way.

Expanding our view to the full range of technical factors, lowering the centre of mass will influence many of them. A wider foot plant and greater hip abduction is not necessary to apply force horizontally into the ground to change direction if the centre of mass is lower. This, too, will reduce rotational knee loading. A second ACL injury technique risk factor, trunk sway, often occurs when the athlete enters the cut with a vertical trunk. A vertical trunk creates a greater moment with a longer lever. Therefore, we can shorten the lever arm and reduce the moment with some trunk or hip flexion (leaning forward on the approach), lowering the likelihood of the trunk swaying.

Ultimately, greater hip flexion and knee flexion, or being closer to your athletic stance, will reduce rotational knee loading during the cut.

This does not mean that we need to be coaching our athletes into deep squat positions during and approaching change of direction tasks. A better way to think of it is that the further you deviate upwards from your athletic stance at every stage of the cutting task, the greater the risk of injury.

Our injury prevention strategies should seek to create stable attractors away from this very upright strategy.

Video 2: Note the slight hip/trunk and knee flexion

Prevention & performance: Trade-offs we won’t make

A major concern for performance professionals when we talk about injury prevention is the potential for negative effects on performance. Some research suggests reducing knee loading by using strategies such as softening landings to reduce ground reaction forces [6] or planting the foot close to the centre of mass during a cutting movement 7). These conclusions follow from the sole intention of reducing knee loading without considering the impact on performance.

Research results and conclusions like these contribute to the performance-injury trade-off conversations. If we consider these suggestions from a performance context, deploying softer deceleration strategies would increase deceleration time; and applying force horizontally into the ground is necessary for enhanced cutting performance [8,9].

But what does the performance-oriented literature have to say about cutting biomechanics?

Leaning and rotating the trunk in the direction of the cut, maintaining a lower centre of mass and resisting movement of the centre of mass towards the plant foot (think lateral stiffness) are all associated with a faster cut. These factors are the opposite of the technical risk factors for ACL injury we discussed above. When you add in that short ground contact times and early force production are also associated with faster cuts, both of which require greater pre-activation and/or co-contraction – which may also be protective – you may start to think, as I do, that performance and injury prevention are not mutually exclusive.

If you address injury prevention appropriately in cutting, it should also improve performance.

Assessing tactical and in-game scenarios for ACL risk

Assuming you buy into my technical factor reasoning (and it’s fine if you don’t!), the next task is to identify the risky scenarios in your sport so you can target them. This is worth considering because they do vary.

In football (soccer), the majority of injuries occur during a defensive press [1], so strategies to reduce risk amongst a playing squad can be targeted for those scenarios. In rugby, 46% of the non-contact injuries occur during attacking cuts – by far the largest proportion – and 21% in defensive pressing and tackling situations [2]. Jumping and landing is more prevalent in AFL, where 37% of non-contact injuries occur during sidestep actions, with 32% and 16% occurring in landing and land and cut actions, respectively.

If American football is your sport, 70% of injuries are non-contact (higher than I would have thought), with 86% of them occurring in cutting, deceleration and running. Of these, 36% were in attacking actions and 44% were in defensive actions [4]. That’s a more even spread across attacking and defensive scenarios than in soccer and rugby. Recent research in basketball found that players with a higher tendency to drive to the basket were at greater risk of ACL injury [5].

Insights like these allow us to improve the targeting of interventions, not only to certain situations but also towards certain players. However, this research is still new. If we’re taking an individual approach to targeting interventions, we need to take a similarly individual approach to identifying which athletes to target. And before all that, we have to decide if we should intervene at all.

When should coaches introduce ACL prevention training, and with whom?

There’s nothing wrong with questioning whether you should implement a preventive strategy.

You may feel that your playing group, by virtue of their competitive or experience level, have some degree of resilience to ACL injury. You may feel that those with risky strategies have already been injured earlier in their career, and have either rehabbed and are back playing or they didn’t make it to that level. You may, therefore, question whether prevention-based interventions are necessary. Your time and your athletes’ time may be better spent on other activities.

An athlete’s stage in career may also play a role in your thought process. Athletes who are approaching the final years of playing may not be best served or even be interested in prevention work. You may also decide that there are higher priorities and that you should invest your time and energy elsewhere within the performance and medical program.

Alternatively, you may opt to use a broad brush approach. This entails applying the same program elements across your entire playing group. This is particularly beneficial if you are working with younger or more novice athletes, as there is likely more room for improvement. If you’re the only coach who will be implementing the program, then this approach is easier on your time than trying to target smaller groups or individuals. This approach also helps you be consistent in your messaging and the way you coach. If you’re part of a larger setup, the entire coaching staff needs to buy in with time and training to ensure consistency in delivery from all the coaches to all of the athletes. Otherwise, you run the risk of the messages diverging from coaches to athletes.

For example, you may decide that to help reduce external foot rotation during cuts you want your athletes to perform their lifts in the gym with a neutral foot position.

How many coaches do you have to get on board with that simple message? How many athletes who have previously done it another way do you have to sell it to, now that you are changing tack? Does everyone buy in enough to make that change?

It can be harder than we first think to implement these changes to a large program or playing group. Another possible downside is that you may be wasting the time of those athletes who already excel in this area. They may be better served addressing other elements of their game.

Finally, there is the targeted approach. This is where you identify certain individuals or groups of players to work with specifically to address their deficiencies. There are a number of ways you may decide on these groups.

Given that increased velocities and ground reaction forces increase risk, you may want to take a closer look at some of the younger players transitioning into the senior setup who are not used to playing at that intensity. Similarly, you may have new athletes joining from another organisation who may be used different tactics. At a soccer team, for example, if a strong defensive press is a large part of your tactical approach and an athlete is joining from a group where it was lemphasized less, they may be a target of your intervention.

Athletes who are exposed to the risky scenarios in your sport more frequently may make the list. In rugby, where attacking sidesteps are the riskiest scenario, you may work with the players for whom an attacking sidestep is an important part of their game.

Certain drill types can serve as a screening tool. One-on-one contests to pick out the athletes with high levels of trunk sway or possession games to find the upright decelerators are some other valid approaches.

Coaches need to develop their observational skills if they are using this approach, along with having a close relationship with the performance analyst. Coaches can also identify players with risky strategies by watching training or game footage of certain scenarios.

Three areas for ACL injury prevention interventions

If you have decided that a change of direction-based intervention is something you want to pursue and that you have athletes who would benefit from it, then what do you do? Obviously, the answer here is that it depends.

Broadly speaking, the aim is to form a stable attractor around your athlete’s ability to get into and out of their athletic stance at every stage of a change of direction. It’s as simple as that. In defensive scenarios and at slower speeds, this athletic stance will be lower than at higher speeds and in attacking cutting actions (see Kobe Bryant clip below). They need to be able to do it forwards, backwards, sideways and in rotational movements, and move seamlessly between them all. They need to do it from stationary starts and while moving at speed. They need to be able to express large amounts of force rapidly as soon as they hit those positions. In attacking situations, and during higher velocities and shallower angles, the athletic stance will be more upright but should still have some level of hip and knee flexion.

There are many options that we can implement to form these stable attractors, reduce risk of ACL injury and improve performance during cutting. We can approach them via three broad, practical programming areas.

Coaches need to develop their observational skills if they are using this approach, along with having a close relationship with the performance analyst. Coaches can also identify players with risky strategies by watching training or game footage of certain scenarios.

Three areas for ACL injury prevention interventions

If you have decided that a change of direction-based intervention is something you want to pursue and that you have athletes who would benefit from it, then what do you do? Obviously, the answer here is that it depends.

Broadly speaking, the aim is to form a stable attractor around your athlete’s ability to get into and out of their athletic stance at every stage of a change of direction. It’s as simple as that. In defensive scenarios and at slower speeds, this athletic stance will be lower than at higher speeds and in attacking cutting actions (see Kobe Bryant clip below). They need to be able to do it forwards, backwards, sideways and in rotational movements, and move seamlessly between them all. They need to do it from stationary starts and while moving at speed. They need to be able to express large amounts of force rapidly as soon as they hit those positions. In attacking situations, and during higher velocities and shallower angles, the athletic stance will be more upright but should still have some level of hip and knee flexion.

There are many options that we can implement to form these stable attractors, reduce risk of ACL injury and improve performance during cutting. We can approach them via three broad, practical programming areas.

The second area you can improve in the gym is technique and capacity during unilateral deceleration. Coaches often overlook cuing the speed of deceleration, particularly in landing tasks where we instead focus on “stability.” Instead, if we cue the landing to be quick, the stability comes with it and you’re also developing early rate of force development qualities within your athletes.

You can also develop good technique habits of linking hip/trunk and knee flexion, starting the move move away from vertical trunk decelerations.

Third is your plyometric work, and moving to incorporate triple flexion in both vertical and horizontal explosive work. Some triple flexion prior to ground contact helps the athlete form habits around safer positions. Drop squat patterns can breed familiarisation with the techniques you want to develop before progressing to drop jumps and lateral rebounds. This differs from the standard approach to plyometric work in the positions athletes are coached into when they interact with the ground.

Multi-task with warm-up themes

The next area you can use to address injury risk is the warm-ups. With warm-ups, you can use the broad brush and targeted approaches alongside each other.

Implementing more challenging movements allows you to be inventive and gives you the opportunity to do some really fun coaching, but requires a little more organisation.

How you chunk these movements and drills is up to you, and may be dictated by the needs of the sport.

Creating themes for drills though will allow you to be a bit more targeted in the areas you want to address.

One theme could be transitions, where you challenge the athletes with the direction and positions of movements. For example, side shuffle movements into a forward run where you are trying to improve the fluency of movement in athletic stance positions. Another theme could be around backwards movement, an area in which I’ve found athletes to be generally poor. When was the last time you coached someone to run backwards? Athletes get injured when transitioning out of backward movements because they put themselves in poor positions. A final theme you might lean on is around shadowing and trying to develop perceptive and transitional skills together. To be even more targeted in this approach, pick your athletes one at a time to cue on positions or movements. This is why I said the organisational elements in your drills is important, as you can then spend your time observing and coaching one-on-one between reps.

The added value that runs through all of those themes is that you improve defensive movements and enhance performance while also addressing some of the risk scenarios for ACL injuries.

Integrating tactical, technical and physical programs

The final area where you can make an impact is somewhat dependent on your coaching environment and the access you have to your athletes within sessions. This is around specific technical/tactical scenarios. It may be that this actually becomes a warm-up theme if you are unable to get space within a session itself. Or, you can link the warm-up theme to the scenario and have a targeted training block.

For example, if your scenario is around improving defensive pressing then you may focus your warm-ups around transitions from forward into lateral movements. In an ideal world, you would present this theme to the athletes as an aim of the training block with performance analysis support and consistent delivery of message between technical, S&C and medical staff. However, you may also be on your own with only a few minutes a week to devote to this. That underscores the importance of consistency throughout the program as a whole. If you combine the influence of your gym and pitch warm-ups, the patterns within your lifts and explosive elements in the gym and any scenario-based work you are able to get in, then it is possible to make a large impact in these areas and you will see them transfer onto the pitch.

Proactive approaches to injury prevention

On the subject of transference, yes, all these programming and technical interventions transfer to the sport. But it takes time, consistency and perseverance on the part of you, the coach. I remember watching a game with a GAA team I worked with early in the second season and seeing a defensive situation where all of the players involved were in the positions we had been working on in training. It seems a small thing, but it was the first example with that group that clearly showed we were making an impact. During a four year stint, we had no ACL injuries.

ACL injury prevention and performance improvement are not separate entities when we consider change of direction and agility. Coaches have the opportunity and ability to improve both simultaneously.

If you manage to prevent an athlete from going through an ACL injury experience, they will never be able to thank you and you will never know who you have helped. But it is possible and worth trying.

‘Life Stories’ Podcast with Dr Ciaran Cosgrave

Listen to this interview with Dr Ciaran Cosgrave, Consultant Sports Medicine Physician at SSC and National Team Doctor IRFU.

This interview by Andy Thomas is part of his Podcast Series ‘Life Stories’ and is available below.

Dr Cosgrave graduated Medicine from Queen’s University Belfast in 2004 and after working for a year in Sydney, undertook an MSc in Sports & Exercise Medicine at Trinity College Dublin. He trained as a consultant in Sports & Exercise Medicine in Liverpool. He has a wealth of experience in elite sport having worked for two seasons at Liverpool Football Club from 2011-2013.

He also provided medical cover at the 2012 Olympic and Paralympic Games and subsequently accompanied Team GB at their High Altitude Training Camp in Iten, Kenya.

Other experience in elite sport includes basketball, Northern Ireland Football, athletics, karate and judo.

Ciaran joined the IRFU in June 2016 having worked as Leinster Rugby Team Doctor from July 2014.

To make an appointment with a Sports Medicine Consultant please contact

‘If I’ll Get Back’: Jack Willis Reveals Rugby Return Anxieties

This article by Bobby Bridge for CoventryLive was published online on Friday, 12th November 2021.

The Wasps and England flanker is documenting his rehabilitation from major knee surgery on his Instagram account. Jack Willis revealed a ‘speed bump’ in his recovery from a major knee injury that fueled doubts if he would return to the pitch. The Wasps flanker suffered catastrophic damage to his left knee playing for England against Italy during the Six Nations clash in February.

It is the second time the 2019/20 Premiership player of the season has suffered a major injury following ACL rupture in his right leg, suffered during the Premiership semi-final against Saracens in 2018. The 24-year-old has been documenting his recovery second time around via his Instagram account, which has nearly 39,000 followers, and a series of videos entitled ‘The Rebuild 2.0’. Episode six was released this week – nine months on from suffering the setback at Twickenham Stadium.

Willis discussed complications he was having that promoted a visit to the Fortius Clinic in London.

“The last couple of weeks haven’t been great,” he conceded. “I’ve had things like this in my past injuries. But this is the first time I’ve had a sort of speed bump, if you like, along the way this time and it’s been pretty tough in all honestly. It’s set me back a few weeks. It’s not only when I’ll get back, it’s if I’ll get back. I’ve never really liked to think like that before.”

A back-up plan of a possible PCL reconstruction by consultant knee surgeon Andy Williams – who was insistent that Willis still had a ‘good knee’ and that route wouldn’t need to be explored. Willis also documented a week spent at the Sports Surgery Clinic in Dublin with Wasps team-mate Joe Launchbury, who suffered an ACL rupture in April. The duo underwent a series of tests and sessions to assess their progress and support their journeys back onto the pitch.

After the visit, Willis’ tone changed to one of confidence about his return, but conceded that anxieties lingered about his return to the pitch.

“It’s a nice point to draw a line in the sand and look back on how far I’ve come,” he said. It’s been eight or so months since I did the injury.

“It’s been unreal having Joe here for the week, and also throughout the whole process, we’ve got a few injured lads we’ve been working closely with, having those boys around you, you get pretty tight when you’re going through the same thing. We stick by each other and get through each day and you know it’ll be pretty special when you’re back out there on the pitch together.

“I’m not a millions miles off potentially being a rugby player again and getting out there on the field. It’s pretty nervous thinking like that, thinking I’m a mile off. Hopefully my confidence improves as well because mentally at the moment I feel pretty nervous. I’ve got a lot of anxiety around being back and playing. Just around being injured again and the risks that come with it but each day hopefully that confidence will grow.”