Kiwi surgeon Dr Rowan Schouten behind international cricketers' returns

Season-ending and sometimes career-threatening, a serious stress fracture can lead athletes from around the world to call on a Christchurch-based surgeon to get them back playing.

Referrals from some of cricket's biggest names and a successful track record has made orthopaedic spine surgeon Dr Rowan Schouten a trusted 'go-to guy', when the careers of not only Black Caps, but Australian, Indian or European athletes are on the line.

Operating on cricketers' backs is a minor part of Schouten's public and private surgical role at St George's Hospital, but it can have major consequences for a player's livelihood.

Schouten operates on 2-3 cricketers a year.

"When you think we do 200-300 operations a year, it's a very small niche market as far as our workload goes, but it's been an interesting role that's sort of built up over the last 10 years or so."

While mostly involved with cricket, Schouten has contributed to other sports.

"We know the spine struggles to tolerate hyperextension loading in a lot of sports," he said. "Stress fractures are not something that are isolated to cricket.

"We see it in dancers, we see it in other sports, like gymnastics and tennis and volleyball, basketball, but certainly cricketers, they're probably the highest incidence of stress fractures among all athletes."

Patient zero: Shane Bond

Former Black Cap Shane Bond started it all and continues to be a big supporter of the surgeon's work.

After years off the field with stress fractures in the middle of his international career, Bond was faced with early retirement or surgery.

The fast-bowler turned to Schouten's mentor, Dr Grahame Inglis, who successfully pioneered a surgical technique, involving cables and screws, that got Bond back on the park.

Before Inglis retired, he sat Schouten down and shared his technique, and the reasons and indications why he would consider surgery.

Together, Inglis and Schouten operated on "a bunch of New Zealand cricketers in the same setting and then things started to go international, just before he retired".

The Australians were the first overseas athletes to be "open to the idea of surgery for some of their trouble making fractures" and from there, others were on board.

"A lot of the cricketers around the world, when they have an injury, they reach out to others that have had similar," Shouten said. "Shane is highly regarded, highly respected, coached throughout the world, so a lot of them contact Shane and then he brings that connection through to us.

"We've operated on over 25 professional cricketers worldwide now and it's not an operation that's done by a lot of people.

"Technically, it's not a challenging operation, but it's having that track record that is appealing and encourages people to come from other parts of the world to do it.

"There are other people around the world that were doing the surgery, in fact, but a lot of them all at the same time, they either retired or they were injured, and couldn't operate.

"Out of sheer luck, we became the go-to for the world and, as a result, we've got some results that are now encouraging enough for other people to take the trip."

While Schouten does not talk about individuals, Indian fast bowlers Jasprit Bumrah, Prasidh Krishna and Mayank Yadav, as well as Australians Jason Behrendorff, James Pattinson, Cameron Green and Lance Morris, are among those publicly linked by their national body to the New Zealand doctors.

Black Caps Matt Henry and Kyle Jamieson are also on the list.

Australian tennis players and UK rugby players have sought Schouten out, as did an ice hockey player who did not require surgery, but wanted advice about how to manage load.

Treating an athlete is a team effort and Schouten said imaging from Pacific Radiology allowed him to make decisions about whether to operate or not.

NZ Cricket high performance physiotherapist Dayle Shackel helps manage rehab and recovery of all the international players, who spend two weeks in Christchurch afterwards, before check-ups become virtual.

Schouten has slowly modified and "tweaked" the technique over time, but the "essence of it is still the same".

"Technology has changed quite a lot, even in the last 5-10 years," he said. "We have computer navigation in theatre that helps us put everything that we need to insert accurately.

"There's also a few other elements of the surgery that we've added in more recent years that I think are important for its success and to make sure that we deload that part of the spine that is so vulnerable to stress fractures.

"When players get back, not only do they have a fracture that's a bit more robust from all the surgery, but also the loads that are going through that spine are not as significant."

Bodies not made for cricket

"It's a tough gig, being a fast bowler, certainly from a spine perspective. When you think of each of these injuries taking 6-9 months to get back, it can be quite a big burden on these cricketers and their careers."

A survey of New Zealand male fast-bowlers in domestic cricket a few years ago found "45 percent of them said they'd had a lumbar stress injury at one part of their career".

"I was talking to Cricket Australia recently as well and they have good data on all their contracted players over the last 12-plus years. When you single out the male fast-bowlers that they have been looking after, they said 39 percent of them had had a lumbar stress injury over that time."

A stress fracture does not happen out of the blue.

"They're not one-off traumatic events," Schouten said. "What happens is you load your spine and you get almost like a bruising of the bone to begin with.

"Then, if you continue to load it, that bruising then accumulates and builds up, and then you get some micro damage and eventually the micro damage, if you continue to load the spine, results in a full fracture.

"It's a cumulative problem. Often, though, you don't get symptoms until the very end of that sequence, but you can often see that the stress is brewing on MRI scans."

As a preventative measure, some cricket governing bodies around the world, like the England & Wales Cricket Board, have their fast-bowlers get Magnetic resonance imaging (MRI) scans at intervals throughout their season to see whether any stress is building up.

"Then you can make decisions about whether you select them for a particular tour or whether you ask them to rest for a particular period.

"The key risk factor for stress fractures is how much bowling the players do.

"These days, when you see the amount of cricket that's being played, and the number of series and the number of formats being played, then quite quickly your workload can escalate significantly into dangerous territory."

Schouten said overseas bowling loads were mapped out to make sure players did not reach dangerous levels "or they don't have big spikes in workload".

"They know that certain types of bowling actions puts people at risk of stress factors, so there's even thoughts and analysis goes into bowling action, and how that can be improved to reduce the risks."

Surgery is not for everyone

The "vast majority" of cricketers, playing at all levels of the game, who have stress fractures, do not require surgery, Schouten said.

"A 16-year-old playing schoolboy cricket is a different scenario than an international whose career is on the line and the timing's important. When they've got big contracts coming up or World Cups to play, it's a slightly different scenario.

"The need to operate on a professional cricketer for stress fractures is very limited and it is normally resolved non-operatively to start with, through a six-month rehab period.

"It's only the ones that re-occur that we start to consider surgery, those trouble-making ones that keep people sidelined repeatedly for sequential 6-9 month periods.

"[With] surgery, we've had some success, but it's not bulletproof and we need to recognise some of those players who, even post-surgery, have had recurrences."

Schouten said those players were not completely healed by surgery were a reminder that the bowling action was stressful for the lumbar spine and that surgery was not the only part of the solution, as it "still requires a whole lot of effort from the players to keep themselves conditioned and to manage their workloads appropriately".

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