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,


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,


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

Friday, 19 February 2016

Laura and me and a ganglion called Gloria

No wonder Ed Holdaway still loves her.
As Laura Branigan and I glided into the MRI chamber, her almost tuneful “Gloria” screeching through my headphones, I’d have to say I felt abnormally calm. Two days earlier, after pushing a trailer up a grassed hill, my right little finger had gone completely numb. Distal branch of the ulnar nerve I thought. No muscle weakness, motor branch ok, definitely a transient compression. Five hours later, once beer, pizza and the cold waters off the Portsea pier hadn’t worked any magic I was aware that I was going to need help. 

Artery and nerve, motor branch at bottom of "V"
Greg Hoy organised an ultrasound and a cortisone injection. The radiologist took a look at the screen, then said he wouldn’t inject. That evening, contrary to doctors’ orders, I played footy and kicked two goals. The next morning, considering my fate with Laura’s unavoidable counsel running through me, I resigned myself to the knife. It was certainly a case of both what and who you know, and I was booked for surgery the next morning. 

Greg greeted me into the operating theatre with his iPhone and a request to “Smile”. I think I called him a bastard in response, which is probably not the best decision I’ve ever made! I woke about two hours later, hand numb, but fingers all moving. Greg had removed a sizeable ganglion that had swum distally from my piso-triquetral joint and pronounced all was well. Mary, the best receptionist a physio practice could ever ask for, came across the road to collect me a little earlier than Elizabeth my nurse would have liked. Mary had coffee and a lamington with her, Elizabeths’ argument didn’t stand a chance. 

One patient to see, I drove home afterwards. Don’t remember much of that. I was worried, because I was talking at an upper limb sports symposium that had been organised by Ben Cunningham. My preparation had been affected significantly by the preceding events, and my concerns were met by Ben with the ever helpful, yet predictable, “Harden up Hamma”! 

I think the talks went well. Again, I really don’t know. Codeine has a fabulous way of making the world seem so much better than it actually is. I do know I had a great steak and a couple of beers with Vanessa from Sydney, Damien from Brisbane, and Stewart from Perth at the days’ end.

It’s Saturday now, and to be truthful, I finally feel like crap. The scar is minimal, the sensation slowly returning, but there’s a nagging ache, and pain if I lift or stretch too far. I know that this will pass, and that I shouldn’t play footy this week. I do wish it hadn’t been necessary because now I’m asking myself questions.

Something else to smile about
Is this what is referred to as empathy? Do I need to be more empathetic? Is it someones’ way of ensuring that I truly understand and can sympathise with my patients? Did I need to go through this relatively smooth process in order to comprehend what they feel? I think the short answer is no. The slightly longer answer is of course not you self-indulgent wind bag. Suck it up, harden up, and call “Gloriaaaaaaaaaaaaaaa”. That always makes you smile. 

Look after those fingers,


Friday, 29 January 2016

It was supposed to be a month off...

Now that's a holiday
Three weeks of travelling through Sri Lanka’s highlands and jungles, before a week of surfing. Ten days before I left, my conscience got the better of me. Kathy Minchin had done a lot of volunteer work in Sri Lanka with Interplast, and was good enough to give me a contact. I emailed  Asha, the senior OT at the National Hospital in Colombo, and she asked if I wouldn’t mind doing a couple of hours work on splinting with some students. Perfect I thought, two hours and I’ve done my bit for the world. Asha however, had different plans. 

In case you need a recap
I prepared a basic talk about playing with plastic before I left, and loaded a couple of other things onto a USB stick. On arrival in Sri Lanka I received an email from Asha detailing the two days I would be spending at the hospital talking to surgeons, treating patients, lecturing to the Sri Lankan OT association, as well as those poor students. I would be talking extensively on shoulders, brachial plexus injuries and tendon transfers. Now, I can crap on with the best of them at any time about any number of issues related to the upper extremity, but brachial plexus injury? I was up the proverbial creek without the paddle in the barbed wire canoe. 

After a bit of negotiation, I was back on more comfortable ground. Sports and fractures, wrists and PIP joints. We scheduled it in for the last week of my trip, and I bundled my family onto a third class train carriage heading north and away from the city. I couldn’t escape Asha’s enthusiastic tentacles however. Within a week another day of talking had been added on, this time with the physios for the Sri Lankan cricket team. Some preparation needed to be done.
Borrowing a laptop from the 16 year old son of a woman we were staying with, I beefed up my talks and created a plan. Unfortunately, that laptop was infected with a virus, and the presentations couldn’t be opened. Ben Cunningham, Greg Hoy, and Sarah from the AHTA came to my rescue, uploading a variety of stuff onto Dropbox. My family left me for the rainforest, I put on my cleanest, most un-crinkled shirt, and headed off to work. 

Anyone I’ve ever talked to or heard talk about volunteering always emphasise how intense it is. I was assaulted (in a great way) from every angle by therapists who were desperate to learn more, patients desperate to get better, and doctors desperate to have their therapists help them achieve the results they expected. The hand therapy room in Colombo was crowded, with patients and families lined along the corridor outside waiting hours for their turn. I talked and talked and talked. I’m certain the students understood nothing in spite of their protestations, however the questions I received from the OT’s were insightful and challenging.

Hamish Highpants and the Sri Lankan cricket team physios
The cricket physios were also demanding. We discussed the usual suspects, then spent a lot of time problem solving how best to deal with metacarpal head bruising and finger web splits. I didn’t have a definitive answer, but as they say in the classics, before you find a solution you must understand what the problem actually is. I talked a lot about the role of the intrinsic muscles in the hand, as well as encouraging proprioceptive training. 

The impression I ultimately left Sri Lanka with was guilt. There was so much more I could have done if I’d been better prepared, if I’d had the inclination to offer help earlier than I did. I don’t believe I wasted anyone’s time, and I know I was able to pass on some of my knowledge, but I also know I could have done it more effectively. Volunteering in countries with developing hand therapists should not be done lightly or in the manner I initially approached it, because to do that creates a real risk of devaluing the intensity of the teaching that is required. Having said that, if you are an expert in some area, your time would be welcomed. All you need is the understanding that two hours will become more, which in turn, will make it worth so much more to you, and those you are helping.  

Look after those fingers,