Return From ACL Injuries
The knee anterior cruciate ligament injury - known to football players as the 'big' knee, was the focus of a discussion on the Fox Footy AFL Channel on White Line Fever on May 7. Dr. Peter Brukner, a sports medicine expert and columnist for The Age, Fox Footy and ABC radio, was joined on a panel including Clinton Grybas, Peter Hudson, Chris Grant, Josh Francou and Dr John Grant (who was a pioneer of knee surgery in Melbourne in the 1960s and 1970s). Peter Brukner outlined that in the USA, particularly in the NBA, that players would return from knee reconstruction after six months. He claimed that in Melbourne, surgeons suffered from the "David Schwarz syndrome", and were scared to recommend return inside 12 months, due to criticism leveled at Melbourne Football Club after David Schwarz twice broke down after early return from a knee reconstruction in 1995 and 1996. Dr John Grant, who performed some of the first knee reconstructions in Australia, told the audience it was worth w aiting 12 months as studies had shown that the graft was at only 40% strength after six months, and nothing in recent years had been shown to increase the speed of healing. Chris Grant (no relation) who is currently sitting out the season himself, also thought that 12 months was the best timeframe, even though he watched his teammate Tony Liberatore return successfully after 16 weeks in the late 1990s. Peter Hudson, who was the VFL leading goalkicker in 1971, then was struck down by an ACL injury in 1972, said it took until 1975 for him to return to full confidence on the knee. He again topped the VFL goalkicking in 1977. He also urged caution on return, which seemed to be the panel conclusion. Other issues discussed were the effects of knee injuries after football and the propensity for these injuries to commonly occur
early in the season.
(.pdf)
Most football players who have an ACL injury elect to have a knee reconstruction. In the general community, possibly up to 10-20% of football players may be able to football without needing an ACL reconstruction, but this figure would be even lower in the elite population (<10%). The last AFL player who was known to continue a lengthy career after a complete ACL injury was Hawthorn and West Coast player Steve Malaxos . In the rugby codes, front row forwards are sometimes able to do without a reconstruction as their position involves less change of direction. Former Penrith player Matt Adamson continued after a complete ACL injury in the NRL. Players may even possibly be able to return within weeks if they don't undergo surgery.
After surgery, a most difficult decision is the return to play. The tendon(s) used for reconstruction take many months (extending to years) before they regain their full strength. The least time taken to return from an ACL reconstruction is approximately 4 months. A recent example of a player successfully playing in finals after a mid-season ACL reconstruction was Tony Liberatore of the Western Bulldogs.
However it is known that the risks of re-injury are greater if a player makes an early return. Click to read the paper from the American Journal of Sports Medicine detailing
Risk factors for ACL injuries in football players
(Acrobat .pdf format).
In season 2002 of the AFL a media controversy occurred when Anthony Koutoufides of Carlton returned from his ACL reconstruction at just under 10 months from his initial injury. Sports medicine expert and prominent AFL commentator Peter Larkins was quoted as warning Koutoufides against returning given that Carlton could not make the finals, because of the increased risk of re-injury compared to waiting until the following season. This statement was controversial as the Carlton support staff had obviously cleared the return to play. This issue highlights the difficulty in making return to play decisions from ACL surgery. The more conservative viewpoint is that all players should minimise their risk by waiting at least 12 months to return. Players and their coaches and doctors must collectively decide whether the potential benefits of an earlier return (whether it is at 10, 8, 6 or even 4 months) is worth the increase in risk, which is hard to quantify. Tony Liberatore made his decision late in his career that to play in an AFL finals series was worth the increased risk, and he avoided re-injury. Yet other players have re-ruptured after an early return, most notably David Schwarz ( read more ). Further research in this area is desirable, but even with this it will always be a case of balancing risks with rewards.
To post a comment or ask a question about these injuries, visit the injuryupdate Forum, click here .
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