Sport Health Volume 39 Issue 1 - ACL Injuries by Sports Medicine Australia

Sport

health VOLUME 39 ISSUE 1 2021

ACL Injuries FEATURING

• Returning to sport after ACL Injury • One Anterior Cruciate Ligament Injury is enough! • The problem of second ACL Injury after ACL reconstruction • ACL Injury and Surgical Considerations

Contents REGULARS

02 From the Chair Professor Gregory Kolt provides an insight to the newly formatted 2021 SMA e-Conference.

03 From the CEO SMA CEO Jamie Crain announces a new three-year Strategy Plan for SMA.

10 The problem of second ACL injury after ACL reconstruction This article by Dr Della Villa talks about risks of second ACL injuries after an ACL reconstruction and the challenges in clinical management.

19 ACL Injuries of the Knee – are we ‘barking up the wrong tree’ with efforts at injury reduction? Sports and Exercise Physiotherapist Tim McGrath (PhD) discusses how ACL injuries occur and what prevention strategies can help in injury reduction.

FEATURES

05 One Anterior Cruciate Ligament injury is enough! Focus on female football players. Anne Fältström shares her insights from her doctoral studies on Anterior Cruciate Ligament injuries in female football players.

Opinions expressed throughout the magazine are the contributors’ own and do not necessarily reflect the views or policy of Sports Medicine Australia (SMA). Members and readers are advised that SMA cannot be held responsible for the accuracy of statements made in advertisements nor the quality of goods or services advertised. All materials copyright. On acceptance of an article for publication, copyright passes to the publisher.

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14 Returning to sport after ACL injury Author Tracy Ward shares the importance of both physical and psychological factors of returning to sport after an ACL injury.

Publisher Sports Medicine Australia Sports House, 375 Albert Rd Albert Park VIC 3206 sma.org.au ISSN No. 1032-5662 PP No. 226480/00028

Copy Editor Jodie Tennant PR, Communications and Marketing Manager Cohen McElroy Design/Typesetting Perry Watson Design Cover photograph gettyimages/wavebreakmedia Content photographs Author supplied; www.gettyimages.com.au

Volume 39 • Issue 1 • 2021

24 ACL Injury and Surgical Considerations In this feature Dr Paul Bloomfield and Dr Keran Sundaraj talk about the understanding of ACL injury management including anatomy, mechanism of injury, risk factors and surgical considerations.

34 Sports Medicine around the World: Norway

38 People who Shaped SMA – Kieran Richardson

30 Quality of life after ACL injuryconsiderations for clinicians Dr Stephanie Filbay talks about the different considerations that need to be provided by clinicians in ACL injury management.

INTERVIEWS

36 5 minutes with Luke Kelly Dr Luke Kelly reflects on his career as podiatrist and his involvement as the Co-Chair of the 2021 SMA e-Conference.

42 SMA Profile – Barry Nicholls

VOLUME 39 • ISSUE 1 2021

FROM THE CHAIR

2021 SMA e-Conference a first in SMA history.

elcome to the latest edition of Sport Health!

As we approach the final months of 2021, the COVID-19 pandemic continues to provide challenges for sports medicine professionals across the country. We are all tested by the lockdowns that continue across several States and Territories, the constant rescheduling of many sports events, and the restrictions regarding the delivery of healthcare. We anticipate, however, that as we reach important vaccination thresholds, we will see the recommencement of community sport, the reopening of many fitness facilities, and our professional lives returning to ways that are familiar to us. I do encourage all our you, however, to evaluate the new ways that we have had to adapt to work in the sports medicine environment over this period – I am sure there is much from that we would wish to continue. I also take this opportunity to point you to the Sports Medicine Australia Vaccine Position Statement released in September 2021 in response to the fight against COVID-19.

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The 2021 SMA e-Conference was launched, providing delegates all around the world an opportunity to join SMA live, online.

In Sports Medicine Australia news, for the first time in our history, the 2021 SMA e-Conference was launched, providing delegates all around the world an opportunity to join SMA live, online for a busy and exciting program featured over two events in October 2021. The Summit, to be held on 8-9 October, will feature Keynote and Invited Speakers including

Australian Olympic Team Medical Director, Dr David Hughes delivering the prestigious Sir William Refshauge Lecture. The Showcase, to be held on 23 October, will deliver the best and latest in sports medicine research including the Best of the Best awards and five streams of sports medicine content in the following areas: Sports Injury Prevention, Clinical Sports Medicine, Sport & Exercise Science, Physical Activity and Health Promotion, and for the first time a dedicated Sports Trainer & Community Sport feature. This month’s edition of Sport Health focuses on anterior crucial ligament and knee rehabilitation, with feature articles leading the way on recognising ACL injuries, injury prevention, and management. We also feature our SMA member Luke Kelly, and our SMA Sports Trainer Spotlight feature on Barry Nicholls . I would like to thank all who have contributed to this issue of Sport Health. I hope that you all enjoy reading it. Professor Gregory Kolt

FROM THE CEO

SMA plans for the future with our new Strategy Plan.

he team at Sports Medicine Australia is excited to commence our first ever SMA e-Conference this month. We are delighted to showcase an incredible line up of talent and provide delegates the opportunity to hear from the latest in sports medicine research. We are also excited to feature for the first time, a dedicated Sports Trainer stream as part of the Showcase being held on 23 October 2021. This will provide our Sports Trainer members the opportunity to hear from our Sports Trainer presenters on the following topics:

ٚ Athlete Management Systems for Recreational Sport ٚ Use of ice in acute injury ٚ The practical side of injury reduction: an example in football (soccer) ٚ What’s in your kit? The guide to what you need in your Sports Trainer Kit ٚ What are pronouns? – How to establish a safe environment for trans athletes. This is an exciting edition to the e-Conference and we hope to see many of you online for this years event. In August 2021 we launched a new three-year Strategic Plan that will guide the direction of Sports Medicine

We are delighted to showcase an incredible line up of talent and provide delegates the opportunity to hear from the latest in sports medicine research.

Australia through to June 2024. Part of this new plan is a one-page Strategy Map that shares a new Vision and Mission for the organisation. The Strategy Plan encompasses three key themes of Members First, Peak Performance and Future Fitness. As part of our plan we have recently kick started our 2021/22 SMA Event

Series. We are excited to be bring you this series which will provide all members a variety of topics in Sports Medicine. We recently held our first ‘SMA Membership Check-In’ where we provided SMA members the opportunity to meet the team and hear the latest information from SMA. This event will be a regular event held throughout the year to provide SMA members the opportunity to speak directly with the team. We will also be launching ‘Next Gen In Sports Research’ which will provide up and coming researchers the opportunity to share their work with the Sports Medicine Australia community. In this edition of Sport Health we are featuring articles Anterior Crucial Ligament (ACL) including exploring treatment options including surgical and non-surgical approached, prevention of injury and re-injury. Sports Medicine Australia is excited to announce that we will also be hosting a Debate Night as part of our 2021/22 SMA Event Series for ACL Surgical VS Non-Surgical Medical Interventions. We hope you enjoy this edition of Sport Health. Mr Jamie Crain CEO

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SUMMIT

SHOWCASE

8-9 OCTOBER, 2021

23 OCTOBER, 2021

ALL ACCESS

2021 SMA e-CONFERENCE OCTOBER 2021

$299

FOR SMA MEMBERS

$199

FOR SMA STUDENT & SPORTS TRAINERS MEMBERS

FEATURE: ACL INJURY FOCUS ON SECTION FEMALE PL HEADER AYERS

One Anterior Cruciate Ligament injury is enough! Focus on female football players

AN ANTERIOR CRUCIATE LIGAMENT INJURY (ACL) IS A SEVERE KNEE INJURY AND YOUNG ATHLETES ARE MORE LIKELY TO SUSTAIN AN ACL INJURY.

fter puberty women have higher risk to sustain an ACL injury and female football players have a 2 to 3 fold higher injury risk than men. Working as a physiotherapist focusing on patients with ACL injuries for more than 20 years, a number of questions were raised. One of the main dilemmas is that there are too many re-injuries after sustaining a primary ACL injury, especially in young athletes returning to contact sports. A quandary as a physiotherapist is to know when it is safe for a patient to return to sport. What tests should be done and how do I know if the results are good

enough for safe return to sport? Are there any predictors for sustaining an additional knee injury and especially an ACL injury? How many players will injure the knee again? If the patient return to sport and injures his/her knee again or injures the ACL in the opposite knee it feels like a great failure for the clinician and, of course, most of all for the patient. The questions ended up in doctoral studies and my thesis – “One anterior cruciate ligament injury is enough – focus on female football players”( http://www.diva-portal.org/smash/get/ diva2:956732/FULLTEXT01.pdf or short

summary in Fältström, 2017) However, many questions are unanswered, so my research in this field (prevention of ACL injury, return to sport, re-injury, predictors for re-injuries…) is continued. To answer some of my questions, we followed female football players with a primary ACL reconstructed knee (6-36 months before inclusion) for 2- and 5-10 years after the ACL reconstruction and also knee-healthy female football players. At baseline they were 16-25 years old and playing football at any level. They answered several baseline questionnaires about demographic, knee function, personality and psychological factors. The players who had returned to football and were still active football players at baseline also performed a battery of tests to assess postural control (Star Excursion Balance Test) and hop performance (single-leg VOLUME 39 • ISSUE 1 2021

FEATURE: ACL INJURY FOCUS ON FEMALE PL AYERS

One Anterior Cruciate Ligament injury is enough! Focus on female football players hop for distance, five-jump test and side hop). Movement asymmetries were assessed with the drop vertical jump and the tuck jump using twodimensional analyses. During the 2-year and 5-10 years follow-up, players were asked to register new knee injuries and if they still played football. In rehabilitation after ACL reconstruction return to sport, no giving way, quadriceps and hamstring strength >90% of the uninvolved limb, and high scores (85%-90%) on patient-reported outcomes are considered important components for successful results. These components are also considered to be important for reducing the risk of additional injuries and other complications, but no formal guidelines or functional tests to indicate safe return to sport currently exist. After an ACL injury and reconstruction only about 50% of the non-elite athletes return to their previous activity level. There is limited information about factors that influence return to sports in female football players who have undergone ACL reconstruction. We found that two factors showed a significant association with return to play: short time (within a year) between the injury and the reconstruction and high motivation to return to football. However, it is not clear from our data whether this means that early ACL reconstruction increases the possibility of returning to sport or if reconstruction is performed in a selected sample of young, highly active patients who want an ACL reconstruction performed as soon as possible to rapidly return to playing strenuous sports. Rehabilitation after an ACL injury is tough and many can lose sight of their return to sport goal. It is therefore important

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to be aware of the importance of motivation for returning to football and to ask about the patient’s motivation during rehabilitation. Historically, clearance to return to sport was based mainly on time after reconstruction. Today, time after ACL reconstruction is still important regarding e.g. the graft healing and cartilage in the knee, but the function of the trunk and lower extremities are more in focus. We investigate

any side-to-side limb differences in functional performance and movement asymmetries in female football players with or without a primary unilateral ACL reconstruction. The reconstructed and uninvolved limbs did not differ, and players with or without ACL reconstruction differed only minimally on the functional performance tests, indicating similar function. We noticed that many players had movement asymmetries, which have previously been associated with an increased

FEATURE: ACL INJURY FOCUS ON FEMALE PL AYERS

risk for both primary and secondary ACL injury in female athletes.

Many different factors, such as age, sex, functional performance, psychological, factors, social-contextual factors, and surgical factors probably affect the risk to sustain a new ACL injury.

However, the validity of the used functional performance tests to predict new knee injuries was poor. Only knee valgus during the drop vertical jump was associated with new ACL injuries in knee-healthy players, but with only fair predictive validity. Thus, our used functional test could not be used to predict which players who will sustain a new knee injury. Many different factors, such as age, sex, functional performance, psychological, factors, social-contextual factors, and surgical factors probably affect the risk to sustain a new ACL injury. To uncover this complex nature of risk factors, we used a so called Classification and Regression Tree (CART) analysis. The analysis showed that interactions among functional performance tests, clinical assessment, and psychological factors could accurately classify female football players at high risk of sustaining a second ACL injury. On the basis of our findings, we recommend not only including functional performance tests with qualitative assessment, clinical assessment, and psychological factors in return-to-sport decisions, but also including continuous follow-up

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FEATURE: ACL INJURY FOCUS ON FEMALE PL AYERS

One Anterior Cruciate Ligament injury is enough! Focus on female football players assessments as long as females with ACL reconstruction play football. Unfortunately, returning to sport, especially contact sports, after ACL reconstruction increases the risk of new knee injury. The female football players with ACL reconstruction had nearly a 5-fold-higher rate of new ACL injuries and a 2 to 4 fold higher rate of other new knee injuries, quit football to a higher degree, and reduced their activity level to a greater extent as compared with knee-healthy controls in the 2- year follow-up. In the long-term follow-up (5-10 years after ACL reconstruction), 42% (!) of the players that returned to football sustained a new ACL injury (either in the reconstructed or the contralateral knee) compared to 19% in players who did not return to football and 11% in the knee-healthy players. New injury may have negative consequences for long-term knee health and should be a critical consideration in the decision to return to play. Patients with bilateral ACL injuries reported poorer knee function and quality of life compared with those who had undergone unilateral ACL reconstruction. Their activities had changed, and they were dissatisfied with their current activity level. Still, there is unfortunately too many re-injuries. It is therefore necessary to prevent and predict new knee injuries. The question how we should do that is still not really answered, but probably involves many factors – surgical, rehabilitation, psychological, anthropometric, environmental... Of course, the best is to prevent the first ACL injury, so the title of this article should be “One ACL injury is one too much”, but that title do not really reflect the content of my thesis and research. Many primary knee injury prevention programs including plyometrics, neuromuscular training, and strength training exercises, and have shown high ACL injury prevention effect and should be used more frequently. So, in conclusion – female football players with ACL reconstruction are at high risk of new knee injuries, which must be considered in the decision to return to play. More efforts toward both primary and secondary prevention strategies are needed. References for each specific study are available upon request.

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Unfortunately, returning to sport, especially contact sports, after ACL reconstruction increases the risk of new knee injury.

FEATURE: ACL INJURY FOCUS ON FEMALE PL AYERS

Author Bios Anne Fältström, PhD is a physiotherapist from Sweden working clinically at the Rehabilitation Centre, Ryhov County Hospital, Jönköping. She is also an adjunct senior lecturer at Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University. She has also started a post-doctoral work at Sophiahemmet University, Stockholm. She has been working clinically with patients with orthopaedics injuries and especially with patients with anterior cruciate ligament (ACL) injuries for more than 20 years. Fältström finished her PhD in 2016 and the research is focused on patients with ACL injuries and reasons for re-injuries especially in women football players. The research goal is to find risk factors to sustain re-injuries with the ultimate goal of preventing re-injuries in the future. She is a member of the Swedish National Knee Ligament Register and also the Swedish Football Association medical committee.

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FEATURE: THE PROBLEM OF SECOND ACL INJURY

The problem of second ACL injury after ACL reconstruction and the association with injury mechanism. Francesco Della Villa MD Education and Research Department, Isokinetic Medical Group, FIFA Medical Centre of Excellence, Bologna Italy f.dellavilla@isokinetic.com www.isokinetic.com www.footballmedicinestrategies.com

ANTERIOR CRUCIATE LIGAMENT (ACL) INJURIES ARE ONE OF THE BIGGEST PROBLEMS IN NOWADAYS SPORTS MEDICINE. FROM PRIMARY REDUCTION STRATEGIES TO GOLD STANDARD CLINICAL MANAGEMENT, THERE IS AN ACTIVE DISCUSSION IN SCIENTIFIC LITERATURE AND STILL AN OPEN CHALLENGE IN CLINICAL IMPLEMENTATION.

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FEATURE: THE PROBLEM OF SECOND ACL INJURY

a follow up of 4.3 years following ACLR the second ACL injury risk after return to training was as high as 18%. Practically one out of five top level football players went on a second ACL injury.

In a recent study, we studied the second ACL injury risk in top level European football players. Even in this very selected cohort of high-level athletes, at

The most important risk factor was how the first injury (index ACL injury) took place, in other words the injury mechanism. A pure non-contact ACL injury was correlated with a 7-fold increase in the probability to sustain a secondary injury. Non-contact ACL injuries in this kind of population is reported for nearly a half of the players (44%) and generally happens in defensive pressing situations (figure 1). In this case one can speculate that these players may carry on

ollowing a recent consensus, experts recommend surgical management (followed by high quality criteria-based rehabilitation) as the gold standard for athletes willing to return to pivoting and cutting sports, like football. Unfortunately, after ACL reconstruction (ACLR), there is a consistent risk of sustaining a second ACL injury (to both limbs). Young and high-level athletes typically carry the higher risk, with rate of second injuries ranging from 20 to 35%.

Figure 1. Sequence of non-contact ACL injury mechanism during a pressing situation in a professional football player. VOLUME 39 • ISSUE 1 2021 11

FEATURE: THE PROBLEM OF SECOND ACL INJURY

The problem of second ACL injury after ACL reconstruction and the association with injury mechanism.

intrinsic risk factors, such us familiar predisposition, bony morphology or altered neuromuscular control and biomechanics favoring high knee joint loading and thus ACL injury causation. More interestingly the second risk factor was having sustained an isolated ACL injury, with a 3-fold increase in the likelihood of a recurrent injury. This finding was contrary to our hypothesis that additional joint structure injuries would have been correlated with increased laxity and thus higher risk. It is possible that players with an isolated injury went on a faster and less cautious recovery.

Combining the two risk factors, the players that sustained a non-contact isolated index ACL injury had a 42% second ACL injury rate (almost one out of two). This shocking number is also a precious information for all the health professionals involved in ACL injuries management.

Continuing secondary prevention strategies also after return to play is crucially important.

There are few important take home messages that the sports medicine community should reflect on. First, we should inform the patient on the real risk of second ACL injury following surgery, considering a non-contact mechanism a key risk

factor for secondary injuries. Honest counselling to the patient is critical. Secondly, we should always adopt a secondary prevention strategy after ACLR. This implies the application of high-quality criteria-based rehabilitation, whose progression is based on quantitative and qualitative measures of movement. The adoption of a targeted neuromuscular training based on patient movement profile is warranted, as this approach reduce the primary risk of ACL risk by 50-70%. Continuing secondary prevention strategies also after return to play is crucially important.

Figure 2. Above. High knee joint loading (high knee abduction moment) COD. Below. After appropriate training low knee joint loading (low knee abduction moment) COD in a young patient. COD: change of direction. 12

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Lastly, and correlated to the point above, an increased attention to biomechanics, especially regarding landing and cutting

FEATURE: THE PROBLEM OF SECOND ACL INJURY

Author Bio After ACL reconstruction (ACLR), there is a consitent risk of sustaining a second ACL injury.

Francesco Della Villa, MD is a Sport Medicine physician, graduated at the University of Bologna, Italy. He is currently working in the Education and Research Department of the Isokinetic Medical Group, which is a FIFA Medical Center of Excellence in Bologna, Italy. He oversees

task (figure 2) is suggested alongside the adoption of a set of more strict return to sport criteria, considering both the physiological (strength, movement quality) and psychological aspects.

research and development and as well of education and updating of the whole clinical group. He is member of different international societies, including ESSKA, ISAKOS and ICRS and serves as a member of the FIFA Medical Centre of Excellence Advisory group. His main clinical interests are

In conclusion, the real advance of sports medicine in the next years should be to break down the barriers to clinical implementation of effective interventions for secondary injuries reduction. The challenge is accepted, helping one patient at a time.

Anterior Cruciate Ligament (ACL) injuries and other sever lower extremity injuries, from injury mechanism and prevention to return to play protocols. Every year the Isokinetic Medical Group organize the largest football medicine conference www.footballmedicinestrategies.com and he is actively involved in the event planning.

Additional readings available upon request.

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FEATURE: RETURNING TO SPORT AF TER ACL INJURY

Returning to sport after ACL injury ANTERIOR CRUCIATE LIGAMENT (ACL) INJURIES REMAIN ONE OF THE MOST COMMON SPORTING INJURIES THAT ALSO HAVE A COMPLEX REHABILITATION PROCESS AND A HIGH RISK OF RE-INJURY FOLLOWING RETURN TO SPORT. THE CONSEQUENCES OF ACL INJURY ARE DETRIMENTAL TO THE ATHLETE AND HAVE A SIGNIFICANT IMPACT ON THEIR ABILITY TO SUSTAIN INVOLVEMENT IN SPORT AT THEIR CURRENT LEVEL. MANY ATHLETES FOLLOWING ACL INJURY SUFFER A SUSTAINED ABSENCE FROM SPORT, RETURN AT A LOWER LEVEL THAN PRE-INJURY, OR FAIL TO RETURN AT ALL.

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FEATURE: RETURNING TO SPORT AF TER ACL INJURY

f the 50% who do return at their level prior to injury, approximately 30% will sustain a re-rupture within two years. There appears to be a lack of consensus on criteria to determine return to sport following ACL injury, and return to sport should be the primary determinant of success of ACL rehabilitation. Return to sport success consists of aligning both physical and psychological parameters and rehabilitation should follow a criteria-based format that measures key physical, physiological, and psychological demands of the athlete’s specific sport and environment, rather than follow a “one size fits all” protocol. As approximately 60-80% of ACL injuries occur in non-contact situations, where the knee is forced in to flexion and then rotated, this makes any sport involving pivoting, twisting, landing from a jump or sudden deceleration high risk. Rehabilitation progress should account for the biology, considering the healing of the graft and recovery of neuromuscular function, as well as the demands of the sport, and the athlete’s internal and external capacity. Time Time is still the most frequently reported criteria for when athletes are cleared for return to sport, and in 90% of these cases this timeframe is nine months post-injury or post-surgery. Those who return to play at nine months or less however, have a seven-fold increased rate of a second ACL injury. This is because time since injury is not indicative of healing, and the graft healing, as well as strength, stability and proprioception of the surrounding muscles must be considered as approximately 70% of ruptures occur within six months of reconstruction surgery. Additionally, there is an increased risk of osteoarthritis (OA) in those who sustain a meniscal injury at the time of ACL injury. 50% of these patients will require meniscal VOLUME 39 • ISSUE 1 2021

FEATURE: RETURNING TO SPORT AF TER ACL INJURY

Returning to sport after ACL injury surgery within the first five years, and trauma following ACL rehabilitation could accelerate poor knee health in future with an increased OA prognosis of 0-13% up to 21-48%. Discharge criteria Athletes who do not meet six key clinical criteria measures prior to discharge back to sport have a four times greater risk of graft rupture compared to those who do meet all six criteria. The six identified measures are: 1. Isokinetic strength testing; This is the strength through range of movement and is measured at various stages to ensure strength throughout. An 85% or more symmetry between legs is recommended. 2. Four hop tests consisting of a running T-test, single hop, triple hop, triple crossover; Hop tests assess dynamic movement for strength

and power, as well as balance and control upon landing. A 90% symmetry is recommended. This is higher than the isokinetic strength testing due to the unpredictability and numerous skills involved that represent sporting activities. 3. Hamstring to quadriceps muscle strength ratio; The hamstring muscles function to resist the forward motion of the tibia produced by the quadriceps and therefore they work with the ACL to prevent further damage occurring. For this reason a higher hamstring to quadriceps ratio is suggested, and for every 10% reduction in this ratio, there is almost an 11% increased risk of graft failure. Physical tests Physical tests should progress through a continuum established by the World Congress of Physical Therapy. This consists of:

Return to sport success consists of aligning both physical and psychological parameters.

ٚ Return to participation; commencing rehabilitation and low level training ٚ Return to sport; sport-specific tasks but at a level with demands below pre-injury ٚ Return to performance; return to their sport and their current or higher level than pre-injury

Strength tests

Criteria to match

Agility & run tests

Single leg bridges

>20

Single leg hop test

>95% compared to the un-injured side

Calf raises

>20

Trip hop test

>95% compared to the un-injured side

Side bridge endurance test

>30 sec

Triple cross over test

>95% compared to the un-injured side

Single leg squat

> 22

Side hop test

>95% compared to the un-injured side

Single leg press

1.5-1.8x body weight

Squat

1.5-1.8x body weight

Star excursion balance test

There is a points system specific for this test

Cooper& Hughes sports vestibular balance test

There is a points system specific for this test

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FEATURE: RETURNING TO SPORT AF TER ACL INJURY

Return to sport should introduce sports-specific drills with optimal loading that progresses to that of the sport requirements. The athlete should be monitored for the ability to withstand the load during the task and maintain this over a consistent training plan. Open skills should be included to challenge the unpredictability and spontaneous elements of game play that require fast reactions and decision-making. The athlete’s capacity to maintain this collectively alongside the onset of fatigue should also be assessed to identify their physical readiness and mental capacity to be “game ready”. The table below details key strength, agility and run measures used to evaluate the athlete’s progress and provide an indication of their position in returning to sport.

outcome measure for evaluating this. These fears must be addressed to optimise patient outcomes and methods include modelling, imagery, relaxation techniques and education in conjunction with a robust physical protocol and a minimum return time of nine months. Summary ٚ Time since surgery is NOT the key determinant for return to sport. Those who return prior to nine months post-injury, have a significantly

higher risk of re-injury or not returning to their pre-injury levels. ٚ All six of the key discharge criteria must be met prior to returning to ensure full physical outcomes are met and provide the greatest chance of success. ٚ Psychological readiness is the largest component for NOT returning and significant emphasis should be placed on addressing fear, confidence, and the mental status of the athlete.

Author Bio Tracy Ward is a Senior Chartered

Psychological readiness Rehabilitation is often strongly focused on the physical outcomes and treatment protocols, that the psychological readiness of the athlete is not considered, or not made a priority. However, if the athlete is not psychologically prepared, no amount of strength and physical rehabilitation skill will overcome this. Fear of re-injury is the single most important cause of failure to return to play, with 30% of athletes reporting this as their primary reason for not returning, and 20% reporting a lack of confidence in their performance as the barrier. Those with self-reported fear have also been identified to be less active overall, have a reduced single leg hop performance, and reduced isometric quadriceps strength, giving an increased risk of re-injury within the first two years. The Tampa Scale of Kinesiophobia (TSK-11) is the recommended

Physiotherapist (MSc, BSc), Pilates Teacher, APPI Course Presenter, and sports medicine writer. Tracy completed her Masters degree in Physiotherapy after she obtained a first-class Bachelor’s (BSc) degree in Biomedical Science. Tracy continuously advances her qualifications, having completed several postgraduate qualifications. She has worked with International level athletes and uses this unique combination of science-based knowledge and clinical expertise to provide rehabilitation and exercise advice. Tracy is the founder of Freshly Centered, a Pilates company leading local classes and Retreats, as well as an online platform of Live classes, Fitness blog, Youtube channel, Workout plans, custom programmes, and an exclusive membership platform for both On-Demand Pilates classes and specialised 6-week rehabilitation programmes. Tracy is also qualified in Kids Pilates, Ante and Postnatal Pilates, and Therapeutic yoga. Tracy is also the author of The Postnatal Pilates Guide ebook, educating new mums on the safe return to exercise postpartum complete with a 6-week Pilates plan.

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FEATURE: ACL INJURIES OF THE KNEE

ACL Injuries of the Knee – are we ‘barking up the wrong tree’ with efforts at injury reduction? Tim McGrath (PhD) Sports & Exercise Physiotherapist Director of Clinical and Research – Pitch Ready

ACL INJURIES – CURRENT STATE OF PLAY Anterior cruciate ligament (ACL) injuries of the knee represent a serious concern in sports worldwide, not only because of significant time-loss from sport but also because of the long-term health consequences, including a substantially increased risk of knee osteoarthritis (OA) in the medium to long-term (30-60% of ACL injuries go on to have radiologically confirmed OA of the knee by 15 years post-injury with the possibility of ongoing impaired lower limb function as well as a re-injury rate of between 5-30% depending on the pre-injury competitive level played. In England alone for example, an estimated 15,000 primary ACL reconstruction surgeries are performed each year. However, this is a modest estimate based on Hospital Episode Statistics (HES) data, and the real figure for a UK population of 63 million may be closer to 50,000 pa (based on Swedish ACL registry data – incidence 71/100,000 pa). Collectively, the global sports medicine market will be worth an estimated ₤8,199 million annually by 2023 (as reported by www. alliedmarketresearch.com). This presents

a serious issue deserving of increased efforts to reduce the problem. Following an occurrence of ACL injury, return to sport (RTS) is generally permitted as soon as six to twelve months following surgery depending on the graft used in surgical cases (or even sooner in the cases of nonoperative management) and the desired level of risk. However, some authors suggest that return to sport might even be delayed until up to two years after surgery for the lowest

chance of reinjury, which can be problematic given the often capricious nature of professional sport. WHEN DO ACL INJURIES OCCUR? Although ACL injuries typically happen across both the pre-season and inseason periods across most team sports and competitions, there is potentially a slight increased tendancy towards injuries occurring in the pre-season and early in-season period, which raises the notion that efforts towards injury prevention PRIOR to injury (termed VOLUME 39 • ISSUE 1 2021

FEATURE: ACL INJURIES OF THE KNEE

ACL Injuries of the Knee

– are we ‘barking up the wrong tree’ with efforts at injury reduction? PRIMARY prevention) might be best facilitated in the pre-season period. In the football codes for example, the most common mechanism of injury is when a player is pressing forward towards an opponent at high speed, followed by regaining balance after kicking or landing after heading the ball. It is also important to note that ACL injuries occur with combinations of internal knee rotation, valgus and relative knee extension, approximately 40 milliseconds after the athlete’s foot has hit the ground, making it too short a period of time for the athlete to make a conscious decision about movement (or a bad one more to the point). Sport is a chaotic environment, and this needs to be accounted for both as a theme in injury risk reduction efforts and as part of the return to sport decision making process. WHAT OPTIONS ARE AVAILABLE TO HELP? Previously-established methods for primary prevention ACL injury come in the form of programs such as the ‘FIFA 11+’, and the ‘ACL Play it Safe Program’. Although cheap and relatively simple to run, these programs focus on generic injury prevention themes, and by design are supposed to achieve base-level competency across a broad range of areas. There is no way of knowing whether participants have made meaningful changes in injury risk reduction, where that individual stands in relation to their peer group, and doseresponse is generally not observed in objective manner. There is a distinct gap in ‘performance-oriented’ themes such as high-speed running, which can be a barrier to implementation in higher level sporting organisations. Other previous attempts at individualised ACL injury prevention such as the Landing Error Scoring System (LESS) is largely subjective and uni-dimensional. The program again does not include movements most known for ACL injury scenarios such as change of direction. The relationship with these programs 20

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and prevention of injury is still also unproven. Furthermore, the onerous manual process of data collection with this process means that only a few trials are captured, opening strong potential for bias or incomplete analysis. There is still scope to improve how we structure and implement injury reduction programs both at amateur and professional level. CAN WE IMPROVE PRIMARY PREVENTION PROGRAMS…? I THINK WE CAN…. From a health perspective across the industry, most efforts arguably seem to focus rigor on specific criteria for return to sport (RTS) in the rehabilitation period AFTER an injury, yet many of the same principles can and probably should be applied BEFORE an injury has even occurred as an important means of injury reduction strategies. UNFORTUNATELY... this approach seems to be little more than an after-thought at both the amateur and professional level. Although implementation of post-injury RTS criteria arguably also needs to improve across the board as we improve our understanding of risk factors, most researchers are generally in agreement

that completion of rehab and objective testing helps to minimise re-injury. The most commonly used methods reflect the various components of rehabilitation following injury. Mutli-factorial functional assessment tests generally include combinations of strength, unilateral hopping, jump landing, and/ or running-based tests. A benchmark of >90% concurrence of the injured limb relative to the uninjured limb is most commonly used to determine satisfactory recovery of function post-operatively, though literature has reported this benchmark as low as 80%, or as high as 95%. A recent meta-analysis published by our group identified that average symmetry varied from 94.6% to 99.6% for the physical performance tests commonly used in measurement of recovery following ACL reconstruction across a healthy active population. Further research completed by our group has also shown that the closer a testing battery resembles the ultimate demands of the target sport, the stronger the correlation with return to sport outcomes at 2 years post-surgery. Absolute benchmarks may be more useful than inter-limb comparisons, as the latter assumes that the reference leg is in itself ‘optimal’.

FEATURE: ACL INJURIES OF THE KNEE

Although this might indicate that the ‘yard stick’ that we apply to RTS criteria is currently too low, encouragingly many of these lessons learned in dealing with POST-injured athletes may provide frameworks for primary prevention of ACL injury BEFORE injury. THE RACE CAR, VERSUS THE RACING CAR DRIVER. People who have heard me talk before know that I like to use a ‘motor racing’ analogy to illustrate what I believe to be the best method of assessing priorities for injury reduction programs or readiness for return to sport after an ACL injury. On one hand, we need to build the ‘race car’ – that is, we need to build a strong, powerful lower limb that has the capacity to resist external forces that are applied to it. This is comprised after an injury (or in some cases wasn’t great to begin with) and needs to be brought within a ‘normal’ range. We also need to ‘train the driver’ so that he or she (the athlete) can zip around the race track and not ‘crash the car’ through poor skill execution – that is, under stress and at-speed to not put their body into a situation where an injury mechanism is likely to occur. Like any skill (my surfing or golf ability for example), we are dealing with higher brain centers that need time and frequency to adapt to any stimulus, so from a rehab perspective, logic dictates that we should introduce these ‘movement stresses’ as early as possible in the the preseason period or in the rehabilitation process that follows after an injury.

Risk Category

Athletes (35)

Knee Injuries During Season

High Priority

Medium Priority

Low Priority

control). Of these tested professional athletes, 150 met the benchmark criteria by normalising both capacity and control metrics in comparison to a reference population, and from these athletes at time of writing we have only had one known ACL (no contralateral) re-injury occur, and this latter recurrence was in a professional male rugby union player

who was attempting non-surgical management after an ACL injury, with the recurrence occurring over 12 months after the most recent testing which in itself is somewhat encouraging.* For further context, there have been 20 athletes that we do not have evidence of normality in terms of either the capacity or control outputs

Since 2017, Pitch Ready has collected data on over 700 tested individuals, and critically provided ACL recovery benchmarking to over 170 professional athletes across multiple sporting codes in both Australia, the UK and now the USA. The analysis and recommendations generated within the reporting framework are targeted to provide actionable insights to help athletes normalise outputs within the testing criteria (both capacity and VOLUME 39 • ISSUE 1 2021

FEATURE: ACL INJURIES OF THE KNEE

ACL Injuries of the Knee

– are we ‘barking up the wrong tree’ with efforts at injury reduction?

(or both) – which does not mean that they did not achieve it, just that we do not have objective evidence of such prior to return to play, with eight athletes subsequently reinjuring their ACL (or contralateral ACL). These results sit well in comparison to research, and we are currently in the process of preparing for peer-review publication in the hope of changing the narrative in terms of traditional approaches to ACL rehabilitation. SO… HOW CAN WE APPLY THIS TO PRIMARY PREVENTION OF ACL INJURIES? Time-loss through injury negatively affects team performance throughout a season, which can also have significant implications in an industry which is judged almost exclusively on win/ loss ratio at the professional level. Furthermore, the average cost to a club in the Engish Premier League for an ACL injury in the UK is approximately £450,000 per injury for example, and so aside from the individual health implications there is probably also sufficient financial incentive to prioritise efforts by implementing gold standard injury reduction strategies for professional athletes. Unfortunately, this is not a new idea. Squad-based injury prevention strategies are often employed within sporting organisations but

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individualising the program can be challenging. These programs are typically heavily dependent on coaching expertise and staffing resources (which have become particularly challenging in the era of COVID-19-affected annual budgets), and often lack empirical evidence for the most targeted interventions or do not assess doseeffectiveness which can potentially lead to suboptimal outcomes. In 2019 we began development of the Pitch Ready PRO format which has primary prevention as the direct focus. The Pitch Ready ‘PRO’ format utilises kinematic joint assessment to identify currently healthy athletes at higher risk of suffering a significant injury. Using the lessons learned in the ‘RTS’ testing framework alongside population derived norms, we stratify individuals into categories to help targeted intervention at the squad level, identifying risk markers common in the following lower limb injuries. Our experience to date suggests that this is best delivered early in the pre-season period, with a seconday battery of data collected later in the pre-season period to judge dose-effectiveness just prior to the commencement of the in-season period. Below is a case study for a professional rugby league team which pre-emptively identified 100% of the serious knee

injuries that occurred within this team as HIGH PRIORITY within the preseason, with 6/11 athletes identified as being within this group. No injuries were sustained within the MEDIUM / LOW PRIORITY group. We have subsequently captured data on just under 200 professional athletes using the PRO product to date, including six elite level sporting teams. Although there is still significant work to do in valdidating these concepts within bigger population groups, and we do not claim the ability to absolutely predict those individuals who will sustain a serious lower limb injury, these encouraging results we feel provide the foundation for targeted interventions in the future. SPECIFIC COMPONENTS TO FOCUS ON WITH PRIMARY PREVENTION. The Pitch Ready PRO program includes the following: 1. Assessment of range of movement in the lower limb. Restriction in movement availability in other limbs can also place stress on the knee as the body tries to solve the ‘movement puzzle’ during sport. 2. Calf strength testing and foot and ankle ‘stiffness’ – the ability for the calf complex to absorb and produce force has a strong ability to attenuate loads before they even reach the knee. 3. Quadriceps strength testing – this is important for sagittal knee mechanics (flexion) and the ability to resist vertical and horizontal deceleration. 4. Hamstring testing – this is important for the generation of running speed and soft tissue injury prevention. 5. Lateral hip and groin capacity – hip strength and movement preferences

FEATURE: ACL INJURIES OF THE KNEE

can dictate knee position via a ‘top down’ approach. Often abhorrent movement observed at the knee can be derived via limitations at the hip. 6. Power profile – horizontal and vertical leg capacity, again, this assures that the leg at least has the ability to resist these forces. I generally like to look at movement strategies at the hip and ankle with these tasks also.

Author Bio Time McGrath PhD is a Sports Physiotherapist is a Sports Physiotherapist with nearly 20 years professional practice

7. Uncontrolled change of direction at speeds above 80% of the maximum linear velocity. This assures a certain level of confidence on the athlete’s part about their ability to decelerate on their injured leg, and I also use this to quantify their ability to make good decisions under stress (avoiding mechanical positions we know are well suited to knee injuries).

and over 15 years full-time experience in professional sport since graduating in 2002. Tim completed his PhD from the Research Institute of Sports & Exercise (UCRISE) at the University of Canberra on the topic of ACL rehabilitation and return to sport following knee injury in 2016. Tim’s clinical expertise focuses on lower

8. Qualitative assessment of training load and skill exposure at speed – have you introduced enough ‘chaos’ into their training? Specifically, have you given due homage to those three common mechanisms that are known to cause injury (in the case of a football athlete)? Have you built in a level of resistance against other injury (most notably soft tissue injury)?

limb rehabilitation, and he regularly conducts clinical consultancy to professional sporting teams within Australia and also overseas for complex cases following lower limb injury. He developed Pitch Ready (www.pitch-ready. com) which combines cutting-edge data science with clinical insights to optimize squad-based injury prevention strategies across organizations as well as return to sport

Bringing it back to the ‘motor racing’ analogy, these components attempt to pay due diligence to the ‘race car’, whilst also to the race car driver. In my humble opinion all need due respect.

decision-making following lower limb injury. In addition to his undergraduate Physiotherapy degree and subsequent PhD, Tim has completed a post-graduate Master’s Degree in Sports Physiotherapy

References available upon request.

and Musculoskeletal Physiotherapy. He has also completed a Graduate Diploma in Extended-Scope Physiotherapy and a Graduate Certificate in Data Science. He has lectured extensively in sports physiotherapy courses for the Australian Physiotherapy Association as well as to other health professions and has authored publications in peer-reviewed journals (see research page of Elite Rehab website http://www. ersportsphysio.com.au/ersp/research/).

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FEATURE: ACL INJURY AND SURGICAL CONSIDERATIONS

ACL Injury and Surgical Considerations MANY ARTICLES HAVE BEEN WRITTEN ON ANTERIOR CRUCIATE LIGAMENT (ACL) INJURIES, BOTH RESEARCH AND CLINICAL EXPERIENCE IN NATURE. IN THIS ARTICLE, WE PROVIDE A BRIEF OVERVIEW OF ACL INJURIES WITH NEW UPDATES IN SELECT AREAS. THIS INCLUDES USING POSTERIOR TIBIAL SLOPE TO HELP MANAGE PATIENT EXPECTATIONS REGARDING ACL INJURY RECURRENCE AND GIVE SPORTS TRAINERS AND OTHER MEDICAL PROFESSIONALS MORE INFORMATION REGARDING THE CURRENT SURGICAL TECHNIQUES AND REHABILITATION CONSIDERATIONS FOLLOWING SURGERY.

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ACL function The primary functions of the ACL are to restrict anterior translation of the tibia, act as a secondary stabiliser to valgus stress and control rotation of the tibia on the femur in terminal extension – “Screw home mechanism”. It also plays a role in proprioception of the knee. Mechanism of injury There are two (2) main mechanisms of ACL injury; contact and non-contact. ٚ Non-contact mechanisms of ACL injury account for approximately 70-80% of total ACL injuries. Typically, these occur during deceleration associated with a change in direction, such as sidestepping in the football codes. Similar deceleration

FEATURE: ACL INJURY AND SURGICAL CONSIDERATIONS

such as occurs in all football codes. These injuries occur due to valgus stress, usually with some rotation, hyperflexion or hyperextension of the knee. They can be associated with other knee structure injuries such as the Medial Collateral Ligament (MCL), Posterior Cruciate Ligament (PCL), meniscal tears or a combination. The more structures injured usually means that greater force has occurred in the injury. Risk Factors Many risk factors need to be considered and addressed when managing each patient’s return to sport following an ACL injury. The specific individual risk factors must be determined on a

Contact mechanisms of ACL injuries account for approximately 20-30% of total ACL injuries.

occurs when landing from a jump, particularly with a sudden stop, such as in netball. Forces involved with sidestepping include internal rotation of the tibia in relation to the femur (more often than external rotation of the tibia) and also axial loading (leading to anterior translation of the tibia on the femur) of the joint, which is also particularly relevant with deceleration injuries such as landing from a jump. They can be associated with other knee structure injuries, particularly meniscal tears.

case by case basis, and the following are examples of things to be mindful of but is not an exhaustive list. ٚ Environmental Factors ͛ shoe/boot to surface interface ٚ Anatomical factors ͛ Notch size ͛ Alignment (e.g., genu valgus) ͛ Posterior tibial slope (PTS) ▷ This can be evaluated most easily and reproducibly on a lateral long-leg alignment film (e.g. EOS imaging). Those patients with a PTS>12º may have up to five times increased risk of ACL rupture (either the reconstruction or the contralateral native ACL).

Figure 2 - Posterior Tibial Slope (PTS) of 8o in 16 y.o. female

Figure 3 - Posterior Tibial Slope (PTS) of 13o in 15 y.o. female

ٚ Contact mechanisms of ACL injury account for approximately 20-30% of total ACL injuries. Contact injuries usually occur in sports involving activities such as being tackled, VOLUME 39 • ISSUE 1 2021

FEATURE: ACL INJURY AND SURGICAL CONSIDERATIONS

ACL Injury and Surgical Considerations ͛ Biomechanical / Neuromuscular factors ▷ Landing position ▷ Axial loading ▷ Quads v Hami activation/timing ▷ Ankle mobility ▷ Proprioception ͛ Female ▷ 2-8x greater risk ▷ Hormonal factors possibly related to oestrogen. ▷ Biomechanical (e.g., anatomical issues such as genu valgus) Presentation The typical acute presentation for an ACL injury (non-contact) involves a change in direction or sidestep. The knee collapses or gives way, often associated with a pop or snap. The severity of pain varies from not much at all to severe pain, which is often poorly localised but can often be posterolateral. There is then usually an inability to continue the activity. Due to haemarthrosis, swelling is often quite pronounced and early in the presentation though not always. Sub-acutely, the patient may present with ongoing swelling, variable severity of pain, lack of confidence in their knee, rotary instability episodes, “buckling/giving way”, or they may present with an associated injury. On examination, the clinician should assess for swelling (haemarthrosis/ effusion or localised swelling), look for signs of associated injury such as locking (may represent meniscal pathology or can be related to the ACL rupture itself impinging in the notch) and associated ligament injuries (MCL, PCL). The Lachman and pivot shift tests should also be performed appropriately; these tests are best placed to assess the function of the ACL (AP translation and rotational stability, respectively).

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Finally, always remember to examine the contralateral knee (and ask if it has previously been injured or operated on) to get a perspective of what is normal for that particular patient. Management ٚ Initial/acute management ͛ RICE ͛ Analgesia as required ͛ +/- crutches (may help with rest and pain relief) ͛ +/- Brace (may help with rest and compression but more commonly used for associated injuries such as MCL injuries) ٚ Investigations ͛ X-ray may assist with diagnosis or alter management in some way. ▷ Tibial tubercle avulsion – requires surgical reduction and fixation rather than an ACL reconstruction with a graft. ▷ Segond fracture (anterolateral capsular avulsion fracture of the tibia related to the anterolateral ligament). ▷ Posterior Tibial Slope measurement via long alignment films (e.g., EOS imaging) – assists with surgical technique, rehab and return to sport recommendations. ٚ MRI scan is not always necessary as an ACL rupture and instability is a clinical diagnosis. It may assist with: ͛ Confirmation of the diagnosis when the clinical diagnosis is difficult. ͛ Determination of associated injuries such as meniscal pathology and MCL injury that may require more urgent surgery. ٚ Ultrasound and CT scans are generally unhelpful for ACL injuries and are not usually recommended.

Conservative management When considering whether or not to pursue conservative management for ACL injuries or to refer for surgical opinion and possible reconstruction, the following factors should be considered: ٚ A small percentage (1%) of ACL ruptures heal. If this does occur, the outcome is likely better than a reconstructed ACL. This needs to be evaluated at three to four weeks postinjury. Beyond this, healing is unlikely. ٚ Age and desired level of function (including work and sport). ٚ Rehab program availability and ability to complete it. ٚ Are there associated injuries that require surgery anyway, e.g., locked meniscal tear? ٚ The willingness of the patient to change sporting/work activities as not all activities require an intact ACL. ٚ Psychological factors play a significant part in the non-operative management of ACL injuries. Due to the general population’s incomplete understanding of the ACL and its function, the popular thought is that everyone who ruptures their ACL requires a reconstruction. This can be a difficult concept to overcome, so individual assessment and education are necessary. Most knee orthopaedic surgeons specialising in ACL reconstruction will also factor these issues into their decision-making process regarding the best management for each patient. Surgical management ٚ “Prehabilitation” ͛ It is best to wait until the swelling settles and pain-free range of motion (ROM) returns before undergoing surgery, as surgical outcomes are improved if this is adhered to. This is, of course, unless

FEATURE: ACL INJURY AND SURGICAL CONSIDERATIONS

A small percentage (1%) of ACL ruptures heal.

other associated injuries such as a torn meniscus causing a locked knee or a distal MCL injury require more urgent surgical attention for a more favourable outcome. Therefore, injuries involving multiple structures in the knee should be reviewed by an ACL surgeon as soon as possible, definitely within ten days of injury. ͛ This is often around 4 to 6 weeks with physiotherapy but can be shorter or longer depending on individual circumstances. This period also allows re-assessment for possible ACL healing (see above). ͛ Prehabilitation should be directed

at regaining quadriceps strength. Literature suggests that each day of intensive prehabilitation can help reduce the required post-operative rehabilitation. ͛ This period is conducted under the guidance of an appropriate physical therapist. In their own time, patients may continue a cyclic loading program using an exercise bike or rowing machine. Such exercise provides excellent quadriceps rehabilitation and returns ROM. ͛ Arthroscopic Surgical reconstruction ▷ Principles of surgical ACL reconstruction

ۜ Graft choice • The graft should be biologically active. • There are multiple options for a biologically active graft, including allograft (nonirradiated fresh frozen donor tendon allograft – FFA or live donor allograft), autograft (including hamstring, bonepatellar tendon-bone BTB, or quadriceps tendon). Note that irradiated allografts are not considered to be biologically active due to the sterilisation process used. VOLUME 39 • ISSUE 1 2021

FEATURE: ACL INJURY AND SURGICAL CONSIDERATIONS

• In recent times, evolution in allograft preparation and an understanding of who the ‘ideal’ donors are for tendons has improved the outcomes for patients undergoing allograft reconstruction. Allograft that has undergone irradiation or that is sterilised in chlorohexidine reduces the graft’s integrity, thus leading to higher failure rates. Donors above the age of 60 in males or 50 in females also have poorer quality tendons and are therefore best avoided for patients who require a more robust ACL graft. • Supercritical CO2 sterilisation is a modernised technique for allograft preparation. Early results from these techniques show highly promising results. • Allograft provides a very much acceptable alternative to autograft, though the general literature on this topic must be interpreted with caution as not all allografts are the same. • By avoiding the morbidity associated with autograft harvesting (tears or loss of dynamic stabilisation with the use of hamstrings or anterior knee pain with the use of patellar tendon), allograft is often better tolerated. • Furthermore, a bespoke sized graft that is patient specific can be created based on their functional demands and specific anatomy. • Synthetic grafts such as LARS (Ligament Augmentation and Reconstruction System) are not biologically active, and when they rupture result in significant synovitis and can lead to early osteoarthritic change. Due to the synovitis and bone tunnel widening, LARS reconstructed knees are significantly more challenging to perform revision ACL reconstruction surgery.

and the graft fully remodelled at ~12 months. Maturation is not complete until ~ 18-36 months. Fixation methods also have varying rates of bony ingrowth that affect recovery periods.

Fig 4 – LARS ligament rupture: following removal

A typical post-operative rehabilitation program would include the following stages and considerations: ٚ Acute post op ͛ 0-2 weeks ͛ Wound healing, swelling reduction/ control, ROM, early strength

Fig 5 – LARS ligament rupture: arthroscopic image of intraarticular rupture

ۜ Graft placement • It needs to be accurate – it is an operation of millimetres between success and failure. For example, if the graft is placed too anteriorly, impingement in the notch can occur, resulting in reduced extension of the knee, associated pain and disability, and failure to rehab completely. This may also lead to graft rupture due to repeated impingement of the graft in extension. ۜ Fixation • Various devices are available, but they fall into two (2) categories: • Interference screw • Suspensory fixation, e.g., endobutton ۜ This is often a surgical preference, but the choice of fixation can influence the early stages of rehabilitation. Post-op rehab The ACL graft needs to undergo “ligamentisation” with reasonable strength obtained at ~8 months,

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Therefore, each surgeon’s rehab program will vary based on their individual choices of surgical technique (including fixation type) and: ٚ Specific patient risk factors (e.g., lack of donor site morbidity in allografts, recurrence rates, anatomical issues) ٚ Patient-specific goals (e.g., professional v recreational athlete)

ٚ Muscular control ͛ 2-6 weeks ͛ Return to normal activities of daily living (ADL) function ٚ Proprioception ͛ 6-12 weeks ͛ Improve confidence ͛ Solo cycle/swim/straight line jogging are often allowed ٚ Neuromuscular and Sport Specific ͛ 3– 5 months ͛ Incorporate lateral movements/ sport specific drills ͛ Start PEP (Prevent injury and Enhance Performance) program or similar ͛ Teach and practice good landing technique ٚ Prepare for Return to Sport ͛ 6-12 months ͛ Upgrade strength programs and skill drills ͛ Continue PEP ͛ Remember to consider each patient’s individual risk factors and goals ٚ Return to Sport ͛ 12+ months ͛ Minimise risk of further injury with shoe/equipment and terrain advice ͛ Continue PEP

FEATURE: ACL INJURY AND SURGICAL CONSIDERATIONS

Again, specific details regarding timing, activities, and exercises will vary based on individual surgeon preferences taking into account patient individual circumstances, associated injuries and surgical techniques used. ٚ Prevention ͛ The rate of another ACL injury is ~1% per knee per year. Generally, this is equal in the ACL reconstructed and contralateral/nonoperative knees. The reinjury rate to either knee (reconstructed or native ACL) may vary based on the surgical technique and graft choice employed. Education by the surgeon of this risk is an important detail that should be addressed with patients so that they are aware of the risks and do not have heightened expectations of surgical results. ͛ Neuromuscular programs (e.g., PEP program and FIFA 11+) as warm-ups help reduce the risk of further ACL injuries. They are helpful for all patients/athletes (some modifications may be required for those <12 years old depending on the chosen program) and should be performed ~2 to 3 x/week. The correct technique must be ensured to help prevent injury, and instructions and videos for these programs can be obtained online. ͛ Addressing risk factors that can be modified and discussing those risk factors (such as posterior tibial slope) that cannot be altered, so that the patient can consider their expectations and potentially make modifications to their activities, are also essential components of preventing further injury.

Author Bios Dr Paul Bloomfield MBBSFACSEP is a Specialist Sport and Exercise Physician who has been involved with many elite and professional sports including football (Soccer), volleyball, triathlon, mountain biking, skateboarding, rugby union and rugby league. He was the chief club medical officer (Club Doctor) for the NRL Manly Sea Eagles from 2000 to 2012 and was the Sports Physician consultant and co-Club Doctor for the NRL St George Illawarra Dragons for the 2013 season. He was also involved with the St George Dragons from 1994 to 1998 as the junior representative’s team doctor and assisted with the 1st grade team at that time. Dr Bloomfield has also had recent extensive involvement with medical policy development to improve player welfare and safety in rugby league over the last 6 years (2015 to April 2021) in his role as the NRL Chief Medical Officer. He is currently the RLPA medical consultant and maintains a strong interest in concussion management and education. In addition to these roles, he has assisted orthopaedic knee surgeons, with a special interest in ACL reconstructions, for over 20 years.

Dr Keran Sundaraj MBBSMSc

SUMMARY In conclusion, ACL injury management requires a good understanding of the anatomy, mechanism of injury, risk factors, surgical considerations and rehabilitation, all of which needs to be individually assessed and applied to each patient. Management starts with the acute assessment of the injury, assessing any potential associated damage, and, if considering surgery, prehabilitation should commence early. If a patient undergoes surgical ACL reconstruction, individual surgeon considerations must be taken into account when rehabilitation continues postoperatively as not all surgery is the same. Also, surgery is only one component of recovering from an ACL reconstruction; post-operative rehab, addressing risk factors, and ongoing prevention programs are equally important components of ACL injury management.

(Trauma) FRACS FAOA is an Orthopaedic Surgeon with a special interest in knee, hip and trauma surgery. At the University of London, he completed a Masters of Science, majoring in Trauma Surgery. He is involved in the trauma service in Sydney’s tertiary hospitals, including Liverpool and Campbelltown. His special interest is in ACL surgery, including revision and complex cases. He joined Professor Leo Pinczewski in partnership following his fellowship at The Mater Hospital in North Sydney. Continuing Prof. Pinczewski’s ground-breaking research, Dr Sundaraj is at the forefront of modern techniques, particularly the use of supercritical sterilised allograft.

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FEATURE: QUALIT Y OF LIFE AF TER ACL INJURY

Quality of life after ACL injury – considerations for clinicians Dr Stephanie Filbay

Quality of life after ACL injury It is not surprising that quality of life is impaired after an acute ACL injury. People can no longer take part in sport and activities that are important to them, work and parenting roles can be challenging, and people are living with a painful, inflamed knee. Within the first few months of injury, people face uncertainty about their future – will their knee ever be the same again? Will they need surgery and what will this be like? Will they re-injure their knee? Can they play sport again and perform at the same level? Should they play sport again? 30

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Clinicians can reduce these uncertainties by providing accurate, evidence-based information about ACL injury outcomes and management options. Clinicians should be cognisant of the psychological and social impacts of an ACL injury, and implement strategies to address these throughout the recovery process. Often overlooked by clinicians, is the potential for an ACL injury to negatively impact quality of life in the decades following an ACL injury. The importance of return to sport and physical activity Our research found that not returning

to sport after ACL injury is associated with poor quality of life 5 to 20 years later. However, after ACL injury some people replace sport participation with other forms of physical activity with a lower risk of knee injury (like running, surfing, yoga, weightlifting). This is associated with maintaining a high quality of life. On the other hand, after ceasing sport some people struggle to find alternative forms of physical activity that they find satisfying, and this can lead to adoption of an inactive lifestyle. For these people, participation in sport was closely related to their sense of

FEATURE: QUALIT Y OF LIFE AF TER ACL INJURY

Within the first few months of injury, people face uncertainty about their future.

wellbeing, and ceasing sport due to their knee could have negative impacts on quality of life across the lifespan. Clinicians can assist individuals with the transition from participation in high-risk sports, to other forms of physical activity with a lower risk of knee injury. This may involve determining what the individual enjoys about that particular sport, and suggesting alternative activities tailored to their needs and activity preferences. Return to sport – a double edged sword The benefits of continuing sports participation after ACL injury should be weighed up against the risk of subsequent knee injury. Sports with a large degree of cutting, pivoting and jumping movements have a high risk of knee injury, particularly when combined with contact and collision. As many as 1-in-3 people who return to such sports after ACL reconstruction re-injure their

knee and rupture their ACL graft. This is a concern because re-injuring your knee after ACL reconstruction is a strong predictor of poor long-term outcomes including osteoarthritis, persistent knee pain, impaired function, and reduced quality of life. Osteoarthritis has negative impacts on quality of life People who develop osteoarthritis after ACL injury report reduced quality of life. We assessed the aspects of quality of life that are most impaired in people with osteoarthritis after ACL injury. Our research found that an inability to take part in sports and physical activity and the challenge of psychologically coming to terms with the state of their knee, were contributing factors to poor quality of life. People who present with knee osteoarthritis after ACL injury may require different management from people who present with

osteoarthritis in later life, without a history of sports-related knee injury. Preventing osteoarthritis after ACL injury There are no studies in ACL injured people demonstrating effective strategies for reducing osteoarthritis risk. However, there is research investigating factors related to an increased risk of osteoarthritis after ACL injury. It is possible that targeting such risk factors could prove effective in reducing the likelihood of developing osteoarthritis after ACL injury. Potential risk factors for osteoarthritis after ACL injury include obesity, hamstrings and quadriceps weakness, reduced single-leg hop performance, poor self-reported knee function and subsequent knee injury. A number of these risk factors were assessed more than two years after ACL injury. This suggests that VOLUME 39 • ISSUE 1 2021

FEATURE: QUALIT Y OF LIFE AF TER ACL INJURY

Quality of life after ACL injury – considerations for clinicians

follow-up consultations with ACL-injured individuals, beyond the typical 12-month rehabilitation period, could provide an opportunity to identify risk factors and intervene to reduce osteoarthritis risk and optimise long-term quality of life. Fear of re-injury The most common reason that people do not return to sport after ACL injury is due to fear of reinjury. Persistent fear of reinjury can lead to poor quality of life. However, in some cases fear of reinjury may reflect a realistic risk of reinjury, particularly when it relates to returning to sports with a high risk of knee injury. For some individuals, fear of reinjury can extend to everyday activities such as walking the dog, going for a jog or playing with their children. Such fears can persist for decades after an ACL injury and negatively impact quality of life. Clinicians should address these fears early on in the recovery process through education and interventions (such as active goal setting, mental practice, use of a role model, and relaxation techniques). What can clinicians do to enhance long-term quality of life after ACL injury? ٚ Address the immediate psychological and social impacts of ACL injury ٚ Assist the individual with evaluating the risks vs. benefits of returning to sport ٚ Support a transition to an active lifestyle once ceasing sport participation ٚ Reduce the risk of subsequent knee injury and osteoarthritis ٚ Evaluate and manage fear of re-injury ٚ Perform mid-term follow-up to identify and address risk factors for poor long-term outcomes References available upon request. 32

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The most common reason that people do not return to sport after ACL injury is due to fear of reinjury.

Author Bio Dr Stephanie Filbay is a physiotherapist, NHMRC Emerging Leadership Fellow and Senior Research Fellow in the Department of Physiotherapy at the University of Melbourne, and an Honorary Senior Research Associate in Orthopaedics, Rheumatology and Musculoskeletal Sciences at the University of Oxford. Dr Filbay’s research expertise includes evaluating and optimising outcomes after ACL injury, developing strategies to improve outcomes for people with knee osteoarthritis, and evaluating the long-term musculoskeletal and psychological impacts of sports participation. She has presented over 30 times at national and international conferences, serves on several committees for international organisations, supervises individuals at various career stages and received numerous awards, scholarships, and grants for her research. She was recently awarded an NHMRC Investigator Grant to fund five years of research aimed at improving outcomes for people with ACL injury and post-traumatic knee osteoarthritis. Follow her research updates on Twitter: @stephfilbay

FEATURE: QUALIT Y OF LIFE AF TER ACL INJURY

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SPORTS MEDICINE AROUND THE WORLD: NORWAY

Sports Medicine and physical activity in Norway MEDICINE IS TAUGHT IN FOUR MEDICAL SCHOOLS ACROSS THE COUNTRY – OSLO, BERGEN, TRONDHEIM AND TROMSØ.

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SPORTS MEDICINE AROUND THE WORLD: NORWAY

At the end of 2020, there were 153 specialists recorded in sports medicine in Norway.

edical school in Norway is a six year education. After that follows a 12 month internship at a hospital, before six months in general practice. A licence to practice is given after completing an 18 month internship. Sports and exercise medicine are not major topics during medical school in Norway. However, there are different courses with sports medicine and physical activity as a part of the curriculum.

these specialities can only take place in accredited hospitals and clinics, and an internship in a university clinic is mandatory. The average time to obtain one of these specialties is five years.

Sports and physical activity medicine is a sub-speciality, so in order to be a specialist in sports medicine in Norway you need to obtain a main speciality. In Norway, the most common speciality is orthopaedic surgery, physical medicine and rehabilitation and family medicine. The training for

1. Obtain a specialisation approved by the Norwegian Medical Association

As sports medicine is a “sub-speciality”, it is the Norwegian Society for Sports Medicine and Physical activity that that governs the training towards a final authorisation also issued by the society. In order to obtain this authorisation, the following requirements have to be met.

3. Obtain 150 hours of other courses in sports medicine, including at least three Norwegian Sports Medicine congresses 4. Participate and pass the Anti-doping course (16 hours), and participate as an observer on a doping control. 5. Work as a team doctor or in a sport medical clinic, sports federation or club. (over 200 hours) There is no renewal of the sports medicine license. At the end of 2020, there were 153 specialists recorded in sports medicine in Norway.

2. Participate and pass exam in the following courses: sports medicine level 1 and sports medicine level 2 (40 hours courses each)

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5 MINUTES WITH

5 minutes with

Luke Kelly

Tell us a little bit about your background So my original qualification is as a podiatrist. I studied Podiatry at QUT graduating in 2003. I worked in private practice for a period of time in Southeast Queensland and then received a fantastic opportunity to move over to Doha in Qatar where I worked at the Aspetar sports medicine and orthopaedic hospital for nearly six years. While I was over in Qatar I had the opportunity to undertake a PhD which I did remotely with the university of Queensland. In 2013 I moved back to Australia where I took up a role in the biomechanics department at Cricket Australia leveraging off the bio mechanics PhD that I’ve undertaken whilst in Qatar. I had spent a period of time splitting a role between running the biomechanics testing services with Cricket Australia and doing some postdoctoral research at the University of Queensland. Subsequently I was lucky enough to secure a National Health and Medical Research Council early career fellowship and then subsequently after that an Australian Research Council discovery early career research award. So I’ve been working in a full time research capacity since about 2015 at the University of Queensland and just recently been appointed as a senior lecturer in Sport and Exercise science. How did you get involved in SMA? I think my first involvements with SMA, were through the Queensland branch as an early graduate attending CPD events and state conferences. It was just it was a fantastic eye opener to the broader community 36

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Through my interaction with Sports Medicine Australia that actually created opportunities for me to go and work overseas. of sports medicine beyond my own profession as a podiatrist. I guess through my interaction with Sports Medicine Australia that actually created opportunities for me to go and work overseas. My role in Qatar, I think it

was through an advertisement with Sports Medicine Australia that I actually applied for that job. Transitioning into more of a research career throughout my PhD, I presented at a number of SMA conferences and then was invited to participate as a member of the SMA Conference Committee in 2015. I’ve been involved with organising the Conference pretty much from that point onwards. What has been the highlight of your career so far? It’s really difficult to say, My time in Qatar was certainly a career defining time that it really opened up my eyes to sports medicine on a global scale. I got to meet and work with some amazing physiotherapists,

5 MINUTES WITH

podiatrists, sports physicians and orthopaedic surgeons from all around the world who had different perspectives on various problems. It was just such an amazing collaborative environment so I probably have to say that with my create highlight but there’s been others as well now. As the Co-Chair of the 2021 e-Conference Committee tell us what you’re looking forward to about this year’s event? Obviously it’s been a challenge in the past couple of years with the lack of face to face conferences and when we transitioned across to a virtual conference we really really worked hard with the SMA staff to try and find a format that would provide

maximum impact for people in maximising their chances to learn virtually and also making sure that we still provide excellent opportunities for researchers to have exposure of their research. The e-Conference has the Summit and the Showcase as two pillars of the event. I’m looking forward to seeing everyone engage with this different Conference format. What is the biggest benefit of being an SMA member? Just the connectedness of the association. It really gets people out of their professional silos and fosters collaboration, I think that is essential in sports medicine. Something that Sports Medicine Australia does really well is to bring

people from so many different professions, as well as clinical and academic people together. Ultimately this produces better outcomes for the public and sports people. What is the best piece of advice someone is given to you? Have a plan but be open to deviations from the plan. I always look at opportunities on their merits and be open to change.

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PEOPLE WHO SHAPED SMA: KIERAN RICHARDSON

People Who Shaped SMA

Kieran Richardson What made you decide on a career in Sports Medicine? I was very interested in sports from a young age, heck – I used to go to bed at night reading Wisdin’s cricketing almanac! I played and watched all sports growing up, and particularly enjoyed basketball, cricket, soccer and AFL. I was an emerging fast bowler as a 13-year-old, and one day broke down on the pitch with severe back pain. Ultimately, I had bilateral pars interarticularis fractures and a spondylolisthesis. I was able to get a diagnosis and return to sports – even won the Year 9 Champion Boy a year later! During high school I was especially interested in studying medicine, physical education teaching or physiotherapy, and eventually decided on physiotherapy as I could combine scientific therapies with my love for people and seeing change. Were you an athlete prior to commencing your career? If so, what sports did you play? Depends how you define an athlete? Haha. I was the co-captain of my school basketball and AFL teams and would have played around 2-3 hours of sports most days of my schooling. Moving into upper high school, I began to realise being a professional athlete was an unrealistic goal, so I continued through my late teens and 20’s playing at a social level. Can you describe your educational background? I have completed a Bachelor of Science (Physiotherapy), a Masters of Clinical Physiotherapy and a Post-Masters Fellowship at the Australian College of Physiotherapy, gaining specialisation in the musculoskeletal field.

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I am currently assisting with research through Sydney University and may look to undertake a PhD at some point in my career, although my wife is doing hers, so happy to wait! How and when did you start working in Sports Medicine? In my final year of studying Physiotherapy I worked as a Sports Trainer at a local Australian Rules Football. After graduating as a physiotherapist I worked in a hospital setting, where I spent time on an orthopaedic ward and in the outpatient department, seeing many patients with serious sporting injuries, and was a part of their rehabilitation.

PEOPLE WHO SHAPED SMA: KIERAN RICHARDSON

Seek out clinical mentors who you respect, are gracious and are committed to your personal growth.

Moving into private practice after a few years, I would see sports-related injuries every week. After years working privately, I developed a special interest in ACL injuries after managing two very distinctively contrasting cases almost simultaneously during my musculoskeletal specialisation training. The first was a female patient in her mid-30s who presented to me on a four-wheeled walker, in distress and in agony, approximately four years after her original ACL tear, having undergone five surgeries at that point. A patient of similar demographics requested my opinion four days after a non-contact mechanism playing sports, without having yet undertaken highpowered imaging. She was adamant that no matter

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PEOPLE WHO SHAPED SMA: KIERAN RICHARDSON

People Who Shaped SMA

Kieran Richardson what the scan showed, she was opting for non-surgical management due to friends having poor outcomes from knee surgery—an MRI later confirmed a full thickness ACL tear. We outlined a plan for management, she vigilantly completed her prescribed home exercise program and returned to field hockey in four months—and has remained symptom-free. How and when did you first join SMA? What was your initial role? I joined in 2003 as a student member. How did being part of SMA help your career? It has helped to consistently provide me with up-to-date information as my career has progressed, as well as stay connected to like-minded and world-leading experts in sports medicine and health around the world. What has been your contribution to SMA? I was fortunate to speak at the national Sports Medicine Australia conference in 2018 on the topic of ‘ACL tear: Non-surgical Management.’ It was apparently the most attended and popular workshop at the conference, provided a stimulating questions and answers time afterward and helped to galvanise common points of agreement across multiple sports medicine disciplines. What has been your career highlight? I was fortunate in 2019 to be interviewed as a part of a Fox Sports Australia exclusive on the topic of non-operative management of ACL tears. This was aired nationally and internationally and has helped to convert both many

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clinicians and patients towards non-surgical treatment solutions. Do you have any career regrets? I wish I had sought out more regular formal mentoring earlier on in my career. I had limited access to this early in my hospital and private practice employment, but what I did receive was incredible. Going through my specialist training, I had both research and clinical experts sharpen my thinking on a consistent basis; this was vital in helping to develop my clinical reasoning and communication. I now have a consultancy company where formal mentoring is a key component of what my consultants offer clinicians locally in Perth, nationally and internationally.

What do you believe is your most important contribution to your industry? I would say communicating the benefits of the Australian Physiotherapy Association’s Specialisation Pathway, as well the genuine benefits physiotherapy can offer within the profession, interprofessionally and to the general public. What is your advice to those starting out in their sports medicine career? My advice would be to seek out clinical mentors who you respect, are gracious and are committed to your personal growth, set up consistent time where you can interact with them and have an e-journal where you document your reflections after. Really there are no silly questions, so don’t be afraid to ask a lot of them and challenge the status quo.

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SMA PROFILE: BARRY NICHOLLS

SMA Profile –

Barry Nicholls How did you get involved at SMA? My son was playing Rugby League and I wanted to know about how they looked after injury management. This led me to a conversation with a coach at the Balmain Tigers (NSWRL) club and then I became involved with them at Leichardt.

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How long have you been an SMA Sports Trainer? I gained my Sports Trainer Level 1 in 1987 and progressed to my Level 2 in 1989 and recently renewed my Level 2 accreditation to celebrate my 73rd birthday.

SMA PROFILE: BARRY NICHOLLS

What do you love most about being a Sports Trainer? Working in community sports, looking after the injuries, and taking care of players. The feeling of being part of a family and having those connections. The sports I am involved with are Touch Football, NRL and AFL. What has been the highlight of your journey as a Sport Trainer so far? I have been fortunate to be made a life member of three different clubs. The Orara Valley Axeman Rugby League club (made famous as being Russell Crowe’s club). I was Head Sports Trainer there for 12 years.

Hunter Hornets Touch Football after serving for 18 years as the Head Sports Trainer as well as Group 2 Rugby League after being their Head Sports Trainer for 10 years. Another enjoyable memory was to be a Sports Trainer with the NSW Country Rugby League representative teams for four years. I also looked after the NRL referees for games in Coffs Harbour when I lived there and in recent years in Perth when scheduled, as I now live in WA.

Working in community sports, looking after the injuries, and taking care of players. The feeling of being part of a family and having those connections.

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Publisher Sports Medicine Australia PO Box 78 Mitchell ACT 2911 sma.org.au ISSN No. 1032-5662 PP No. 226480/00028