Disclaimer

It’s worth noting from the outset that I have no inside information on Jaeger. I dearly wish I did, but I don’t. I have no professional links to the future star, the Gold Coast Suns or the Hawthorn Football Club. The details in this article are a (poorly) cobbled together mix of what I could take from years of extensive media coverage of Jaeger’s knee and my many years of clinical experience. I have great respect for the way AFL medical teams go about their business, so to be VERY clear… no pot shots here.

This is a light-hearted attempt to get my point out there and create some discussion, so please take it in the spirit that it’s intended.

It’s also worth noting that I am a Hawthorn supporter and long-term member. Coincidentally I have also experienced similar knee issues as a junior footballer. So it’s fair to say I’m invested. If those who know me professionally think I’m a massive nerd about the human body, your head would explode if you even began to think about how much nerdier I am about the AFL. It’s U.G.L.Y. And I ain’t got no alibi…

Introduction

A ruptured Patella Tendon preceded by long-term Patella ‘Tendonitits’. That’s the unfortunate mix of issues that has plagued Jaeger for the last three and a half years.

NOTE: The term ‘Tendonitis’ is a little old-school as ‘-itis’ infers some inflammation. There’s some great work by our tendon experts that highlight a distinct lack of inflammation amongst tendon dysfunction across the board. There may be no ‘-itis involved. So let’s call it what it is – Tendonopathy.

As a Physio, I’m afforded the luxury of recognising and exploring certain patterns. Things that seem to pop up time and time again with the same problems. I’ll get in to the specifics of Jaeger’s issues a little later, but as an amuse-bouche (had to google that myself), I’m seeing a pattern I’m not sure many others are in terms of a potential cause for Patella Tendonopathy.

For the purposes of this article I hope to assume that everything reported in the media is indeed correct. If not, it probably doesn’t matter as even though this post is about Jaeger, it’s not really about Jaeger. Having said that, I have (creepily) stalked his Instagram account for pics that highlight what I see far too often here at Peninsula Physiotherapy. I’ve also relied on a cameo from Victor Cruz, the NFL superstar who succumbed to a Patella Tendon rupture a few years ago.

In short, I think we are missing something vital when dealing with WHY we develop Patella Tendonopathy. Something simple, but potentially very important. And I hope to leverage Jaeger’s obvious misfortune in a positive way to garner some attention and help spread the word.

So with that out the way strap yourselves in and let’s get weird.

Jaeger’s (complicated) history

As most reading this may already appreciate, Jaeger’s a gun. He’s been earmarked for greatness even before being drafted by the Gold Coast Suns back in 2011. His first two years in the AFL seniors yielded 44 consecutive games – a rare feat for anyone let alone a debutante. This included the 2013 Rising Star Award for the best young player in the game.

On April 4th, 2015, during a preseason practice game in Cooparoo, Queensland, Jaeger ruptured his right Patella tendon when an opponent fell across his knee whilst attempting to kick. A rare injury amongst the elite.

Interestingly, it was revealed that Jaeger had required off-season surgery for severe bilateral Patella “Tendonitis” during the previous season. An issue that apparently prevented him from training much, if at all that year [1]. At the time the Gold Coast medical staff were adamant that the rupture and recent surgery were unrelated. It was deemed a “freakish accident” [2].

The original aim was for a full 12 months out. However when on the cusp of a return to reserves football again, Jaeger was sent in for an Arthroscope.

It wasn’t until July, 2016 when Jaeger was able to play again. He played well in the reserves on limited minutes over the next few weeks, until succumbing to soreness in the knee again. It was his 3rd game back.

Unfortunately that signalled the end of Jaeger’s 2016 campaign.

A few months later he was poached by/reluctantly traded to Hawthorn – a team renowned for their elite medical team.

This took his time out from senior football to two whole seasons. Again, another rarity in today’s game.

Taking a conservative approach during the off-season, Hawthorn made it very clear that Jaeger’s return to the elite level would not be rushed. Originally, his return was slated as 4-5 rounds into the 2017 season [3]. Interestingly, Jaeger ended up playing EVERY pre-season practice match and the first three games of the Premiership season before missing the next two for an unrelated knock to same knee [4]. He returned in round 6, only to be limited in his output and subsequently sent away to work on his fitness and conditioning indefinitely [5]. At the time of publishing (pre-round 13), Jaeger has still not returned. By all reports he’s on track to return soon but negative speculation remains rife.

Patella Tendonopathy

Time to nerd out for a minute.

The Gold Coast medical staff were adamant the rupture was unrelated to Jaeger’s previous surgery for Patella Tendonopathy. I’d like to take them at their word.

For the purpose of this let’s assume the Tendonopathy itself pre-empted the rupture. After all, healthy tendons should’t rupture on their own, right?

For those unaware, the Patella Tendon (or ligament) forms part of the structure that connects the Quadriceps to the top of the shin via the knee cap. It’s essential for straightening the knee.

Clinically, Patella Tendonopathy (also labelled Jumper’s Knee) is looked at as a loading issue.

As the label implies, sports/activities requiring repeated jumping, landing and running seem to claim a lot of Patella tendons.

We blame abnormal increases in training load, frequency and intensity. We blame a surface that is too hard and often think of it as an overuse issue – despite this potentially conjuring up the wrong images.

The role of poor leg mechanics?

Classically, the above load-related factors have formed the linchpin of our thinking surrounding the onset of Patella Tendonopathy. More recently we have become more sophisticated by recognising the importance of pre-existing biomechanical dysfunction. Issues that, when exposed to altered training factors, will become exposed and eventually fail. We’re talking tight Quads, weak trunk and hip musculature etc.

This is where I’d love to play for a minute.

Despite the Medical industry’s sophistication, I feel we are missing one MAJOR thing. One factor that if recognised and successfully altered, has the potential to change the game completely. It may provide a strong platform for initial prevention, faster recovery and long-term prevention. This MAY be why Jaeger and many others are prone to a really frustrating knee issue.

So after such a big pump up, what the hell is all this about..?

What I’m finding clinically

After such a big build up I’ll cut straight to the chase. Over the last few years it seems that EVERY Patella Tendonopathy I see here at Peninsula Physiotherapy is associated with stiffness in a very specific area of the back.

To flesh this out a little more, I’m noticing a lot of stiffness through the upper Lumbar and lower Thoracic spine.

Not necessarily any overt pain or discomfort, but specific stiffness. The kind best found by direct poking and prodding.

It’s often news to most patients that this section is actually stiff in the first place.

The T12-L3 segments consistently seem to be stiff (to varying degrees and distributions for each patient). The super-nerds may recognise two things. These segments house both the Femoral Nerve (travels down the front of the hip to the Quads to supply this general area) as well as the body’s knee-related Dermatomes and Myotomes (sensory and muscular neural connections left over from our development from a fetus).

This spinal stiffness also seems to be accompanied by some increased neural tension through the Femoral Nerve, which makes sense.

My working theory is that this specific spinal stiffness “pulls the slack” from any associated neural and soft tissues. It essentially acts as a hand-brake to the knee. This may force a long term shift in way the Patella tendon is loaded, therefore pre-empting the changes we see in Patella Tendonopathy.

It sounds quite a stretch to tell a patient that an asymptomatic back may contribute to their knee pain. It can and probably will sound ridiculous. But my clinical experience tells me otherwise.

By mobilising a patient’s spine in the above areas there is often some level of IMMEDIATE change in their symptoms. It’s by no means a cure-all or a quick fix as clearly the tendon has to remodel itself through exercises and rehabilitation. But it’s a start.

Take a hand-brake off anything and things will speed up and function better.

It’s important to note that I would not expect all stiff lower backs to end up with Patella Tendonopathy. However, I am yet to see someone over the last half a decade with Patella Tendonopathy who isn’t stiff/dysfunctional in this specific area.

Please read in to that as you will. I urge those treating these issues out in the real world to at least humour me enough to go and have a look yourselves. Prove me wrong. Do all the testing you can to get a robust sense of your patient’s current situation. Smash the crap out of that spine, get it moving better and then re-assess everything that’s important to you. Like me, I hope you find some surprising results.

What’s in a picture?

To hopefully illustrate my point, this is where I’ve turned stalker/groupie. Instagram has been a life saver in this regard.

I’m aware that trying to reinforce a theory through photos is a tough strategy. A picture solely captures a moment in time and nothing more. That moment in no way guarantees a pattern, nor does it allow for too many inferences to be drawn. But it’s the best I can do without assessing the men in person. Despite this, I think these are very helpful.

I’ve laid out four random pics I’ve taken from Instagram and Google Images. Without too much prompting, can anyone see something consistently sneaky happening to the mid/low sections of their spine?

Hopefully you can. It’s what I see everyday with my Patella Tendonopathy patients.



Jaegar O’Meara via Instagram



NFL superstar Victor Cruz via Instagram.



Victor Cruz again via Instagram. He suffered the same knee tendon rupture as Jaeger.



Victor Cruz working hard post-knee injury.





In each of these pictures, there seems to be a very definable “hinge” in their spinal curvature. If trying to maintain a neutral spinal position, clearly the back should be “straight”. If bending forward, the spine should ideally flex with a “global” bend, one without any specific sharper angles involved. Clinically, these hinges tend to be a beacon for stiffness as a sign of improper spinal loading.



Can you see the hinge in his back?



How about this hinge when sitting?



This hinge is more subtle.



Notice the hinge here when Victor squats?

Try this out yourself.

Sit up comfortably “tall” and then relax back to where feels usual for you. Where do you sink through to relax?

Where is the sharpest point of the curve? Is it a uniform bend or are you kicking a hinge into that spine somewhere?

If these pictures reflect a true sense of what’s happening in their respective lower backs, Jaeger and Victor’s spinal function may have directly set them up to fail. Maybe not the degree of a rupture, but most certainly when talking performance and function. Upon examination I have the EXACT same weak point in my spine. One that hinges just below my Thoracic spine. This same area is prone to stiffness with poor postures and positions.

Not every patient presents with an obvious hinge like Jaeger. But they are stiff regardless.

Clinically, this idea does seem to scale from our weekend warriors up to our elites. We are all still prone to the everyday trappings of the modern world. And with that in mind, we unfortunately end up discussing sitting postures and positions. In my opinion, it’s our exposure to these everyday postures that foster the majority of our spinal dysfunction. We may then see this trickle-down into the leg and effect the Patella tendon.

Elite or not we still have to sit for large periods throughout the day. We all still travel and commute, we all know what a TV looks like and what a couch feels like to relax in to. We have no shortage of regular opportunities for prolonged exposure to poor spinal shapes.

The elite may have more opportunity to mitigate against these shapes through conditioning and exercise, but the modern world effects us all.

Where to now?

Awareness and interest.

That’s hopefully where it starts. My industry has put a lot of time into understanding tendon dysfunction. I honestly think this discovery also warrants strong consideration.

It’s important to note that treating spinal dysfunction alone will clearly not resolve long-term tendon dysfunction. It’s clear these days that the make up of a tendon changes in order for it to become problematic. But by improving our spinal function we could a) potentially nail one of, if not THE original causes of our tendon dysfunction, and b) speed up our recovery and reduce the risk of re-occurence.

Is there a chance that Jaeger’s back is still a constant negative influence on his knee?

In my opinion, almost no injury is back luck – or at least we give luck far too much credit. Any musculoskeletal problem happens for a reason. It’s just that that reason may not always be instantly obvious if you aren’t looking for it. Accidents clearly do happen – Jaeger can’t help someone falling across his knee as he attempted to kick the footy. But the state of our tissue and it’s underlying mechanics could be the difference between a year on the sidelines, a few weeks out or potentially nothing at all.

Which ankle is more likely to break if you roll it? A stiff, poorly functioning one? Or a supple, flexible one?

There are obviously horrible accidents. One’s that are nasty enough to cause damage regardless – fall from a great height, horrible car accident etc. But thankfully these moments alone are reserved for the truly unlucky. For the rest of us, I think we have much more control over our fate than we realise.

Conclusion

Despite the industry’s knowledge of Patella Tendonopathy, I think we miss the role of the lower back completely. And why wouldn’t it be? Spinal joint stiffness and dysfunction is often asymptomatic to most people. But it’s there. Or at least that’s what I am consistently finding here at Peninsula Physiotherapy. In my experience we need to be resolve this at some point. Conventional rehab is still vital, but can we hasten the whole process by treating the lower back as well?

Could the state of Jaeger’s back been the defining feature that led him down the rabbit hole of Patella Tendonopathy? Could it have left him vulnerable to a rupture in the first place?

I’d love to get my hands on the young man and see for myself.

So with all of this in mind I hope to draw the attention of the wider public and those in my field to this phenomenon. I hope to arm those suffering from Patella Tendonopathy with the same perspective that I have come to learn. Take a step back and check this out for yourself – don’t just take my word for it. Speak to your relevant health professional and get them to check your back out. Hell, grab a foam roller and go hunting yourself. It’s safe, free and may be a missing piece to your rehab puzzle. It’s hard to argue with results.

I hope that I can raise a little interest towards something that I have never seen mentioned in regards to this before. I also hope that those with the ability to research and solidify this idea at least consider it’s merit. Selfishly I hope this promotes the kind of deeper exploration I really enjoy doing here at Peninsula Physiotherapy.

Honestly, I am even expecting to receive some form of backlash from those in the industry by putting this, and myself, out there in this way. The internet is such a crowded, crappy space filled with magical “cures” and false promises. Why wouldn’t someone be sceptical of something like this? I would be. No hard research-based evidence presented, just a whole bunch of words from a random, faceless keyboard warrior shamelessly self-promoting etc. The greater medical industry is littered with those ready to promise the world and deliver absolutely nothing. It’s also heavily populated by close-minded and aggressively stubborn people. This kind of article would seem to be prime fodder for both – YIPEE!

Finally, of MOST importance, I hope that this assists Jaeger and the Hawks in some small way. My ego isn’t anywhere near big enough to assume it will, or that they’ll even get wind of this. But as a long suffering Hawks supporter (come at me – #winkyfaceemoji) it’s at least worth putting this out there for that reason alone. GO HAWKS.

Check out Grant’s website Your Wellness Nerd here to find a wealth of knowledge about health and physiotherapy