Playing On Through Injuries

Considering that one of the NHL’s issues with the Olympics is potential injury risks to players, they sure do an absolutely horrendous job at managing safety throughout the league. Back when the Mighty Pucks was just starting, there were a series of posts about toxic masculinity in particular I wrote about playing through injuries being seen as a sign of manliness. The more “manly” a player perceives himself to be, the less likely he is to seek psychological treatment following significant injury, and although there are many reasons for playing on – including to benefit the team – in my personal view, one of the biggest road blocks is peoples’ attitudes.

NHLers are expected to be tough, to suffer through broken bones, stitches, busted teeth etc. They’re tough guys. They battle every night. They’re warriors, etc, etc, etc. It’s boring. Hockey culture has normalised playing on through injury to the point that players in the NBA are laughed at for leaving the court with sprains. Consider this: These are professional athletes whose income depends on their body’s ability to perform. It would take a lot of courage for a hockey player to say “you know what, I’ve done something to my ankle, I’m taking a couple of games off to rest”. However, say there are around 82 games in the regular season, NHL players have little time to recover from their knocks and if they took the time to fully recover, there’d likely be nobody in the roster. It’s been said that they can only really get to grips and heal in the off season and just “put up” with all their injuries.

Thank goodness that the San Jose Sharks have been knocked out in round one of the playoffs because Joe Thornton has been playing with a torn ACL and MCL. What did head coach Peter DeBoer have to say?

“I’ve never seen a guy play with a torn MCL and ACL… It’s a courageous effort as I’ve ever seen.”

Courageous?! It’s utterly ridiculous! His knee was floating! The man has torn two major ligaments in his knee. How the hell is he still moving around? Thornton, who is 37, had a 50 point season for the Sharks, and even in his four playoff appearances notched up two assists, however this was his lowest season since 98/99. The veteran player is a free agent this summer, so perhaps he was keen to show that he was still a valuable player. He has since undergone surgery for the tears with no timeline of return announced which leaves his future up in the air. A fellow veteran and teammate, 37 year old Patrick Marleau, is also an unrestricted free agent this summer. Like Thornton, he was also nursing a broken thumb during the post-season which will have affected his ability to shoot the damn puck.

There must be something in the water over in San Jose because a THIRD player has also been playing in the playoffs with an injury. Tomas Hertl had around 19 minutes of time on the ice during the playoffs despite having a broken foot. Not to mention that Logan Couture took a puck to the face towards the end of the regular season and said that it hurt to breathe. His bottom teeth were being held together by wires and the top had a plastic coating to stop them falling out. A member of the Sharks’ dental team explained that due to the freak deflection to Couture’s face, it was akin to him being hit with a large hammer. Nonetheless, Couture was back for the playoffs wearing a cage – risking taking another knock to the face. It is likely that he’ll need a good number of those teeth removed this summer now he has the opportunity to recover.

“In my mind, I wish I could have played right after it happened”

Is any of this making you ask “what the hell is going on in the NHL?” because I certainly ask that on a daily basis.

Zach Werenski attempted to block a shot and deflected a puck into his face but returned to the game in the third period… however due to extreme facial swelling he did not play in overtime and was ruled out of the remainder of the Blue Jackets postseason. He was allowed to play until his face swelled so much! That’s not right! Erik Karlsson of the Ottawa Senators revealed that he’s been receiving injections in his heel because he’s skating on two hairline fractures. What’s scarier is that Karlsson leads in total time on ice during the playoffs with 182.23 minutes.

These aren’t just rare superhuman feats found in this year’s playoffs… Back in 2014, the Penguins favourite Finn, Olli Maatta took two weeks out of the season to have surgery to remove a cancerous tumour from his thyroid. TWO WEEKS. Also in 2014, teammate Kris Letang, who was 26 at the time, suffered a stroke and took a lengthy six weeks out. Yeah, six whole weeks after suffering a stroke…

I understand that the majority of players in the playoffs are dealing with injuries and we only really find out the extent of them once the team is eliminated, but it is worrying how normal this is to them. Athletes have a very short “lifespan” as a pro and there’s a toss-up between sucking it up and continuing whilst hurt, risking further injury, or taking time away to actually heal and worry about coming back. To the owners of the league, the players are disposable. One of the biggest issues I have is that boys in general are taught from a very young age to be tough and not to cry when they’re hurt, and this seems to be a thousand times worse with hockey players. Granted, it’s a rough game, but there comes a point where toughness becomes a ridiculous rigid resilience where health is neglected and the players are congratulated for continuing to play with their limbs hanging off. Secondly, the NHL is terrible at enforcing safety throughout the league yet have the audacity to proclaim a big reason to not attend the Olympics is due to injury risk. For one thing, players rarely fight in the Olympics because they’re ejected from the game – and fighting increases your risk of injury without a doubt, yet still exists in the league. Then there is the lack of concussion prevention/support which is a huge issue in hockey, but the NHL is too busy lining their pockets than actually focussing on the player’s health.

The short version: Hockey players are applauded for suffering through injuries and continuing to play as a result of a toxic, normalised attitude, and the league is unlikely to do anything about this because players are replaceable cogs in the money making machine that is the National Hockey League.

Concussions Part II – Hockey & Concussions

Elite hockey players are fast and physical athletes therefore it is one of the sports with an inflated risk of concussion due to collisions and checks, despite players wearing helmets. Whilst the majority of concussions will resolve themselves in 7 – 10 days, some players experience post-concussion syndrome – most notably Sidney Crosby.

During the Winter Classic game in 2011, Crosby took a headshot from David Steckel then five days later, Victor Hedman ran him hard into the boards. After his concussion diagnosis, Crosby missed a staggering 68 games. However, only eight games into his comeback, Crosby collided with liney Chris Kunitz and was out for another 43 games. The player himself admits he questioned whether he would ever recover enough to play professionally again. Since that first bout of head injuries, he has gone on to win an Olympic gold in Sochi, a gold world championship medal, the world cup of hockey, the Stanley Cup, the Conn Smythe, and the Hart trophy, as well as various MVP awards. Yet, in 2016 Crosby was diagnosed with a concussion again following an incident in practice.

The cursed jersey

Coach Sullivan said at the time “Injuries are a part of our game. Part of the challenge for us is to try help Sid get healthy as quickly as possible”. It’s understandable that the Penguins wanted their captain and star player back quickly, but hurrying him back from a concussion could do more harm than good – particularly given his prior history. As it happens, Crosby missed six games but that was all.

Whilst Crosby is the most well known NHLer to suffer drastically from the effects of concussion, there are several others. Jeff Skinner, who won the Calder in his rookie year, hasn’t been able to hit the heights expected of him and injuries have likely played a role in this. During his second season, Skinner missed sixteen games following a concussion then suffered another head injury in the lockout-shortened season. A relatively productive season occurred in 2013-14 with Skinner scoring 33 goals, but again last season he suffered his third concussion in four years – and he’s only 24. It’s worrying.

Not every player is the face of the franchise, Sidney Crosby, who perhaps is allowed more time to recover to ensure he’s in pristine condition. For other players, there is an underlying need to get back in the team quickly, especially for a 3rd or 4th liner – professional sports are tough, and you’ve gotta fight for your position to show that you deserve to be on the team. As concussions are diagnosed by a symptom checklist, I question whether some players have omitted details because they’re eager to be back in the line up  – putting themselves at further risk. Likewise, once you’ve received an injury, you don’t want it to happen again and in a physical game like hockey, you can end up playing scared – not making hits, not rushing to the net etc. It’s also interesting to note that video analyses of concussions during a five year period in the NHL showed that at the time of contact the player was often not in possession of the puck and often penalties were not called on the play. Checks to the head are too frequently being dismissed by officials or are being played off as accidental; one of Skinner’s concussions arose from his face hitting Matt Niskanen’s elbow – or so Niskanen said. Whilst many occurrences are clean hits, there are some players who play dirty and go for the head or take cheap shots which is something the NHL needs to tighten up on.

The most frequent cause of concussions were collisions with another player and nearly half occurred in the first period. This could be due to the higher energy/adrenaline levels in the beginning, easing into the game and adjusting spatially, or setting the tone for how physical the game will be.

The Jets’ Patrik Laine – who leads all rookies in scoring – suffered a concussion on the 7th. It was a hard hit, but not a dirty one. He was spotted watching the team train on Sunday (8th) in good spirits, but did not feel 100% to play. Here’s hoping he makes a full recovery. That being said, at the beginning of this season, the NHL introduced “spotters” to games. Teams still have a responsibility to identify and report players who ought to be removed from play and evaluated for concussion, but additional support is now provided following an agreement between the NHL/NHLPA. Central league spotters will monitor games from the player safety room in New York where they can authorise a player’s removal from play if they exhibit certain visible signs. Teams who violate this ruling will receive punishments, likewise a player may not be re-admitted to the game until he is cleared to. More can be found here.

Whilst this should be seen as a good move, some players are already mad. McDavid was taken out the line up for a concussion check just as his team was on the verge of a 5-on-3 against the Wild. The captain said of the incident “obviously the spotter thought he knew how I was feeling”. Whilst McDavid’s frustration is understandable, over 100 ex-NHLers are suing the league due to the treatment of their concussions and the concealment of information regarding later issues, including dementia or chronic traumatic encephalopathy. And it’s not just in the NHL,  similar law suits have been brought against the NFL.

To sum up, concussions – whilst considered minor – can actually have prolonged and worrying implications that affects players’ careers and later life. The newly implemented spotters will be able to react and remove those players believed to have suffered a concussion, but do nothing to actually reduce a concussion occurring. As a parting note, hockey is a sport where players are expected to drop the gloves and fight; an enforcer can fight once or twice a month, so should fighting – which increases the risk of head injuries – be banned?

Can I just make a final confession, though? I don’t care what people remember about me as a hockey player, but please remember this one thing: I didn’t love to fight. The actual 30 seconds of fighting was fine. Your adrenaline takes over and the competition of battling at such a high level is actually enjoyable. The problem is all the anticipation of having to drop the gloves with another very skilled individual who can hurt you. The waiting is what drives you crazy. It’s not very easy on your psyche, especially once you have a family. – John Scott for The Players Tribune

Concussions Part I

Starting the New Year off with a happy topic…

A concussion is considered to be a minor traumatic brain injury. For the 48 hours following a concussion/blow to the head, careful monitoring should be carried out because there is an overlap between symptoms of concussions and haematomas/haemorrhages (bleeds on the brain). However, if a brain scan is carried out and there’s no bleeding or swelling only then can concussion be diagnosed. Generally a concussion isn’t a huge source of worry, but evidence has suggested repeated concussions can cause long term problems with mental abilities and trigger a form of dementia called chronic traumatic encephalopathy. This is a particular issue in athletes who suffer repeated severe concussions.

Delving a little further into the causes of concussion, it occurs when a sudden impact causes a disruption to the reticular activating system (RAS) in the center of the brain. This area helps to regulate awareness and consciousness; for example sleep cycles, attending to important information such as your name being called in a busy doctor’s surgery. If a head injury is severe enough to cause a concussion, the disruption in the brain cells triggers symptoms such as loss of memory and mental confusion.

 

Certain sports have a higher-than-average risk, including rugby, boxing, cycling, and martial arts. It’s argued that the benefits of regularly engaging in these sports outweigh potential concussion risks, particularly if correct equipment is worn. However, boxing is highlighted by doctors as dangerous because  the risks of serious brain injury are unacceptably high – the aim of the game is to beat the crap out of each other after all. (We’ll get to concussions in hockey in a later post and why it’s a hot topic currently!).

Mild concussions can be treated with self-care techniques such as a cold compress to reduce swelling, paracetamol for pain relief, rest, avoiding alcohol and drugs, and no contact sports. There is no definitive agreement on when one can safely return to sports following a concussion. The general steps are to wait until symptoms have passed for at least 24 hours then light exercise can be brought in, sport specific exercises (that exclude any impact to the head), non-contact training then full training with a return to play. However if symptoms re-emerge then take a step back. A concussion takes – on average – 7 to 10 days to recover fully.

It is worrying though that despite the awareness and research that has gone into concussions, we still do not have anything particularly concrete on them. Are certain individuals susceptible? Could we develop a biomarker to definitively diagnose a concussion? What about a treatment that actually does something rather than rest and gradual return?

Post-concussion syndrome (PCS) is used to describe symptoms that last for several weeks or months but the exact cause is poorly understood: There are thoughts that it could be a result of damage to nerve cells in the brain or a chemical imbalance triggered by the initial injury. The majority of PCS cases resolve within three to six months, and treatments for specific symptoms can be used to alleviate it, for example migraine medication for headaches or anti-depressants for depression. [X]

Shoulder Injuries

Pathology:

• AC injury
• Shoulder dislocation
• Labral tears – SLAP lesion, unstable joint; if the joint is unstable then bicep will still function but will be less efficient
• Bankhart’s lesions
• Cuff tears – overloading young sports players or degenerate joints in old people are most common causes
• Impingement

Cuff Tears:

• Partial
• Complete
• Acute
• Chronic

Impingement:

• Pathology
• Most common in overhead athletes such as swimming or racquet sports
• Causation
• Intrinsic e.g. acromium made the wrong shape
• Extrinsic e.g. what you’re doing such as excessive serving for tennis

Rehab:

• Core stability; fix core, scapula, move well
• Scapula control; often anterior structures are damaged
• Range of movement
• Cuff strength
• Strength through range

Achilles Tendon Injuries

Structure and Function:

 

• Two muscles in calf joint (gastrocnemius and soleus; gastro goes across two joints – knee and ankle)
• Ankle-plantar function
• Elastic structure
• Key function: absorbs force and recoils
  

Pathology

• Rupture
  • Acute injury
  • Possible pre-existing pathology
  • History – feels like somebody kicked them
  • Examination
  • Investigation – if examined immediately then can feel the tear, but then blood clot will fill it.
  • Treatment
    • Surgical – mixed results for stitching
    • Conservative
  • Rehab
    • Pathology/procedure
    • Degree of atrophy
    • Commitment to rehab
    • Very hard to get back to the same standard after achilles tendon damage
  • Tendonopathy
    • Also known as tendonitis but this is false as it suggests inflammation, but anti-inflammatory tablets will do nothing.
    • Pathology
      • Pathology is a continuum
      • Reactive tendinopathy
      • Tendon disrepair
      • Tendon degeneration
    • Symptoms
    • Investigation
    • Underlying causes
    • Role of Pain
      • Occurs at any point – normal looking ones can hurt
      • 2/3rds of ruptures have no pain

Treatment:

• With so many treatments available, none can be gold standard

Unloading	Eccentric loading	Strengthening	NSAIDs
Massage	Surgery	Orthotics	GTN patches
Acupuncture	ESWT	Dry needling	Various injections

Hamstring Injuries

Structure and Function:

• Three muscles
• Crosses two joints; they start above the hip and below the knee.
• Complex balance of concentric and eccentric actions.
• Greatest function is eccentric and very demanding; control.
• Acute hamstring injuries come from sprinting most often. People feel something rip – like carpet tearing.
• Check the spinal movements e.g. sciatica as hamstring pain can often be neurological rather than something genuinely wrong with the muscle.

Pathology:

• Tears
  • Grade 1 – microscopic damage; mild muscle pull or strain
  • Grade 2 – majority of tears; partial muscle tears
  • Grade 3 – one bit torn away from the other; complete muscle tear
• Tendonopathy
  • Proximal
  • Distal
  • How much of the muscle is involved?

Diagnosis:

• Clinical
  • Strength; will hurt them, assess strength and pain
  • Stretch; also going to hurt, assess flexibility and pain
• Investigation
  • Ultrasound
  • MRI; looking for the size of the injury, not the size of the edema

Treatment:

• Interventional
• Rehabilitation – a lot more options available
  • Pathology
  • RICE – limit secondary muscle damage
  • Mobilise
  • Strengthen – weights, open and closed chain; look what strength they have within a comfortable range.
  • Return to function
• Strength
  • Low level of activity: knee flex and extend hip so leg raise. Hamstring and gluteals extend hip so need to strengthen glutes to prevent future hamstring injury.
  • Build up to low resistance flexion with the rubber bands around ankles or hips and a post.
  • Resisted weight machines as these are closed chain activities; it strengthens the muscle but it is not functional.
  • Put the closed chains together, making it open chained, so squats, lunges, and dead lifts.
  • Must be able to walk before they can run.
  • Cycling – mainly concentric, low risk, protects cardiovascular fitness and gets muscle working.
  • Cross trainer is a good progression from walking with reduced loading compared to running, but is a similar action.
  • Walking then uphill or backwards then jogging.
• Speed
• Acceleration
  • Acceleration/deceleration are very important in sports but likely to damage hamstring, so this must be put into rehab
  • Can use GPS tracking to get a look at speeds etc
  • The quicker you push an injured athlete and harder, more likely they will break
  • Have to introduce sport specific skills e.g. spring to this cone then kick a ball
• Endurance
• If fibres heal shorter than others then they will take all the stress so need to make sure they’re flexing and lengthened

Anterior Cruciate Ligament Injuries Part Two

The first post on the anterior cruciate ligament (ACL) focused mostly on the anatomy of the knee joint and how injury occurs there. This second part will look at treating one, from a sports physiotherapist point of view.

Conservative or Surgical:

• Often both methods are required
• Depends upon:
  • Age of athlete
  • Degree of instability
  • Associated injuries
  • Pivoting in sport
  • Compliance with rehab programme
• Basically, is it worth the surgery? It’s a long lay off for ACL injuries in terms of rehab, and if you’re just playing football on a Sunday morning with your mates, you may have to consider whether a lengthy rehab plan is worth it.

Surgical Treatment:

• People will often say that it gives way – the knee is trying to slip out of place due to no ACL and that puts the meniscus at risk and can lead to joint degeneration.
• Aim is to replace the torn ACL with a graft that reproduces the normal function of the ligament. You cannot repair the ACL, it would be like trying to repair a piece of string.
• Surgery options:
  • Bone-patella tendon-bone; this gives a chronically sore knee so bad if you need to kneel a lot
  • Hamstring graft; doesn’t anchor as well and is quite thin so you can double it up to make it less stretchy

Problems:

• Patella tendon reconstruction is associated with pain on kneeling, a higher rate of morbidity and a big scar.
• Hamstring reconstruction is associated with decreased end range knee flexion power.
• If a hamstring graft is done then you almost must ensure this muscle goes through rehabilitation too.
• Often methods depend on surgeons and countries. Some countries they will use the hamstring from the injured leg, whereas others prefer to take it from the non-injured knee. There’s no right or wrong option here either.

The next half of this post will go over a general rehab plan for ACL injuries.

Accelerated Rehabilitation: 

• Prehabilitation
  • Reduce swelling/pain, restore FROM and educate the athlete. This can be walking, cycling or easy front crawl in a pool. Surgeon will not operate until injury site is ready with ROM and effusion has stopped. Talk to player, reason with them and explain why the operation cannot be performed immediately. PRICE and movement are key. More you move, the quicker the swelling goes down.
• Phase 1 (0-2 weeks) Post-Op
  • Partial/full weight bearing, or functional brace could be worn. Aim to reduce swelling and get 0-100 degree movement range. 5/5 hamstring and quads strength. Start with simple exercises and build up; quads, VMO, bilateral calf raise, hip adduction and extension, hamstring pulleys, gait drills.
• Phase 2 (2-12 weeks) Post-Op
  • No swelling, full flexion 130 degrees and full hyperextension. Full squat ability and good balance with unrestricted walking. ROM/quads, mini-squats and lunges, leg press, step-ups and exercise bike.
• Phase 3 (3-6 months) Post-Op
  • Full ROM/strength. Return to jogging/agility. Restricted sport specific drills. Straight line jogging, road bike, jump and land drills, agility drills.
• Phase 4 (6-12 months) Post-Op
  • Progressive return to sport, restricted then unrestricted training. Partial match play then competitive match.
  • Must do skill work too – practice kicking balls if they’re a footballer.

Outcome Measures:

• Return to sport
• Re-injury rate
• Prevalence of osteoarthritis

Anterior Cruciate Ligament Injuries

Anatomy: 

• The knee is the largest joint in the body and it’s made of a double condyloid joint that includes the distal femur, proximal tibia, and patella bones.
• There are two types of ligaments- collateral and cruciate. The collateral ones are medial and lateral, and the cruciate are posterior and anterior.

Functions:

• It resists excessive anterior movement of tibia on femur.
• It prevents hyperextension.
• It aids resistance of excessive valgus stress.

ACL Injuries:

• Very common sports injury-in the UK, majority from football, but this is due to the sheer number of people who play football. You’re more likely to tear your ACL in a sport like taekwando that involves a lot of pivoting.
• It can occur in isolation or in combination with a meniscus or MCL
  (medial collateral ligament) tear.
• If left untreated then it can lead to instability, degeneration, or meniscal injuries.
• Symptoms include an audible pop or sensation, extreme pain and swelling within an hour.

ACL Injuries and Women:

• Women are 3-6 times more likely to injure their ACL than men, but statistically more men injure their ACL because more play sport.
• Anatomically; women have a wider pelvis and the intracondylar notch is narrower (where the ACL starts)
• Hormonal; progesterone has an effect on the tensile strength of ligaments and tendons
• Neuromuscular; women can’t control their knees as well as men?

Common Sports Injuries I

This mini-series will examine some of the more common sports injuries. The first post will be on menisci injuries. The meniscus is a section of cartilage in the knee.

Function:

• Shock absorbers that act as an impact cushion
• They spread load – without it, the femur would smash against the tibia in a small area so the force is much higher, by spreading the meniscus out across the tibia, is disperses the load.
• Stabilises the joint
• Nutrition and lubrication – in the peripheral areas, there is a healthy blood supply in the menisci

 

Mechanisms of Injury:

• Most commonly arises from a twisting injury
• Degenerative tears are also common – for example there may be a slight tear in the meniscus which causes no issues when walking but serious injury then occurs with twisting.
• It can also be associated with another injury, for example ACL tears.

Diagnosis:

• Sharp pain when doing something particular
• Swelling and loss of extension ability
• X-Ray can be used but sometimes it’s difficult to see some cracks as it can be torn in variety of ways; arthroscopy can also be used to a degree of success

Treatment:

• With time, a lot will settle – especially if there is a good blood supply available
• Gluing the tear is done though is not overwhelmingly successful
• In previous years, removing the meniscus was routine however this results in knee degeneration and is no longer recommended
• The most common route is to surgically remove all the tear but leave as much mensicus as possible. The surgeon must ensure that a slight crack isn’t left as it is likely to tear fully again.
• Bio-absorbable stitches can be used, but they will not heal without a blood supply.

Rehabilitation:

• Rehab will depend upon the pathology of the injury – how big, the angle, what percentage is lost to surgery, muscle atrophy
• Muscular atrophy – the vastus medialis oblique (VMO) plays a vital role in patella control but can atrophy within three days.

Rehab Plan:

• Movement resolves swelling so in early stages, athletes can go on an exercise bike at low speeds and resistance to regain movement as there is no knee rotation involved. Progression could be onto a cross trainer as this is low impact. Following that, running in a straight line followed by increasing agility by running round sets of cones.
• Open and close chain activities – open focus on whole muscle groups whereas closed hone in on just one
• Remember the athlete is being rehabilitated not just the injury and it is a holistic process.

General Sports Rehab III

This post will be a toe dip into a general rehabilitation plan.

This grid can be useful for physiotherapists and the general rehab team in examining and maintaining an athlete’s recovery. Obviously not every injury will be a perfect twelve week layoff – some are significantly longer – and each section can vary in length dependent upon progress, nonetheless it’s a good framework to use. The aims in the first column are fairly straight forward as to what they are and how they relate to recovery. (Prioprioception is the body’s ability to sense movements within the joints and their position; an ability to know where the limbs are in space without needing to look).

Things to consider
– Some athletes do not deal well with injuries whereas others need to see a long term plan to focus on, so it can be beneficial to get an athlete’s input.
– In professional sports, you will more than likely have pre-injury data to compare progress, but this is unlikely to be the case for amateur levels.
– Regular meetings to focus on the athlete’s aims with measurable targets are essential