Sunday, 18 October 2015

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
New injuries per club, per season
Prevalence: Missed games per club, per season
Head / Neck
Shoulder / Arm / Elbow
Forearm / Wrist / Hand
Trunk / Back
Hip / Groin / Thigh
Shin / Ankle / Foot
Non-football related

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,



Gaston, R.G., Sports Specific Injuries of the Hand and Wrist. Clin Sports Med 34 (2015) 1–10
Orchard, J.