‘If you don’t do the rehab you pay the price’

In part two of the investigation into cruciate injuries, we look at advances in medical science.

Éanna Falvey can remember his own uncle’s situation, for instance: a diagnosis of ‘fluid on the knee’ in the ’60s brought his hurling career to an end, and by the time a London surgeon saw the injury — a cruciate ligament tear — four years later, a successful outcome couldn’t be guaranteed.

“The operation now isn’t a patch on what it was,” says Falvey. “You’re back in six to eight months if you do the rehab.”

That’s an encouraging prospect, but one thing patients should bear in mind is their surgeon’s familiarity with the procedure

“Per Renstrom in Scandinavia says – controversially – that anyone who’s not doing at least three cruciates a week isn’t an expert in cruciate repair,” says Falvey.

The rehab work must still be done afterwards, though, and it’s a challenge.

“What’s guaranteed is this,” says Falvey, “the better shape your quads are in before a cruciate operation, the better you’ll do after it.

“The more work you do afterwards the better you’ll do: there’s a threshold of work to do and if you don’t do enough of it you’re putting the graft at risk.

“A good operation is a fantastic start, but if you don’t do the rehab you pay the price.

“The whole reason the knee is so special is that it’s bone sitting on bone with all the stability being provided by ligaments and muscles – neuromuscular control – and those muscles have to be retrained after the operation.

“When you stand, for instance, your muscles are working against each other. Little accelerometers in the joint are constantly telling your brain to adjust your stance to avoid toppling over – your joint has to be retrained in all that after a cruciate operation.”

Falvey points to the “massive research and money” that are put into rehabbing cruciate injuries.

“Look up the research from the States. Where does the early stuff come from? What sport?

“Skiing. When you ski your ankles are locked and your knees take all the stress. Most of the cruciate research in America comes out of places like Aspen, Colorado, where you have dozens of skiers getting injured and there’s a lot of cash involved. The Steadman Clinic, which a lot of people would have heard of, is in Vail, Colorado.”

The fruits of that research are seen in the quick return to action of pro sportspeople after cruciate injuries.

“A professional rugby player who comes back to play within six months has had twice-a-day physiotherapy. That may not be true of Joe Bloggs who tore his cruciate in a five-a-side game, obviously.

“Something that should be factored in, though, is the isolation that sportspeople can feel in recovering from a cruciate injury. That’s very real.

“Someone in a team sport is suddenly removed from the people he spends eight or nine hours a day with normally, and that emotional isolation can affect their appetite to do the rehab work. Sportspeople can become genuinely depressed because of that.”

One question may not be strictly medical: how did the cruciate become so well-known?

“There’s a reason cruciate injuries get so much publicity. The two big time-loss surgical injuries are cruciates and shoulder dislocations.

“The latter are more common in American football, rugby, and maybe Gaelic football, but not really in soccer.

“In terms of time lost to sport, the big injuries, hamstring is number one, cruciate number two and groin number three. With a cruciate you’re out for six months. If I have 40 players and one of them tears a cruciate, he’s out for six months and I’ve lost 1/18th of my squad.

“If I have four hamstring injuries, each of them is two months, but it’s only about the same as one cruciate.

“However, there’s no operation to get a hamstring victim back on the pitch, while there is a cruciate op. So it’s big because it happens a lot.

“In rugby union studies it’s the second biggest reason for time lost to sport after hamstring injuries, and there’s more cutting and twisting in Gaelic football, so you would expect more cruciate injuries.

“Also, the media is more clued-in now and are more focused on injury details in a way they weren’t 10 years ago, even.”

Ten years ago — 20 years ago, even — the broken leg seemed more terrifying to a sportsman, it seemed, but recovery from that injury seems almost guaranteed now.

“Trauma surgery has come on a lot,” says Falvey. “We had a rugby player who fractured and dislocated an ankle, and back in the day with that injury, there’d have been a screw put in, and six weeks after that it’d have been taken out, and six weeks after that he’d have been back in again.

“Today, though, when you dislocate the ankle you can have damage to the cartilage, so we checked his injury with an MRI to make sure there was nothing there, and then we scoped the ankle. And then we put it together.

“So he came out the other side because there was nothing else in the joint that had to be fixed as we were working on it. The level of technology is a lot better.

“But you still have guys with their careers ended by broken legs today. The difference with years ago is that you would have had guys not playing because they had ‘bad knees’, and fellas would have been saying, ‘what’s wrong with him, no fracture and he can’t play’.

“They didn’t know it was a cruciate injury — or how bad that injury was.”

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