Australia has the highest incidence of ACL injuries in the world, with figures soaring in the past 15 years. So what are key sporting bodies and medical experts doing to reduce the risk? By Jill Stark.

Working to reduce ACL injury rates

Adelaide Crows co-captain  Erin Phillips after rupturing her ACL in the AFLW grand final in March.
Adelaide Crows co-captain Erin Phillips after rupturing her ACL in the AFLW grand final in March.
Credit: mark brake / getty images

When Erin Phillips collapsed to the ground, clutching her knee in the third quarter of this year’s AFLW grand final, it was a heartbreaking moment.

Arguably the competition’s most talented player, the Adelaide Crows superstar has inspired a new generation of girls to dream of playing football at an elite level.

But now that she is facing, at age 33, a second knee reconstruction and up to a year on the sidelines, tearing her anterior cruciate ligament (ACL) could force Phillips into retirement.

In the same game, her teammate Chloe Scheer also succumbed to a serious injury that was later confirmed as an ACL rupture. It was the eighth such injury in a nine-week season contested by 10 clubs.

For critics who have been only too eager to stick the boot into the fledgling women’s game, it was further proof that female athletes aren’t built for the physical demands of a traditionally male sport.

But the spate of knee injuries in the AFLW forms part of a more complex trend that goes far beyond the football field. Australia now has the highest rate of ACL injuries in the world. A study published in The Medical Journal of Australia last year revealed a 74 per cent increase in the number of young Australians having knee reconstructions for ACL injuries in the past 15 years.

Women are two to 10 times more likely to suffer the injury than men – in part due to biomechanical differences in the size, shape and movement of bones and ligaments. But the greatest increase in ACL ruptures is being experienced by children under the age of 14 – an emerging and costly health crisis that has experts rattled.

Orthopaedic surgeons warn that without intervention it will condemn a generation of young people to a lifetime of pain and medical complications.

“When I started practice 15 years ago I hardly ever saw children rupturing their ACL but now I’m operating on multiple young people every week,” said Christopher Vertullo, a specialist knee surgeon and director of Knee Research Australia.

“These are devastating lifelong events and many of these teenagers end up needing knee replacements by the time they’re 40 because their joints are so badly damaged.”

It’s also leading to an epidemic of osteoarthritis, with patients as young as 15 developing the condition after tearing their ACL at an earlier age. “It’s catastrophic. It’s very hard to explain to a 12-year-old what that means for their future,” Vertullo said.

The reasons for Australia’s unenviable title of ACL injury capital of the world include our growing participation rates in sport – particularly among girls and women – and a temperate climate that allows team sports to be played all year round.

Childhood obesity and sedentary lifestyles are also a factor. Young people are bigger and heavier than ever, reducing their agility and making them more injury-prone when they move from the couch to a high-risk sport. Up to 80 per cent of all ACL ruptures are sports-related, non-contact injuries, usually occurring when stepping, landing and changing direction – movements prevalent in popular sports such as AFL, netball and basketball.

One in three people who suffer an ACL injury will have a recurrence – partly because after so long on the sidelines they subconsciously favour the stronger leg when resuming physical activity. Frustratingly for those working in this area, potentially more than half of these injuries could be prevented if people were taught how to move and land more safely when playing sport.

Vertullo chairs a working group for the Australian Orthopaedic Association, lobbying the federal government to establish a national sports injury prevention program. The group’s cost–benefit analysis found such a program could save the health system $142 million a year in surgical costs alone. “For every one person you expose to an agility training program – 20 to 30 minutes, three times a week during the playing season – you prevent about $900 in future medical costs,” he said.

While successive Labor and Liberal governments have turned down funding requests for the establishment of a national injury prevention program administered by Sport Australia, progress is being made by the AFL, particularly in the women’s competition.

The league has partnered with La Trobe University on Prep to Play – an injury reduction program showing promising results after being introduced in the 2019 AFLW season.

In the 2018 AFLW season, eight players suffered ACL injuries; in 2019 the figure remained at eight. “Given that we had two more teams, more games, more players, we do feel like the level of training being offered to players in AFLW this year is starting to make a difference,” said Nicole Livingstone, the AFL’s head of women’s football.

The program, which teaches a series of warm-up movements, is also being rolled out at the community level in a bid to teach safe practice from an early age.

“There’s been such an influx of girls coming to play Australian rules football, but if we can start to influence the movement, the training of those athletes and the exercising that they’re doing, then perhaps we can start to reduce the instance of injury,” Livingstone said.

Brooke Patterson, a sports scientist with La Trobe University’s Sport and Exercise Medicine Research Centre, and until recently an AFLW player for Melbourne, helped formulate the Prep to Play program with centre director Kay Crossley.

Patterson developed a passion for injury prevention after tearing her ACL playing semi-professional basketball nine years ago and is hopeful her work will reduce the risk for young women playing AFLW. But she wants more investment in training programs tailor-made for the unique needs of female athletes.

With AFLW players having to fit conditioning work around day jobs, they are potentially at a disadvantage in terms of injury prevention. “The men train in the morning, have some lunch, refuel and then go into their strength training, whereas we have to train until 8.30, 9 at night,” Patterson said.

“We know that we’re different with hormones and maybe doing certain exercises at certain times of the month will provide more gains. But there isn’t really enough research to show what strength training and physical preparation should look like for females because it’s all been done in males.”

David Hunter, a rheumatology specialist and professor of medicine at the University of Sydney, welcomed the AFLW’s program, but said a national approach from grassroots sports to the elite level is critical if we are to halt rising rates of ACL ruptures and osteoarthritis. He points to countries such as Norway and Denmark, which have seen significant reductions after introducing nationwide injury prevention programs.

The cost of not acting, he said, will be high. “About 20,000 Australians will experience an ACL injury every year and the mean age is under 25. Seventy per cent of them will get osteoarthritis before they’re 40,” he said.

“These are young, typically active people who are developing a disease which is painful and disabling and has ramifications for their life and their profession. So they become much older earlier in their life than they need to be.”

Brooke Patterson believes that for most female athletes, the benefits of playing team sport far outweigh the risks, and that with the right injury prevention programs, children should still be encouraged to take part.

“You don’t want parents thinking that it’s too dangerous, that they’re going to get a head injury or a knee injury and then having kids just sitting on the couch,” she said.

“Because that way they’re more at risk of injury when they do end up playing sport, or all the chronic diseases that come with being physically inactive.”

This article was first published in the print edition of The Saturday Paper on May 18, 2019 as "On our knees".

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