ACL research survey can help tackle 'curse of the cruciate'

By John Harrington

When Crossmolina Deel Rovers hosted the 2023 North Mayo Winter League Final between Lahardane and Cill Chomáin one of the match stewards, Liam Moffatt, noticed a lot of familiar names on the match programme.

Nine of the players involved were former patients of the Physiotherapist who he had helped rehabilitate after ACL (Anterior Cruciate Ligament) surgery, a fact he and subsequently others, found quite alarming.

That was the starting point for a journey that led to the announcement last week that the GAA’s Medical, Scientific and Welfare Committee (MSW) is seeking input from membership across the GAA, LGFA and Camogie Associations to assist with an ongoing research project into ACL injuries in Gaelic Games.

Moffatt is a member of MSW and currently undertaking research in the area of ACL injuries in Gaelic Games.

He believes if enough players and administrators take part in the surveys that will feed into MSW’s research then we will have a much fuller picture of the physical, psychological, and financial toll of ACL injuries and be better equipped to manage this burden.

“We know in the GAA that ACL injuries don't affect a huge amount of players, but for those that it does affect, the impact is significant,” Moffatt told GAA.ie. “We also know from the injury fund side of it that the numbers are quite consistent.

“But there is also a cohort of Gaelic Games players who have private health insurance who don't enter that fund. So, while we know a lot about this problem, there is also plenty we don’t know.

“One of the things that we definitely don't know in Gaelic Games is the direct impact this injury has on players and clubs.

“If we have a better understanding of that it will give us a baseline position for this project.

“Simultaneously, another part of the project is looking at the mechanism of how this injury happens.

“We have a video analysis component and part of our survey is a request that, if players are comfortable with it, that they would share publicly available videos of their ACL injury mechanism with us to review the mechanism in detail across the codes.”

By studying the mechanism of how ACL injuries have occurred and finding commonalities, the hope is that the research being undertaken by MSW will ultimately be used to mitigate the risk of ACL injuries to players.

“Yes, that's the hope,” says Moffatt. “You can never prevent, you can only try and reduce the risk.

“We know that one of the most successful methods of reviewing sports performance is video analysis. It's the same in injury.

“When we look at other sports that have done video analysis work they have learned an awful lot from it. From our own initial findings, we're learning a lot from it too.

“The hope is that you reduce the risk, but there's a caveat there that insofar as we're not sure at the moment the full extent of it in the GAA. We do have certain information, but we'd like a bit more.

“Where we're at now with the project is we're looking for that data to come back from players on what is the impact of this injury to you, physically, psychologically and financially.

“Also, if you have any video evidence of what happened to you and you were willing to share it with the Association, we can certainly learn from that with this research project.

“Once we have that data, then in the recommendation stage there may aspects that we might need to do differently.”

A ruptured ACL is the injury that elite sportspeople fear more than any other with good reason.

A study published last year investigating anterior cruciate ligament (ACL) reconstruction surgery outcomes in 1,891 Gaelic football, hurling and camogie players found players typically returned to sport following injury after around 10.8 months, which is a significant period of time to be sidelined.

While the diagnosis of ACL injury is common, rarely are ACL journeys the same for players and the road back can be a lot tougher for some than others.

“For the sports person an ACL injury is significant and within the context of ACL injuries, there are different gradings of severity,” says Moffatt.

“It's obviously a serious injury when you tear your ACL, but within that then you can have extra injuries such as meniscus injury, cartilage injury, or fracture on top of tearing the ACL. So, it depends on the extent of the trauma that the player has to come back from.

“Like other performance environments with an ACL rehab there is often a physical component, a psychological component, a technical component, a tactical component at different stages of the process.

“When you're returning your athlete from that sort of injury you're looking at their health and welfare first and you're also taking into account what type of surgery they had.

“Some surgeons would repair with patella graft, some might use a hamstring, some might use a quad tendon. And you're just factoring that into your rehabilitation to help your player.

“We look in depth at the mechanism with ACL patients and factor this into the rehab and we have asked this question in our survey as well.

“If it happened when you landed, then what is your landing technique like? Were you landing with contact or non-contact? Were you landing when you were distracted by the task at hand?

“If it was a change of direction mechanism was the player highly fatigued at the end of the game? Or, as we see with some cases, did it happen in the first couple of minutes.

“So, you look at the context of the injury and work it back from there.

“In terms of what we can do about it, there are aspects of ACL rehabilitation that are common to everyone and within this project there would be recommendations that would come at the end that might make life easier for those players who don't have access to the resources that other players may enjoy that might help them recover from ACL injury.”

There is a significant financial cost associated with ACL injuries. From 2017 to 2020 the total cost of the GAA’s Injury Fund was €22.1Million of which €12.1Million (54 per cent) went on treatments for knee injuries.

A 2023 study by Dr. Siobhan O’Connor and DCU colleagues found that while ACL injuries in Ladies Football from 2012 to 2020 accounted for just one in 12 claims, these claims amounted to 47 per cent of the LGFA’s injury fund and 66 per cent of hospital related costs.

“There's a direct and indirect cost with any injury,” says Moffatt. “Direct costs are essentially the medical fees associated with the treatment of the injury. The indirect cost is what it does to you to get those medical treatments.

“So, things like time off work, travel to and from appointments and loss of earnings; we have factored these questions into the survey for players.

“There is significant cost. We're grateful that in the Association’s we have our Injury Fund and the great work done by those who administer this fund so there's a pathway there for players who don't enjoy having their own private health care.

“One of the things that's clear from the research we've looked at is there's the injury itself and then there's the afterlife. So, 10, 15 years later, what's your knee like?

“Through the work of Andrew Ross there's been a lot of research in Australia into the financial costs and the impact on the individual as they age. Looking from the lens of ACL injury in Australian soccer the long-term financial costs to the economy were very significant.

“We've also seen that in the LGFA where Dr. Siobhan O'Connor did a brilliant study in 2023 on the financials. One of the findings was that the rate of medical inflation by 2023 had increased by 70% over the course of the previous nine years.

“So, we know from the work that Siobhan has done and we know from the work internationally that there is a financial price to pay as well as a player-welfare price with ACL injury.

“We also know from colleagues in Europe that research on ACL injury, work absenteeism and a productivity has been looked at. We know countries like the Netherlands, for example, had a 130% rise in ACL injuries since 2007, which is also significant.

“Those unfortunate enough to sustain the injury have to take time off work. If you're a desktop worker, that might not be too bad. But if you're a manual worker it can be hugely challenging at times to meet the demands of your work with a reconstructed knee.”

To successfully address a problem you must understand it first, and Moffatt believes a high participation rate in the online ACL injury surveys would help hugely helpful in that regard.

“We're really interested in the human story behind this,” he says. We're really interested in how our clubs and players feel about it, what their experience has been.

“We’re trying to establish the scale of a problem that’s affecting our Associations from a player welfare standpoint and from a financial point of view.

“We're trying to get a baseline to really look at this problem in more detail and see if we can help it and reduce the impact on our players. We may not be able to reduce the incidence of ACL but hopefully the impact of it on players.

“The player survey takes 10 minutes, and we’d love for players to participate and to share it in player WhatsApp or email groups.

“The club survey takes five minutes and is going to club secretaries who do incredible work and it would be great if they too could fill it out in high numbers.”

The GAA’s Medical, Scientific and Welfare Committee is seeking input from players and across the GAA, LGFA and Camogie Associations to assist with an ongoing research project into ACL injuries in Gaelic Games by completing a survey.

The Player Survey can be completed HERE.

The Administrator Survey can be completed HERE.

Go HERE for more information on the research in to ACL injuries in Gaelic games.