My son, Dylan, is a 14 year old boy who has played rugby union since he was 3 years old.
He could be assessed as an elite level player, due to his previous innate potential. Coaches, players and parents have consistently singled him out for his qualities and vision on the field, and he explains rugby as his life.
Just over two years ago Dylan started to experience some pain in his knee, and during a game his studs got caught in the mud on changing direction of travel and his knee gave way. He was initially diagnosed with ‘growing pains’ and encouraged to play through the pain by an NHS physiotherapist. He played on with discomfort and his knee gave way twice more before we, his parents, halted him playing until he received a more realistic diagnosis.
He has seen numerous NHS specialists, over an 18-month period, receiving a multitude of diagnosis. He has undergone arthroscopic investigatory surgery, which resulted in confirmation in the right ACL being ruptured, and there being a meniscus tear in the same knee, which the specialist at the time attempted to repair, and we now know has failed due to his asymmetric knee, highlighting an early onset of growth injury.
The NHS had given us no timeline for the ACL repair and the decline in Dylan’s mental state forced us to contact the NHS specialist to hasten and explain the fragility of Dylan’s mental state. We did not receive a reply. It was at this stage we decided to reach out to private specialists to receive their view, hoping they could offer a more pragmatic approach, outside of NHS protocol, opening the availability of groundbreaking treatment to him.
One of the private specialists we approached was Professor Adrian Wilson, and he was the only one to assure us he would take complete management of Dylan’s knee. He is also the first medical professional to give us a realistic, pragmatic view on Dylan’s rugby future.
As a parent I hold much regret, and with hindsight I should have acted sooner to ensure safeguards were put in place to protect Dylan from injury.
I am a professional boxing coach and hold a BSc in coaching, which includes practical qualifications such as registered exercise professional (REPS) level 4. During all of warm ups I witnessed him and his teammates undertake before rugby games, there were no synovial fluid release exercises conducted, minimal dynamic stretching and certainly no specificity rugby stretches which would assist with the warming specific muscle groups up. The majority of the warm up exercises I witnessed pre-game were high impact in preparation for tackling, which required a high volume of activation of leg muscles, which were not warm or ready to conduct that level of impact.
On reflection, the most worrying lack of preparation was during the rugby festivals, which normally took place over a day, two days, or even sometimes three consecutive days. For example a warm up (insufficient for specificity) would be conducted prior to the children’s first game, on completion of this game there were prolonged periods of the children becoming static, sitting around awaiting their next game. After a prolonged period the children would then get called, often hastened onto the pitch to play another game, receiving no further warm up.
Dylan has gone from being a confident, grade A student who was following clear goals, revolving around becoming a professional rugby player, to a shell of his former self.
He is now anxious, depressed and consistently questions the meaning of his life. He has lost any trust in medical professionals, due to many having differences in opinions when explaining the problems with his knee, and what they believe to be the best solutions with offering treatment. His peer network has dramatically changed since his injury, and his academic grades have nose-dived. He lacks self-esteem and often can’t attend other children’s parties as they include activities, which include dynamic pivoting movement such as paint balling, flip-out and play-zone.
The costs of his private treatment, which has been approximated as being around £13,000, based around consultations, scans, operation, physiotherapy, and post operation support, has severe financial implications on his family, which he is fully aware of. He also has to come to terms with the potential of never playing rugby again, which is devastating for him. As his schooling has been heavily affected, we are looking at potentially changing his school or employing tutors, which will bring further financial burdens on our family life.
Dylan has had to come to terms with the fact he will no longer fulfil his dream of becoming a professional rugby player. I don’t believe the true impact of this has been felt yet; Dylan still has hopes his forthcoming operation will fix his knee and he will be on the rugby field again one day, sadly, the reality of his situation does not support his dream. As parents, we want to facilitate his knee being repaired to the best possible shape, by the best available surgeon, to live the rest of his life, limiting the possibility of reoccurring injuries.
This has been, and continues to be, a heart breaking experience for us all and I would urge all parents to not advocate responsibility of their children and ensure the coach he or she plays under is suitably qualified, and has adequate experience.
I would encourage all governing bodies, such as; The FA (Football) RFU (Rugby) and AIBA (Boxing) offer specificity, mandated warm ups and cool downs for children at specific ages, for specific sports. I would encourage experienced coaches, physiotherapists, strength and conditioning coaches, and fitness professionals all be part of the structure of the design process. It would also be beneficial for people like Prof. Wilson be invited to speak at AGMs to discuss the trends in injuries they see, offering preventative strategies.
When I first saw Dylan in October 2018, he was sadly already in a fair amount of valgus having sustained a growth injury on the right side as a result of his ACL rupture and lateral issues. He is slightly valgus on the left and quite significantly valgus on the right.
With his parents I talked about whether we should correct the alignment or do the ligaments first. I thought that this was fairly complicated surgery, and proposed that we went for the ligaments first and then look at the alignment. If there is any further progression, we could think about intervening sooner rather than later using one of the paediatric surgeon’s at The Portland or for him to go through the NHS for this.
I discussed why I would recommend an extra-articular ACL reconstruction, and that is because there is a high failure rate in children of 20%, perhaps even 25%, and we could reduce this with an extra-articular tenodesis. We could also reduce Dylan’s chance of re-rupture by him entering in to an injury prevention programme.
We discussed the other risks and I explained there is a risk of growth plate disturbance with the surgery, but that the current thinking is that transphyseal is the best way to prepare the tunnels and carries the least risk for the ACL, although of course there is a risk of growth disturbance. I explained this risk is low and certainly in my practice, in all the paediatric ACL’s that I have treated, I have not had to send anyone through for realignment surgery as the result of a growth arrest following ACL.
We discussed all the other risks of anaesthesia and surgery and after consideration the parents were keen for him to proceed. In December we did a right knee EUA and arthroscopy, and proceeded to a revision lateral meniscal repair with all-inside technique and an all-inside ACL reconstruction using quadruple GraftLink semitendinosus with lateral tenodesis using a modified McIntosh technique with ITB.