Club Statement: Clay Smith

[G-Mo77]

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http://www.westernbulldogs.com.au/news/2015-05-11/statement-clay-smith

Western Bulldogs Midfielder Clay Smith will undergo a knee reconstruction after scans confirmed a torn ACL graft in his right knee.

Smith re-injured his knee in the second quarter of yesterday's match against St Kilda.

The Club has made arrangements for Smith to undergo a knee reconstruction this week.

Clay and the Club would like to acknowledge the messages of support from Bulldogs members, fans and football followers in general following the injury.

Because of the specific circumstances of the events of the second quarter, the Club has reviewed the matter and the medical management of Clay’s injury.

That review was led by Club President Peter Gordon and was also conducted by acting CEO Michael Quinn and football director Chris Grant.

The Club understands the following to have occurred.

Clay injured his knee midway through the second quarter of the game. He was taken off the ground and into the rooms where he was assessed both clinically and functionally by one of the Club’s doctors and also by its senior physiotherapist.

Clinical assessment at this point revealed the graft from Clay’s last knee reconstruction to have ruptured.

Despite this, Clay had no pain or swelling and maintained that his knee felt fine and he was assessed to be able to cope functionally in running, jumping, twisting and weaving manoeuvres.

Clay was informed that despite his knee’s functionality, he would need reconstruction surgery and would be out for a prolonged period.

Clay expressed his strong desire to return to the field of play.

The Club’s medical staff permitted him to do so on the basis of their clinical judgment that because the graft had already ruptured, the prospect of it being made worse by a second incident was an acceptable risk.

The functionality of his knee in the period between the first incident and the second incident (just on half time) was due to the strength of his knee’s surrounding musculature and the second incident constituted, in essence, the failure of the surrounding musculature’s ability to continue to provide stability to the knee.

The medical staff were and remain of the view that the second incident did not clinically aggravate the injury.

Their opinion as to these events was supported by the result of an M.R.I. scan Sunday morning which demonstrated that the only injury was a clean tear of the graft (which clearly occurred in the first incident,) and with no meniscal or other structural injury.

The Club has obtained independent opinion (in knee orthopaedics and in sports medicine) from two experts, one in Australia and one overseas.

On the basis of our inquiries and those opinions, we are satisfied that the medical judgments made by our staff were appropriate; that the second incident did not aggravate the injury and that permitting Clay to return to the field did not put him in a position of unacceptable risk.



Exclusive to westernbulldogs.com.au

[SlimPickens]

Interesting, I'd imagine this statement is mitigating the risk of a negligence issues down the track.

[bulldogtragic]

Interesting, I'd imagine this statement is mitigating the risk of a negligence issues down the track.

Sounds a little like it doesn't it?

[soupman]

That is a scenario I did not think of.

[lemmon]

So there is no risk of further damage by playing on an already ruptured ACL?

[soupman]

So there is no risk of further damage by playing on an already ruptured ACL?

I guess its already as bad as it can get, and if the player is keen theres nothing stopping it.

Seems weird but the club doctors know more than I do.

[LostDoggy]

Total respect for Clay Smith - geez hes tough. Good luck with the rehab Clay and look forward to seeing you in the bulldogs colours round 1 next year.

[lemmon]

I guess its already as bad as it can get, and if the player is keen theres nothing stopping it.

Seems weird but the club doctors know more than I do.

A guy I knew ruptured his and it wasn't found till about 6 months down the track by which time he'd already completed the majority of a soccer season, no idea if there was any further damage done though

[LostDoggy]

I'm still confused. If they knew he'd torn his ACL, wouldn't he still be told no you can't go back on? Understand that he said it was ok and felt fine etc etc but...

[bulldogsthru&thru]

Does this imply he's going the traditinal knee reco again and not LARS?

[lemmon]

Does this imply he's going the traditinal knee reco again and not LARS?

Heard yesterday that he will be undergoing the traditional op

[always right]

The only part of this statement I'm still unsure of is this....
Clay was informed that despite his knee’s functionality, he would need reconstruction surgery and would be out for a prolonged period.

Is reconstruction surgery the same as what he will now endure? Was the length of the "prolonged period" the same as the length of time he will now miss?

[SlimPickens]

So there is no risk of further damage by playing on an already ruptured ACL?

Not particularly. What can happen with a rupture is that the swelling acts like a splint to the knee itself and the knee actually feels quite stable (some may remember Lenny Hayes playing out a full game with a ruptured ACL). There is some possible risk of cartilage and meniscus damage but generally Clay would have been in a hell of a lot more pain and wouldn't of been able to run at all if this was the case.

[G-Mo77]

The only part of this statement I'm still unsure of is this....Clay was informed that despite his knee’s functionality, he would need reconstruction surgery and would be out for a prolonged period.

Is reconstruction surgery the same as what he will now endure? Was the length of the "prolonged period" the same as the length of time he will now miss?

Thought that myself.

[SlimPickens]

Total respect for Clay Smith - geez hes tough. Good luck with the rehab Clay and look forward to seeing you in the bulldogs colours round 1 next year.

I hope he gets the full 12 months till he is even considered for selection.

[Sedat]

So there is no risk of further damage by playing on an already ruptured ACL?
There's no risk in further tearing an already torn ACL - once it is torn it needs to be replaced (ie: reconstructed) with a hamstring tendon, patella tendon, or a synthetic fibre (in the case of LARS). There is, however, a risk in the possibility of cartilage damage occurring as a result of instability within the joint - thankfully this didn't happen to Clay.

There are 4 ligaments in your knee - the anterior cruciate ligament is basically your twisting and turning ligament, and is the only one that cannot repair itself (hence when it is torn it needs to be replaced/reconstructed). If your quad and VMO (the ball muscle just above the knee joint) are particularly strong, then this can have a cushioning effect on the knee joint even in the event of damage to your ACL. However, if there is any quick turn or change of direction when there is weight bearing on the knee in question, you will collapse.

[AndrewP6]

I'm no doctor, but the idea of them okaying a player to go back out after they know he's torn an ACL doesn't sit well with me, regardless of his desire to want to continue.

[LostDoggy]

I read that medical report and found it concerning. Gutsy by the guy but it sounds like a risky situation no matter how much they are saying it wasn't.

He ruptured the graft, so he had no ACL, but going back on the park was very little risk of doing more damage? Not sure that seems realistic, if the ACL is gone then the range of movement required for AFL football would be severely compromised and the possibility for other ligament and meniscus damage surely heightened.

I mentioned when he was first picked that I was concerned it was too early, I think this was a problem, he shouldn't have come back to AFL until mid season and probably wouldn't have if not for Libba and Wallis injuries. I was told the graft is known to be fully settled at 12 months.
I love the club and love the guy and I'm no medico, I have had one myself but there is probably much I don't understand.

[jazzadogs]

Well done to the club for clearing that up. I was certainly disappointed when he came back on, as the tests for ACL tears only have a sensitivity (ability to pick up injury) of about 60-70%, meaning there would have been a 30% chance they were incorrectly saying it was fine. Admittedly this also means there is a chance that they initially got a false positive, but that's unlikely based on the results of the scans.

If the diagnosis was a complete rupture of his ACL, then it cannot be made worse. He would have been undergoing a complete ligament reconstruction, with the full 12 month rehab pathway, regardless of going back onto the field. I agree with the club that his return to the field could not have made the injury and treatment any worse.

All the best to Clay.

[The Bulldogs Bite]

I wonder why we haven't went down the LARS path?

If the traditional reco didn't work the first two times, why would it work a third?

[lemmon]

I wonder why we haven't went down the LARS path?

If the traditional reco didn't work the first two times, why would it work a third?

Age must have something to do with it, he is still only 21 with a lot of time left. It may have been a different decision if this had all occurred at 27 years of age. In saying that, didn't Troy Menzel have LARS after two recos? Seems to have been relatively successful there.

[Cyberdoggie]

Not particularly. What can happen with a rupture is that the swelling acts like a splint to the knee itself and the knee actually feels quite stable (some may remember Lenny Hayes playing out a full game with a ruptured ACL). There is some possible risk of cartilage and meniscus damage but generally Clay would have been in a hell of a lot more pain and wouldn't of been able to run at all if this was the case.

Ok so he apparently ruptures it the first time, is able to walk ok, gets told the news decides to have another crack at because it feels ok.
If he is moving ok then you assume there isn't much swelling?... I would of thought if it started to swell up he wouldn't be able to run like he did.

Then if he has already ruptured it, why did he go down with so much pain and require a stretcher the second time it occurred?
That doesn't make sense to me.

Unless things have changed recently the only test they can do at that point is to basically pull on his lower leg to feel for the clunk sound if the ACL is still there, but that is not 100% sure, it would tell them yes this is a worry or it seems ok.
I still don't understand why they sent him back out there, not only could it of made things worse for Clay, it definitely effected the team seeing him go down twice, the second causing a long delay and a big send off on the golf buggy. This would of certainly entered the minds of the players as a distraction. They had the whole half time break to be thinking about Clay instead of the game because that seemed under control, then it was taken from underneath them.

[Remi Moses]

Been handled poorly .
Clay shouldn't have come back on regardless how annoyed or angry he was.
I think he was in a state of shock, and let's just wish all the best for him

[FrediKanoute]

A guy I knew ruptured his and it wasn't found till about 6 months down the track by which time he'd already completed the majority of a soccer season, no idea if there was any further damage done though

I had my left knee diagnosed with a ruptured ACL in Jan 15. I told he Doc he was wrong because there is no way I have ruptured an ACL. He suggested it may be an old injury.......25 year old injury one I had damaged playing at University, but at the time the diagnosis from about 3 docs, a surgeon and my physio was lateral and meniscal damage, the ACL was fine.

My surgeon this year has said, the muscle mass meant that the knee was kept stable, but he noted that I probably would have struggled to play Aussie Rules - which was true was never the same player and gave up after regularly "jarring" the knee. Had no trouble skiing and playing cricket though!

[Cyberdoggie]

Well done to the club for clearing that up. I was certainly disappointed when he came back on, as the tests for ACL tears only have a sensitivity (ability to pick up injury) of about 60-70%, meaning there would have been a 30% chance they were incorrectly saying it was fine. Admittedly this also means there is a chance that they initially got a false positive, but that's unlikely based on the results of the scans.

If the diagnosis was a complete rupture of his ACL, then it cannot be made worse. He would have been undergoing a complete ligament reconstruction, with the full 12 month rehab pathway, regardless of going back onto the field. I agree with the club that his return to the field could not have made the injury and treatment any worse.



I'm confused by this as you mentioned that there could of been a 30% chance of mis-diagnosis, so then if they cannot be 100% sure he has ruptured it, and he seems ok with movement, why send him back out?
The facts are conflicting with each other to the point where it raises questions and doubt. His symptoms weren't like a normal ACL rupture where a player goes down with pain and can barely walk, given his history and the facts above you would err on the side of caution.

I'm very worried they made a bad mistake that could cost this kid his playing career and are in damage control.

[Greystache]

I had my left knee diagnosed with a ruptured ACL in Jan 15. I told he Doc he was wrong because there is no way I have ruptured an ACL. He suggested it may be an old injury.......25 year old injury one I had damaged playing at University, but at the time the diagnosis from about 3 docs, a surgeon and my physio was lateral and meniscal damage, the ACL was fine.

My surgeon this year has said, the muscle mass meant that the knee was kept stable, but he noted that I probably would have struggled to play Aussie Rules - which was true was never the same player and gave up after regularly "jarring" the knee. Had no trouble skiing and playing cricket though!

Cadel Evans won the Tour de France with a ruptured ACL, he wasn't going to get it reconstructed until after he retired.

[jazzadogs]

I'm confused by this as you mentioned that there could of been a 30% chance of mis-diagnosis, so then if they cannot be 100% sure he has ruptured it, and he seems ok with movement, why send him back out?
The facts are conflicting with each other to the point where it raises questions and doubt. His symptoms weren't like a normal ACL rupture where a player goes down with pain and can barely walk, given his history and the facts above you would err on the side of caution.

I'm very worried they made a bad mistake that could cost this kid his playing career and are in damage control.

Basically there are no physical tests which can ON THEIR OWN 100% rule in or out an ACL tear, or any other damage to the knee for that matter. When combined with the clinical history, the fact that I'm sure our doctors have performed the same tests on Clay countless times and know his knee, plus the mechanism of injury, they would have been pretty much 100% sure that it was a complete rupture. I was pretty close to 100% sure and I was sitting down the Footscray end! This is backed up by scans which show a clean rupture...no other injury.

It seems to me that Clay ruptured the ligament, the medical staff correctly diagnosed a ruptured ACL which was still functional in the immediate term, the prognosis of another complete reconstruction was explained to Clay, he completed the functional tests including sudden direction change and returned to the field of his own accord. At the moment he stepped back onto the field, he was still going to be having a complete reco this Tuesday whether he made it through the match or not.

If they had have claimed there was no rupture, then I would have been extremely disappointed. In my professional opinion they acted appropriately.

[chef]

Well said

[Maddog37]

I heard that Clay threatened to body slam each of the medical staff one by one if they didn't let him back on the ground!

[Doc26]

Basically there are no physical tests which can ON THEIR OWN 100% rule in or out an ACL tear, or any other damage to the knee for that matter. When combined with the clinical history, the fact that I'm sure our doctors have performed the same tests on Clay countless times and know his knee, plus the mechanism of injury, they would have been pretty much 100% sure that it was a complete rupture. I was pretty close to 100% sure and I was sitting down the Footscray end! This is backed up by scans which show a clean rupture...no other injury.

It seems to me that Clay ruptured the ligament, the medical staff correctly diagnosed a ruptured ACL which was still functional in the immediate term, the prognosis of another complete reconstruction was explained to Clay, he completed the functional tests including sudden direction change and returned to the field of his own accord. At the moment he stepped back onto the field, he was still going to be having a complete reco this Tuesday whether he made it through the match or not.

If they had have claimed there was no rupture, then I would have been extremely disappointed. In my professional opinion they acted appropriately.

If our medicos confirmed a rupture of the ACL, I fail to accept at that stage why we might risk any severe and permanent damage to Clay's remaining meniscus cartilage and the joint surface cartilage regardless of how small that risk might be.

Not that I see it as relevant but we were up at that stage by 48 points. I just can't see what there was there to be gained other than taking on a level of risk that for mine couldn't be justified.

[Ghost Dog]

If he couldn't damage it further, he couldn't hurt it. So what's the harm?

[Topdog]

The Ox has mentioned an increased possibility of the knee giving way and therefore it being an increased risk for other injuries (running into a marking contest, knee gives way and his head is in danger).

What do we think of that?

Andrew summed it up perfectly for me. I'm no doctor but I'm not comfortable with what we did.

[jazzadogs]

The Ox has mentioned an increased possibility of the knee giving way and therefore it being an increased risk for other injuries (running into a marking contest, knee gives way and his head is in danger).

What do we think of that?

Andrew summed it up perfectly for me. I'm no doctor but I'm not comfortable with what we did.

Well then Koby shouldn't have been out there, because his corked glute meant that he didn't have as much control over his leg, and was running with an abnormal gait which meant he could have tripped head first into the fence. I understand the point, but it's a highly unlikely situation.

The onus on the doctors is to have an informed discussion with the patient, and then it is the patients decision.
Someone needs cardiac surgery, doctor explains the pros and cons, patient decides not to have the operation and die of a heart attack two days later. Who is at fault?
Someone is obese. Doctor explains risks of obesity, how it can contribute to diabetes/hypertension/every other medical condition. Patient does not change, remains obese, and has a stroke. Who is at fault?
Patient suffers a ruptured ligament during a football match. Doctors explain the implications, that surgery will be required, that further damage is highly unlikely, but patient feels that he has enough stability to return to the field and does so. Who is at fault?

I'm sure Clay returning to the field was not suggested by the medical staff. I'm sure it was not their first choice management strategy. But if you explain the risks to someone, and they decide to proceed, then that is their choice.

I understand that there are potentially other Workcover issues at play, but from a medical POV I don't see what they could have done differently.

[AndrewP6]

Well then Koby shouldn't have been out there, because his corked glute meant that he didn't have as much control over his leg, and was running with an abnormal gait which meant he could have tripped head first into the fence. I understand the point, but it's a highly unlikely situation.

The onus on the doctors is to have an informed discussion with the patient, and then it is the patients decision.
Someone needs cardiac surgery, doctor explains the pros and cons, patient decides not to have the operation and die of a heart attack two days later. Who is at fault?
Someone is obese. Doctor explains risks of obesity, how it can contribute to diabetes/hypertension/every other medical condition. Patient does not change, remains obese, and has a stroke. Who is at fault?
Patient suffers a ruptured ligament during a football match. Doctors explain the implications, that surgery will be required, that further damage is highly unlikely, but patient feels that he has enough stability to return to the field and does so. Who is at fault?

I'm sure Clay returning to the field was not suggested by the medical staff. I'm sure it was not their first choice management strategy. But if you explain the risks to someone, and they decide to proceed, then that is their choice.

I understand that there are potentially other Workcover issues at play, but from a medical POV I don't see what they could have done differently.

That's not how football works. If it was solely the players' choice, there'd be countless examples of people continuing with serious injury, and making it worse. They have an obligation to the players' welfare, and allowing him to continue whilst knowing what he'd done, is IMO, the wrong move.

[jazzadogs]

That's not how football works. If it was solely the players' choice, there'd be countless examples of people continuing with serious injury, and making it worse. They have an obligation to the players' welfare, and allowing him to continue whilst knowing what he'd done, is IMO, the wrong move.

Yes but they have deemed that the risk of further injury was so low that it was an acceptable risk and I would agree with that. It's impossible to quantify what the risk actually was, and who knows what previous damage he had done to the meniscus (perhaps he has already had a meniscectomy in one of his previous surgeries, and therefore risk of damaging the meniscus is zero!), but at the end of the day he was made aware of the risks and there was no definitive medical rationale to stop him re-entering the field of play.

[LostDoggy]

Thanks to all who have more of an insight into Clay's injury. It doesn't make it any easier to swallow but helps explain quite a lot.

[AndrewP6]

Yes but they have deemed that the risk of further injury was so low that it was an acceptable risk and I would agree with that. It's impossible to quantify what the risk actually was, and who knows what previous damage he had done to the meniscus (perhaps he has already had a meniscectomy in one of his previous surgeries, and therefore risk of damaging the meniscus is zero!), but at the end of the day he was made aware of the risks and there was no definitive medical rationale to stop him re-entering the field of play.

Was there any definitive rationale which made it a good idea (medical, coaching etc)? Appalling decision in my view.

[jazzadogs]

Was there any definitive rationale which made it a good idea (medical, coaching etc)? Appalling decision in my view.

And you have every right to your view. I think that the emotional view is "how dare we put a young man in danger" but the decisions of our medical staff have been backed up by two independent specialists, as well as local experts such as Dr Peter Larkins.

There is definitely a precedent for this (think Lin Jong's broken hand one week ago, with zero negative comment only 'gee he was brave'), but it has been made to look worse because Clay collapsed on the ground despite suffering no additional injuries.

[LostDoggy]

Just shows the measure of the man , comes off knowing that something is horribly wrong , gets fully assessed and a full tear of the ACL graft is confirmed but he still wants to go back on the field , most players would have just stopped to try and take the situation and reality of the moment in but for Clay the reality was that the boys were on the field he wanted to be with them , I,m pretty sure the moment when he collapsed was the moment the situation and the reality of the moment really hit him , its going to be a tough time for him and his family and the Club and all the Supporters will be with him on his journey back

[Ozza]

I'm sure if this happened again - the player would not be allowed back on the ground, regardless of the player's insistence.

If everyone had their time again, Clay wouldn't have gone back on the ground on Saturday.

[Cyberdoggie]

So what about the increased swelling? The fact that he was running around you would think that it would be minimal, after the second time when he was in severe pain, I would think not. Others will probably know better than me but I thought the more swelling you have the harder to operate and recover.

From all we've heard and discussed there are several reasons for not sending him out, and the only reason I can think of for putting him out is perhaps because of Clay's character in that he wanted to still contribute, not let the side down, or perhaps a last run around for his career (hopefully not).

[Cyberdoggie]

On the AFL page apparently Smith has had a successful surgery using a quadriceps tendon, normally they use hamstring tendon's but as this is the third operation they used a quad tendon.
Let's hope it all goes well for Clay.

[Doc26]

Let alone the physical aspects required, I can't imagine the mental strength required to get past a third knee reconstruction.

All strength to Clay over the next twelve months and then beyond.

[ratsmac]

I hope the Quad tendon holds up better than his hamstring tendons.
I hope hope he's in good spirits considering what he's been through as well.

[chef]

Every player on the list has chipped in to send him on a holiday for his birthday

[wimberga]

Every player on the list has chipped in to send him on a holiday for his birthday

Absolutely rapped to hear this.

We have a group of fine young gentlemen rebuilding the very fabric of this club, and it feels stronger than ever before.

Thanks for letting us know chef.