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Injury Updates 

Round 1 Injury Wrap-up

NRL Physio

The NRL Physio is back for another week to give you the wrap up on injuries and recoveries from Round 1 of the 2017 NRL season.

 

Disclaimer: The opinions given by the author of this article are given by a qualified physiotherapist, HOWEVER they are based on the information available to the author at the time of publication; are general; and are not based on any formal physical assessment and/or diagnosis by the author. If you believe you may be suffering from an injury similar to one commented on by the author, do not rely on the author’s advice as it may not apply to you – see a qualified physiotherapist for a full assessment, diagnosis and treatment plan.

 

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Greg Inglis

Busy time to start putting pen to paper. As many of us saw on Friday night, Greg Inglis fell to the turf clutching his left knee after attempting to tackle James Tedesco. Non-contact injuries almost always scream ACL, but this mechanism also involved Inglis’ knee jarring into the ground as he came to a halt. The physio came out and performed a few tests, most notably the Lachman test which is a highly sensitive and specific test to identify/rule out the presence of an ACL rupture. At the time Inglis was reportedly cleared of any serious ligament damage to the knee, strapped up with what appeared to be a lateral (outside) support taping and continued playing. At half time Inglis was re-examined, and through consultation with Inglis himself as well as the Rabbitohs medical staff he was allowed to return after half time. He played on for a total of 40+ minutes after the injury, even scoring a try, before succumbing to the injury and leaving the field. We have since learnt that Inglis suffered an ACL rupture, and will be out for a minimum of six months (unless he opts for an artificial ligament, which I will address later).

 

 

Now I must stress again I am not the treating physio, I did not examine Greg. Diagnosing an injury implies physical examination coupled with treatment. I can only give an injury impression using video to analyse the mechanism of injury, which is not going to be perfect. On Friday night as I was watching, a big warning sign was the vision of Inglis’ Lachman test (credit to @nrlmagicsponge on Twitter, good bloke). A Lachman test involves pulling the tibia (lower leg bone) upwards whilst stabilising the femur (upper leg bone, see video below). If the ACL is present (ie not ruptured) there will be a lot of stability to the knee and very little movement, and if there is no ACL the tibia will translate much more (knee is unstable). Some orthopaedic specialists even consider the Lachman test to be as accurate as an MRI for identifying the presence of an isolated ACL rupture.

As you can see in the video below, there appears to be laxity (looseness) in Greg’s knee as the physio is performing the test. Now the question has been asked, how can an ACL tear be missed? There are a few reasons, with three of the most common being swelling, hamstring firing and the presence of a meniscus (cartilage tear).

  • Swelling can cause the knee to be quite stiff, which can give the illusion of stability in the knee.
  • The hamstrings can also fire (contract) whilst the test is being performed, holding the tibia from moving during the test. This is countered by the tester placing their fingers around the back of the leg to feel is the hamstrings contract whilst performing the test.
  • If there is a cartilage tear, sometimes this can cause a block in the knee meaning most manual tests will be inaccurate. This can be ruled out if the Rabbitohs media release is accurate, as it stated there was no further damage outside of the ACL

 

 

There is also the consideration Inglis may have somewhat clinically unstable knees to begin with (some people have “looser” knees than others). This injury was to his “good” knee though, so with no injury history there you would hope to not see that much movement in a healthy knee.

If you followed my tweets at the time, ACL was a massive concern for me; non-contact injury mechanism, loose ACL testing. However, I will always defer to the assessment and opinion of the treating medical professionals. They had by reports cleared ligament damage, and they were the people in the best position to make that call. Should Inglis have stayed on the field? It is easy now to say definitely not, but there were many signs that pointed to possible ACL damage and there are risks to playing on with this injury.

This has been my big frustration over the past few days. The line that “there was no risk of further damage” because the initial injury mechanism resulted in the ACL being ruptured. This statement is simply not true. If you apply this statement to his ACL alone, there is truth to it. Once an ACL is ruptured it is gone, you can do no further damage to it. And yes the rupture of Inglis’ ACL happened during the initial mechanism; partial ACL tears are very rare and with what we now know the movement in that Lachman test is almost certainly not of a partially torn ACL. But what about all of the other structures in the knee?

The best way I have heard it put is playing with an ACL tear is like driving a rally car with no seatbelt. It’s all well and good until you end up through the windshield. Inglis was obviously lucky enough to avoid any further damage as has now been reported. But the biggest risk of him playing on is severe and permanent damage to the meniscus cartilage and articular (joint surface) cartilage in his knee. It is easy to fix the ACL, but damage to this cartilage is almost always irreversible and is linked to early and progressive arthritis.

And the argument that “Inglis said he was ok to play on” is not a strong one. It is quite common for an athlete who suffers an isolated ACL rupture to have initial severe pain that wears off after a few minutes to just be left with a “loose” feeling knee. As I said about the ACL earlier, once it is torn it is torn, you can’t do any further damage to it hence you won’t feel pain from the ACL. With GI’s history of playing with pain, of course he is going to say he feels ok to play on. It is in the hands of the medical staff to make the call if it is safe for him to do so.

Where does Inglis go from here? If you read my last article, the two most common options are ACL reconstruction via autograft (traditional, Inglis’ own tissue, 9-12 month recovery) or allograft (donor tissue, 6-9 month recovery, higher failure rate). The reports he could be out “up to 6 months” cannot be true if he opts for these procedures, it would be minimum 6 months and more likely 9+.

However, there is one procedure, using an artificial (LARS) graft, that can have GI back on the field in 3 months. Now this sounds great when you put it that simply, however the risks with this graft almost always outweigh the benefits. It is only a new procedure and until recently any medium to long term results of the procedure were not available. The evidence is now starting to show the use of this ligament can be quite detrimental as time passes. Being artificial the life expectancy of this material is only 7-10 years and can cause extensive joint inflammation due to reaction from the artificial material. This can cause early arthritis, persistent swelling and stiffness, and significant pain. And with a limited graft life expectancy and inevitable failure of the graft, this means Inglis may suffer another traumatic injury with risk to other structures in his knee. With GI being at the back end of his career a case could be made to have the LARS reconstruction and have it naturally reconstructed when he retires. Hopefully he opts for a more traditional reconstruction and comes back bigger and better next season. I wish him all the best for the recovery ahead.

 

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Concussions (Alex Glenn, Isaac De Gois etc)

You cannot be minorly or severely pregnant. You are either pregnant or you are not. This same rule applies to concussions. The words “minor” and “concussion” should never be used together for many reasons, with the most obvious being head injuries that appear mild initially can become more severe as time passes.

A common saying is concussions are like snowflakes; no two are the same. Any injury to the brain should be considered serious but the signs and symptoms can vary greatly. As we have seen in the NRL a player can fail a HIA during the game and not return that day but play the following week (Alex Glenn), and symptoms can also be persistent or prolonged resulting in multiple weeks on the sideline (Isaac De Gois).

Concussions used to be graded, but as more has been discovered about the course of symptoms and risk of long term complications these grading systems have been abandoned in favour of more individualised management. Many grading systems centred on loss of consciousness (LOC); if the athlete suffered LOC they were considered to have a higher grading concussion than those that did not. But medical professionals were finding LOC did not determine length of recovery. Athletes who were knocked unconscious sometimes recovered quicker than who did not lose consciousness at all. When making decisions about return to footy for players suffering concussion clinicians will treat each case individually, using tools to assess the clinical signs and symptoms, cognitive dysfunction and physical deficits.

In terms of return to play guidelines, there is no universal timetable. At the minimum a player must be free of all signs and symptoms at rest to begin physical activity, and then free of signs and symptoms during physical activity to return to footy. There are also neurocognitive function tests (like the HIA) the player must perform to pre-injury levels.

So the question many will want an answer to when a player suffers a concussion, “how long will he be out for?” is impossible to answer. It will be in the hands of the treating doctor, and with the unpredictability of concussions it would even be difficult for them to produce a definite timeline.

 

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Jesse Bromwich

It has been reported that Bromwich suffered no fractures or tendon/ligament damage when he dislocated his IP (distal) joint in his thumb on the weekend. This is great news for his potential return, and can seem quite surprising considering it was an open dislocation (bone poked out of the skin).

Whilst it can look quite serious, the recovery from a dislocation of this nature is only held back by how quickly his skin can heal where he was stitched back up. This means his recovery will likely be 2-3 weeks, as opposed to a potential 6+ week absence if a fracture or further soft tissue damage was present. Lesean McCoy, a running back in the NFL, had this exact injury in 2016 and played the very next week. With the use of gloves in the NFL the risk of infection is much lower in a healing wound of the thumb.

When Bromwich comes back his offload and grip should not be affected; with the only major damage occurring to the soft tissue in the pad of his thumb in 2-3 weeks there should be no lingering issues.

 

 

Jarrod Croker

 

Billy Slater

 

Peta Hiku

 

Dylan Pythian

 

Matt Dufty

 

As always if you have any questions, throw a comment down below or hit me up on Twitter @nrlphysio

Head to Zero Tackle for the full list of injuries and suspensions.

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NRL Physio

The "NRL Physio" is a qualified and practicing physiotherapist. He tweets from @NRLPhysio and writes for us about injuries to NRL players and their recovery times.

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NRL Physio

The "NRL Physio" is a qualified and practicing physiotherapist. He tweets from @NRLPhysio and writes for us about injuries to NRL players and their recovery times.