We have the highest known rate of ACL injuries in the world, and the numbers are soaring.
With a goal kicked against St Kilda at the SCG in June, Lance “Buddy” Franklin become the fourth highest AFL/VFL goalkicker of all-time.
The statistical “greatest of all time” (GOAT) is his Swans compatriot Tony Lockett, who famously overtook Gordon Coventry in 1999, where he remains the career-goals recordholder. The goals at each end of Marvel Stadium in Melbourne are named after Lockett and Coventry respectively.
Some commentators have recently suggested Buddy Franklin’s relative career performance may have been ever greater, as he’s had to overcome playing in an era where AFL defences have had the betters of attacks.
Lockett played in the golden era of goalkickers, when attack reigned over defence, and crowds were enthralled by multiple great goalkickers, including Jason Dunstall and Gary Ablett Snr.
An overlooked additional handicap that may have stopped either Dunstall or Ablett Snr catching the Coventry record was that both of these players suffered a dreaded knee anterior cruciate ligament (ACL) tear in the twilight of their careers.
Knee reconstructions, and the prolonged recovery thereafter, put an end to their chase of Coventry. A glass-half-full perspective is that they were still lucky that they suffered late-career ACL injuries rather than early-career ones, meaning they remain in the all-time top six.
Two of the all-time most talented VFL goalkickers were John Coleman and Peter Hudson, both of whom suffered ACL injuries in the middle of their careers. Coleman, after whom the AFL names the Coleman medallist as the season’s top goalkicker, never played again as his injury came before doctors in Australia could diagnose an ACL injury, let alone treat it.
Of course, this means we can’t be certain he suffered an ACL injury, but it seems by far the most likely sudden-onset knee injury that could lead to instant retirement. Hudson’s injury was in the 1970s, just as the anatomy of the ACL was starting to be understood, (1) and although he was able to eventually return it was not with the same potency.
ACL reconstruction and MRI scans were perhaps the two key sports medicine advances of the 20th century. This meant that excellent AFL goalkickers of the 1990s, such as Tony Modra and Matthew Richardson, could return from ACL reconstructions and still have outstanding careers, compared with Coleman who was forced into early retirement.
Despite dozens of different techniques for surgical ACL reconstruction, none of them is perfect. (2)
Surgery remains a miracle, but a slightly flawed one in that it doesn’t meet the early promise of making the knee stronger than it was to start with. Any attempts to make the recovery time much quicker than six to nine months have ultimately met with a higher rate of surgical failure, (3) starting with the ill-fated 14 weeks attempted by David Schwarz in the mid 1990s and including the LARS ligaments that were trendy in Australia in the late 2000s.
The present focus of ACL research is in trying to determine how many athletes could possibly get as good a result without using surgery at all. (4) This research is being led by Dr Tom Cross in Sydney. Reminiscent of Gary Ablett Jnr also being one of the all-time great players, Tom is the son of Merv Cross who was one of Australia’s pioneer knee reconstruction surgeons in the 1980s. (1)
The future focus of ACL research (like most medical research) will involve accumulation and analysis of data. New Zealand and the Scandinavian countries have well-established ACL registries. (5) Australia has a great knee replacement registry and it is overdue that we start a ACL registry as well. (6)
This is especially so given we have the highest known rate of ACL injuries in the world, (7,8) perhaps partly due to our warm climate. (9)
In particular, women have relatively higher rates of ACL injuries than men, and our overall rates of ACL injury are skyrocketing as women – rightly – are playing much more football (of all codes) than they did last century. (10)
As we celebrate our great athletes, it is a reminder that injury can stop an athletic career in its tracks.
We owe it to the male and female athletes in the present and future of Australia to start an ACL registry and do what we can to prevent knee injuries in the future.
References:
1. Norwood LA, Cross MJ. Anterior cruciate ligament: functional anatomy of its bundles in rotatory instabilities. Am J Sports Med 1979;7(1):23-6. doi: 10.1177/036354657900700106
2. Iriuchishima T, Goto B. Systematic Review of Surgical Technique and Tunnel Target Points and Placement in Anatomical Single-Bundle ACL Reconstruction. J Knee Surg 2021;34(14):1531-38. doi: 10.1055/s-0040-1710521 [published Online First: 20200601]
3. Chaker Jomaa M, Gultekin S, Orchard J, et al. Australian Footballers Returning from Anterior Cruciate Ligament Reconstruction Later than 12 Months have Worse Outcomes. Indian journal of orthopaedics 2020;54(3):317-23. doi: 10.1007/s43465-020-00092-9 [published Online First: 2020/05/14]
4. Filbay SR, Dowsett M, Chaker Jomaa M, et al. Healing of acute anterior cruciate ligament rupture on MRI and outcomes following non-surgical management with the Cross Bracing Protocol. Br J Sports Med 2023 doi: 10.1136/bjsports-2023-106931 [published Online First: 20230614]
5. Janssen K, Orchard J, Driscoll T, et al. High incidence and costs for anterior cruciate ligament reconstructions performed in Australia 2003-04 to 2007-08: time for an anterior cruciate ligament register by Scandinavian model? Scand J Med Sci Sports 2012;22:495-501.
6. Lekkas C, Clarnette R, Graves SE, et al. Feasibility of establishing an Australian ACL registry: a pilot study by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA 2017;25(5):1510-16. doi: 10.1007/s00167-016-4398-1 [published Online First: 20170214]
7. Moses B, Orchard J, Orchard J. Systematic Review: Annual Incidence of ACL Injury and Surgery in Various Populations. Res Sports Med 2012;20:157-79.
8. Orchard JW. Why does Australia have a higher rate of knee reconstruction surgery than New Zealand (and Scandinavia) and what can we do about it? J Sci Med Sport 2011;14(4):276-7. doi: 10.1016/j.jsams.2011.02.004 [published Online First: 2011/03/29]
9. Orchard J, Waldén M, Hägglund M, et al. Comparison of injury incidences between football teams playing in different climatic regions. Open Access J Sports Med 2013;4:251-60.
10. Zbrojkiewicz D, Vertullo C, Grayson JE. Increasing rates of anterior cruciate ligament reconstruction in young Australians, 2000-2015. Med J Aust 2018;208(8):354-58. doi: 10.5694/mja17.00974 [published Online First: 20180423]
