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.”
Another 23 female potential victims have reported that they may have been raped by Zhenhao Zou – the Chinese PhD student detectives believe may be one of the country’s most prolific sex offenders.
The Metropolitan Police launched an international appeal after Zou, 28, was convicted of drugging and raping 10 women following a trial at the Inner London Crown Court last month.
Detectives have not confirmed whether the 23 people who have come forward add to their estimates that more than 50 other women worldwide may have been targeted by the University College London student.
Metropolitan Police commander Kevin Southworth said: “We have victims reaching out to us from different parts of the globe.
“At the moment, the primary places where we believe offending may have occurred at this time appears to be both in England, here in London, and over in China.”
Image: Metropolitan Police commander Kevin Southworth
Zou lived in a student flat in Woburn Place, near Russell Square in central London, and later in a flat in the Uncle building in Churchyard Row in Elephant and Castle, south London.
He had also been a student at Queen’s University Belfast, where he studied mechanical engineering from 2017 until 2019. Police say they have not had any reports from Belfast but added they were “open-minded about that”.
“Given how active and prolific Zou appears to have been with his awful offending, there is every prospect that he could have offended anywhere in the world,” Mr Southworth said.
“We wouldn’t want anyone to write off the fact they may have been a victim of his behaviour simply by virtue of the fact that you are from a certain place.
“The bottom line is, if you think you may have been affected by Zhenhao Zou or someone you know may have been, please don’t hold back. Please make contact with us.”
Image: Pic: Met Police
Zou used hidden or handheld cameras to record his attacks, and kept the footage and often the women’s belongings as souvenirs.
He targeted young, Chinese women, inviting them to his flat for drinks or to study, before drugging and assaulting them.
Zou was convicted of 11 counts of rape, with two of the offences relating to one victim, as well as three counts of voyeurism, 10 counts of possession of an extreme pornographic image, one count of false imprisonment and three counts of possession of a controlled drug with intent to commit a sexual offence, namely butanediol.
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3:16
Moment police arrest rapist student
Mr Southworth said: “Of those 10 victims, several were not identified so as we could be sure exactly where in the world they were, but their cases, nevertheless, were sufficient to see convictions at court.
“There were also, at the time, 50 videos that were identified of further potential female victims of Zhenhao Zou’s awful crimes.
“We are still working to identify all of those women in those videos.
“We have now, thankfully, had 23 victim survivors come forward through the appeal that we’ve conducted, some of whom may be identical with some of the females that we saw in those videos, some of whom may even turn out to be from the original indicted cases.”
Mr Southworth added: “Ultimately, now it’s the investigation team’s job to professionally pick our way through those individual pieces of evidence, those individual victims’ stories, to see if we can identify who may have been a victim, when and where, so then we can bring Zou to justice for the full extent of his crimes.”
Mr Southworth said more resources will be put into the investigation, and that detectives are looking to understand “what may have happened without wishing to revisit the trauma, but in a way that enables [the potential victims] to give evidence in the best possible way.”
The Metropolitan Police is appealing to anyone who thinks they may have been targeted by Zou to contact the force either by emailing survivors@met.police.uk, or via the major incident public portal on the force’s website.
An 11-year-old girl who went missing after entering the River Thames has been named as Kaliyah Coa.
An “extensive search” has been carried out after the incident in east London at around 1.30pm on Monday.
Police said the child had been playing during a school inset day and entered the water near Barge House Causeway, North Woolwich.
A recovery mission is now said to be under way to find Kaliyah along the Thames, with the Metropolitan Police carrying out an extensive examination of the area.
Image: Barge House Causeway is a concrete slope in North Woolwich leading into the Thames
Chief Superintendent Dan Card thanked members of the public and emergency teams who responded to “carry out a large-scale search during a highly pressurised and distressing time”.
He also confirmed drone technology and boats were being used to “conduct a thorough search over a wide area”.
He added: “Our specialist officers are supporting Kaliyah’s family through this deeply upsetting time and our thoughts go out to all those impacted by what has happened.”
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“Equally we appreciate this has affected the wider community who have been extremely supportive. You will see extra officers in the area during the coming days.”
On Monday, Kerry Benadjaoud, a 62-year-old resident from the area, said she heard of the incident from her next-door neighbour, who “was outside doing her garden and there was two little kids running, and they said ‘my friend’s in the water'”.
When she arrived at the scene with a life ring, a man told her he had called the police, “but he said at the time he could see her hands going down”.
Barge House Causeway is a concrete slope that goes directly into the River Thames and is used to transport boats.
Residents pointed out that it appeared to be covered in moss and was slippery.
Major developers will only deal with one regulator under planning reforms which ministers say will “rewire the system” to get Britain building – all while protecting the environment.
A review by former Labour adviser Dan Corry into Britain’s sluggish system of green regulation has concluded that existing environmental regulators should remain in place, while rejecting a “bonfire of regulations”.
But Mr Corry suggested there might be circumstances in which the government look at changing the wildlife and habit rules inherited from the EU, which protect individual species.
The government has now explicitly ruled out any such change in this parliament.
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Campaigners have questioned whether the changes go far enough and will make a major difference to the rate and scale of building in the UK.
Speaking to Sky News, Environment Secretary Steve Reed insisted that accepting nine of the recommendations from the Corry review would amount to wholesale reform.
The minister said: “We can get a win-win for economic growth and for nature. And that is why we are moving ahead with proposals such as appointing a lead regulator for major developments so that the developers don’t have to navigate the architecture of multiple regulators.
“They just work for a single regulator who manages all the others on their behalf. Simplifying the online planning portal.
“These are huge changes that will save developers billions of pounds and speed up decisions doing damage to the environment.”
Mr Reed insisted that there would be “no more bat tunnels” built, even though the Corry review suggests that more work needs to be done to look again at the relevant guidance.
It says: “Rapidly reviewing the existing catalogue of compliance guidance, including on protecting bats, will identify opportunities to remove duplication, ambiguity or inconsistency.
“Natural England has already agreed to review and update their advice to Local Planning Authorities on bats to ensure there is clear, proportionate and accessible advice available.”
The review will mean:
• Appointing one lead regulator for every major infrastructure project, like Heathrow expansion
• A review on how nature rules are implemented – but not the rules themselves
• Insisting regulators focus more on government priorities, particularly growth
Economist and former charity leader Mr Corry, who led the review, said it shows that “simply scrapping regulations isn’t the answer”.
“Instead we need modern, streamlined regulation that is easier for everyone to use. While short-term trade-offs may be needed, these reforms will ultimately deliver a win-win for both nature and economic growth in the longer run.”
However, Sam Richards from Britain Remade, a thinktank trying to get Britain growing, said that while the steps are welcome, the number of regulators that report to the environment department would remain the same before and after the review. He questioned whether this would have the impact ministers claimed.