Thursday, 23 May 2019

Triathlon & Hands

Image result for matt hopkinson physio
Matt Hopkinson. Ordinary triathlete, elite dancer!
I was recently chastised in a nice way by my “landlord” Matt Hopkinson. Matt is the owner and principle physiotherapist at “Glenferrie Sports and Spinal” which is where I work every Monday afternoon. Matt, and Ben Holland the peoples’ podiatrist, had just returned from a weekend in Sydney on practice management, and in particular, the use of social media. Matt had a crack at me for not keeping my presence on social current. He’s right of course, it has been 10 months since my last blog, and so I promised him I would get something down. 

The something that has been buzzing around in my head is the result of a triathlon I completed in February. Around the same time, I saw an elite triathlete, who had had an extremely nasty injury to her wrist after a fall from her bike. The injury, whilst it didn’t necessarily stop her from training, certainly impacted on how she trained and what she could do.

Image result for clip art triathlonTriathlon is a sport that demands different things from the body at specific times. There are things that are similar between the disciplines, eg cardiovascular fitness; and there are things that are different such as the demands on upper body in swimming that are not there in running. I would argue, and I will argue, that a wrist or hand injury can impact all three; swimming, cycling, and running. 

I first saw triathlon on the Saturday afternoon TV show “Nines Wide World of Sports”. The Hawaiian Ironman. This race began in 1978 when Judy and John Collins proposed combining the three toughest endurance races in Hawai’i—the 2.4-mile Waikiki Roughwater Swim, 112 miles of the Around-O’ahu Bike Race and the 26.2-mile Honolulu Marathon—into one event. 15 people raced that year, 2400 last year in what is now a qualification only event (1).

It really is that colour. Swimming through goose poo.
My first triathlon was in 1985 around the Kew Boulevard. We swam in the Yarra River which is revolting now I think about it, and I was 296th out of the water in a field of 300. Jumped on my trusty but rusty 10 speed Lawrencia bicycle with its pack rack still attached and rode my guts out. Did okay in the run and ended up in the First Aid van with cramp at the end. A fantastic morning and whilst the experience never led to a lifetime of racing, I’ve always loved the sport.  

In the next blog (and it will be up very soon), we’ll talk about swimming, my least favourite leg but an important one for fingers!!


(1) http://ap.ironman.com/triathlon/events/americas/ironman/world-championship.aspx#ixzz5onGPe21q

Thursday, 19 July 2018

One screw or two?

It's getting towards the end of the Australian rules football season. It always seems around now that I see more people with hand and wrist fractures than I did at the start of the year. maybe it's the cold, maybe it's fatigue, maybe it's that the games become more desperate with finals around the corner. Surely someone knows?

Better in brown & gold! Scaphoid 2016.
In any case, this week I have seen 4 footballers with scaphoid fractures. All were simple non-displaced waist fractures. Two were casted, two had surgery. One of these had one screw inserted to repair the bone, the other two. A physio I really respect asked whether the two screw thing was new, and why would the surgeon opt for what appears on the outside to be much more difficult surgery to a small bone that already has a poor reputation for healing. The surgery and the science weren't new to me, but a translation of their impact was obviously required so let's start at the start. 

Facts about the Scaphoid (1,2)
Scaphoid fracture through waist. One screw, result at 4mths. Not my patient.

  • Most commonly injured carpal bone
  • Frequently diagnosed late if at all, with high rates of bone non-union
  • Best assessment indicator remains pain on palpation of scaphoid in radial snuffbox (below thumb)
  • The part nearest your wrist (proximal) has poor blood supply, often lost with a fracture of the middle section (waist)
  • Casting can be required for 2-6 months
  • Surgery appears to have better outcomes in the short term
  • It appears thumb immobilisation is unnecessary in a cast (3) (but I still include the thumb at least initially because I definitely don't trust young, male footballers!). 
Not an option in Aussie rules footy!!
If I am just talking about athletes, then they are looking at the quickest possible return to their sport. This makes a fracture during the season more likely to be addressed with surgery in spite of the real risk of complications. There remains a risk though. Surgery will ensure good bone compression and stability, but the bone still requires protection in a splint, and active movement outside of the splint is not always encouraged such is the reputation of this poor little bone (1,2)

The reason surgeons started looking at two screw fixation was that they wanted earlier movement at the wrist to reduce concomitant weakness, and there have been significant improvements in available hardware since development of the Herbert screw in 1984(5). There was also a recognition of the potential benefit of permitting controlled stress across the joint to augment bone growth. 

Cupcake bouquets. Who knew they were a thing?
Keen students of previous blogs will be aware that the scaphoid is a tricky little beast, not always moving in a singular plane. The problem with a single screw, was that it still permitted rotation of the scaphoid. Proponents of the two screw method argued that torsional stability of the bone would be enhanced with two points of fixation (4,5). This makes sense to me. One toothpick in a cupcake bouquet and the cupcake will slide off. Two toothpicks and it can't. Simple! 

Obvious complications are that inserting two screws is technically very difficult, it effectively doubles the likelihood of malpositioning, and it is more expensive (4). It is a new technique; one that is not available to all patients, and one that is not yet supported definitively. Rehabilitation protocols specific to this surgery have not yet been established. 

Notwithstanding the risks, and relative newness of the research, the biomechanical theory comparing one vs two screws is promising. Both lab based and clinical results do indicate a better stability, stiffness and energy absorption compared to a single screw. Whilst these studies concentrated on scaphoid fractures involving non-union or displacement, the implications are that an earlier introduction of mobilisation, loading and strengthening may be tolerated (4,5); possibly even an earlier return to play... just in time for finals!

Look after those fingers,

Hamish


References
  1. Rambau GM et al. Evaluation & management of nondisplaced scaphoid waist fractures in the athlete. Operative Tecniques in Sports Medicine 2016 24:87-93
  2. Winston, M., Weiland AJ. Scaphoid fractures in the athlete. Curr Rev Musculoskelet Med 2017 10:38-44
  3. Buijze, GA. et al. Cast immobilisation with and without immobilisation of the thumb for nondisplaced and minimally displaced scaphoid waist fractures: A multicentre, randomised, controlled trial. JHS Am 2014; 39(4):621-627
  4. Mandaleson, A. et al. Scaphoid fracture fixation in a nonunion model: a biomechanical study comparing three types of fixation. JHS Am 2018;43(3):221-228
  5. Garcia RM. et al. Scaphoid nonunions treated with two headless compression screws and bone grafting. JHS Am 2014;39(7):1301-1307



Sunday, 28 January 2018

Low to High Hamma, Low to High

John Egan; back 2 back 2 back winner of the
Cannons Mark of the Year
Gary Coleman Cup
My mate Jumping Johnny Egan is one of the best marks of a footy that I have ever seen. As he launches himself towards the ball, his hands move from down by his waist into the air above his head before snapping open with wrist extension just before the ball smacks into his palms. Conversely, and keen readers of this intermittent blog will know exactly where I am going with this, I am one of the worst marks of the footy I have ever seen. At least, I used to be.

The local junior footy club (Go Sharks) began to run training nights for Dads. There was no game, just an excuse to run hard and do circle work. One night, in the middle of another ball dropping performance beyond belief, the bloke running the show pulled me aside and asked if anyone had ever taught me how to mark a footy. Before I’d even had a chance to realise that he wasn’t taking the piss, Jacko proceeded to outline exactly what I needed to do. I needed to be more like Johnny. 

Talk about "Low to High" Poppy!!
When Johnny marks the ball, his hands aren’t coming up from below the ball’s trajectory. Instead they are coming towards the ball but in such a way as to offset the trajectory and speed of the ball so as to give his hands as much time as possible to grasp it. Now that’s not what Jacko told me, but it is what he meant when he said “Low to high Hamma. Low to high mate”. It is however what an Italian neuro-physiologist found in a mind numbingly involved article with the disarmingly simple title, “Grasping and Catching” (1). 

Catching is a combination of predicting the velocity and path of the object, adjusting proximal structures in such a way that grasp of the object is possible. Experience helps which probably is one reason the recent explosion in girls playing footy has seen a similar explosion in finger injuries within that cohort. What also helps is visuo-spatial ability, which is a little more difficult to train up if you haven’t been gifted with it to the same ability as Jumping Johnny. 

Above: Mind you, a sticky glove helps too... right Clokey?
Below: I don't need one says Roughy!
Whilst the article is at pains to point out differences in catching ability between professional and amateur sports people, it does indicate that a combination of training, technique and experience can make a difference. It is all about maximising the time you have getting your hand into position before it needs to grasp the ball to hang on to it which may be why an over hand catching technique proved more reliable. This technique may not be transferable to Australia’s greatest game in every instance, but the concept is, and getting your hands into position is the best way to start. 

Look after those fingers,

Hamish

(1) Cesqui, B. et al. Grasping in one-handed catching in relation to performance. PLoS OneJuly 2016



Tuesday, 5 September 2017

The Stress is Killing Me

A lot of trees have been sacrificed in the name of better understanding bone stress injuries to the lower limb. Brukner and Khan’s latest edition of Clinical Sports Medicine devotes a whole chapter to their management... in feet.  Admittedly with good reason; they are debilitating and difficult to treat.  However, at the risk of being seen to harp again on my favourite theme of “what about the hand”, what about the hand? If B & K don’t mention them, and do they even exist? 

The answer is of course yes, it’s just that they are rarer. A Spanish paper in 2010 reported that only 12 cases of stress fractures to the metacarpals had ever been written up. The authors of that paper then published a case series of 7 tennis players with stress fractures of a metacarpal. All were adolescents, and all had altered their training or some aspect of their game prior to this injury (1). Volker Schoffl, that rock-climbing, x-gaming hand surgeon in Germany also published a paper on bony oedema in climbers (2). Aside from that there are a few case studies, but not a lot.

I've got almost too much in common with this guy!
So if they’re not talked about much, are we talking about the same thing? Well, essentially yes. B & K devoted a chapter to this subject; I’m going to try to paraphrase them in 150 words. Actually, I’m just going to copy what Stuart Warden wrote because it’s nice and succinct… (3) “A bony stress injury (BSI)represents the inability of bone to withstand repetitive mechanical loading, which results in structural fatigue and localised bone pain and tenderness. It occurs along a pathology continuum beginning with a stress reaction, which can progress to a stress fracture, and ultimately a complete bone fracture”. Thank you Stuart. Of course there is a lot more too it, and his chapter is a good read so get into it if you want to know more. 

Should be obvious.
MRI stress #. Not my patient
(4)
“Treatment then is what?” I hear you protocol driven fiends out there screaming. Rest and controlled load says Stuart, among other pearls. But let me make this a bit more personal, this is what I did...
·    Tennis player, bone pain in second metacarpal, had come on strongly over the period of a clay court tournament but had likely been festering for some time. Essentially the pain was so severe he could no longer hold his racquet and hit a forehand with any force. Stress reaction confirmed on MRI, dorsal interossei inflamed also which made anatomical sense. 

·         -Weeks one to two, rest in hand forearm orthosis overnight, hand based radial metacarpal joint immobilisation orthosis during the day, coming out for gentle range, modalities and very light massage only. Pain with turning on tap.
·         -Week three initiate very light isometrics to the interossei. Shadow racquet swings with large diameter light cardboard roll – NO PAIN. Decreased splint use, taps almost ok. Continue overnight splinting, stop day splint.
·         -Week four introduce light grip vs theraputty, continue to build load. Roll ball on racquet head. Grip rolled up towel.
·         -Week five to six, continue to build load, isometrics well tolerated now, introduce graded hitting ie soft balls, no forehands just yet. Progress putty density, light gym weights.
At this point, I passed him back to the tennis physios as the interossei were now pain free to heavy loading, although forceful grip was uncomfortable especially when hitting, and he still had pain with palpation of the second metacarpal. However my outcome measures had all been met, and it was felt he needed to focus on the tennis side of things.

Not my patient btw. Just a funny photo.
It is now 4 months since he last hit a tennis ball in anger, but he has finally been given the green light to resume competition. That’s a long time off for something that was initially seen as a short term reaction to increased activity. The time frame does does however, fit published case studies (1,4). It’s also likely that this stress reaction was in fact a fracture. I can absolutely guarantee that if any of the team involved with this injury come across any similar injury that occurs in another tennis players metacarpal will be taken just as seriously as if it had occurred in a metatarsal. “What about the hand” indeed! All part of my cunning plan. 

Look after those fingers,

Hamish

(1)    Balius, R. et al. Stress fractures of the metacarpal bones in adolescent tennis players: a case series. American Journal of Sports Medicine 2010 38:6 pp 1215-1220
(2)    Hochholzer, T., Schoffl, V. Overuse bone marrow oedema of the hands in sport climbers. Sport Orthop Traumatol 2013 29:3 pp 219-24
(3)    Warden, Stuart. “Sports Injuries: Overuse” in Brukner, P & Khan, K. Clinical Sports Medicine 5th ed. 2017
(4)    Duarte, M. Metacarpal stress fracture in an amatuer tennis player; an uncommon fracture. Revista Brasilera de Orthopedia June 2017.

Wednesday, 18 January 2017

If a tree falls in the forest...

Nothing wrong with those fingers Dennis
I have often said in this forum and in others, that injuries to the hand are often neglected by patients, especially it seems, in an athletic population. For that I think we have only ourselves as therapists to blame. In spite of best intentions, these injuries are regarded as less important and less crucial. The only real way to change this perception is through researching the impact and incidence of hand injuries within a sporting population. 

For many years, Dr John Orchard has been compiling injury reports in elite cricket. On the back of these papers, a great deal of good work has been done to address hamstring, groin and back injuries at all levels of cricket, with particular attention to fast bowlers and the development of appropriate workloads. 

In a recent publication, Dr Orchard revisits injury incidence within an elite cricket population, and updates the injury definitions. The article is well constructed, discussing at length the most common injuries and whether rule changes might make a difference. What stood out for me having been alerted to the article via Twitter by Alex Kontouris, the Australian cricket team physio, was that in spite of ranking third for incidence and fourth for most affected body part over a ten year period, wrist and hand fractures were not discussed at all.(1) 

Does "!" make him soft?
To be fair, the article was written to address the rise in hamstring injuries in connection with the rise in Twenty20 cricket becoming a the most popular cricket format. I also accept Alex's comment that most fractures occur in situations which cannot be controlled in the manner that a soft tissue injury can be. Yet if a maintained incidence rate at an elite level is not commented on, if those injuries aren't considered worth commenting on at an elite level then the perception of laypersons become that the injuries aren't worth taking seriously even though those of us who treat elite athletes know that isn't the case. 

Getting amateur sports persons to take wrist, hand and finger injuries seriously before they become chronic is an issue I face every day in my clinic. I need someone to show me how to make Dr. Orchards' research have an impact in my clinic for the everyday athlete. Any takers? 

Look after those fingers,

Hamish

Refs:    (1)  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5167453/

Thursday, 22 December 2016

Surf safe

I certainly haven’t been all over social media this year in the way in which allied health marketing guru Amy Geach of @MaidaLearning tells me I should. However, all good things take time and given that we are perilously close to the end of the year, I thought I’d have a final crack at spreading the word about the rehab of wrists and sport. Specifically a sport close to my heart, surfing. 



Gnarly tatt dude



A therapist wrote to me this week about a patient of hers with a wrist injury who wanted to go back to surfing. In short, she didn’t know whether he could do so safely and without significant risk to his wrist. I suggested she try and replicate what he needed to do in the water in the clinic. “But I don’t surf” said she. “That’s ok”, said I, “...he should know, and if he doesn’t, he doesn’t really surf!” 


If he can do it...

My comment wasn’t supposed to be as flippant as it sounded. Instead what I meant was that if you have a patient who needs to do something with their hand that you are unfamiliar with, be that work or sport, ask them to show you. Put them in the splint or the tape that you think is best suited to protect the injury. Then have them teach you how to hold a golf club, or show you what the western grip of a tennis racquet looks like, or have them demonstrate popping up from a surfboard by lying down on the floor in your clinic with their hand gripping the sides of a 5cm thick text book. It won’t be the same as going out for a paddle with them, but it will be as close as you can get.

Santa drops in
If the patient is educated in the precautions of their injury, and can gain an expectation of what they might feel during a particular activity, then they will truly be in a position to control their condition without you sitting on their shoulder. 

All the best for 2017 everyone. My New Years resolution is to get amongst it (and to surf at least once a week!) 

Look after those fingers,

Hamish

Wednesday, 13 July 2016

Travis is a Cheater!

Couldn't find a photo in school uniform. Think his gloves were sold at Target!
Travis Cloke, a key forward at the Collingwood Football Club was fined yesterday for wearing a glove on his left hand. The wearing of a glove is not a new thing; not for Travis, not for patients of mine, not even for a fat bloke I went to school with called Tony Campbell  (he played for Melbourne and Footscray back in the day and would have no idea who I am!). The problem with Travis is that he wore a glove that is prohibited for use in AFL football. The bigger issue I think is that there is no way that Travis or the staff at Collingwood could not have known that that glove was on the unapproved list. 

Palm completely covered by silicone coating
Travis’ glove is made by Nike, and has a full silicone covered palm. It is incredibly sticky, and there is no doubt in my mind that it would have given him an advantage in the game last weekend. The reason this glove was not used more often by others, apart from the fact that it was banned two years ago is that the stickiness hampers ball drop, i.e. release of the ball when kicking. This is why gloves are usually removed when players kick for goal. 

Suction caps for hands
There is a readily available list of the approved gloves put out by the AFL to all clubs. I’m happy to forward this list on to Collingwood and I’ve already shown it to players from the Eastern Football League. The problem with the list is that the best glove, the Franklin with its’ pseudo suede palm, is no longer easily found. Gloves are not commonly used in Australian sport, although they are in America where there does not appear to be such a hang up about equipment designed to give players an advantage, or even a modicum of protection. That being said, the NFL is investigating whether the tackiness of a glove needs to be regulated. 

Go Sharks!
The rules governing what can be worn at a professional level and what can be worn at an amateur level are often very different and variable. There is no way that my son could have taken the field for the Camberwell Sharks under 13’s with Travis’ glove. I tell all my patients to make sure that any protective splint or guard I supply is compliant with the rules of their sports’ governing body or risk being told they can’t play. 

Gloves are usually worn for protection of a finger or hand injury, to more easily permit adherence of a thermoplastic guard, or to compensate for a loss of strength due to pain. On this last point, it is unlikely they help, with grip and pinch strength shown to significantly deteriorate once gloves are donned (Rock, 2001). 

Gilbert make a range of gloves for rugby,
some are AFL approved.
Another researcher with too much time, Dr Lewis at the University of Sheffield, has determined that different glove surfaces are appropriate for different weathers, with the spacing of “pimples” on the palm of the glove dramatically altering ball handling errors in Rugby 7’s players by enhancing the friction between palm and ball essential for grip. He predicts a time when gloves and balls will be designed in such a way that they can “interlock”! Say it isn’t so. 

And that is the point isn’t it? Friction. Travis didn’t need to enhance his grip strength. He may have a chronically sore finger, but that could have easily been protected by a legal glove. Instead, Travis Cloke and the Collingwood Football Club knowingly chose to use a glove that was banned in 2013 not for marketing issues as club president Eddie McGuire claimed, but banned because its’ full silicone palm was too sticky and provided too much of an advantage. 

Hey @AFL I know you guys banned some gloves today, I was just checking that mine was still ok? Cheers Jack
That advantage allowed him to kick four goals in a game his team was expected to lose. That advantage allowed him to have his best game for the year in a season where he hasn’t been able to get a kick in the magoos. That advantage was illegal, he knew that, and that’s why Travis Cloke and the Collingwood Football Club are cheats. 

Look after those fingers,

Hamish

Refs:
The effects of gloves on grip strength and three-point pinch Rock, Kim M;Mikat, Richard P;Foster, Carl Journal of Hand Therapy; Oct-Dec 2001; 14, 4; Health & Medical Collection pg. 286