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Netball’s $2.4m knee injury battle

Over the last year, rising netball star Holly Fowler has had to learn how to jump, land and even walk again.

Last March, before the inaugural ANZ Premiership season had even kicked off, Fowler ruptured the anterior cruciate ligament in her left knee.

The incident looked so benign. In the middle of a training game, she simply leaped in the air to catch the ball - a movement she’s made on the netball court countless times. There was no jarring collision; no one was within cooee of her.

“I just landed funny. My legs were too wide, my knees buckled in,” the Northern Stars midcourter recalls.

“I’d never had a major injury like that, but as soon as I did it, I just sat there and thought, ‘Yep that’s my ACL gone’.” And with it went any chance of playing netball again for a year, including missing the World Youth Cup in Botswana, which her New Zealand under-21 team won.

Her rehabilitation over nine months was intense. “After coming out of reconstruction surgery, I’d forgotten how to use my left leg. I walked with a limp, so I had to work on getting my patterns right. It was the same with my jumping, landing and squatting - it was learning how to do those things all over again,” she says.

Fowler’s story is in no way exceptional. We’re halfway through this year’s ANZ Premiership – New Zealand’s foremost netball league – and four of its original 60 players have had their seasons ended by major knee injuries.

“I just landed funny. My legs were too wide, my knees buckled in."

Young Magic midcourter Sydney Fraser ruptured her ACL in a pre-season match, while the Steel’s Jamaican import, Malysha Kelly, suffered the same injury making an intercept in a training session. That also ruled her out of the Commonwealth Games.

Tactix captain Jess Maclennan landed awkwardly in a game last month and knew straight away that she’d torn the ACL in her right knee. She’d done the same to her left knee only two seasons before.

And the latest casualty, Steel defender Dani Gray not only ruptured her ACL during a clash with the Pulse a fortnight ago, she also damaged her medial collateral ligament, meniscus and cartilage in an ungainly landing.

Devastating knee damage isn’t restricted to the country’s elite netballers. Around 400 New Zealand netball players of all ages have ACL reconstruction surgery each year. According to ACC statistics, netball knee injuries alone cost the country $10.4 million in the year to June 2017, and there were almost 4500 new claims.

But the number of knee injuries reported to ACC have been steadily falling over the last four years. Netball New Zealand would like to think that's the result of an injury prevention programme introduced to netball courts throughout the country in 2016.

The idea behind NetballSmart was to combat the growing number of injuries in the game as it became faster and more physical. Netball NZ wanted to change a decades-old culture of how players warmed up before training and competition.

Former Silver Ferns physiotherapist Sharon Kearney has led the charge, and with a significant increase in funding from ACC - $2.4m over the next three years - she now has a fulltime role managing the programme.

“[Girls] grow, get a bit gangly, and they change their landing strategies - to their detriment. They bend their knees differently; they do the things that we know could predispose them to ACL injuries."

For 30 years as a physio, Kearney has been what she calls the ambulance at the bottom of the cliff. During her time with the Silver Ferns – through six world championships and two Commonwealth Games - she helped manage the return of players felled by ACL injuries; the likes of Grace Kara, Bailey Mes, Kayla Cullen and former Ferns captain Casey Kopua.

Now she’s turned her attention to repairing the way netballers land, before they jump. And the focus isn’t on the high performance level of the sport, but girls still at intermediate school.

The problems begin when girls hit puberty.

“They grow, get a bit gangly, and they change their landing strategies - to their detriment. They bend their knees differently; they do the things that we know could predispose them to ACL injuries,” Kearney says.

While females in the 15-25 age bracket suffer the most severe injuries, it’s the intermediate-aged girls who are injured most frequently, and the age group where the programme is now being heavily pitched to make change.

“We’re making a big push into communities,” Kearney says. “We need to make a difference in girls at a really young age, so by the time they come into that 15-25 age group, they are jumping and landing well. They are stronger in their core, so they can withstand the forces of the game, and they understand that it’s a really important part of their game.”

Contributing to the problem, Kearney says, is a societal change where our young girls aren’t as active as generations before them.

“In years gone by, jumping and landing was just an innate ability – we jumped out of trees and went ‘Oh that wasn’t very good, I’ll do that a different way'. Now we actively discourage our kids from doing it because we don’t want them injuring themselves,” she says.

This season, the NetballSmart programme has seven facilitators tasked with running through the “dynamic warm-up” with 19,500 girls in intermediate schools.

The warm-up has evolved from the world-acclaimed FIFA 11+ programme, created for footballers and first introduced in Switzerland and New Zealand. Kearney worked with ACC to make the programme specific to netball. It sticks with the original four key components of strengthening, running, dynamic preparation and sport-specific preparation, but puts more emphasis on jumping, landing (especially on one foot) and turning.

“We’re looking at the mechanics of netball and empowering our coaches to be better at teaching kids how to jump and land, the real nuts and bolts of the game,” she says.

“Most of the ACLs are non-contact injuries, compared to rugby where they’re often tangled up in each other. If we can help our coaches to help athletes do those landings under pressure in a better way, then we know we can make a difference.”

“It’s sickening to think these young girls are getting injured so early in their netball careers."

And she believes netball is beginning to win that battle. “This is the first time the knee injury numbers have been on a decline. Because we have a much bigger project now, and a lot more capability to connect with communities, then it will continue to do so.”

Nevertheless, knee injuries are still ruining the seasons of young players. Kim Hunter coaches a college grade one team at the Howick-Pakuranga Netball Centre, and is “gobsmacked” that two of her defenders have both suffered ACL injuries in the past few weeks.

“I was a netball player for 20 years, I’ve been a physio and I’ve coached a few teams. But I’ve never see anything as significant as the injuries we’re having,” she says. The two players who damaged their knees were Year 11 and 12 students, and the injuries happened when they were with their school teams.

“It’s sickening to think these young girls are getting injured so early in their netball careers,” Hunter says.

She gets her Pohutukawa Coast team players to do the NetballSmart warm-up twice a week at trainings, and then before a game. She encourages them to find time during their week to do the core strengthening part of the programme. She hopes it’s making a difference.

“The intensity of the game is changing, and these girls have a lot of things going on in their lives, too. When I was a girl, my parents made me choose one sport,” she says. “I just hope the girls who’ve suffered these injuries return to netball - they are fantastic players.”

Kearney quotes international studies that show only 28 percent of females make it back on the court after they’ve suffered a significant knee injury. Some players, having gone through rehabilitation of nine to 12 months, may not be prepared to take that risk again.

“But some will tell you they come back as a better athlete. My challenge to physios is to make sure they come back better, because if you don’t, the potential for them to rupture the other knee is higher than someone who has never done an ACL,” she says.

Fowler is one who is convinced she’s come back stronger.

“My first season at this level of netball was straight out of high school, and I know now that my body was definitely undercooked in the strength department,” says the 20-year-old, who is making a big impact this season, having moved out of circle defence and into centre for the Stars.

“With all the warm-up exercises I do now, I’m really conscious of my landing and jumping patterns. I spend about 15 minutes with bands, making sure all the muscles are fired up properly before I get out on court.

“I always look for silver linings with my knee, and I think it was good to step away from the court for a year and focus purely on getting my body right for that level of netball. I’ve definitely come back a lot stronger than I was before.”

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