Dr Courtney Lai is just over a year into his PhD at La Trobe and has been an Australian Football League (AFL) goal umpire since 2011. A knee injury led to him missing the 2013-2014 seasons, the disappointment spurring his own interest in orthopaedics.

At the same time, a record number of players went down with ACL injuries – many of them repeat injuries. The AFL wanted to know why this was happening, prompting La Trobe’s audit on ACL injuries in elite athletes, currently focusing on the AFL.

Can you tell us a bit about your research and how it might change how we deal with ACL injuries?

There are a lot of footballers who’ve had ACL injuries. I’m in the process of talking to the majority of the players from the past 15 years who have sustained ACL injuries. It’s certainly a significant injury in terms of their career – football is such a big part of their identity that it affects their lifestyle too.

A lot of them have the ability to get back and play in the AFL, but there’s also a portion that don’t.

In the past five to seven years we’ve seen the reintroduction of the use of synthetic ligaments to treat these injuries. So the thought is: If we can put a man on the moon, why can’t we improve how we deal with ACL injuries?

The perceived advantage with using a synthetic replacement avoids the more common approach where we ‘rob Peter to pay Paul’. In reconstructing the anterior cruciate ligament, we usually take a bit of the quadriceps tendon, hamstring tendon or the patella tendon – and this has its own side effects.

At this stage the indications are that the synthetic ligaments have a higher likelihood of re-injury, compared to traditional surgical techniques. The main thing was to see whether there was anything we could do better surgically to improve the chances of players getting back to their pre-injury level of performance.

How do ACL injuries generally happen in the AFL?

The non-contact type of injuries tend to dominate in the AFL, like changing direction, trying to evade players, and landing after taking a high mark.

Then you’ve got situations where there’s no direct contact to the leg, but there might be contact to the body, like bumps or tackles – where the foot is planted on the ground and the body gets twisted around in a different direction.

The instances where the leg is directly wiped out by a player sliding in are less common.

What’s the general recovery time after receiving an ACL injury?

Typically, players in the AFL aim to get back around 12 months after their ACL reconstruction. Perhaps a bit earlier or longer, depending on their progress. This was a big driver towards synthetic ligaments.

There have been players who’ve had the synthetic ligament reconstruction get back to playing at around the three month mark – meaning it’s not a season-ending injury. However, there are the potential side effects associated with that course of action.

How does this compare internationally?

We’re just in the process of finishing a systematic review that’s looked into ACL injuries of elite sports people across the world – a bit over 80% of elite athletes that undergo an ACL reconstruction do end up returning to play another game – and it seems that about 5% of them suffer a further graft rupture.

Looking at those numbers they’re comparable to the AFL cohort, in terms of returning to sport – but perhaps there’s an increased risk of further injury in the AFL – which shows you what a risky game it is.

How long do you think we are from producing a synthetic ligament that improves on current procedures?

My hunch is we’re not close. There’s exciting new avenues being researched all the time, but I think it’ll be a while before any of those avenues are mainstream and proven to be superior.

You’re also an AFL umpire – how did that come about?

As a teenager, my body couldn’t cope with the demands of playing football at any sort of decent level, so I took up goal umpiring – something I didn’t need to do too much running for, and theoretically you can avoid body contact as well – and it was a great way to stay involved with the game.

How did your own injury happen?

I was goal umpiring a match between Fremantle and the Western Bulldogs – at this stage I was working full time as a doctor in the hospital system and thinking about becoming a general practitioner.

Often there are tight contests around the goals… An attacker was running in, kicked the goal, and the defender wasn’t far behind and thought he’d apply a bit of extra pressure… He tried to bump the attacker and [instead] bounced off him, lost control of his own movement, cannoning into the side of my own leg. It felt like my knee exploded.

That whole episode reminded me that orthopaedics and knee injuries was an area that I had a deep interest in – and that really brought it home. It was a long rehab to get myself back to umpiring in the AFL, but with a lot of help along the way I did get there.

What quality do you notice in all athletes that manage to come back from a potentially career ending ACL injury?

They’ve almost got to be possessed to get back to an elite athletic level. It’s a very competitive environment to begin with – and then you have this massive injury – you lose strength in your muscles, your agility, confidence – it takes a lot of determination and putting the fear of getting re-injured aside.

La Trobe University researchers have found that in the under 20 age group, one in three people who’ve had ACL reconstruction surgery will suffer a second injury within five years. That can have a devastating psychological effect on young people, who naturally expect to be active for much longer.

Find out more about what we’re doing to improve the lives of young athletes.

Image: AFL by Steve Davidson (CC BY-NC-ND 2.0)