Keyhole surgery is perhaps a misleading term: despite the technology, expertise and extreme finesse involved, it’s also hugely physical.
Sky News watches as surgeon Luke Jones performs an anterior cruciate ligament reconstruction in an operating theatre in King Edward VII’s hospital in central London.
Mr Jones (male surgeons are referred to as Mr rather than Dr) doesn’t just remove a hamstring: he pulls it out with force.
Drills bore through bone. Flesh smokes as it is cauterised. There’s a fair amount of hammering: “Mallet, please,” Mr Jones asks his assistant.
The ACL is a small band of tissue running through the middle of the knee that keeps it stable.
But watching the operation, it’s easy to understand why tearing it is so devastating. Even though the patient will only have three tiny scars, their knee has taken a pummelling.
“There’s 90 minutes in theatre with me,” Mr Jones tells Sky News, adding: “And then there is one year of rehabilitation with your physiotherapist afterwards.”
That’s why ACL injuries are so feared, especially by one type of athlete: female footballers.
‘Way too many’ women’s players with ACL injuries
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Between 25 and 30 players – enough for an entire extra squad – will miss the upcoming World Cup because of ACL injuries. England stars Beth Mead and Leah Williamson have been ruled out. Data from ACL Women Football Club suggests 195 elite players have suffered the injury in the last year.
It has been described as an “epidemic”. And it is an epidemic that affects women far more than men: they are 2.5 to 3.5 times more likely to rupture an ACL than a male athlete. And we don’t really know why. Even as the women’s game has boomed, research has lagged behind.
One player who is going to the World Cup is England defender Jess Carter. Speaking before departure at St George’s Park, England’s national football centre, she tells Sky News: “There’s been way too many women’s players who have had ACL injuries and not enough research that’s been done about it.
“Why are there so many injuries? How can we prevent it? Why are they happening? A question I sometimes ask is: if this was happening to high profile men’s players, would more work be going in to try and improve things?”
Image: England’s Leah Williamson. Pic: AP
Nature versus nurture
The problem is that there isn’t just one answer.
“I’ve made a list the other day, and I think there are 30 reasons that have been discussed in the literature that I could find,” says Kat Okholm Kryger, a sports rehabilitation researcher at St Mary’s University Twickenham and a medical researcher for FIFA.
“And I think we can split it into two main categories. And I like to call them nature and nurture.
“So the nature is like the biology: the genes, the way the body is shaped and muscle mass, etc… But also the nurture of the environment that the women are in. So the way that young female players are managed compared to male players, the facilities, the professionalism around the sport, the quality of the staff that they have available.”
I ask whether research into injuries in the women’s game has received as much attention as men’s.
“Attention? No. But generally that’s across all research in football and in sports medicine. The male has been the norm,” she adds.
Research will end up benefiting the men’s game too
Take one issue from the realm of ‘nurture’ that Kat is studying: football boots. The male foot was the norm. It’s only in recent years that boots designed specifically for women have become available. And even then we don’t understand the differences properly, which is why Kat has done 3D scans of hundreds of feet, to map them.
That research will end up benefiting the men’s game too because Kat is also charting the differences between ethnicities. Because the default foot isn’t just a man’s, it’s a white man’s.
The male is also the norm when it comes to other environmental factors, like booking a pitch.
On a Thursday evening in Kent, the Gravesham Girls and Women’s Football Club, founded in 1999, is training ahead of the start of the season. About 20 players, kitted out in yellow, are doing shooting drills and balls are flying. A Sky News camera operator cops one in the belly but bravely continues.
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Toni Allen and Keylie Oliver have both ruptured their ACL in the past. “I just screamed – everyone thought it was a fox,” Allen says. Both were out for a year.
“It’s quite daunting, and especially when you realise it’s not just football that it can impact, Oliver says.
“We have lives outside of football and it impacts that as well… At grass roots, the ladies always have a two o’clock kick-off. And that is because in our world, men’s football takes priority over women. We always have to play after – so the pitch is always ruined.”
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11:52
Women’s football: The ACL epidemic
The importance of the factors can change
Another difficulty is not just that there are lots of factors involved, it’s that the importance of the factors can change.
Professor Kirsty Elliott-Sale is professor of female Endocrinology and Exercise Physiology at the Manchester Met Institute of Sport.
She works closely with clubs, including Arsenal, to study how the menstrual cycle, or taking the Pill, can influence injuries. Research seems to suggest that some hormones can make ligaments looser, increasing the risk of rupture.
So over the course of the season Prof Elliott-Sale measures the laxity of players’ knees, charting that against their hormones, and cross referencing it with other factors like match congestion.
“It’s definitely a jigsaw,” she says. “And it’s about sort of putting all the pieces together.
“But once we have all the pieces, we don’t necessarily know which factor is going to play a bigger role on any given day. So it’s not like all of the pieces are the same size. Some days, a particular factor that might influence this type of injury might be amplified, whereas on another day, it might be turned down.”
Biology remains a large part of the answer
But even then the difference between female and male body types – which in the past led to some dismissing women as too “fragile” to play traditionally male sports – may not be as much of a factor as previously thought.
Because in some sports, the ACL injury discrepancy disappears.
“If you compare sports, where males and females start at the same age, have the same training intensity throughout their sporting life, and perform the same movements during that sport, then actually, the rupture rates equalise,” Mr Jones, the surgeon, says.
“And a very good example for that is elite dancers. So elite dance athletes, where the males and females start their training at the same age, they perform the same pivoting, jumping, twisting movements, and they have the same intensity of training and the same conditions. If you compare their rupture rates, they’re actually equalised.”
“And what that suggests is the impact of your training and your conditioning is really essential and avoiding this injury.”
Every expert I spoke to stressed the role of strength and conditioning in preventing injury. Here, nurture influences nature.
“We have that attitude of, you know, women do yoga, and pilates and men lift heavy things in the gym,” Ms Kryger says.
“But the reality is everyone needs to lift heavy things occasionally to prevent injuries and have a healthy body.”
Image: England’s Beth Mead has also been ruled out due to injuries. Pic: AP
The good news is that quantifiable progress is being made here.
Matt Whalan is a sports scientist who works with the Australian men’s and women’s football teams – the Matildas who will be competing in the World Cup. He spoke to me from the men’s under 23s camp there.
Football Australia introduced a programme called ‘Perform+’, which can be worked into warm ups, that has reduced injuries, including ACLs, by 40%.
And crucially, it’s not just for elite players.
“This is designed so that mom and dad coaches can just go online, take down the programme, all the videos are there, there’s information about how you can deliver it with your athletes, and from under-sevens through to 55-year-olds, 95-year-olds, if you want to, you can do these exercises,” Mr Whalan says.
“The benefit of that for us at the higher end level, working with national teams, is if we have players that have been doing that, since they’re 12,13,14 years old, it makes our lives a lot easier.”
That remains in the future. When the World Cup starts next week, it will do so without a host of stars.
As England forward Chloe Kelly tells Sky News: “Having suffered the ACL injury myself, it’s so sad when you see so many players suffering that injury. Hopefully, we get the research that we need to stop these injuries happening so often.”
You know bad economic news is looming when a Chancellor of the Exchequer tries to get their retaliation in first.
Treasury guidance on Tuesday afternoon that Rachel Reeves has prioritised easing the cost of living had to be seen in the light of inflation figures, published this morning, and widely expected to rise above 4% for the first time since the aftermath of the energy crisis.
In that context the fact consumer price inflation in September remained level at 3.8% counts as qualified good news for the Treasury, if not consumers.
The figure remains almost double the Bank of England target of 2%, the rate when Labour took office, but economists at the Bank and beyond do expect this month to mark the peak of this inflationary cycle.
That’s largely because the impact of higher energy prices last year will drop out of calculations next month.
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5:27
Inflation sticks at 3.8%
The small surprise to the upside has also improved the chances of an interest rate cut before the end of the year, with markets almost fully pricing expectations of a reduction to 3.75% by December, though rate-setters may hold off at their next meeting early next month.
September’s figure also sets the uplift in benefits from next April so this figure may improve the internal Treasury forecast, but at more than double the rate a year ago it will still add billions to the bill due in the new year.
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10:13
Minister ‘not happy with inflation’
For consumers there was good news and bad, and no comfort at all from the knowledge that they face the highest price increases in Europe.
Fuel prices rose but there was welcome relief from the rate of food inflation, which fell to 4.5% from 5.1% in August, still well above the headline rate and an unavoidable cost increase for every household.
The chancellor will convene a meeting of cabinet ministers on Thursday to discuss ways to ease the cost of living and has signalled that cutting energy bills is a priority.
The easiest lever for her to pull is to cut the VAT rate on gas and electricity from 5% to zero, which would reduce average bills by around £80 but cost £2.5bn.
More fundamental reform of energy prices, which remain the second-highest in Europe for domestic bill payers and the highest for industrial users, may be required to bring down inflation fast and stimulate growth.
Schools need to be “brave enough” to talk about knives, Sky News has been told, as the killer of Sheffield teenager Harvey Willgoose is sentenced today.
His killer, who was also 15 and cannot be identified for legal reasons, had brought a 13cm hunting knife into school.
Image: Harvey Willgoose. Pic: Sophie Willgoose
Following Harvey’s murder, his parents Caroline and Mark Willgoose told Sky News they wanted to see knife arches in “all secondary schools and colleges”.
“It’s 100% a conversation, I think, that we need to be empowered and brave enough to have,” says Katie Crook, associate vice principal of Penistone Grammar School.
The school, which teaches 2,000 pupils, is just a few miles away from where Harvey was killed.
After being contacted by the Willgoose family, it has decided to install a knife arch.
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The arch – essentially a walk-through metal detector – has been described as a “reassuring tool” and “real success” by school leaders.
“We’re really lucky here that we don’t have a knife crime problem – but we are on the forefront with safeguarding initiatives,” says Mrs Crook.
“I didn’t really think we needed one at first,” says Izzy, 14. “But then I guess at Harvey’s school they wouldn’t think that either and then it did actually happen.”
Joe, 15, says he did find the knife arch “intimidating” at first.
“But after using it a couple of times,” he says, “it’s just like walking through a doorway”.
“And it’s that extra layer of, like, you feel secure in school.”
After Harvey’s death, then home secretary Yvette Cooper said that she would support schools in the use of knife arches.
But there remains no official government policy or national guidance on their use.
Some headteachers who spoke with Sky News feel knife arches aren’t the answer – saying the issue required a societal approach.
Others said knife arches themselves were a significant expense to schools.
But Mrs Crook says they are “well worth the funding” if they prevent “a student making a catastrophic decision”.
“I’m a parent and, of course, my focus every day is keeping our students safe, just as I want my son to be kept safe in his setting and his school.”
Mrs Crook says she thinks schools would “welcome” a discussion at “national level” about the use of knife arches and other knife-related deterrents in schools.
“It’s sad, though that this is what it’s come to, that we’re having lockdown drills in the UK, in our school settings.
“But I suppose some might argue that has been needed for a long time.”
If you eat beef, and ever stop to wonder where and how it’s produced, Jonathan Chapman’s farm in the Chiltern Hills west of London is what you might imagine.
A small native herd, eating only the pasture beneath their hooves in a meadow fringed by beech trees, their leaves turning to match the copper coats of the Ruby Red Devons, selected for slaughter only after fattening naturally during a contented if short existence.
But this bucolic scene belies the turmoil in the beef market, where herds are shrinking, costs are rising, and even the promise of the highest prices in years, driven by the steepest price increase of any foodstuff, is not enough to tempt many farmers to invest.
For centuries, a symbolic staple of the British lunch table, beef now tells us a story about spiralling inflation and structural decline in agriculture.
Mr Chapman has been raising beef for just over a decade. A former champion eventing rider with a livery yard near Chalfont St Giles, the main challenge when he shifted his attention from horses to cows was that prices were too low.
“Ten years ago, the deadweight carcass price for beef was £3.60 a kilo. We might clear £60 a head of cattle,” he says. “The only way we could make the sums add up was to process and sell the meat ourselves.”
Processing a carcass doubles the revenue, from around £2,000 at today’s prices to £4,000. That insight saw his farm sprout a butchery and farm shop under the Native Beef brand. Today, they process two animals a week and sell or store every cut on site, from fillet to dripping.
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Today, farmgate prices are nearly double what they were in 2015 at £6.50 a kilo, down slightly from the April peak of almost £7, but still up around 25% in a year.
For consumers that has made paying more than £5 for a pack of mince the norm. For farmers, rising prices reflect rising costs, long-term trends, and structural changes to the subsidy regime since Brexit.
“Supply and demand is the short answer,” says Mr Chapman.
“Cow numbers have been falling roughly 3% a year for the last decade, probably in this country. Since Brexit, there is virtually no direct support for food in this country. Well over 50% of the beef supply would have come from the dairy herd, but that’s been reducing because farmers just couldn’t make money.”
Political, environmental and economic forces
Beef farmers also face the same costs of trading as every other business. The rise in employers’ national insurance and the minimum wage have increased labour costs, and energy prices remain above the long-term average.
Then there is the weather, the inescapable variable in agriculture that this year delivered a historically dry summer, leaving pastures dormant, reducing hay and silage yields and forcing up feed costs.
Native Beef is not immune to these forces. Mr Chapman has reduced his suckler herd from 110 to 90, culling older cows to reduce costs this winter. If repeated nationally, the full impact of that reduction will only be fully clear in three years’ time, when fewer calves will reach maturity for sale, potentially keeping prices high.
That lag demonstrates one of the challenges in bringing prices down.
Basic economics says high prices ought to provide an opportunity and prompt increased supply, but there is no quick fix. Calves take nine months to gestate and another 20 to 24 months to reach maturity, and without certainty about price, there is greater risk.
There is another long-term issue weighing on farmers of all kinds: inheritance tax. The ending of the exemption for agriculture, announced in the last budget and due to be imposed from next April, has undermined confidence.
Neil Shand of the National Beef Association cites farmers who are spending what available capital they have on expensive life insurance to protect their estates, rather than expanding their herds.
“The farmgate price is such that we should be in an environment that we should be in a great place to expand, there is a market there that wants the product,” he says. “But the inheritance tax challenge has made everyone terrified to invest in something that will be more heavily taxed in the future.”
While some of the issues are domestic, the UK is not alone.
Beef prices are rising in the US and Europe too, but that is small consolation to the consumer, and none at all to the cow.