Oh really?

I know it's close to Christmas, it's the silly season, but this brilliant observation has capped off a year for me during which I have dealt with more "if he can run he can play" idiocy than I've ever seen before. J.J Watt broke his thumb, but resumed playing NFL for the Texans within a week.

The news feed I saw after the game against the Patriots quoted a Patriots staffer below.

"He really only had one hand," as one Pats staffer put it. "He couldn't really pull or tug and that's where he gains his advantage. He couldn't really get his arm over for that move. He was very limited. No doubt about it. He couldn't really use that hand."

You think? Have a look at the photo! Seriously fellas, there must have been someone else on that roster who could have done a better job. Oh, and if the Patriots need a new staffer to hand out observations of gold, then I'm pretty sure Mr Magoo hasn't had a gig in a while.

Look after those fingers,

Hamish

If you can run, you can play.

Below is an edited and adapted extract of the talk I gave this weekend on sporting injuries to the wrist and hand as an invited speaker at the Australian Hand Therapy Associations national conference in Perth.

If you can't be a champion, find a way to hang out with a champion team!

...Today I’ll be discussing hand & wrist injury in sports. However, I’m not going to talk about specific sports and specific injuries or statistically which sport is the worst for hand injury, because I don’t believe that is important or different enough to be practice changing. I will however, talk about how these injuries are reported, and what I believe needs to change with regard to that. My principle theme, one which I will be referring back to incessantly over the next half an hour, is that currently, our role as hand therapists and hand injury experts with regards to the sporting population is undervalued because the injuries themselves are undervalued.

Whilst there is certainly potential for increased hand therapy intervention in sports, what is more likely to happen in the short term, is that there will be a better approach to hand injury from the generalist sports physios. The problem with this is that any monkey, even Ferno, can make a thumb guard, but not everyone can rehabilitate a chronic UCL injury as well as you in this room can (well, the full members that is). If we are to have more of a role in sports injury management we need to be better able to define and demonstrate our expertise.

I doubt anyone in this room would dispute the impact sports participation has on their work.

3 – 15% emergency presentations for upper extremity injuries are sports related. 25% of sports injuries are to hand / wrist. These statistics vary according to sport and population, with combat, motor and contact sports being the usual suspects, but the public perception of the severity and potential impact of sporting injuries to the hand is limited.

For if 25% is an accurate figure, then why don’t we see more? What the sport is or how the injury happened, is not the issue. The issue is in how these injuries are perceived. There's been nothing in the  press or online that I could find re Sally Pearson’s horrific wrist injury since July, until two days ago when I read an article that said she was having difficulty moving her wrist, and that her thumb had only just regained some strength. 

Although she historically is known for keeping a tight rein on her image, the lack of information about such a severe injury is deafening and I think a lot of that comes from the belief that it is not an injury that will affect her because she’s a runner. But her sprint starts are from a crouched all fours position, and she gets drive over the hurdles with her arms. Her wrist injury will affect how she trains and prepares both on the track and in the gym. The impact of her injury on her preparation for the Olympics in Rio next year will only become known if she fails to medal. My hope, is that when she does medal, that she publicly acknowledges the work her hand therapist, not her physio, has had to do to get her back.

And this is not new situation. If you can run, you can play. This image is of a Melbourne player in the 50’s who had only 3 fingers on his right hand. The type of injury that occurs is not the issue because I have never seen a sports related injury I haven’t seen in the clinic. What is different is the circumstances in which the injury happens, and the environment the athlete works in outside of the field of play. How many times have you seen chronic PIP joint degeneration referred to by  your pt as an old football injury. Two days ago I saw an AFL player whose mallet finger had not been addressed appropriately, and was now presenting to me for the first time with a painful, snapping swan neck deformity. As hand therapists, we have a responsibility to attack the premise that these injuries are not significant, in a way that benefits both the athlete and ourselves.

As per the AFL, this is NOT an injury. (I do realise that this athlete plays soccer)

The AFL define an injury as an … “injury or medical condition which causes a player to miss a match”. So who is going to bother having hand therapy for a compound dislocation, much less a collateral ligament strain? If junior players don’t see professionals missing games after dislocating a finger, then why should they even consider it? Why should they even seek help from experts? It also means that many injuries are under-reported if at all. AFL is essentially a running game. I know of several players who have completed games with a fractured metacarpal. If they can run, they can play. However, I have treated 70% of the players on Hawthorns list at least twice this season so it’s not as if injuries don’t happen.

AFL 2014. Injury Report	Incidence: New injuries per club, per season	Prevalence: Missed games per club, per season
Head / Neck	1.8	2.7
Shoulder / Arm / Elbow	2.7	17.7
Forearm / Wrist / Hand	1.6	5
Trunk / Back	2.7	8.3
Hip / Groin / Thigh	10.0	32.8
Knee	4.3	27.6
Shin / Ankle / Foot	10.3	48.3
Medical	2.4	3.7
Non-football related	0.3	0.5
Total	36.1	146

Orchard, J. (2014) 

The current focus of discussion in aggressive sports like AFL, rugby and American football is all about concussion. I’m not saying that that is not worthy, and certainly, the potential for severe dysfunction is more likely following repeated head injury, whilst the ability to play is severely hampered by an ACL tear in the knee. What gets lost amongst this, is that injuries to the upper extremity are actually more common than head injury and ACL injury. I showed you that in the AFL slide a few back, but an NFL (American football) study of musculoskeletal disorders also demonstrated this.

There is a paucity of information on the real impact of hand injury in all sports in spite of the established importance of the hand to the athlete. The photo is of how they measure hand span in NFL. It is measured because they have established a correlation in their game between hand span and success, specifically as a quarterback (ball thrower) but to a lesser degree in other positions. Shouldn’t it follow then, that if you regard hand span as important enough that it determines to an extent, the make-up of your team, then maintenance of hand span be also considered important? 

This NFL study is significant in the time period it considers, and the specificity of the injuries it considers. I’m involved in a similar audit of hand and wrist injuries in the AFL for 2015, however we are including any player who chooses to report a problem, which is in line with Gaston’s suggestion for how best to define sporting injuries to the hand. “Classification (of hand injury) is best done not in terms of what or how but in preferring to classify and treat these injuries in the context of injury pattern, sport, position, level of competition, ability for protected play, and time frame for return to sport.” (Gaston, 2015). In order to define a role for HT in this population, how we gauge an injury needs to be addressed better and promoted more aggressively.

So what then, do I see as the role of the hand therapist with a sporting population? Well, there are several areas. 

Enduro cross, not easy with a fractured scaphoid!

• Education: What are the implications of not treating now? If the athlete understands why we are taking a finger injury seriously for the first time in his career, we have a better chance of fixing the problem
• Expertise. Splinting easy, but it’s not what do we do better than anyone else. I don’t necessarily make a better thumb splint than any of the sports physios I work with (well actually that’s not entirely true), but I do understand how to rehab a hand and a wrist better than anyone else in the physio room at Hawthorn & that’s why I’m there.
• Pre-hab. Help the athlete to create habits especially those with chronic complaints, or those coming back from serious injury eg a scaphoid fracture in an enduro-cross motor bike rider. 
• Consider the potential or current injury. What is worst thing that could happen to prolong or worsen the injury? That will happen in the sport. How do we stop that?

The implications are that as hand therapists we need to consider what is best management and to acknowledge that there is a flow on from professional down. At the very least we need to know how we best protect the injured hand in play, because we know they will be returning to the field. Protection can be plastic, neoprene, tape depending on what is legal for your sport and I’ll talk more about that later but you do need to be aware that what is legal at a professional, elite level, is not always permitted at an amateur level. 

I will talk a little about what I do at Hawthorn because it is such a unique environment, and so different to what most of you experience. Since 2013, I have been a contracted, in-house hand therapist with the Hawthorn Football Club. Daniel Chick was at Hawthorn well before me. My main job as I see it, is to ensure that no Hawthorn player, and by extension, no patient that sees me ever has to have a finger amputated because of a chronic PIP joint injury. 

There are 45 players on the list, this year I have seen 33 of them at least twice this year.

My role is as it is in my own clinic. I management and assess the hand and wrist injuries. I splint & I treat. I have no game day role. I am at the club for two + hours a week, and there is an understanding that any player who needs more than that will be seen in my clinic. 

I am part of a team with three physios, 2 full time. Two sports doctors (part time = full time). There are four fitness coaches, they are full time exercise physiologists. Two part time dieticians, one part time kinesiologist, one part time osteopath, one part time podiatrist, and 8 part to full time masseurs. All are intense, focussed and highly intelligent. The biggest difficulty I have had is not that I’m not intense, focussed or highly intelligent although some might argue that point, but I do work at the bottom of the hierachy of the club as a part-timer in a new role dealing directly with injuries that have rarely been considered prior to me being there. And I'm comfortable with that because I understand that the benefit of my presence does mean that the physios can focus on the injuries that will stop the athletes from getting out onto the park. It also tells the players, that their injuries, regardless of how small will be taken seriously.

Hodgey and his premiership winning "Finger Dinger"

Communication is paramount especially with relation to what my recommendations are, an I’ve had to learn when ignore a niggle and to pull my head in, and what niggles to make a big deal of and discuss with the training staff. As the players come through on a Monday morning, I follow up on any twinges reported post game, and those previously treated. Pleasingly, players are self-reporting more and more.

The injuries I treat are usually pretty mundane, with my greatest contribution to the team being the development of the “finger dinger”, a neoprene tube that provides compression, warmth and protection. I’m also gradually getting the boys to be better at icing and compressing there sore hands after a game. It’s amazing how many will look after a swollen ankle appropriately, but look at me in amazement when I suggest they apply a cold pack to an oedematous finger. 

I’m also responsible for player rehab post wrist and hand surgery. I set up protocols for when I’m not there, discuss with fitness staff how best to adjust a recovering player into pre-season training, and create strengthening and stabilization programs for those players with chronic problems that affect their thumb or hand strength.

(I’ve cut out the sections on orthoses, and comparisons between management of amateur and professional athletes. Will likely include that as a “part 2” at some stage) 

It's not all about the Hawks! My eldest son is an Eagles fan!

In summary then, 

• the injuries professional athletes have to their hands aren’t different, but the way they sustained them may be and the environment into which the athlete will be returning is. We need to consider how we classify these injuries and if we can do that, I anticipate our management of these injuries will also change for the better.
• If you are treating an athlete and don’t understand his or her sport, ask them. You have the anatomical understanding and pathology knowledge to be able to apply to both diagnosis and management of the injury within the context of their sport.
• Your job as an HT in sport, is to educate, guide, and protect as best you can given an environment that is inherently unpredictable. We are experts which is why we are being asked to treat. Elite athletes are experts at what they do also, when they understand what you need them to do and why, they will usually follow through.

Yeah you can run, yeah you can play, but if you let me fix that finger, you will play even better! Thank you.

Look after those fingers,

Hamish

Refs:

Gaston, R.G., Sports Specific Injuries of the Hand and Wrist. Clin Sports Med 34 (2015) 1–10
Orchard, J. http://www.afl.com.au/staticfile/AFL%20Tenant/AFL/Files/2014-AFL-Injury-Report.pdf

Procrastination

Looking forward to it, and to it being over!

It's 9:00 am on a day when I don't see patients. I day I have identified as being suitable to devote wholly to getting my presentation on the management of hand injury in sports for the Australian Hand Therapy Conference next month sorted. 



I have been in front of the lap top for an hour now. Twitter is updated (nice banter with @mike_hayton), Linked In is updated for both ISSPORTH and Sporting Hands, the roof racks have been cleaned (don't mention the Discovery), I've had a cup of tea, breakfast and two glasses of water. Haven't opened the presentation yet. 

Great work Josh, Go Dees!

I'm procrastinating for no good reason other than I can't focus. My football team play a preliminary final in three days, win that (as they should) and they are through to the Grand Final for the fourth year in a row. Is there something else I could have done for the player with the acute boutonniere? He's playing of course, but what else could I offer? Or what about the rookie player for another team who got dropped after four years without a senior game. Could I have helped him more after his FDP tendon avulsion, to get him back sooner and help him make his mark? The mate of mines' kid, who has a double dislocation of his thumb in outback Australia playing football. I told them to ice it, and protect it, and to keep him away from sport for a time, which was more than they got from the hospital... could I have done more? 

B2B2B?

The short answer is yes, but probably no. They all got the best I had to offer then, and it's unlikely I'd change anything even with hindsight because they all got back to the game. My minds clear now, thanks for letting me purge, I'll get back to my game. 

GO HAWKS, look after those fingers!

Hamish

Athletes Are Real People Too!

Look Ma, no hand!! Position of wrist looks dreadful btw.

On the Fourth of July this year, not one, but two highly paid NFL footballers blew at least one finger off one of their hands by doing stupid things with fireworks. I've seen what blasts can do to hands and it's not pretty. The loss of a finger is bad enough, but sustaining severe burns to the palm of the hand can be especially debilitating. My understanding of the game is limited (GO JETS), however I know enough to realise that for one of them, as long as they can get his wounds under control, and avoid joint contracture, he should be able to get back on the park to tackle, push and hit. The other was a cornerback and he sometimes has to be able to intercept and catch the ball. He lost two fingers and I wasn't surprised to hear he has decided to "step away from the game" while he recovers. 

One Google hit led to another, and I started to read about other foolish sports injuries to hands that didn't happen during the sport itself. There's a lot out there, but I'll tell you about some of the best I found. 

Kudos to the hand therapist. Nice splint, although not sure re direction of pull.

Lindsey Vonn is a champion skier. She sliced what appears to have been a flexor tendon in her thumb on a champagne bottle after winning a race in the 2009 World Championships. After surgery, she skied the rest of the season. She did break a finger once too, but bizarrely did that skiing.  

Digitally altered image. 

Joel Zumaya was a baseball pitcher who missed several games of baseball because he was so addicted to Guitar Hero that he sustained an acute forearm tenosynovitis that was so bad he couldn't throw. Standard treatment for tenosynovitis is to stop doing the activity that caused the problem. He worked that out, and managed to return to his sport. 

Seems to be able to catch alright

In 2008, another NFL footballer called Brandon Marshall slipped on a discarded McDonalds bag whilst wrestling with a family member. His right arm went through a television screen and he "sustained right forearm lacerations to one artery, one vein, one nerve, two tendons, and three muscles". That's almost a spaghetti wrist. He's done well since, is till playing (GO JETS), but did say that his right hand was numb for the whole of the 2008 season! I'm betting ulnar nerve, but he did well if he avoided damaging the motor branch. 

But the best, and most gruesome injury belongs to an athlete who could play his game even if he had both hands amputated. He actually almost tested that theory out. Diogo jumped up a fence celebrating a goal. Unfortunately, on the way back down, his wedding ring got caught on the fence resulting in a ring avulsion injury. That is, the finger was effectively skinned or as it is also termed, degloved. Photos clearly show exposed bone and tendon. The YouTube clip is worth a look if you like that sort of thing.  
 https://www.youtube.com/watchv=qRzHu4heNiU 

That will do. Acknowledgements go to the athletes that have just proved to us all that they are human, Wikipedia, and various webpages that are entitled "50 Dumbest Sports Injuries of all Time" etc. I'll get back to the boring, real life stuff next time!

Look after those fingers,

Hamish

A Quick Bite

Lives to surf another day

Watching Mick Fanning disappear behind a couple of waves just after the world had seen him turn to face a shark in the final of a surfing contest in south Africa, my first thoughts were of Bethany Hamilton. For those of you that don’t know, Bethany lost an arm to a shark whilst surfing in Hawaii. She recovered well enough to compete and win several professional surfing titles. Mick’s encounter was the premium topic of conversation with all of my patients that day, but Bethany’s story was the one I discussed with one particular patient. 

Chicky

Ned (not his real name) wasn’t an elite sportsperson. He had rolled a car almost 20 years previously resulting in a terrible crush injury to his right arm, and the eventual amputation of his index finger at the metacarpal (knuckle) joint. His right hand had adapted really well to this, with his thumb bypassing the now gone finger, and working with his middle fingertip in order to pinch and grip strongly. Unfortunately, Ned had never attempted to increase his left hand use to compensate for his injuries. His right hand now demonstrated advanced degeneration, and he had significant pain related to muscle overuse and strain. Treatment involved supportive splinting, exercises to divert stress to under utilised muscles and away from the overworked ones, and loads of education on how to adjust activity including dirt bike riding.

Jack before...

Jack after.

Ned also wanted to know how I felt he would go if he had another amputation and I told him I believed he would adjust well albeit with a caveat. Several Australian Rules footballers have had a finger amputated and have been able to play at the top level, Daniel Chick being the first to spring to mind. My first patient ever in my career was a former champion amateur golfer with only one arm who claimed to have taught Jack Newton how to play golf again after he had walked into a propeller. The key is something called neural plasticity combined with something they all had in common called perseverance. Ned hadn’t been too keen on the latter, and was now suffering the consequences. 

My point is, that it is all very well to understand that the brain will automatically start to redirect its’ energies towards existing fingers or limbs once it recognises that it has lost fingers and / or limbs. There has been plenty of research to explain this with a good article at http://www.thenakedscientists.com/HTML/interviews/interview/1000517/ and the NOI group website http://www.noigroup.com/en/Home a good place to start learning. However, there is a disturbing tendency in my profession to put patients in front of a mirror box for half an hour and expect them to come out of the session with no pain and full movement. It doesn’t happen because even though neural or cortical plasticity is automatic, cortical retraining is not. It takes work. If patients like Ned are not prepared to put the work in, then non-dominant hands will remain non-dominant, and allowing a thumb to bypass an amputation will not be enough. 

Preachy? You bet!

I know I have simplified things almost too much. Certainly I am guilty of being too preachy. But then, that is part of my role. Using Bethany, Jack and Daniel as examples helped me explain to Ned what he needed to do. Will he do it? I have no idea. I’d back Mick Fanning in though had that shark been hungry. 

Look after those fingers,

Hamish

Don't Lay Down Sally!

Ouch

Running. It’s not just about your legs. Sure, strong hamstrings, powerful glutes, and quads can hurl you down a track, but they’re not the be all and end all of speed. In order to harness that energy, you must have control, and control is far more difficult to achieve if it’s not innate. 

Bob running at school (digitally altered image that's nothing like Bob)

When I watch runners, I watch their hands. When I run, I’m conscious of my hands especially when I’m tired. There was a good runner at my high school. Bob Moore was his name. He ran with a loping, stretched out and lazy gait that mimicked the sort of student he was. Kind of like the Dalai Lama in sneakers. I might have been smarter than Bob, but I was never going to be as fast as him. Once I’d accepted that, I decided to at least try and run like him. I worked out quickly that the easiest way to start was with my hands. 

Bob ran with his thumb lightly touching his index and middle fingers. There was no tension, just the slimmest of contacts. Somehow, this connection worked to release any tightness in his arms and shoulders, directing all energies to where they were required.  I saw Bob recently at a school reunion and we talked briefly about that. He laughed as I explained my theory, and said he just ran without wasting time about thinking how his hands were held.

I'm sure that scaphoid's gone too...

I’m sure Sally Pearson has always been a Bob Moore sort of a runner as opposed to a Hamish Anderson type. At least, I’m sure she was until she got good, really good. Because at her level, everyone is powerful, and everyone is quick. Differences are minute, and control is crucial. With her fracture of her ulnar, her radius, quite possibly the scaphoid, and the dislocation, the potential for a loss in motion is significant. 

Wrist extension, finger extension and significant loading to push off

A loss in motion means that as she runs, there is a reduction in the co-ordination of her wrist movement which in turn affects her balance as she hurdles. There is also the certainty that her starts would be affected because of an inability to weight bear through the affected hand. But would that be enough of a reason for Sally to pull out of World Championships that are 10 weeks away? 

Left wrist extended and fully pronated. Could be tricky now.

At two weeks post fracture, Sally would not yet have any idea of what her wrist would be feeling like in another two weeks, let alone ten. Her fracture on x-ray, whilst significant, isn’t going to keep her from running, but it will stop her from running well at least in the short term. It will rob her of that sense of fluidity she has always had, and the control she has developed. That affects her training, and that affects her ability to compete at an elite level. I think Sally is aware of this and I think that is why she has pulled the pin early. 

I can only hope that the surgeon who operated has been able to do so in such a way that Sally is already moving her wrist. I can only hope that the rehab staff she has have the good sense to ask for help before it is obvious that things aren’t progressing because whilst I’m sure they’re world class with hamstrings, I bet they don’t see “exploded” wrists every day like I do. Will she be able to run like Bob Moore again? Time will tell. I just hope she never runs like Hamish Anderson!

Look after those fingers,

Hamish

Playing with Plastic.

No bunny hurt in the taking of this photo

At the risk of doing myself out of a job, and incurring the wrath of hand therapists everywhere, I want to share front-line management of thumb MP joint injuries. Greg Hoy, the hand surgeon I work with, refers to tears of the radial collateral joint of the thumb as "AFL (Australian Rules Football) thumb". Tears to the ulnar collateral ligament are more commonly recognised as "skiers or gamekeepers thumb. 

GAWN

No matter what the moniker nor whether the ulnar collateral, radial collateral, volar plate, or a combination of all three ligamentous structures of the thumb MP joint are injured, taping is usually not sufficient to allow the player back to sport safely. Splinting is required. 

I find smug, self serving amusement in the fact that so many skilled therapists and doctors shrivel at the thought of using thermoplastic to support a joint. Whilst their trepidation works to my advantage, ultimately it helps no one. So here is a basic recipe.

It should look similar to this too thick, poorly fitted pre-fab thing 

1. Get a piece of thermoplastic, 1.6mm thick.
2. Cut out a pear shaped piece, long enough to extend from just proximal to the IP joint of the thumb, to just distal to the CMC joint. 
3. Put the plastic in hot water just as if you were softening a mouth guard.
4. When it has softened enough, place it over the dorsum of the thumb, working it into shape so that it contours well
5. Trim to fit, making sure it doesn't impinge over the CMC with wrist extension and radial deviation.
6. Tape on. 
7. Refer to a hand therapist for treatment (happy with that BC?)

Before something

Different players in different positions like different things about these splints. Some can't have any coverage over the thenar eminence. Some like it to wrap around the proximal phalanx. As long as it protects the MP joint, and restricts movement but permits play, it's good. 

After something

Rehabilitation after that is more involved, and here's where you need to refer to an experienced hand therapist because the splint cannot be expected to do anything more than limit more damage. If you can get that at least half right, it's a start. I can always fix up your smashed up, finger dinted thermoplastic disasters afterwards and no one needs to know but us!

Look after those fingers,

Hamish

Surely it's not that tricky?

Come on Doc. You've had at least 6 years of study to get to where you are. The nature of the two letters that come before your name engender an immediate level of respect that no other working stiff can generate. So why is it so bloody hard for you to treat a finger volar plate injury? I just explained this injury to an eight year old, and she got it. Surely it's not that tricky a concept? 

Spot the tiny bit of bone. 

For the purposes of keeping things simple for the late referrers out there and truth be told, you're not all doctors, I'll just talk about the middle joint of the finger today, the PIP. Think of the volar plate as a bridge across the palmar aspect of the PIP joint. If this bridge is hyperextended too far, either the bridge will snap, and / or a piece of bone connected to the bridge will be pulled off. If that piece of bone is less than 50% of the articular surface, not significantly displaced or overtly unstable, the finger can heal without surgery.  

Broken bridge means bits are missing...

From here, there are only two things you need to know, so stick with me. When you splint the patient's finger in extension, the ends of the broken bridge are too far apart to join up. Do I need to say that again? I will. When you splint the patient's finger in extension, the ends of the broken bridge are too far apart to join up. 

I drew this. Brilliant right?

Point number two. If you tell the patient not to bend the finger, the finger will get stiff very quickly making my job even more difficult when you eventually decide to refer him or her on after 7 weeks of ineffectual management. Bending the finger will not stress the repairing ligament. Straightening it too far will. 

One option. But understanding the concept is everything.

If you are still with me, you should be able to understand what to do next. Right. Splint the finger in a bent position. This will approximate the ends of the bridge, allowing the natural healing process to join them up. Encourage the patient to bend the finger as tolerated as long as there is no instability. Again depending on the patient and the circumstances, next week, straighten the splint a little. 

My treatment protocol varies significantly according to the patient. Some are in a splint for 4 weeks, some more, some just 2 and then buddy taped. Some never get splinted at all. They're an easy injury to treat properly, but can quickly go pear-shaped if basic principles are ignored. What you, dear late referrer need to comprehend, is that none of my patients are ever splinted straight because although my wife tells me I need the money, fixing your mistakes is not work I enjoy. 

Look after those fingers,

Hamish