Meet the `Rehab Guy`

Thursday 07th June 2007

Just as Madonna and Paris Hilton have their own celebrity trainers, the rugby glitterati seem to be becoming ever more reliant on the skills of American knee guru Bill Knowles to keep creaking players on the field of play.

With a star-studded list of rugby clients such as Richard Hill, Dan Ward-Smith, Charlie Hodgson, Austin Healey, Jason White, Ollie Smith, Lewis Moody, Seru Rabini, Henry Tuilagi, Leicester Tigers, and from other sports: David Boston (Tampa Bay Buccaneers), Hannah Teter (2006 Gold Medal Snowboard), Michael Owen (Soccer), and many Olympic skiers, Knowles is fast building a reputation on both sides of the Atlantic as the world's foremost rehab specialist for severe knee issues and in Anterior Cruciate Ligament injuries in particular.

James Griffith paid Bill a cyber-visit to his clinic high in the snow-capped Vermont Hills to find out why ACL injuries seem to be contagious and what is causing the epidemic...

JG: Hi Bill, good to meet you. So with all these star players dropping like flies, what is it about our game of Rugby Union that is causing so many high profile ACL injuries?

BK: Rugby is a collision sport that has inherent risks, just like American football. The strong, the weak, the fast, the slow... they are all at an equal risk once you step on the field. Are the higher profile players taking additional risks to increase their chance of injury? This is a good question. The adage - "bigger, faster, stronger" has its pros and cons. The bigger you are, the faster you run. The harder you hit, the quicker you rotate at the knee joint. Across all sports and levels within the sport, athletes are injuring their knees. The frequency is no higher in rugby than in American football.

JG: Yes, but the number of recent cases seems to be rising...

BK: The injury rate is often just bad luck. Athletes often have no chance to walk away from certain situations. But then again, we must also look at fatigue factors...both mental and physical. How many games are being played...is there enough recovery, etc. Good luck is rarely considered the main reason for a winning season. Likewise, bad luck should never be weighted too heavy when evaluating an injury-prone season. We may find no compelling evidence that points to poor preparation, but a program should always evaluate itself critically each season.

JG: How does the game demands differ to the other sports you're involved with? Where are the 'pressure points' in your opinion?

BK: As far as rehab and reconditioning goes, ground based sports are fairly similar. The goal is to get their strength up quickly and then allow them to express their inherent athletic ability through "movement" training. Sounds simple, but the trick is in managing when to advance the workouts and when to hold back. This is the "pressure point". Too often when the athlete begins to make quality progress they are pushed too hard and setbacks (physical and mental) can occur. Likewise, holding the athlete back too long can be a problem.

JG: So you think professionalism and the match workload is placing greater strains on the players' bodies and also their performance expectations than before?

BK: Quite simply, 'more' is most times not better. Unless it is recovery from competition when 'more' could be very beneficial! The Premiership rugby season is very long compared to other collision sports. Then add in the internationals and it is easy to see how some players may be subject to injury. Regardless, it is impossible to prevent injury in rugby... you just try to decrease the incidence within your team. There is no doubt that pro players are expected to perform week in, week out, even if not fully recovered. This is the nature of pro sports. Those teams that manage this situation the best have a tendency to have a healthier team. Once again though, injury happens even with the best preparation in the world!

JG: Are these knee issues related to position or are they just a general thing? We would have thought that someone like a flanker or half-back would have greater cyclical or rotational strain on a knee than say a big lock or a prop, who might suffer more lateral or linear strain?

BK: I have not seen the exact stats on injury by position to make an accurate statement here. In general, all positions are at risk of some kind of knee injury. A very common ACL mechanism is a non-contact, change of direction. Amazingly, this can still occur at low intensity loads, where the player is not even involved in a play. One second they are jogging/moving, the next they are on the ground in the classic knee injury holding position. As smart as we think we are, no one can predict when or why these injuries will happen.

Also, don't forget the chronic knee injury/arthritis. Your locks and props are carrying some additional weight and have abused the articular surface of the joint for years. Just because they haven't dropped with a blown out ACL doesn't mean their situation isn't just a serious. They need to be managed well or their career will be shorter.

JG:Well, what are the actual mechanics of the classic ACL injury? In layman's terms what is it that actually breaks down or goes wrong?

BK: Typically the foot is planted and fixed to the ground with the toes pointing to the right. Then a change of direction or contact with a player causes the hips and torso to twist to the left. A high twisting force occurs at the knee and "pop" goes the ACL. Typically again, the Anterior Cruciate Ligament is torn completely in half, like breaking a tennis racquet string in the sweet spot. It snaps with great force! Often players on the field can hear the noise clearly.

JG: In that case, when would you get involved with a player? Is it always post-op or at the moment of 'pop'?

BK: I usually get involved with professional athletes from overseas who have had a knee injury around 2-3 months post-op. The necessary physio work has taken place to put the athlete in a strong position to advance their rehab. Athletes from the States have come in immediately after the injury or surgery as well. Then there are the healthy athletes that are looking for performance training. This occurs regularly at iSPORT.

JG: And, how would you structure a recovery regime and what are the key points on the road to a successful recovery?

BK: Players will typically come to work with me for 2-4 weeks at a time. During this time I rehabilitate, train, and educate the athlete on the necessary progression and training regime to follow once they leave iSPORT. I have had excellent communication with the professional clubs and they are comfortable to implement my plan for a few weeks back in the UK. Then they continue to design the "comeback" accordingly.

JG: Educating rugby players can hold its own challenges at the best of times (!)...

BK: The key points are properly managing the progression the athlete is on. You should never hold them back, but they should never be advanced so fast that set backs occur. This tipping point for pros is much different than the average athlete. Having experience in this area is critical.

JG: How did you get involved with all our lame superstars? Rugby is certainly not particularly high profile your side of the pond.....How did you first make contact and who was your first high-profile rugby client?

BK: Put it this way, my friend, no media from the States has ever expressed any interest in any of the "lame superstars" that have come to Vermont! But honestly, that is what makes this setting so perfect for the athletes. No distractions, beautiful mountain landscapes, and an intense rehab camp! As for rugby, I was fortunate to meet Calvin Morris (director of RFU Strength and Conditioning) in the Fall 2002. I was lecturing on advanced rehabilitation techniques for ACL injured world-class alpine ski racers and he fell asleep because it had nothing to do with rugby! Calvin liked what he saw and appreciated my approach. In winter '03 Charlie Hodgson and Austin Healey both injured their knees and Calvin suggested I get involved to help prepare them for the Rugby World Cup that year. Both athletes came over to the States for four weeks. It was culture shock as we were in the middle of nowhere with nothing to do but rehab and train. Kind of like Rocky in Siberia.

JG: Talking of Rocky, Richard Hill's second ACL rupture took place after fully loading and unloading his knee in the 2005 Lions series. Do you believe that it was pure coincidence or do you think that perhaps he tried to come back too early in retrospect?

BK: I have seen the video clip of this injury multiple times. I watched it with Richard as well. I am confident to say he experienced a proper rugby injury. It was bad luck, and just a part of the game.

JG: So he didn't ask for his money back?!

BK: No comment!

JG: One of the things we've noticed is that players who have suffered these injuries never seem to come back with the raw pace they once had. Do you think that this is a true physical issue, such as a lack or elasticity in the soft tissues, or is it a confidence thing, a hesitation before loading the knee up fully in a sprint scenario?

BK:Wow! Well the comeback has many sides to it, and not all can be measured or noticed on the pitch. Pure speed on the track, weight lifted in the gym, and agility training are most often gained back and improved in the first year after surgery. Implementing this into a match is another story. Often the technical aspects of the game take longer to develop. Is the delay on the pitch a result of poor confidence in the knee, or in the player's overall willingness to takes strategic risks? It may not be the injury, but just game sense and game speed that is lacking. Confidence building opportunities are critical throughout the first year for sure! Once the athlete "owns the knee", then performance will usually return or improve.

JG: A lot of physios will always tell players an ounce of prevention is better than a ton of cure. What is your view on this?

BK: Proper training programs include prevention and strength development, technical development on the pitch, and recovery. If this is in balance you can say a "pro-active approach" toward reducing injury is in place. That's it. You cannot prevent all injuries. You are just trying to reduce the incidence.

JG: So what can the average player do to better prepare themselves and to manage potential major injury?

BK: If the athlete follows all proper training principles on a regular basis, then they are in the best position to stay healthy and perform well. Another reason to follow the "proper training approach" every minute of every day is to be in the best possible shape if injury should occur. The more fit you are going into the injury, the better the recover can be.

JG: Bill, obviously you've worked with some amazing athletes in your time. How would you place the all round fitness, conditioning and skill levels of someone like Hill or Hodgson compared to other sportsmen from other sports in which you are involved?

BK: I have been very fortunate to work with many successful and determined professional and Olympic athletes. Each one brings a quality that is slightly different from the others. That being said, they all are extremely focussed and driven to be the best at what they do. What can separate the best from the rest is the unrelenting commitment to do what it takes to get better. Even if this means doing less to allow an injury to heal. Backing off is the hardest task there is. Only the most mature can handle it properly, and then have the patience to slowly advance according to a plan. Richard Hill has been a master at this over the past two years. When it is actually "go time" following an injury and rehab cycle, then the inner athlete takes over and they strive for perfection once again.

JG: That must be a very rewarding process?

BK: I truly come away from training sessions with rugby players with intense motivation to continue my career. I get a great deal of energy from their efforts in training!

JG: With your reputation growing and your relationships with the international sides increasing, Have you considered specialising in the sport yet or do you feel cross-using knowledge gained from other sports assists you??

BK: My future plans are to continue working with athletes of all sports. It is here that you learn the most about multiple types of injuries and scenarios. My experience with world-class ski racers has helped me tremendously with rugby players, and vice versa. Plus, better to make a mistake and learn on another athlete rather than the rugby lads, eh? Ha,ha.

JG: Now you've gotten involved do you try and follow the game and the fortunes of your clients, and more to the point, how is your understanding of the rules?!!

BK: I cruise around the internet daily to check on the athletes of course...because I have nothing else to do. Ha-ha! Fortunately and unfortunately I haven't worked with any cricket athletes. I am at a total loss of the rules there. Rugby is no problem!

JG: Who was your favourite rugby client and what did you enjoy most about working with them?

BK: Let's just say I had great time working with Austin Healey in 2003 and 2005. His constant banter never threw me off my game and I consistently did everything better than he did, although he would never admit that, would he?

JG: It's doubtful! Have you been to a live international yet? We are betting there is no shortage of ticket options for you, even from Healy?!

BK: I was fortunate to be on the sideline with the team for a pre-season at Leicester in August '05. I have an opportunity to catch an England RWC warm-up match at Twickenham in August.

JG: And finally, after you've completed a rehab programme and you are winding down, what is the most satisfying thing about your work?

BK: With the professional athletes, I make video clips of their progress and send them home with a 20-minute DVD highlighting their efforts over 3-4 weeks. I find sitting back and watching this video tremendously rewarding and motivating. Their efforts are inspiring. Then, seeing the athletes return to action and watching them on TV is great! But lets be real...it is the athlete that is responsible for the comeback! I'm just a rehab guy.

JG: Well, you do a top job. Many thanks for your time Bill, keep up the amazing work and best wishes for the future.

Bill Knowles is Director of iSPORT Training at the Vermont Orthopaedic Clinic. For more information, go to www.isporttraining.com