Episode 6: Playing through an ACL Rupture. The remarkable story of NSW Waratahs Mitch Short's Super Rugby debut. Also featuring current Wallabies team doctor, Sharron Flahive.

We were very fortunate to share this fascinating story of professional rugby player Mitch Short, and the ACL rupture he suffered on debut. Mitch is joined by long-time NSW Waratahs and current Australian Wallabies team doctor Sharon Flahive, who was the treating physician at the time. 

In 2018,  Mitch Short was the third-choice scrum-half for the NSW Waratahs rugby team. Prior to a tour to South Africa to play the Bulls in Durban, first-choice half Nick Phipps was down with a calf strain, so Mitch was on the bench set to make his Super Rugby debut. With about 15 minutes remaining in the game, Mitch came on, and with one of his first touches of the ball, he twisted and felt his knee go numb. Mitch completed the game and even scored a try but the medical staff later confirmed that he had ruptured his ACL.

It became apparent very early on that Mitch was an 'elite coper' and continued to function at a very high level as the tour continued to Argentina. After the second-choice scrum-half Jake Gordon suffered a concussion, Mitch was next-in-line to make his run-on debut. But could he start a game of international standard rugby with a recently torn ACL? Listen in as we hear the full story from Mitch and Dr Flahive.

Transcript

Bevan Colless  

Okay, hello, and welcome to another episode of The Knee Gurus podcast. I'm your host Bevan Colless. And I'm very excited to have two guests on the show today, Mitch short and Sharron Flahive. Mitch is a professional rugby player who's currently plying his trade with Racing 92 in Paris. And Sharron Flahive was the team doctor for many years at the New South Wales Waratahs in the Super Rugby competition, and she's also the incumbent team doctor for the Australian Wallabies rugby team. So we're going to find out about a remarkable set of circumstances that occurred in 2018, when Mitch ruptured his ACL on debut for the Waratahs while they were playing in South Africa. Now rupturing his ACL wasn't that remarkable. But what happened afterward, really was. This story of Mitch rupturing his ACL and how it was managed, and how his recovery went has been whispered about in sports medicine circles, almost as if it's an urban myth. So I'm really excited to hear the story straight from both of your mouths. So if we can start with Mitch who's very kindly gotten up early in the morning from his base in France, where he's just signed a contract with Racing 92. Thanks for getting up so early and congratulations on the contract. Mitch, how long have you been over in France for?

Mitch Short  

No worries. Thanks for having me. This is my third week now, I’m enjoying the experience so far. We'll see. Maybe need to scrub up on the French but, so far, so good.

Bevan Colless  

It was a bit of a whirlwind decision to go and play there from what I hear.

Mitch Short  

Yeah, it will happen pretty quickly. Basically, they're sort of in the middle of their season now, which is quite long. So they've picked up a few injuries and it was just one of those things which popped up and I jumped at it pretty quick with Racing being quite a big French club and, you know, good opportunity to sort of experience the top 14 and just went from there.

Bevan Colless  

Terrific. Really. Almost one of the biggest rugby clubs in the world really.

Mitch Short  

Yeah, I think so.

Bevan Colless  

Alright, so if we can take you back to 2018. And maybe I can just set the stage around the circumstances for what happened over in Durban. So Mitch's position is scrumhalf which is also known as halfback. So for those of you who don't know rugby, the scrumhalf tends to be a smaller player, a zippy sort of a guy whose job it is to feed the scrims and pass the ball from the set plays out to the backline and often make short darting runs around the field. So in 2018, Mitch, from what I understand was third in line scrumhalf for the Waratahs, which is the state team for New South Wales. And he was behind probably some of the top two scrumhalf over the last decade in Australia in Nick Phipps and, and Jake Gordon. So, Mitch is up and coming 22 year old I think at the time, biding his time. And I understand Nick Phipps, who has played a lot of games for the Wallabies had been injured. And so Mitch, you finally get your chance to make your debut and you come off the bench with about 15 minutes to go. Is that correct? So maybe I'll just, I'll let you take the story over from there.

Mitch Short  

Yeah, I think that was right. Pretty good opportunity. We obviously went away for my first game. And we're in Durban, and I think when I got on the field, I had probably been on for a couple of minutes. I remembered I sort of managed to sneak through a gap and actually went on a bit of a run, in a bit of open space. So I sort of took off, and then there was the final defender, a fullback or a winger in the backfield. And I sort of made an interesting attempt to try and step him from memory and, and got tackled. And it was probably when I stood up I just had this sort of numbing feeling. Numb in my leg, is how I explained it at the time. And and I sort of yeah, just sort of stood there for a bit, I think, had a bit of time out. And I just, didn't really know what I’d done, but I hadn't had that feeling before and didn't really know what was going on. But I managed to play the rest of the game out. And I think after the game, it was when

Dr Sharron Flahive  

When you score a try?

Mitch Short  

Yeah. Yeah, that was probably 10 minutes later, had to take off for that while which was pretty bad. I mean, I could feel something was not right. But I just didn't know what. But I didn't really think about it too much. Sort of on debut probably a bit of adrenaline and all that stuff going on that probably helped as well.

Bevan Colless  

You must have been buzzing. After the injury did you go down injured? Did you get assessed by Sharron or the physio on-field during the game? 

Mitch Short  

After the game was when, you know, that was when I was probably hurt the most to be honest. And then I was going to do a bit of running after the game just because I hadn't played massive minutes. And we're on tour. And we had a game next week in Argentina. So I was about to start some running. And I was just sort of flagged it and said there's a bit of pain. And then I came off. And that's when Sharron was there. And I didn't even know at the time what an ACL test was. And yeah, that was when Sharron sort of took over.

Bevan Colless  

So you didn't actually assess him, Sharron, until after the game?

Dr Sharron Flahive  

That’s right. In fact, Dave Garrick, who was the physio at the time, he sort of quietly called me over after the game because I mean, we know that sign on Lachman’s testing. We weren't really aware of an incident during the game. And Mitch had finished the game and it just kind of set off his knee a little bit. And it was one of these tours when you play in South Africa, then we were literally leaving the next day to go to Argentina, and it was late at night. And we're thinking to ourselves, ‘This can't be, like he can't have. And trying to think of the logistics around everything at that time were really difficult. So it was like, I don't know, if you've ever had had that expression like you want to know something's right, rather than hope. And I think we hoped we we took an approach that just maybe just feel like things are okay, and maybe we're just not examining it correctly. And let's get on a plane to Argentina because irrespective we were never going to get on a plane back to Australia at that time. And, you know, ACLs don't grow on a plane all the way to Argentina, but we kind of had that hope that it might look a little bit better by the time we got to Buenos Aries. And it didn't.

Bevan Colless  

And Mitch, you didn't get a swollen knee? It never really blew up like a lot of ACLs do.

Mitch Short  

It was a little bit I think, not nothing. I mean, I'm no expert, but I don't think it was major at all in terms of swelling. There was a little bit I think I was sort of, you know, that was when I was probably in the most pain was like, after the game in the hotel that night just sort of sitting there icing my knee. And then on the flight I mean, I felt okay and the flight and just  hoping. I was hoping as well that it was going to be all good. On the way to Argentina.

Dr Sharron Flahive  

Yep. And then when we got to Argentina, obviously we'd had a plane flight. So it wasn't I would describe it as mild to moderate effusion, not a moderate effusion. And there definitely was an absent endpoint on Lachman's testing and a slight pivot glide. So remember that taxi? Remember that taxi drive? 

Mitch Short  

That was the alarm. Remember that? After the scan?

Dr Sharron Flahive  

Yes, we sort of, you knew, Mitch the whole time, like, he's a young 22-year-old as he described himself, and he's like, it just doesn't feel that bad, he’s like, ‘My knee feels, it feels fine. I'm gonna be fine'. And we've got that, awful feeling in your gut like we, and we kind of know it's not right. Yeah. And so through, I think, an interpreter and then through to another doctor, we managed to get on to the Argentinian chief medical officer and arrange an MRI somewhere, and an organized a Taxi, which brought us through the streets, streets of Buenos Aries. And it was like one of those moments when I think you know, you're always having awkward conversations with the players, because, you know, all I want to do is find out what the diagnosis is. And it's just, it's just a really uncomfortable time. You can't be funny, you can't like until we had this long taxi drive, to get the MRI, and I had the opportunity to kind of stand and see as the pictures on the screen, you know, and immediately understand that this is not good. Not good.

Bevan Colless  

And it definitely wasn't a pre-existing ACL. Because in our Ski clinics here we assess, Lachman’s tests all the time. And sometimes you find people who've done their ACL before but never really known about it. But this was obviously an acute one?

Dr Sharron Flahive  

Yeah, and I've had that situation where one time for the exams for the registrar's, a friend of mine’s daughter had an ACL rupture. And I thought she would be a perfect candidate for the examination. And then I went to examine her knee. And, you know, it was like, she'd never had surgery, but she had been clearly ignoring it had had successful conservative treatment and had an endpoint. So, you know, but Mitch didn't have any real history of any knee injury. And he had that kind of classic lateral femoral condyle bone bruise. So, you know, he had all the classic signs of a new ACL on that first MRI that we did, and even then, it was hard to convince him that, he wasn't going to be able to play that following week because we were short because Nick Phipps the other scrum-half wasn't actually with us. If you remember Mitch, Nick had one of those tricky soleal aponeurosis and tendon injuries that were eight weeks and we were still struggling with

Bevan Colless  

And then I believe Jake Gordon got a concussion but you say you didn't play in Argentina Mitch?

Mitch Short  

Yeah. I went home after that scan. After that interesting taxi ride that shot me down. I think the next day I was pretty much out of there. I mean, I remembered sort of joking trying to tell them that it wasn't that bad, but I was on the plane, I think the next day, back home.

Dr Sharron Flahive  

What was the name of the player who came out? 

Mitch Short  

I think Nick Duffy came out from Norths.

Bevan Colless  

At the last minute?

Mitch Short  

Yeah, I think he must have flown out, on I don't know I'm gonna say Wednesday midweek and he must have been on his way over at the same time I was going back. 

Bevan Colless  

So you go back to Sydney and the team plays the game against the Jaguars and all go back to Sydney. Then what happens with your management? I guess you having ongoing discussions with Sharron and Dave Garrick at this time?

Dr Sharron Flahive  

You maintained that attitude that you thought your knee felt pretty good. You continued with that attitude and, and Mitch and I went to see the surgeon because that's what you did. And even though that consultation, Mitch still maintained this idea of, ‘Could I consider conservative management?’. And it was around that time where people were starting to think again about surgery. What is it in Australia, 90% of the time, it’s surgery and it's something we considered, but obviously, we're in Argentina. And, that wasn't really what we're thinking about at the time. But certainly, Mitch maintained that line all the way through, like, I'm just not convinced that I can't play with this. 

Bevan Colless  

The brilliance here I think is from you and Dave Garrick the physio, like, actually listening to Mitch and progressing on because I think in most circumstances, that team Doctor and Physio would just shut that conversation down: ‘Look, you've done your ACL, you’re a professional athlete, you have got to have an operation, or even if we do go for conservative management, you're going to have to wait at least three months before you're ready to play again. But you guys, obviously were bold enough to not go that route. How did that play out?

Dr Sharron Flahive  

We did find that there was a case history of this football player. And the soccer player who had had conservative management, I think he'd returned at about the eight-week mark. But I suppose the complication was what had happened is exactly what you mentioned before, Jake Gordon got a concussion in that game over in Argentina. So we arrived back in Sydney with Nick Phipps still not ready. And Jake Gordon, coming back with still some concussion signs earlier in the week. So, he was ruled out pretty early in the week, actually. So we now had both of those half-backs out and Mitch perkily kind of going like ‘I still think I'm good to go’. And, and that that really sent us all down this pathway of like, is this unrealistic? To consider this? Playing now? And obviously, there are a lot of conversations around risk. I often asked myself, what was this going to be? God knows, a fairly hectic time, and you sort of ask yourself the question, ‘Does this pass the pub test?’. If something happens, and Mitch plays, we're going to look like at the front page or the back page of the newspaper.

Bevan Colless  

Imagine after two minutes he goes down and does damage or something.

Dr Sharron Flahive  

So between the three of us and obviously consultation with the coaches, we had to think about how we would progress that next sort of 10 days, I think it was in order to bring Mitch back and see if he actually wouldn't be fit to play on. How do you remember it, Mitch? It’s important to hear how you, you remember that because all the time I was thinking obviously, the medico-legal risk that we were taking or hoping that I was counseling you enough. But also getting you ready to actually play.

Mitch Short  

No, you're exactly right. I think you were I remember, you know, the whole time talking to me throughout it. Obviously, it was a bit of a hectic few days. But yeah, I think I remember I trained, I think once or twice maybe with the team, but maybe once alone, and speaking to you the whole time. So it was all good, I thought. I think you were a bit more nervous than I was. But I just had this bit of confidence inside. Like, I just thought I'd be okay with the way that I could move on it that it wasn't that bad. I mean, I strapped it up and see how it goes. But yeah, I was a bit hesitant.

Dr Sharron Flahive  

So there are a few things that we took into consideration. And so obviously, one was the maintenance of his quads control and his bulk which he had maintained since we've been in Argentina and he only had a minimal effusion by the time we got back to Australia. And so the first thing was we had back in those days, we had probably, or we were still using like GPS and that our kind of rehab runs to progress from level one to level five. So on the Wednesday of that week, leading up to the game, Mitch did pretty much every component of that level five in order to sort of judge that he'd be fit to try some component of the main training session of the week on Thursday. And so, they took them out there, with I think it might have been Aaron Scully the strength and conditioning coach. And he looked awesome. And I was getting sent videos of every single thing he was doing. And it was pretty hard to pick which leg that he'd actually injured. And then we obviously assessed it the following day. And then on Thursday, I think, Mitch, you did the training session, but you obviously had to do the main team run, and then it was the same thing on the Friday of the Captain's Run. You know, you really didn't do too much at all that day, but again, on neither occasion had you said he didn't have much effusion and we made the decision that if he was to play that he would have to start. And we started to feel worried about newspaper headlines the following day.

Bevan Colless  

Did the media know that Mitch had done his ACL? Was it common knowledge ow were there any stories published? Or did you decide just to keep it quiet and, and not tell anyone?

Mitch Short  

I don't think before the game many people knew to be honest. I remember I actually bumped into one of the Rebels players the day before the game. And yeah, I was just like, ‘I did my knee’ and we had a bit of a laugh, but I don't think anyone really knew to be honest. 

Dr Sharron Flahive  

When you tell a story, Bevan, I'm sitting here thinking, ‘Did we really do this?’. But we have, in our head, always things around effusion, like he only had a pivot glide, he never really had a true pivot shift. And, you know, there was no quads wasting and, you know, his function was great, and I think prior to that rehab, we even did some of that T-test stuff and some of that lateral hopping. So, you know, we, we made a decision that you know, although the bone bruising was a slight concern, we made a decision that because he hasn't missed any time, then we should be able to bring them to top-level really quickly. And as long as we progress, to that top-level testing, that we're going to get an idea of whether he's going to be okay, or not, as opposed to backing off, and allowing him to lose the condition and the time and the muscle activation that might put him at risk.

Bevan Colless  

In the ski resorts here, obviously, I think we saw you, Sharron, just after you did your ACL back in Niseko 10 years ago, or something from memory. And we're seeing ACL injuries in here on the side of the mountain every day and have been doing so for many years. And one of the things that I caution our staff is, is that there can be a really wide presentation with exactly the same injury with ACLs. You know, we have some patients who are carried in by their spouse, and who are really non-weight-bearing and needed to be taken down by ski patrol. And that's more of the classic presentation. But you will have the odd one, you know, a little bit like Mitch, one out of every 20 or 30, who sort of walk-in almost without a limp and say ‘Well I just felt something twist in my knee earlier today when I was skiing, and probably wouldn't have even come in, but I saw the physio sign, so came in’. And then you do a Lachman’s test, and you find out that they're that they've done their ACL. So there's this sort of division between copers and non-copers that is quite common in ACLs. And obviously, Mitch was obviously in an elite coper. So you obviously recognize that early and acted on it.

Dr Sharron Flahive  

Yeah, and what happens sometimes with those key ones is you shut them down without allowing them. I always believe this point that sometimes your patients will teach you more than, than what you know. Yep. And now they'll tell the story where they actually have gone on and skied for a few days, and then they're getting it checked out. Yeah. And so we've all been we've all been through that kind of school where you shut everyone down. ‘You couldn't possibly ski’. I think what was really interesting with where Mitch was that at that stage, the original plan was prior to Jake failing his concussion test, which is something that probably shouldn't have made us encourage Mitch to play. But as it was a small amount of time and Mitch pretty quickly learned that Jake wasn't going to play. So then he put his hand up to make himself available. We would have, we would have gone a slower course, without the pressure of selection. But what's amazing, as I mentioned, but he plays that game. And I think you played for maybe 60 minutes match and get man of the match.

Bevan Colless  

Yeah. What do you want to find out more about that story? I mean, you must have been jumping out of your skin, Mitch finally biding your time being third in line and finally, getting your opportunity to start and understand it was was a big game against the Rebels and Australia's top scrumhalf Will Genia was your opposite number, and you're lining up with an ACL deficient knee only a few weeks gone. It must have been a surreal day, that one can you talk us through that game if you can remember?

Mitch Short  

Yeah there were a lot of unknowns. But I just thought, you know, as I said, I felt okay. And I was confident afterward doing that stuff out in the field that I, you know if my knee would hold up. So. Yeah, the game was, I mean, it was my first start, I hadn't, I'd only come off the bench that week, before 10 days before. So I was really pretty excited, but also pretty nervous just with how I’d go. I really still wasn't sure, I mean, getting tackled and stuff was a bit of a concern. But if I mean, the boys though, it was just one of those days.  I think in the first half it was a bit of a grind, and then they're actually ahead from memory at halftime. And then we sort of managed to score a few tries in the second half. And then ran away with it a little bit. So that was pretty enjoyable. I think, you know, at home in New South Wales. My family was there. And yeah, just winning that game in general. And coming off the field, not injured. Yeah, I think Sharron and I had had a bit of a laugh together afterward.

Bevan Colless  

Both very relieved, no doubt. And yeah, and you got Man of the Match. I believe Mitch and scored a try. Is that right?

Mitch Short  

Yeah, the try was pretty funny. I think the Man of the Match at those games is a bit of a popularity contest, I think with the fans going, probably because it was my first start thought everyone was just voting on SMS but now it was what it was. Yeah, it was pretty cool afterward, just Yeah, I suppose it was enjoyable an enjoyable day out.

Bevan Colless  

As as I said before, what a remarkable story. And what happened after that? Did you continue to play? Did you ever have a knee reconstruction? Did your ACL heal?

Mitch Short  

We still just sort of went with the conservative approach. I think for the following week, or maybe two weeks, I think I just sat on the bench. Because I think Nick Phipps wasn't back yet. And I was sort of keen to just, you know, just, I thought this is how I remember it was to just try and stay on the team for a little bit. But I think after that, once everyone was back fit and healthy, I think I could then have time to manage it conservatively, which is what we did. I think it was probably eight or 10 weeks where I think we scanned again, Sharron.

Dr Sharron Flahive  

So what actually happened. And this is the interesting part, I think, just from a lot of sort of emotion and a lot of things involved in this, but you were on short term contract at the time Mitch.  And so he came to the end of the short-term contract. And, you know, Mitch pretty much, you know, put his career on the line for us. And then we're at the end of the short-term contract that was this kind of contracting they were thinking well he's ruptured his ACL. So why would we, why would we contract him? And that was like a red rag to a ball when they said that to me, like I'm like, ‘Yeah, you’re happy for him to play. And so then I think then after that, you had a gap match and then we signed you after that for a period of time and during that gap, we looked at, we scanned it again. And because the You know, even then we weren't seriously considering ACL reconstructions, we just had a little bit of concern over the lateral femoral condyle bruising, and its proximity to the condyle surface. So in the interest of sort of saving the chondral surface so we made a decision to keep Mitch off after that short-term contract came to an end for a month. So he did four weeks, even though he kept saying he was fine. He did four weeks of no running. And then as he said, we sort of built him back over, over another four weeks back into training and playing, I think, how I remembered after that match, and then we said the repeat scan confirmed the rupture of the ACL. It looked very similar to the one in Argentina, aside from the lateral femoral condyle. And then because you basically continue playing didn't you match?

Mitch Short  

Yeah, I think I finished the year off after that. Sort of eight to 10 weeks. Think back at Randwick. Yeah. Because I think super rugby was, I don't know what time it was. But yeah, I think I finished that. I'd signed and then came back in. Yeah, I was looking for braces. And I think, and then that was that I'd been I think I strapped it for a little bit, then. And then I think by sort of the next year, after probably six months, I think I stopped strapping. And I was just pretty confident on it. 

Dr Sharron Flahive  

In January 2020. I repeated a scan was an I think it was it was a really difficult thing to ask too ask much, because will he be comfortable through repeating the MRI just because I didn't notice that psychological side, I think, I'm not sure whether Mitch really wanted to find out what it actually looked like. And, you know, whether that would, you know, mentally kind of destabilise you a little bit, but we did repeat the scan. And I've got I've actually got the report right next to me here. It says the anterior cruciate ligament appears intact! And he had and the good news was that there was no chondral surface degeneration and no meniscal tear. And the patellofemoral joint looks quite normal. Now, they've reported that as the anterior cruciate ligament appears intact, when you actually look at it sort of slightly, some people might say it looks a little bit flatter. But it's definitely, you know, it has continuity. And, and, and was, was, most people wouldn't pick it as an injury. And the other thing about evidence when you look at it at that beautiful black colour,

Bevan Colless  

So vascularized and healthy!

Dr Sharron Flahive  

Yeah, but vascularized and healthy. And so on the back of that, I was able to tell Mitch, it was all good.

Bevan Colless  

Was it was a discussion, Mitch about waiting until the end of the season and then doing a reconstruction, then even though you were obviously coping pretty well without one.

Mitch Short  

No, I don't think that was the discussion. I think the conservative approach was suggested and, and we just ran with it. And then yeah, I don't think there were very little, to be honest, very little hiccups after that. Yeah, I think I played, you know, I was playing. By the end of that year, I was sort of playing 80 minutes. And then, you know, it's been two years after that. So it was kind of like, you know, I was handling pre-seasons and, and stuff like that, that was pretty arduous. So yeah, that was I don't think that was ever really discussed

Dr Sharron Flahive  

He never really got much effusion after that. And he's got that slight glide, but he's got a good endpoint on Lachman’s that's maybe, you know, a little bit more than the other side. But there were times when, you know, I mean, we didn't examine his knee a lot, but when we did, we'd be like, ‘I'm sure that feels like there's a good input there now.

Bevan Colless  

Yep. And have you had any episodes with giving away Mitch, is it buckled under you many times, or would it always feel pretty stable?

Mitch Short  

I think early on, I was trying to explain that side. Sometimes, you know, just walking, I had a couple of instances, but they stopped pretty quickly. Like I'd say, my last time would have been, you know, three months post or even less. Just walking, or it was very little, like if I'm walking, and I like there's a pothole or something I just sort of I feel a little bit but that was it really the very minor looking back at it now that they were the ones that kind of was like, Oh, is it right? But then it just, you know, went away. And I think they work pretty hard on like, the strength of my quad. I found that stuff really helped. Just maybe, I don't know, even mentally just that, you know, I was strong around my knee. 

Bevan Colless  

About that mental aspect to the injury. Do you find you trust your knee? Do you think about it during the games or training? 

Mitch Short  

No, not at all. I mean, early on, obviously, I was but yeah, now it's pretty funny. When people asked me about this, I kinda like, feel stupid, telling them that, you know. Some don't even believe that it was actually ruptured. They are like ‘So was it actually ruptured?’. And I'm like, ‘Yeah, I scanned it three times, but it just sounds strange. It's a funny story. I don't know. It's sort of it's all good, though. I don't even consider it now. I think I'm full range with all my movements, squatting, and all that in the gym and stuff. So yeah, it's all good.

Dr Sharron Flahive  

Today when I was consulting, and I thought I'll just take just quick look at your scans again, now just to know that it was a rupture. Yeah, there are different ones. But you know, what it is like, I can remember that day in Argentina. And I can remember when we did it, and, you know, it was ruptured.

Bevan Colless  

It wasn't an avulsion?  I found the avulsions don't tend to swell up and tend to be a little bit high functioning, I guess because there isn't that tear in the mid substance. So there's not as much bleeding? Can you remember where it was torn?

Dr. Sharron Flahive  

It was sort of proximal, and it looked like, you know, it looks like the whole thing's kind of three times the thickness for the mid substance

Bevan Colless  

So he did it properly.

Dr Sharron Flahive  

Yes. And like, when I even when I think through the story, I think, you know, it was a series of circumstances. And I keep coming back to that Pub Test. And know, you know, always wanting to know, and Mitch himself. He didn't know what an ACL was, he was a 22 year old like it was, there was a real balance between safety and risk. And we weren't allowing someone to make a foolish decision. And I think by the end of that, we felt like, you know, it has happened over a few days, but that we had done enough to make a decision to put him on the field. Now, what's interesting is, in putting him on the field, and he still ended up healing his ACL. That's what's quite interesting.

Bevan Colless  

It is.

Dr Sharron Flahive  

Yeah, as opposed to, you know, he may have been treated over a long period of time, conservatively, maybe you'd think that might lend itself to healing his ACL on what actually happened was, he played his way through into a healed ACL

Bevan Colless  

And it still didn't impede his healing, even though he was cutting and running. We're finding out more and more about ACL healing. And I believe currently, you're doing some work with Tom Cross on ACL healing because it was a lot of whispers about this ACL healing study that's being done out of Sydney.

Dr Sharron Flahive  

He's doing some 90 degrees kind of bracing. Yeah, I think he's getting more information about what type of ACL might have the potential to heal. I suppose that's where the big questions going to be asked around, you know, is there the end of which is, you know, prescriptive, bracing, 90 degrees, no weight-bearing, and then adding in extension. And then there are the stories that we're telling here, which is, well, that was almost supervised neglect and the funny one, and then there's that mid sort of story, which is someone that doesn't like an MCL ACL and you put them in a range of motion brace at 30 degrees. And through that, I get conservative healing of an ACL. And I suppose that's where we need to go with this whole story. Is it How prescriptive do you need to be?

Bevan Colless  

The idea that there is a universally accepted protocol to maximize ACL healing isn't there yet. And I wonder if there ever will be because they seem to heal in a wide range of circumstances, but maybe Mitch’s youth helped as well, just being 22. They do say that younger people maybe have a higher ability to heal.

Dr Sharron Flahive  

Well, there's that, then there's the conversation, that at 22 the risk of re-rupture if you do a reconstruction is so much higher. So, you know, we're weighing that up. I thought sort of four times the risk that if they had surgery that they'll have a re-rupture.

Bevan Colless  

 That re-rupture rates for teenagers are staggeringly high, unfortunately. And Mitchell, how's it gone with the contract? Do the clubs have any concerns about your knee? Do you need to disclose it to them? Or did they talk about it?

Mitch Short  

Yeah, I actually did. I mean, you have to, obviously, part of the protocol over here or anywhere really to is that you pass the medical tests when they assess you. And yeah, I actually, I just told him, and then he, he quickly just had a little feel, but that same test and it was all good. Yeah, yeah. I'm not really too concerned. I mean, I felt like, Oh, that was a bit silly, sort of saying that. But I mean, yeah, it was part of my injury history, I guess.

Dr Sharron Flahive  

For sure. Are you most proud that MRI now to be quite valuable in this space if ever needed?

Mitch Short  

Yeah.

Bevan Colless  

And Sharron, has this changed the way that you think about ACLs? The way you manage ACLs? This case, do you think? 

Dr Sharron Flahive  

I think we're all doing a revisit on how we manage the ACL and the language that you use with a patient around. So you could start your conversation with the patient saying, you know, the majority of people, etc, 40-year-old, 35 year old, you could say the majority of people in the activities they don't require the ACL like often a good skier, and you know, yourself a very good skier. Often they can do without their ACL. Or you can kind of, say,  if you rep cheat, you need this for pivoting and turning. And then they say, Oh, what about tennis? And then you end up in that conversation was that, oh, well, a lot of people can actually don't need their ACL. But if you're going to pivot and turn, so it's almost like you can, you can talk your way with the patient and surgical conservative management. And I think that's where we're at now, as I think we're getting better at providing options to our patients, as opposed to providing them with a conversation that just goes ACL, if you want to do anything aside from running or cycling, you need to have a reconstruction. You know, if you think in Australia, the landscape is, I think it's 90 Over 90% of ACLs get a reconstruction. And, and the truth is that a lot of them never return to the activity they were actually doing when they ruptured their ACL yet they're doing surgery to get back to that activity. Yep. All around that. 

Bevan Colless  

Pretty, a remarkable set of circumstances, I think to your point about those conversations you have with patients in the advice that patients are given soon after rupturing their ACL because it's a little bit overwhelming similar to Mitchell, he probably didn't even know much about an ACL injury at all, he just knew that he felt his knee was feeling pretty good and often you as a clinician you feel like you must have to talk to patients out of that and we're having these conversations every day in the ski resorts when people have just ruptured their ACL skiing and don't necessarily know that they've done it. They're a little bit isolated off in the hills of Japan, I think we actually had the conversation myself and you Sharron 10 years ago just after you'd ruptured JCL and I remember we were having similar discussions and you ended up deciding to have a reconstruction event. Did you?

Dr Sharron Flahive  

So what actually happened with me was when I went back to the wild has a season, and I was able to remember going and playing golf when I got back, and that was fine. And then I did 10 weeks at rugby running a sideline, that sort of thing. And that was also fine because it was like I didn't have you know, you don't have time. I don't have time to get an ACL reconstruction. And but what I ended up getting Bevan was I had a big Cyclops lesion. Right. And so, yeah, and so I couldn't get a full extension. That's a decision. Yeah, I made a decision on the basis of that not necessarily instability. So, you know, surgeons are likely one. So once we're in there, we might as well just reconstruct.

Bevan Colless  

Yes.

Dr Sharron Flahive  

So yes, I did have a reconstruction. I've had no further issues with that either. Yeah.

Dr Sharron Flahive  

Mitch was saying is like he and that's why I was, I find it really, you know, we have to think so much about how we speak to our patients and our players, as you can hear from what Mitch was saying, he did put a lot of faith in us. And, and we had to accept and appreciate that faith, because, realistically, we know that didn't matter how many times I had a conversation with Mitch, he was never going to understand, and nor should he, you know, what possibly could happen. And so we had to be very comfortable with what we did. And part of that was around, you know, and this is the other thing as you said, Did you tell anyone that that's not quite, it wasn't like we went to the media. But I can tell you, I had a conversation with probably three or four orthopedic surgeons. I discussed it with Tom, I think at the time, like, sharing the burden of that decision was really important for me, in that in that period of time, because you need to know that you're not keeping a secret from your peers, and just hoping upon hope that it's going to be okay, so I think any of these decisions, and I say that to anyone as you share, like, share that burden, I talk and if, if the person that you share the story with looks at you like, what are you thinking like that as the most, then you know, perhaps you are, you are being affected by the emotion and the energy of the moment and the competition. And a young kid who says, I reckon I'm good to play. So you know that that was very much where we, and I think even Mitch knew Tim Musgrove at the time or some of his friends, so we definitely did share it in the medical fraternity.

Bevan Colless  

What's great, is that you saw that the type of surgeon who was open to this type of management, I think Australia's probably leading the way in a lot of ways there and whether the orthopaedic surgeons are a little bit more open than other parts of the world to conservative ACL management, aside from probably Scandinavians who've gone a long way down the track for non-operative ACL, but we're having the same conversations with our skiers who, have ruptured their ACL on their international holiday that they've been looking forward to all year. And a lot of them want to get back out there and ski the same trip. And I guess it's important to note that Mitchell's case, and with skiers who do go back out skiing after they've done their ACL, it is very atypical. So there are not many ACLs that present, like Mitch’s, who, who are still running around and still functioning at that higher level. Well, I really hope this gets out to people who, who might have done their ACL and are considering all their different options because I think it was a fascinating story. But I also think it's an important one for people to hear that. Just because you're actually done an ACL, it doesn't mean you definitely need to go for an operation and you need to weigh up a lot of different factors before you you make that decision.

Dr Sharron Flahive  

Yeah, yeah.

Bevan Colless  

Well, thanks very much for your time, guys. It's been a terrific story. And, and great work on both of you for getting through that stage and coming to a great outcome. You know, I think it's it's a great story as well that'll live on. So well done to you both. Thanks.