In every bone in the body there is a growth plate which is made up of cartilage and on X-ray, looks like a gap across the bone at each end just under the line of the joint.  When these growth plates are active they lay bone cells down in this “gap”.  This area widens again and the bone is longer.  Unfortunately it doesn’t happen like this in the muscles.  They have to stretch over the longer bone and as they get used in day to day activities and sport, like playing rugby.  This doesn’t happen sat in front of the TV!

Sometimes a growth spurt can be so significant that the growth plate can become a little inflamed and sore.  The most common age for these growth spurts is 10-12 years in girls and 12-14 in boys.  It is at this adolescent phase that the growth rate can double and growth is only officially complete when all the growth plates are completely converted to bone.  This is approximately 18 in girls and as late as 21 in boys, although from 15 in girls and 17 in boys there will be little further increase in height gain.

The muscle that attaches near the plate may also become inflamed or so tight that it pulls on the bone and causes more inflammation.  These points are commonly the back of the heel and the boney point at the top of the shin bone just below the knee.  The achillies tendon attaches the calf muscle (Gastrocnemius) from above the knee onto the heel.  The patella tendon does the same for the front thigh muscles (Quadriceps) from the top of the thigh and over the hip to below the knee.  The knee cap sits in this tendon and can also be a source of pain.  Pain in the boney point below the knee is known as Osgood-Schlatters disease and unfortunately this and the heel pain do need rest.  You may need a week or two out of rugby training.  It can be a problem for about 4-6 weeks and there may be more than one episode of it.  Ice and anti-inflammatory drugs are effective during the acute phase and once this has settled it is really important that the calf and quads muscles are stretched regularly to minimise any further episodes.      

Stretching is best done when the muscles are warm.  This can be immediately after a warm bath or shower, or straight after rugby training or a rugby game.  At this time you will hold the stretch for at least 30 seconds to try and lengthen the muscle.  You should feel the stretch but it should NOT be painful.  Stretching before training or a game should be just to move your muscles through their normal range and often these are “dynamic”.  When you are trying to lengthen muscles I always ask that you hold onto something stable to minimise the risk of pulling the muscle if you wobble.

Calf Stretch in Standing

Aim

• To maintain good lower limb biomechanics
• To have enough ankle movement for good propulsion during starts and turns

Method

• Standing with both hands supported on the wall or suitable fixed surface
• Start with both feet shoulder width apart, toes forward and arch lifted up
• Keep both knees straight and the heels down
• Lean forward, toward the wall from the ankle
• This stretch may be felt in the calf

Repetition

• 10 seconds to loosen up before exercise, 2-3 repetitions on each leg
• 30 seconds when warm or after exercise, 2-3 repetitions on each leg

Watch Points

• The feet may turn out
• The arch may flatten
• The heel may lift up
• The knee may flex
• Progression
• If the stretch sensation in the two-legged position is mild the stretch may be progressed to step-standing, with the watch points above

Quadriceps Stretch in Standing

Aim

• To allow full extension of the hips during leg kick, without pulling on the lumbar spine and pelvis

Method

• Hold onto a wall or suitable fixed point
• Transfer body weight onto one leg and flex the knee fully
• Take hold of this ankle and regain an upright posture in the upper body.
• Engage the lower abdominals and set neutral pelvis and spine
• Bring the thigh in then start to move the knee back to meet the other
• The buttock should be engaged as the leg is moved back
• The abdominals should maintain the spine and pelvis in neutral

Repetition

• 10 seconds to loosen up before exercise, 2-3 repetitions on each leg
• 30 seconds when warm or after exercise, 2-3 repetitions on each leg

Watch Points

• The lumbar spine may hollow and pelvis tilt anteriorly 
• Leg may move outward into abduction

Variation

• As well as adducting the hips, or bringing the thigh in before trying to engage the buttock and extend the hip, the hip may be left in 10-20 abduction, if the Ilio-Tibial Band (ITB) is tight.

Lisa 

(Reproduced with kind permission from PP4P Ltd)

What Can happen to knees?

The ligaments on the sides of the knee can be sprained if the foot stays on (or in) the ground but the rest of the body goes in the other direction.  It is more common for this to happen on the inside “medial ligaments” and can be very sore and painful to walk initially.  You will often find for the first couple of days that the knee is most comfortable in a slightly bent position, which takes the strain off the ligaments.  Following the PRICE regime that we have mentioned in the overview of common injuries can help with any immediate pain and swelling.  Then start to try and bend and straighten the knee as much as the pain allows.  A physiotherapy assessment is always beneficial to determine if this is all that is injured and to what extent. 

The cruciate ligaments are inside the knee and stabilise forward and backward knee movements.  Excessive push or pull on the lower leg can cause strain or rupture of these ligaments.  There is usually a lot more immediate swelling and often unable to weight-bear through the leg.  This needs urgent medical attention and an MRI scan will need to be arranged if a cruciate injury is suspected.

The meniscus is another vulnerable structure at risk of injury in the knee.  This is usually referred to as the cartilage and is the shock absorber in the knee, injured most easily in twisting movements.  Again there will probably be some swelling but the classic sign for “cartilage” problems is locking of the knee, where it gets stuck in a particular position.  There are tests medical staff can carry out to decide if this is the problem but ultimately an arthroscopy, where a tiny camera is used to explore the joint, will be required to trim and stabilise any tear.    

An “unhappy triad” is a very sorry combination of all three!

What would rehab involve?

Pain relief is important to help get the knee moving again and PRICE will help with controlling this and the swelling.  After the first few days it is really important to get full movement back as it will be limited by the swelling and pain.  The thigh muscles control the alignment of the knee cap and they become weak with this sort of injury so strengthening these is also important.  Often much of the emphasis is placed on getting back into running but not on balance. 

A player should not return to play if they cannot change direction, stop and start and accelerate and decelerate without hesitation.

Can any of these problems be avoided?

Obviously if the knee is in the wrong place at the wrong time there is little anyone can do to prevent an injury but if you are quick and light on your feet you have a fighting chance of getting your knee and the rest of you out of there!  Balance reactions also help so next time you are warming up, try passing the ball stood on one leg.  Try this again whilst hopping.

As I will say at the end of every article, if you are in any doubt go and seek qualified medical advice.

Next time, how does growth affect the legs?

 Lisa

Over the next few weeks I am going to look at the most common injuries that occur playing Rugby. I will also look to give some fairly standard and generic advice. Though I should stress from the outset every injury is different and you should always seek professional medical advice.

Let’s start from the bottom and work our way up. Ankle and foot injuries generally fall under the following categories:

• Sprained Ankle
• Broken Ankle
• Metatarsal Fracture

Sprained Ankle

A sprained ankle is one of the most common ankle injury in Rugby. An ankle sprain refers to soft tissue damage to the ligaments around the ankle joint. Typically this ankle ligament damage is characterised by ankle pain and a swollen ankle.

Severe sprained ankles should be reviewed by an orthopaedic doctor although physiotherapy treatment is very effective for most sprained ankles where there is no bone injury. In the early stages it is important the follow the PRICE protocol – protection, rest, ice, compression and elevation. An Ankle Support can be very helpful for the treatment and prevention of a sprained ankle injury.

Common Sprained Ankle signs & symptoms:

• Ankle pain.
• Swollen ankle.
• History of a twisted ankle.

What to do

• Consult an expert – Doctor / Hospital
• Apply Ice
• Wear an ankle support / strapping for protection
• Use a wobble board in rehab for strengthening

Broken Ankle

Although a common injury outside of rugby a broken ankle is more uncommon in rugby. A broken ankle may occur as a result of direct contact, usually as a result of a collision with an opponent. The brake is usually the result of a fall where the ankle twists under the weight of the opponent.

The orthopaedic doctor will evaluate how the injury occurred and formulate a plan to restore normal ankle alignment. The ankle is reviewed with an x-ray and CT scan as the bones must be re-set within millimetres of normal position to prevent the later development of Ankle Arthritis. A broken ankle and any associated ankle dislocation must be ‘reduced’ to its normal anatomical position as early as possible to prevent nerve damage, damage to the blood supply or damage to the skin around the fracture.

The key principle of ankle fracture rehabilitation is to maintain the restored anatomy of the ankle joint, while restoring full range of ankle motion as early as possible. Walking as soon as the Orthopaedic Doctor indicates that it is safe to do so, using a Removable Plastic Cast Walker is also important. This prevents complications such as muscle wastage, joint stiffness and degeneration of joint cartilage. By putting a carefully controlled load through the injured ankle it also stimulates fracture healing and helps to prevent non union.

Common Broken Ankle Injury signs & symptoms:

• A history of ankle trauma.
• Ankle swelling and deformity.
• Ankle pain and loss of function

What to do

• Consult an expert – Doctor / Hospital
• Wear an ankle support / strapping for protection
• Use a wobble board in rehab for strengthening
• Use a buoyancy aid for pool fitness exercises
• Use resistance bands to strengthen the ankle

Metatarsal Fracture Injury

Metatarsal fractures account for over 30% of traumatic foot injuries. Broken Metatarsals have been prominent across all professional sports in the past five years, with several high profile footballers (Beckham and Rooney) suffering Metatarsal fractures. Metatarsal fractures can be caused by direct trauma, excessive rotational forces or overuse. By far the most common  Metatarsal injured is the fifth.

Treatment of metatarsal fractures van vary and is dependent on the type and location of the fracture. If the fracture is the result of a direct trauma but the fracture fragments are well aligned then the treatment is can be a straight forward immobilisation in a Removable Plastic Cast and restricted weight bearing for between 6 – 8 weeks. However, stress fractures of the base of the Fifth Metatarsal sometimes show a poor healing capacity, and in these cases surgery may be needed.

Common Metatarsal Fracture Injury signs & symptoms:

• Severe foot pain.
• Swollen foot with bruising.
• Inability to walk on the broken foot.

What to do

• Consult an expert – Doctor / Hospital
• Apply Ice
• Protect using a removable cast
• Use a buoyancy aid for pool fitness exercises

Obviously there are other types of injuries that can occur to the ankle or foot. The above are just the more common. As I have said before always CONSULT AN EXPERT.

Lisa

The most common injuries in Rugby Union involve the soft tissues.  These include the ligaments that hold joints together, tendons that attach muscles onto bones and the muscles themselves.  There are many ways they can be injured, especially in contact sports and the degree of injury is often considered as mild, moderate or severe.  A direct knock or bang on a muscle may cause mild damage where the muscle will still contract and support weight or a moderate problem where there would be some loss of power and difficulties weight bearing.  If a muscle were to be over stretched or strained this may also result in mild or moderate damage or there may be complete rupture within the muscle belly or tendon in severe cases.  With these it is not possible to bring about any movement in the direction the muscle would normally move a joint.  There are specific tests that a qualified medical practitioner would initially carry out but confirmation would need tests such as ultrasound or MRI scan.

Mild ligament sprains might cause some limping initially or soreness at the end of a movement and there may be some swelling but moderate injuries would restrict what the joint normally does and there will be significant swelling and possibly some bruising.  In severe cases the joint will be unstable if a ligament is ruptured and again diagnostic tests from hospital would be necessary.

What should we do if there is a bang or a sprain that is causing some pain and swelling?

The PRICE  regime should be followed for mild to moderate injuries. 

P – Protection

R – Rest

I – Ice

C – Compression

E – Elevation

Bandages or tape can be used to protect the injury from further damage, although not always necessary.  Rest may limit the pain and swelling but it is a good idea to keep the joint moving as much as pain allows.  Ice can be as simple as a bag of frozen peas wrapped in a damp cloth to avoid an ice burn.  The skin under an ice pack should go evenly red and not have white patches in it and certainly no ice formation!  This can be applied for up to 20 minutes but lifted up every five minutes to check the skin.  Crepe, cohesive or elasticated bandages will apply Compression.   The bandage should reach from the joint below to the joint above the injured area, not just around the joint itself as this will just restrict blood flow and congest the swelling.

To assist with PRICE clubs can invest in a small amount of wool and crepe bandage (the roll of wool goes under the crepe to provide padded compression.  More common now is the use of cohesive bandages, which are slightly elastic and stick to themselves but not to the skin.  These are better than tubular bandages which are the same size top to bottom, unlike the average rugby player’s leg.

Ice has always been most cheaply applied by ice cubes in a food bag and often held in place with cling film wrap.  Sealed gel packs that can be frozen before a game and taken in a cool box can be used if access to ice cubes is a problem.  The cold from these is better than the instant packs you “crack” to activate and much cheaper as they can be reused once they have had a wash.  As with all ice applications the skin should be protected from the ice pack burning. 

More effective are cold compression units where there is a bucket you fill up with iced water and a cuff to wrap around the joint which is then filled with the iced water by elevating the bucket.  This is kept cold by running the water back out of the cuff and refilling every so often.  The pressure from the water also applies a nice even pressure around the injured area  but they are more expensive as the cuffs are for individual joints.  The results however are worth the investment even if a club just had the common joint cuffs such as the ankle and knee (You only need one bucket as it clips off from the cuff).  There are now versions where you chill the cuff liner and inflate the cuff.  Although the liner will eventually warm up they are quite cold even out of the fridge!  These are particularly good for home use if you have got an injury.

All this matters because in the first 48 hours you are trying to control the amount of swelling and bleeding that is going on around the injury.  Mild swelling is actually delivering the ingredients the body needs to repair the injury but you can have too much of a good thing!  The positive side of swelling is one of the reasons  why research is suggesting that anti-inflammatories such as Ibuprofen are not given in the first 3 days.  Pain relief from paracetamol (if there is no sensitivity or allergy) will not hinder this process in these first couple of days.

Once the “stuff” is delivered the body sets to over the next few days, trying to lay down new fibres to repair the damage.  The body needs reminding at this stage which direction it is best to lay these fibres in so moving and weight bearing through the injured joint will create forces in the direction which the repairs should be made.  

Once these fibres are in place the speed and loading of the joint or muscle can increase, then skill drills added and return to play.

The full soft tissue healing process always takes at least six weeks but how long away from training and playing will depend on the extent of the injury. 

Finally if you are unsure of how much damage has been sustained consulting a physio or other medical practitioner is essential.  These guidelines will help you understand the advice you may be given but cannot replace their assessment.  

 Lisa

Following on from my reply to Jack’s posting I have talked about functional movements. 

We practice squats in an upright position and abs lying on our backs but these positions are not very rugby specific or “functional”.  These positions are necessary as we need to work against gravity to load muscles however within the game our body and with it our centre of gravity (CoG) is often outside our base of support (BoS). 

If we are stood upright with our feet shoulder width apart the CoG will be in the centre of the BoS and the postural muscles will be under minimal strain. 

If we then lean forward we can only go so far until we have to take a step forward.  The BoS is trying to catch up with the CoG and keep the body in a stable situation.  To control the body and CoG OUTSIDE the BoS requires the strength and stability we all keep droning on about.

Going into a tackle or scrum the BoS will move outside the CoG and the Glutes are required to power this drive forward.  Not only do the trunk muscles need to be strong enough to maintain a healthy back position but they have to resist the impact of the opposite force the body is going to meet on contact.  You do not want your spine to act like a crumple zone! 

Practicing these correct positions with resistance and at different speeds will go part way to strengthening the stabiliser muscles needed to control these shifts in CoG and BoS.

Lisa

The Health and Safety (First Aid) Regulations (!981) legally oblige your club/school to provide a suitably stocked first aid kit. The container being identified by a white cross on a green background.

For the purposes of this article I will deal with a first aid kit suitable for incidents and injuries likely to occur on the pitch (including training).

There is no statutory list of items that must be included in a first aid kit. However, below is a list of the minimum requirements that will deal with the majority of injuries likely to occur. Remember first aid is exactly that – FIRST AID – if you cannot deal with the injury in front of you dial 999.

It is the responsibility of the first aider to check the contents of the first aid kit and first aid room prior to each game and training session. Making sure all equipment is in date, sterile and present. It is the clubs responsibility to provide the necessary equipment in the first instance.

Suggest First Aid Kit Contents

Gloves x 2 pairs (hypoallergenic)

Resusci face shield

Eye patch or dressing

Plasters – various sizes and waterproof

Sterile dressings – various sizes

Tape and bandages

Gauze swabs

Yellow plastic bag – for disposal of soiled items

Ice packs

Crepe bandages

Triangular bandages

Sterile pods

Foil hypothermia blankets

Tuff cut and normal scissors

Incident report book

In addition access to running water and a land line phone.  A mobile is useful to have but battery levels and reception must be checked.

This is by no means an exhaustive list, other items may be added. Simple first aid kits can be purchased off the shelf and quite cheaply. Don’t get caught short.

Lisa

Risk Assessment

Risk assessment is for any club or coach not just a statutory requirement, it is best practice. As I said in my last article we live in an age of litigation. Accidents do happen, at which point it can become a blame game.

Rugby is a collision sport and it is inevitable that people will get hurt. Risk assessment is about minimising that risk, by putting in place processes and control measures.

The process of producing a risk assessment for rugby is no different than that adopted in any other industry. Guidance can be found on the following website:

 www.rfu.com/ManagingRugby/ClubDevelopment/LegalAndAdmin

Essential considerations are as follows:

• What are the playing and non-playing hazards and risks?
• Is there an historic record of specific injuries and accidents?
• How many people are involved (players and spectators).
• Don’t forget the risks to players at away matches. i.e. travelling.
• The nature of the players in terms of size, age and experience.
• The remoteness of the site from emergency medical services.
• Access to first aid resources.
• Access to first aid trained personnel.
• Are then specific risks for specific groups i.e. children, disabled players.
• Will the weather impact significantly on the risk?

Once you have completed your risk assessment you can then put in place your control measures to minimise the risks. This of course will include your first aid provision. The RFU recommend the following:

• Emergency procedures should be developed and readily available (for further guidance on emergency procedures visit www.rfu.com/ManagingRugby/FirstAid
• Emergency services contact details must be readily available;
• Ambulance access to the pitch/training ground must be maintained at all times.
• Establish contacts with the local NHS Ambulance Trust and Hospital Emergency Department. Maintain a good of level of communication with them on the clubs activities, especially festivals.
• Appropriate first aid facilities and equipment based on their risk assessment and level of training of personnel.
• Regular training of personnel in assisting first aiders should be carried out.
• First aid equipment must be appropriately, stored, maintained, and cleaned.

It should also be remembered to update your risk assessment regularly as things do change, and what may be appropriate today may not be later in the season.

Next time I will look at what the contents of your first aid kit should be.

Lisa

With the new season just started I thought I would look at first aid provision. This week I will give you information on your clubs statutory responsibilities as laid down by the RFU. This will be followed with some basic advice on how your club might undertake a basic risk assessment in my next article.

I will then go on to look at basic first aid provision, and then look at immediate on pitch first aid. This will then be followed by more specific information relating to sports injuries, plus articles on topics you the Ruckingball subscriber want to know about.

Statutory Responsibilities

We now very much live in an age of litigation and the RFU has recognised this and has set out some very clear and sensible rules and regulations which all involved in the sport need to follow.

RFU Guidance States

“Clubs have a responsibility towards the health and safety of those people who use the club facilities. During rugby activities, in common with all sports, players, officials or spectators may suffer injury or sudden illness. While the arrangements for spectators and officials are likely to be the same as for any other sport, because rugby is a full contact sport, the arrangements for players will need to reflect this. It is the club’s or organiser’s responsibility to ensure that arrangements are in place so that participants receive appropriate immediate attention if they are injured or taken ill, until the emergency services arrive.

While there is a general requirement, it should be recognised that there is variation in the level of care that that would be considered appropriate and this will depend on the individual circumstances at the club or venue. It will also depend on what is reasonably practicable for the club or organiser to provide; it is not reasonably practicable to expect a Level 11 club to provide the same level of care as that provided in the Premiership.

In order to provide a safe environment in which the game can be enjoyed by all, clubs should encourage members, coaches and volunteers to attend a first aid training course so that they can respond to basic first aid situations with confidence.”

This in essence means that as a club you need to:

• Complete a risk assessment to determine the appropriate level of first aid provision.
• Ensure that all your first aid providers are appropriately trained and qualified, and undertake recertification when required.
• Ensure the reporting system for injuries and accidents is adhered to.
• Provide appropriate first aid equipment and facilities.
• Ensure there is adequate cover for absences (holidays, etc).

If you do the above you will be covering all your statutory responsibilities.

Next time we will look at risk assessment.

Lisa

The physio is very much a part of a wider medical team and as such I am delighted to be able to offer a surgeon perspective on knee injuries written by Andrew Pearse who has a great deal of experience in this area.

Enjoy

Lisa

The Meniscus

The knee is a commonly injured joint in most sports. In simplistic terms this is because we put a huge demand through this relatively stiff weight-bearing joint. Although it would appear logical that we would expect the contact nature of rugby to account to a large proportion of knees to get “crunched” the reality is that most knee injuries are non-contact in origin. We have all heard of the “my boot got caught in the mud whilst my body went the other way” scenario. The mainstay of injuries comprise damage to the menisci and the ligaments, in particular the medial collateral and anterior cruciate ligaments. In this section we will concentrate on the menisci.

The Menisci

There are two menisci in the knee: the medial (inner) meniscus and the lateral (outer) meniscus. They serve to protect the all-important articular or joint lining cartilage (the white shiny stuff you see when you rip a chicken leg in half!) and to improve stability between the rounded femur and the flat tibia. The medial meniscus is relatively fixed in its position making it more susceptible to damage during a twisting injury compared to the lateral meniscus, which moves with the femur during flexion. An acute tear will cause immediate pain, although frequently the player is able to complete the session. The knee often swells up slowly over the course of the next 12-24 hours.  The joint should be treated with the now familiar:

P       rotection

R       est

I        ce

C       ompression

E       levation

After 48 hours the swelling often begins to subside but the player must look out for:

(i) Fixed flexion – the knee will not extend fully and remains in about 20 degrees of flexion. This may indicate that a large fragment of the meniscus has moved out of position and is prevent the joint from straightening out. If left for long periods (more than 6 weeks) it can lead to a permanent loss of extension even after the problem has been corrected.

(ii) Locking – this especially occurs after a deep squat, where the knee becomes “jammed” and will not straighten. Often the player has to wriggle the knee free or manipulate it straight. It is often associated with the sensation that something moves out of the way as it corrects.

(iii) Giving way – a fragment of the meniscus comes out of place and catches between the femur and the tibia causing the knee to give out without warning.

The first symptom (i) in particular should prompt urgent attention. However they would all tend to trigger the surgeon to consider keyhole surgery. In the athlete the aim would in the first part try to repair the meniscus with internal stitches. However in many instances repair is not possible and the meniscus may need to be partially removed. As one of the meniscus’ primary functions is to act as a shock-absorber to protect the joint lining (articular) cartilage it’s removal may leave the athlete vulnerable to osteoarthritis (wear-and-tear) in later years, hence the surgeon’s ambition to retain as much functioning meniscus as possible by repair or when necessary minimal debridement.

Another important factor to remember is that meniscal injuries are often associated with other injuries in the knee. So any injury that causes immediate or delayed joint swelling warrants assessment by a specialist physio or doctor.

By Andrew Pearse

Consultant Knee Surgeon

Well it’s the end of the season and time for a break but for the medical staff at most clubs it isn’t time for a rest. This is the time of year when you will see many players undergoing operations for niggling injuries they have played through.  Chris Ashton for instance has just gone under the knife for a “washout” on his knee.

You will also find that this is the time of year when the Head Coach will sit down with the medical and conditioning staff to work out the off season and pre-season training programmes.

From a Physio point of view this is when I would be looking to profile and screen the players and give them individual prehab programmes to work on, along with the pending conditioning work they will need to undertake.

The whole profiling and screening area of my work is something I feel really strongly about and as well as it forming part of my Masters Degree I have launched PP4P, a multimedia software package that contains a screening tool to produce individual assessments and full video support of all the recommended prehab exercises,(www.pp4p.co.uk) in addition to my Physio practice (www.thephysioclinic.net).

I must say that the medical support at most professional rugby clubs has improved dramatically over the last ten years. My passion is to see this good practice permeate through to the community game. That of course is a big, big challenge.

Lisa