When he began operating in the 1990s the patient would start their recovery in a plaster cast, be on crutches for months and embark on rehabilitation with a withered leg. American orthopaedic surgeon Don Shelbourne broke new ground with an “accelerated” rehab model that featured full extension and weight bearing from day one post-surgery. “That went really well, until we realised there is a limit. The graft that we put in doesn’t reach full strength – and get strong enough to withstand the rigours of sport – for around six months.”
Synthetic grafts of Gore-Tex or carbon fibre, rather than conventional grafts from the patient’s hamstring, quad or patella tendon, started appearing in the 1980s. The French introduction of a ligament augmentation and reconstruction system (LARS) was seen as revolutionary, with footballers returning to play in little more than three months rather than the standard eight to 12. It proved a fad.
“I put a few in,” Dr Morris says, “but the problem is they all fail. All of the AFL footballers who’ve had them put in have had them done at least twice. I tell you right now, there’ll be no more AFL players having a LARS.”
The great advance in knees is understanding what actually happens when an ACL ruptures. This appreciation of damage done to the joint’s homeostasis – essentially, the knee’s overall health – leads Morris to view it as an 18-month to two year recovery process. “If I’ve got young kids who have a significant injury, I’ll say to the parents, ‘Give it two years.’ But it’s diffcult – these kids are elite athletes, if they were going to get drafted and I say two years, that’s the end of their career.”
Research into stem cells, growth hormones and other means of speeding up healing continues apace, but just as knee and hamstring injuries still occur, their recovery times remain relatively rigid. “Allan Jeans said to me once, ‘A hamstring is an 18-day injury’,” Brukner says, essaying his best imitation of the legendary coach. “He’s still not far wrong. It won’t become a nine-day injury unless we can find some magical way of injecting something that’s going to accelerate the healing of the muscle tissue. But we’re way, way off that.”
Schache points to the AFL’s 25 years of injury surveillance data, in which the first five years showed an average of slightly more than six players per club suffering hamstring injuries each season.
In the most recent five-year block, that’s dropped to a little more than five, not a huge gain, but progress. As with knees, the improvement in how the player presents upon returning to play, and the subsequent recurrence rate, is where the major ground has been made.
Brukner has worked with Australian Olympic teams, the Socceroos, Liverpool and, most recently, was head doctor for the Australian men’s cricket team. He regards the determination of when an athlete is ready to resume playing among a sports physician’s biggest challenges, particularly within games. “In your sports medicine practice you’re in your little room, the patient comes in, you sit down, take a history, do an examination, perhaps get an MRI done and then make a diagnosis. Whereas, you’re in the middle of the MCG, there are 80,000 people watching, the coach is screaming down the phone, ‘Get him back on, get him back on!’ Send someone back on and their knee buckles, it’s pretty public.”
The reality is that just as sports medicine continues to advance, more is being asked of the human beings playing games at the elite level. Schache likens it to driving a car, where even wearing a seatbelt and sticking to the speed limit can’t safeguard you from mishap.
“Maybe the demands of the game have increased substantially,” he says of AFL, in particular. “Yes, we might be getting better at preventing injury, but the game keeps asking more and more.”
Read more about concussion management in the AFL.