Bengaluru: Snap! A crack and then excruciating pain. As though the knee was struck by a hammer with full force.
From Tom Brady to Pullella Gopichand and Ravindra Jadeja to Vinesh Phogat, athletes across sporting disciplines have suffered the trauma over the years and the latest high-profile player to fall prey was Carolina Marin - encountering the horror for the third time during her semifinal clash when the Spanish badminton ace was leading 21-14, 10-6 against China’s He Bingjiao at the Paris Olympics.
The moment the left-handed Marin landed oddly on her right leg, following a smash, the knee caved in. Collapsing to the ground, the 2016 Rio Olympics champion screamed in pain even as Gillian Clark, the most well-known voice in badminton, got the chills in the commentary box and went: "Oh no, no, no! This is simply tragic. She’s done her knee again, the ACL."
The ACL - Anterior Cruciate Ligament at the centre of the knee that connects the thigh bone to the shin bone - tear has become one of the most common injuries among athletes to such an extent that it is being termed as an epidemic by the medical fraternity.
It is also proven that female athletes are more susceptible to an ACL injury because of a woman’s physiology with wider pelvis, being marginally knock-kneed to hormonal changes among others. Alarmingly, in an 18-month period between September 2022 and February 2024, a staggering 195 elite women footballers suffered an ACL injury.
The repercussions are plenty. If being suddenly physically limited while hobbling around in crutches for weeks added to skier Vonn's frustration, the feeling of being left out and forgotten bothered footballer Sam Kerr mentally.
According to latest records, the overall annual incidence of ACL ruptures was found to be approximately 7.3 per 100,000 population in the USA. However, no proper registry is available in India to keep count of the cases except the fact that it is on the rise here too. And the reasons for more and more athletes suffering an ACL injury are manifold.
From an increase in the number of people taking up sport to packed competition schedules at the elite level that leaves little time for an athlete to recover and prepare; from unscientific training methodologies inculcated by coaches at early and mid stages of an individual’s sporting journey to unintentional confrontations in contact sports, the causes are many which put careers in a state of limbo.
Though the setback isn’t considered entirely career-threatening, the process of getting injured, going through a surgery to repair the damage, rehabilitation before regaining confidence to perform to one's potential afresh is painstakingly long, expensive and always attached with a sense of doubt and fear. Studies suggest that the return to sport post ACL reconstruction (ACLR) data stands approximately around 70-80% (in US).
“An injury of this type is never 100% preventable,” begins Dr David V Rajan, arthroscopic surgeon and the head of faculty at Ortho-One - an orthopaedic speciality centre in Coimbatore.
“However, the right kind of training involving balance and plyometrics should be done regularly to minimise the chances of an ACL injury. But the coaches and trainers, especially in India, don’t insist on it because of lack of awareness and mostly laziness,” says Dr Rajan.
The other blunder, according to Dr Rajan, is that most coaches or parents commit is postponing surgery due to worry without knowledge or misconceptions which eventually aggravate the affected knee.
It is to be noted that the ACLR procedure differs for an athlete as compared to a common person suffering the exact same injury. While the quadriceps tendon or patellar tendon are the two grafts of choice for the former because they don't stretch out in the long run, a hamstring graft is good enough for the latter with comparatively lesser physical activity. Over time, the graft would go on to be augmented with fibers for athlete patients in a process called ‘internal splinting’.
“The tendons will not be strong enough initially, so the grafts are braced by fibers to help provide immediate strength,” explains Dr Sanjay Prasad Hegde, orthopedic surgeon at Manipal Hospital in Bengaluru.
In recent times, news of athletes getting back to elite sport after a complete ACL tear without a surgery is doing the rounds on the internet. Both the doctors, who specialise in treating injured sports persons on a daily basis, bust this myth.
“Not at all, it's not possible. The knee will be unstable and wobbly. Also, age is not really a criterion because a surgery gives stability to the knee joint. That’s what is required, more so for athletes,” offers Dr Hegde while Dr Rajan states: “That’s a lot of rubbish. When it comes to athletes, a surgery has to be done in the right way by the right person. Only then can they get back to sports.”
Once a surgeon is done reconstructing the ACL, an athlete is given little to no time to begin the postoperative rehabilitation. It first involves a physiotherapist to get the operated knee to a pain-free full range of motion (because the knee would have become straight and stiff) along with getting them to bear load (meaning, making him/ her walk).
The most arduous part on this ‘road to recovery’ arrives in the period between starting to walk and beginning to play. This is further divided into three main phases - stability, strength and power training, says Deckline Leitao, sports conditioning and fitness specialist.
“Stability is building base muscle endurance like one leg balance, bozo ball drills before doing higher repetitions with light weights. Strength is lifting heavy for approximately three-five repetitions to build maximum force (the ability of a muscle to contract and move an object slowly) like bench press or squat. And power (athletic phase) is a combination of strength plus speed like clap push-ups, box jumps, weightlifting moves. Focus on eccentric training (deceleration control) and not just lifting is also key.
“Each phase can take about 4-6 weeks, so that's a total of 18 weeks. Ideal time to completely recover from an ACL injury is 9-12 months. Re-injuries happen because most people jump the gun and get into the power phase,” explains Leitao.
Another observation, a rather concerning one, is the number of ACL injuries that happen during practice or training which the experts opine can be completely avoided.
“Injuries during a match is an occupational hazard, nothing can be done. But injuries during practice are due to training when tired, overtraining, bad technique, not loading properly… There should be investigation as to where and why it happened and the concerned support staff/ coach be accountable for it,” says Leitao.
“Take for instance, triple jumpers, pole vaulters... They suffer because the landing pit is not prepared properly or is substandard. But the coaches insist on jumping anyway. They jump and tear the ligament,” adds Dr Rajan.
Pain prevention and injury management deserve dedicated attention if athletes - at a young age who are peaking or the established ones at the top of the game - need to be protected. In a profession with a short life span, losing precious time to injuries as harrowing as an ACL rupture means losing out on players with the potential of being world-class athletes.
It's time to re-think before another snap shatters dreams.