Is the dreaded ACL injury on the rise in the GAA?

The Brainstorm Long Read: understanding the pattern of Anterior Cruciate Ligament injuries is key to managing the risk for players at every level.

This article by Aoife Ryan-Christenson was published on RTE’s Brainstorm in September 2019.

“I heard the pop and then when I fell, I tried to move it. Then I heard the crack and I knew. When I went to my physio and he said ‘cruciate’, I burst into tears. I just thought it was the end of the world. It still kind of hasn’t really hit me yet”.

That’s 16-year-old Sarah Condon from Co Limerick. She’s played camogie since she was just four years of age and plays for Knockaderry Camogie Club and is on Limerick’s minor county team.

It was a really rainy, mucky day in February of this year when she returned to the pitch for a match after a week off training due to an injury. Going into a huddle, another player hit the side of Sarah’s right knee with the butt of a hurley and that was it. “I fell down then and the pain was like a shot in the knee, it was outrageous. It was something I have never felt in my life,” she explains.

Up until the injury, Sarah was training “probably every night of the week” between football, club camogie and county camogie. “I was aware of it, but I never thought it would happen to me. The first thing I thought was that my knee popped out. But then when I saw it, my reaction was ‘oh my god my cruciate is gone’.”

Sarah isn’t alone. Mayo’s Jason Doherty has had to bow out of the Championship thanks to an Anterior Cruciate Ligament (ACL) injury. In June, Tipperary’s Patrick ‘Bonner’ Maher was ruled out after a season-ending rupture on his ACL during the team’s Munster championship win over Limerick.

The dreaded injury is relatively rare but significant and can take a player off the pitch for up to a year – or for good in some cases. Research shows that around 83% will return to playing their sport within 12 months and about 65% will return to playing competitive sports. People who rupture their ACL have a higher risk of re-rupture or an ACL injury on the opposite knee and some face long-term consequences later in life with osteoarthritis. Women are also more likely to sustain an ACL injury than men and research has shown that menstrual cycle tracking could help optimise girls’ and women’s performance and decrease the risk of injuries.

“It feels like there’s a lot more younger people (injuring their ACL),” Sarah says. Two other boys in her school have ruptured their ACL. When Sarah told the team that her cruciate might be injured, many of them had stories to tell about friends it had happened to. “When I did it, I kept hearing about more people doing it and they were really young as well,” she says.

The ACL is a strong ligament in your knee and its main job is to prevent the shinbone from moving forward in relation to the femur, says Dr Colum Moloney, Senior Physiotherapist in Isokinetic Testing and Rehabilitation at University Hospital Limerick. “In simple terms, it provides stability to the knee so that when you twist and turn it stops the knee from giving way.”

Anecdotally, it seems ACL injuries are on the rise, but whether it’s actually happening more often or not is not definite at the moment, Moloney says. “But if it is, then the key thing is to prevent it,” he adds. “Once you’re injured, it’s a long road.”

Data from the GAA Injury Benefit Fund reports show that claims for all knee injuries accounted for 30% of all claims in 2018, up 10% on the number of knee injury claims in 2008. But getting an accurate picture of the trends in ACL in Ireland “is nearly impossible, as we don’t have a national registry like they do in other countries,” says Dr Catherine Blake, Associate Professor in the School of Public Health, Physiotherapy and Sports Science in UCD.

“For example in Denmark, Finland and Sweden, all orthopaedic trauma injuries are registered to a database through their national health systems. Another example would be an injury database from hospital admissions in Victoria, Australia. These are definitive, high-quality datasets and while there are year to year variations, they do show a trend to more ACL injuries in children and adolescents. At the same time these are still relatively rare injuries when you look at the number occurring per 100,000 population.”

Because Ireland doesn’t have a unique electronic health record, people’s contact with the health system can’t be tracked. On top of that, much of the sport-related ACL emergency care and surgery is provided by private clinics, which means the Irish Hospital Inpatient Database for the public system doesn’t capture ACL injuries well, Blake says.

She has been involved with the GAA National Injury Surveillance Database since its inception in 2006 in collaboration with UCD. It’s the largest systematic injury surveillance database in Ireland, but it only captures inter-county male teams. Dr Mark Roe, a postdoctoral researcher in UCD with the GAA database, says that teams have to opt-in at the start of the year to join the database and that to accurately track the incidence of injuries, what’s needed is mandatory compliance. Another way would be to integrate the insurance claim database with the injury surveillance database.

Since 2008, the database has tracked injuries across football and hurling for a total of 83 seasons. “It’s a big dataset,” Roe says, “but there’s certainly a lot of room for improvement in terms of recruitment.” Ideally, the database would capture all players down to club level, both ladies and mens and at all ages.

Roe says ACL injuries account for about 22% of knee claims made to the GAA insurance fund and that overall they account for 6% of all injuries. “It sounds like a lot. But the big thing is that when we look across all running-based field sports, it’s about 1.5% of athletes. So what we can say is that most senior inter-county teams will not sustain an ACL injury this season, but when we put two seasons together, they’ll probably pick up one.”

This means about one in 68 players will sustain an ACL injury and to prevent just one injury, 130 athletes would have to go through a prevention programme like the GAA 15, a warm-up which was designed in part to reduce ACL injuries and which focuses on teaching fundamental movement skills, landing techniques and change of direction. Roe explains that trials of these programmes have found that they can cut the risk of injury in half for players, making prevention key.

But there’s something unique about the patterns that do emerge in ACL injuries and they tell us a lot about what needs to be done to prevent them, Roe explains. The first is that the majority of ACL injuries are non-contact and typically occur when changing direction or landing and about 30% of them are contact-related.

“The other thing we know is that two-thirds of these injuries will occur in match play and that’s interesting because the field sport athletes on average, will only spend about 10% of their time in total in actual, competitive games. So that’s something a bit unique about the demands of match play and how they relate to training. If we’re going to manage risk, we have to prepare players for the demand of their sport, that’s the big take-home message.”

International studies suggest that ACL injuries are on the rise in adolescents, but it’s not possible to capture that here in Ireland and there might be a caveat. “We definitely can’t say (that there’s an upward trend). Even if there is an increase it’s still an incredibly low rate and that might be one of the reasons for the upward trend. Because the base number is so small, it’s more likely, in relative terms, to appear to be a much bigger problem,” Roe says.

Mr Daniel Withers, consultant orthopaedic surgeon at the Sports Surgery Clinic (SSC), explains that rather than a true increase in the number of people with ACL injuries, it’s likely to do with advances in diagnostics and treatment and an increased awareness around the injury, as well the sheer number of people involved in the GAA particularly.
Diagnosis and surgery for ACL is much more accessible now, he says. An MRI will confirm the rupture and the surgery to reconstruct or repair the ligament takes about an hour, followed by a night’s stay in the clinic and then you’re home the next day.

“I think Ireland is quite a unique country in itself – the GAA is so massive here,” Withers says. “Every single village, every town has a GAA club and every club has girls playing, boys playing, all ages. There are so many people playing the sport. So you’ve got GAA, you’ve got people who like soccer, you’ve got rugby, you’ve got a lot of different sports where there’s a lot of twisting and turning and pivoting and landing and jumping, where that puts you at risk of an ACL injury.”

The biggest issue for someone with an ACL injury is the time lost from sport, Enda King, Head of Rehabilitation at SSC, says. “There’s a period post-injury where you’re preparing for surgery. There’s the time required to let the knee settle down before repair and then there’s quite a long recovery time afterwards, anywhere between six months to a year.”

“There are very few injuries that require that kind of extensive lay-off,” he says. What’s so dreaded about it all isn’t the nature of the injury, it’s the long-term, guaranteed time loss. Thankfully, the vast majority are able to go back to their sport, King adds. Return to sport is a “multi-factorial thing” that depends on personal choice and circumstance, but “there are very few barriers to return to play after ACL reconstruction.”

“There can be a little doom and gloom around (ACL injuries) and that’s understandable because a year out is a big deal for anybody. But those that want to get back generally get back. It’s not how long has it been, it’s how do I test and that’s what you can judge your success on, or how ready you are, or how good your knee will do.”

Mark Roe with the GAA injury surveillance database believes that what’s needed at the top level, between team coaches, physiotherapists and doctors, is an understanding of the trends at play. “They need to understand how, where and when injuries happen. They need to understand how in terms of are they contact or not, when in terms of what stage of the season or the game, then where in terms of what activity, is it training or match play. Because if we don’t understand the pattern of how these injuries happen we’ll never be able to do anything about how we manage the risk.”

Patterns of injury across all field sports are remarkably similar, he says. The top 4 injuries that will account for 40% of the total, are: hamstring, ankle sprain, adductor-related groin pain and quadriceps pain. “It’s kind of frightening how similar it is all the time. These aren’t random events, this pattern is crystal clear to us at this stage in all these field sports. This is happening again and again and again and I think it’s largely because we’re not actually fully wrapping our heads around how these events unfold.”

There’s been a shift. We’re getting to grips with understanding these trends around these injuries. So rather than calling them injury prevention programmes, we are now calling them risk management studies. Because we may not prevent this but we are doing something to manage the risk of it happening.”

For Sarah Condon, the first two days after surgery were fine. “But then when the painkillers wore off after the surgery, oh my god”, she remembers. “I described it to my mother as if someone got a hammer and started squeezing my knee and hitting my knee. I would spend most of my time sitting on the couch and I remember standing up and I could feel the blood rushing through my knee and I could feel absolutely everything going on. It was awful, I wouldn’t wish it on my worst enemy.”

It’s a long road to recovery and, if all goes well, she expects to be back playing in February 2020. “I probably won’t go back to football, but I am fully going to go back to camogie. Camogie is my one sport. If I can, I will, but if I can’t… I just can’t.”

For further information on ACL Injuries please email sportsmedicine@sportssurgeryclinic.com 

 

Public Information Meeting Athlone – Photographs.

On Monday 11th of February, Sports Surgery Clinic hosted a public information meeting focusing on Orthopaedics and Rheumatology in Athlone.

At this meeting SSC clinicians specialising in hip surgery, knee surgery and rheumatology gave presentations and answered questions on potential surgery or conservative treatment of injuries.

The following SSC Consultants presented at this event:

  • Mr Dan Withers, Consultant Orthopaedic Surgeon specialising in knee injuries.
  • Dr Barry Sheane, Consultant Rheumatologist specialsing in arthritis and rheumatoid arthritis.
  • Mr Gavin McHugh, Consultant Orthopaedic Surgeon specialising in hip pain.
For further information on upcoming public information meetings please click here 

SSC Specialists Set For Athlone Public Meeting

Dr Barry Sheane, a Consultant Rheumatologist at  Sports Surgery Clinic, joined Dave Hooper on Shannonside Radio to discuss what people can expect at SSC’s Public Information Meeting in the Hodson Bay Hotel on Monday, February 10th.

Click here to listen to the interview in full

Dr Barry Sheane will be joined in Athlone by the following SSC Clinicians:

Mr Gavin McHugh, a Consultant Orthopaedic Surgeon, specialising in hip pain and Mr Dan Withers, Consultant Orthopaedic Surgeon specialising in knee surgery.

Click here to download the flyer.

For further information on this event, please contact gp@sportssurgeryclinic.com

Educational Meeting – Tullamore – A selection of photographs.

A selection of photographs from our educational evening for GP’s and Physiotherapists

This event focused on Orthopaedics and Sports Medicine and took place at the Bridge House Hotel in Tullamore on February 4th.

At this event, presentations were by the following SSC Clinicians:

  • Mr Dan Withers, Consultant Orthopaedic Surgeon specialising in knee pain.
  • Dr Wilby Williamson, Consultant Sports & Exercise Medicine Physician
  • Thilina Vitharana, Senior Physiotherapist at SSC specialising in knee injuries.
Barry Sheane Rheumatologist

‘What exactly is Arthritis?’ by Dr Barry J Sheane Consultant Rheumatologist Santry

This article by Dr Barry J Sheane, Consultant Rheumatologist at Sports Surgery Clinic, was published in the Senior Times Magazine.
The term ‘arthritis’ means ‘joint inflammation’ and refers to a disease of a joint, or in many cases, multiple joints. However, there are many forms of arthritis, and in turn, specific treatment and medication for those individual types of arthritis. A Rheumatologist is a doctor with specific skills that allow her or him to differentiate between the different kinds of arthritis and prescribe the relevant course of treatment.
In simple terms, Rheumatologists will determine if a patient’s arthritis is one of two main forms: osteoarthritis or inflammatory arthritis. The differentiation between the two is of paramount importance because each type carries its own specific prognosis and will require different therapeutic approaches.
Osteoarthritis
Osteoarthritis (OA) is also referred to as ‘degenerative’ arthritis, ‘wear-and-tear’ arthritis, or arthritis ‘of advancing age’. The lay term ‘rheumatism’ refers to OA. This condition can affect a single large joint such as a hip or a knee, but commonly affects multiple joints, including the articulation between the metacarpal bone of the thumb and wrist (manifesting as pain on the thumb-side of the wrist), the joints in the fingers closest to the nails (‘distal interphalangeal joints’ and manifesting as bony lumps) and that of the ‘big toe’. A joint with osteoarthritis is typically more painful during or immediately after activity and may intermittently swell or even develop permanent deformity.
Inflammatory arthritis
Inflammatory arthritis is that which is caused by, or involves, aberrancy in the immune system such that a system that ordinarily is used by the body to stave off and fight infections, turns on specific components of the body, in this case, the joints, and attacks them. This results in joint inflammation, which manifests in the sufferer as pain, swelling and morning stiffness in the affected joint or joints. Characteristically, these symptoms of inflammatory arthritis improve with movement or exercising the joint.
There are a variety of specific types of inflammatory arthritis, including Rheumatoid Arthritis (RA), Psoriatic Arthritis (PsA) and Ankylosing Spondylitis. Rheumatoid arthritis is the most prevalent in the community and, left undiagnosed and untreated, results in joint deformity and disability, particularly in the hands and feet. Psoriatic arthritis is a type of inflammatory arthritis associated with the skin disease psoriasis, and can also cause joint deformity, while ankylosing spondylitis primarily affects the joints of the spine, from the neck down and including the joints of the rib-cage. ‘Ankylosis’ means ‘fusion’ and ‘spondylitis’ refers to inflammation of the spine. Through this process of inflammation, the many articulations of the spine fuse, which can cause severe restrictions in movement for the patient.
Treatment advances
Enormous strides to understand the genetics and immunology of these inflammatory arthritides have been made in the last three decades, culminating in an expanding repertoire of highly effective medications that target and block specific components of the immune system that are central in the perpetuation of these conditions.
In contrast, OA has not been privy to the advancements that have been made in the science of inflammatory arthritis. Currently, treatment options for a patient diagnosed with degenerative arthritis including physiotherapy, occupational therapy, pain-killers and/or joint injections with steroid/’cortisone’. If OA continues to advance, joint failure ensues. When this occurs in a large joint like the hip or knee, an orthopaedic surgeon will replace the failed joint with a prosthetic one, which is not without significant risk.
The ‘bad arthritis’
In years past, Rheumatologists used to refer to inflammatory arthritis as ‘the bad arthritis’ because of the limited efficacious treatments available and as a consequence, the development of deformity and disability. While a cure for inflammatory arthritis does not exist, patients have a real chance of achieving disease remission with the medications currently on offer.
Unfortunately, this assurance cannot be given to sufferers of OA. There is no medication currently available that can halt the degeneration of the joint, and in that sense, OA is the new ‘bad arthritis’ to have. However, scientists continue on the journey to understand the cause of OA and how it might be treated. Progress has been slow but it is time for researchers involved in musculoskeletal science to focus their efforts and resources on this neglected condition so that the moniker ‘bad arthritis’ can be removed from that associated with OA.
To make an appointment with Dr Barry Sheane please email rheumatology@sportssurgeryclinic.com
Dr Andy Franklyn-Miller

Dr Andy Franklyn-Miller discusses Hip & Groin Pain on SEN Breakfast

In this interview with Melbourne based Radio Station, SEN Breakfast, Dr Andy Franklyn-Miller, Director of SSC Sports Medicine, discusses SSC’s unique approach to rehabilitating hip and groin injuries and how SSC can assist clubs in return to play of injured players.

Click here to listen to the interview

For further information on hip pain or groin injuries, please contact sportsmedicine@sportssurgeryclinic.com or call +353 1 5262030

 

 

Getting Old – Deal With It – Dr Andy Franklyn-Miller Interview on Newstalk Radio

In this episode of Newstalk Radios ‘Alive and Kicking’ show, presenter Clare McKenna interviews Director of SSC Sports Medicine, Dr Andy Franklyn-Miller.

Listen to Dr Franklyn-Miller, a Consultant Sports & Exercise Medicine Physician as he discusses the benefits of Sports Surgery Clinics Health Lab and Fitness Lab and how combined with Dexa Total Body Scan can set you on the road to a healthier lifestyle.

Click here for the interview (starting at 5 minutes end ending at 20 minutes)

Click here for Health Lab Flyer in PDF

Click here for Fitness Lab Flyer in PDF

For further information on Sports Surgery Clinic’s Fitness Lab Services or Health Lab Service please call 01 526 2050

Educational Evening focusing on Orthopaedics, Rheumatology and Sports Medicine.

On Monday 20th January Sports Surgery Clinic hosted an educational evening focusing on Orthopaedics, Rheumatology and Sports Medicine.

Dr Catherine Sullivan, Neil Welch and Ms Ann-Maria Byrne.

At this event, SSC Clinicians presented on the following topics:

  • Dr Catherine Sullivan, Consultant Rheumatologist specialising in arthritis, osteoarthritis and fibromyalgia.
    • ‘Rheumatology case presentations.’
  • Ms Ann-Maria Byrne, Consultant Orthopaedic Surgeon specialising in Hand injuries, wrist and elbow surgery.
    • ‘Hand, wrist and elbow conditions’
  • Neil Welch, Head of Rehabilitation specialising in knee injuries and back pain.
    • ‘The physical factors related to low back pain.’
Click here to see a list of upcoming educational events at Sports Surgery Clinic.

 

Annual GP Study Day 2019 – A selection of photographs.

A selection of photographs from our recent Annual GP Study Day which took place in Santry on Saturday, December 7th.

This event consisted of presentations and practical discussion groups with the following SSC Consultants:

  • Mr Michael Kelleher, Consultant Neurosurgeon
    ‘Patient Journey from examination, investigation, surgery and rehabilitation for spinal fusion’
  • Mr Jabir Nagaria, Consultant Neurosurgeon
    ‘Head Injury and concussion from a neurosurgical perspective’
  • Mr Gavin McHugh, Consultant Orthopaedic Surgeon
    ‘Early osteoarthritis of the knee & how to treat’
  • Mr Ray Moran, Medical Director & Consultant Orthopaedic Surgeon
    ‘Examination of the Knee’
  • Mr Michael Donnelly, Consultant Orthopaedic Surgeon
    ‘Hip and knee arthritis’
  • Mr Keith Synnott, Consultant Orthopaedic Surgeon
    ‘Red flags in the Spine’
  • Ms Noelle Cassidy, Consultant Orthopaedic Surgeon
    ‘Pain Issues in the Adolescent’
  • Mr Paul Moroney, Consultant Orthopaedic Surgeon
    ‘Management of hallux valgus and lesser toe pathology’
  • Mr Cliff Beirne, Consultant Maxillofacial Surgeon
    ‘Temporomandibular Joint Disorders’
  • Mr Owen Brady, Consultant Orthopaedic Surgeon
    ‘Complications of Knee Replacement’
  • Professor Cathal Moran, Consultant Orthopaedic Surgeon –
    ‘Cartilage damage and how we treat it.’
  • Dr Paul Dobbelaar, Consultant Sports & Exercise Medicine Physician
  • ‘Adjuvant therapy in tendinopathy’
  • Dr Jim O Donovan,  Sports Medicine Physician
    ‘Anterior knee pain’
  • Ms Noelle Cassidy, Consultant Orthopaedic Surgeon
  • ‘Pain Issues in the Adolescent’
  • Mr Tom McCarthy, Consultant Orthopaedic Surgeon
    ‘ Knee complaints’
  • Dr Barry Sheane, Consultant Rheumatologist-
    ‘Bone Health & Pathology in the Young Person & Athlete’
  • Dr Philip Hu, Pain Management Consultant
    ‘Examination of the Spine’
  • Mr Ronan McKeown, Consultant Orthopaedic Surgeon
  • ‘A GP’s guide to the shoulder’
  • Mr Neil Burke, Consultant Orthopaedic Surgeon
    ‘Hip Arthritis’
  • Mr Dan Withers, Consultant Orthopaedic Surgeon
    ‘Injection techniques’
  • Dr E. Kathir Tamilmani, Consultant Pain Management Physician
    ‘Pharmacotherapy or Interventions?’
  • Dr Catherine Sullivan, Consultant Rheumatologist
    ‘Rheumatology Case Presentations’
  • Mr James Walsh, Consultant Orthopaedic Surgeon
    ‘Foot injuries’
  • Dr Ciaran Cosgrave, Consultant Sports Medicine Physician
    ‘Experiences as a Team Doctor at Rugby World Cup’
For information on future events please check out our Upcoming Events.