After 3 ACL reconstructions, 1 x PCL rupture, and a knee arthroscope, you could say I know my fair share of information and experience about knee injuries. This devastating injury ruined my dreams of becoming a professional rugby player and once you do your first ACL, the number of stories you hear from other players about their ACL tears is astronomical.
The AFLW's wretched run with ACL injuries claimed two more victims at the start of the 2020 season, with Melbourne defenders Shae Sloane and Katherine Smith both set to miss the entire season. There were nine ACL injuries suffered by players across the competition's 10 clubs last year.
Since the NRL has recommenced after Covid-19, we have seen several players tearing their ACL’s with the most high-profile knee being Jack Bird of The Broncos. The headline reads “Jack Bird suffered a non-contact injury to his left knee today at training.” His left knee apparently just buckled beneath him and he fell down clutching his knee.
We hear this way too often, that it was a non-contact injury and that the knee has just given away underneath the player. The most common excuse we hear from this is the quality of the turf underneath the feet or it was just a “freak accident’.
I was 22 when I did my first ACL, and I had never actually heard of the injury until this moment. It is crazy the number of stories you hear of other athletes tearing their ACL's and having their sporting dreams crushed. Fast forward 3 more years and I had ruptured my other ACL - twice! Which led to my retirement from the sport I love at the prime age of 26!
Fast forward another 7 years and here I am as an experienced Myotherapist and Personal Trainer, we are still hearing horror stories of top-level athletes being cut down on the field as their knees buckle from beneath them, and with the majority of the ruptures occurring from no contact at all.
It really gets me thinking and wondering how we are getting it SO wrong with the way we approach sport and what we are doing to reduce this risk of knee injuries.
As a 22-year-old, sat on the physio table after surgery, I had 100% trust in my physio as I knew no better and they were the professional. I spent hours and hours of contracting my quads and squeezing my hammy to build some strength around the knee.
Although this sounds like the right thing to do to strengthen my knee - after 10 years in the fitness industry and 6 years in the health industry, I now know that this approach to my rehab was not the most efficient.
Yes, I needed to gain some strength around the knee to build the best structure possible, but nine times out of ten, with knee injuries, it is not the knee's fault. The knee has to deal with having the middle child syndrome in that it's two older (upstream) and younger (downstream) siblings, being the hip and the foot are the main instigators in the mechanism of injuries.
If the hip (older sibling) does not have the necessary stability and mobility, it cannot help control the knee joint. We have a MASSIVE problem in our society today as the majority of us have a sedentary lifestyle and we spend most of our days sitting on our butts! We think that this is just a problem for adults but once you turn 5 years old, you are given a full-time desk job at school, spending a minimum of 6 hours sitting down, being told to sit still, sit up straight (yeh, right) and don't move. The moment a kid starts to fidget and not sit still, they are then diagnosed with ADHD!! The human body is designed to move and sitting still is the last thing a young kid wants to do!
We sit to eat, to drive, to work, to be entertained, to relax, to socialise.....sitting down has become the norm in our society and the ones who want to stand up are seen as the "weird" ones. The body is a magnificent piece of machinery and also very clever in that it will adapt to its most common positions and postures. A lot of people are now "strong" in a sitting position because this is where they spend their lives. Now this "strong" sitting position may help them sit at a desk all day long but once they head to the gym or go for a hike or pick up their kids, the brain is exploding with confusion and therefore sends all kinds of pain signals to muscle and joints because this is now not "normal" to the body.
Now, these top athletes have recently been stuck in lockdown, potentially sitting down more often than they are used to and not training as hard as normal as they are not in the same professional environment they are used to.
They have now been thrust back into high intensity, fast-paced games and expected to compete at the same levels as they were pre-COVID-19.
The muscles around our hips, mainly the glutes, help keep us stood upright and strong. Imagine being sat on and squished into a hard chair all day long, and then being expected to sprint on the footy field or squat 100kg! Our glutes are there to create stability in the body, functional movement, and provide protection to our joints, including the knee. If you were running at full pace and then decide to quickly sidestep to change direction, you need to recruit your hip stabilisers to help fulfill this action. BUT if they are stiff, weak, and have a poor signal to the brain, they are not going to help you out. Nobody has "weak" glutes, otherwise, you would not be able to stand upright. The problem a lot of people have is that the connection between your brain and glutes has gone walkabout. The neural pathways between the two have been muddles because of the consistent sedentary position.
So now it's all up to the knee to help change your direction, and guess what, SNAP! 1, 2, or even all 4 ligaments take the full load of your body turning direction, and they just cannot handle it.
Now, this isn't only the issue our older sibling causes. If we add in the problems the younger sibling brings to the table, we have an even bigger recipe for disaster.
The moment we start to walk as a toddler, our feet our wrapped up in stiff, rigid, and tight shoes. Human foot function is an engineering marvel—26 bones connected by a ridiculous amount of connective tissue to make 33 joints, along with 20 intrinsic muscles and 13 extrinsic muscles. All designed to work seamlessly as a team to carry us for thousands upon thousands of steps each and every day.
The two biggest flaws that shoes have are the size of the toe box (where your toes sit) and the heel pitch. Over time as your feet are squashed into a shoe that doesn’t actually look like a foot, your toes start to adapt to the lack of space and cause all kinds of problems such as foot pain; lack of balance; loss of proprioception; rolled ankles; plantar fasciitis, etc, and this is only pain associated with the feet.
Your feet are your body’s foundation and connection to the ground. Without these structures working efficiently, everything else above the feet will be compromised in some way, including the KNEE.
The nerves on the bottom of our feet are sensory kings. We use our feet to help tell the brain what terrain we are walking across, to help with balance, proprioception, muscle tone, and posture. The moment we add a thick (normally cushioned) sole to, we lose this necessary feedback loop. It is like wearing a blindfold instead of sunnies. We only need to protect the feet (barefoot shoes) from the environment, we don't need to blindfold (cushioned shoes) them.
One of the big reasons we see so many knee injuries, not just in sport, is because of the shoes we wear and the lack of sensory input our brain is receiving from our feet. If we imagine a sport like Netball, where most young athletes are wearing cushioned, supported and stiff shoes - the moment they need to turn direction and the ankle starts to roll over, the foot cannot tell the brain it is in danger, to then tell it to switch on the hip stabilisers (older sibling), to help pull the ankle back into a good position! As this ankle is supported by a stiff shoe and most likely be wearing an ankle brace (for some reason), the ankle cannot move naturally and so the next joint that can move, is our middle child - the knee! (Not what it is designed to do!)
So, you can now see why the knee has a constant problem with its family and no wonder so many athletes at all ages are tearing their ACL's more than ever.
Several studies report that balance training does, indeed, reduce not only ankle injuries but also hamstring and ACL tears. Improving balance develops the coordination necessary to keep the body in the correct position and alignment when performing an athletic activity.
Year-round weight training in sports is still a relatively new concept, and much of that weight training has not changed in decades. Sports-related injuries that are simply considered par for the course are, in my opinion, often unnecessarily suffered as a result of out-of-date training methods focusing on large, mobiliser muscles while neglecting the stabiliser muscles designed to aid in their use.
Shannon Turley, strength and conditioning coach for Stanford’s football team, reduced his team’s injury rate by 87% between 2006 and 2012 by focussing less on raw strength and mire on mobility and balance. He banned freshmen from weightlifting until they had been adequately trained in the program, and he incorporated yoga and Pilates into his regimen.
Those injury rates remain low because Turley does not have his players build strength simply for strength’s sake. The body has certain power muscles (mobiliser muscles). These are muscles that move body parts. When weight is lifted, these are the muscles that are used. When an object has to be moved with greater accuracy, requiring speed and direction to be accounted for, a different type of muscle is required – The stabiliser muscles.
To haul equipment, we use large, heavy 400 horse-powered diesel trucks. They don’t corner well, require a long distance to stop, and although powerful, does not accelerate well. I would love to drive a 400 horse-powered Ferrari, which can change direction like a chased rabbit, accelerate like a hungry cheetah, and stop on a dime. The truck has the ability to haul stuff; the Ferrari has similar power but with the added dimension of control. That is what stabiliser muscles do: they provide control. They determine coordination and agility.
The danger of building only mobiliser muscles is that actions requiring strength could possibly result in injury if that strength is not properly controlled. Building large muscles without also developing the controlling stabilising muscles has the potential for injury.
The solution is quite simple in that humans need to get back to what the body loves to do most - move in its most natural positions - barefoot and minimal sitting down.
Parents need to be educated in a way that allows their toddlers to be barefoot for as long as possible and buy shoes that are actually shaped like a foot. Do yourself a favour right now and take a shoe off, take out the insole and stand on it - your foot will most likely spread out over the insole (unless it has fully adapted to being squashed in your shoes over a long period of time). The widest part of our feet is at the tip of our toes but if you go to most shoe shops, they will measure you at your knuckle joints and fit you a shoe according to this data. The moment our big toe gets pushed inwards and squashed, we lose our ability for toe extension, which limits our ability for full hip extension, and THEN limits our ability for full glute activation! (Again, another problem for the knees).
This is the problem we get with footy boots! 100% of boots these days are tapered at the toe and you have to basically squash all your toes in to get them to fit. Athletes are jumping high into the air to catch the ball and then expected to land safely with a very narrow contact point to work with. Imagine if they could come down from a jump with a nice splayed foot, helping create a bigger base to support the structures upstream. Basically, we are losing a lot of potential strength, stability, and mobility we get naturally from our feet.
Humans beings have evolved over thousands of years and have been designed in a certain way for us to thrive in our environment. It is pretty obvious that we are doing something wrong if we are constantly getting injured. Statistics say that 45-75% of runners get injured annually! Now running is the one thing humans excel at, as we needed to be able to run back in the day, just so we could eat or avoid being eaten. We evolved in a certain way to allow us to run our prey to death and do it again the next day. The moment the modern-day running shoe was invented, only 50 years ago, this is when we started getting problems!
So STAND UP, and TAKE OFF YOUR SHOES!