Returning from injury – Johnathan Thurston
Determining whether Johnathan Thurston is fit to return from injury in Origin 1 is one of the most challenging issues any medical staff would have to face. It is obviously of vital importance to get this right, as a return too early can result in further/more severe damage and a much longer stint on the sidelines. As Thurston himself has indicated, if he returns too soon his partial tear (grade 2) can quickly turn into a complete rupture (grade 3) and result in a 6-month recovery process, effectively ending his season. Whilst it can’t be guaranteed that he will not injure or re-injure himself when he does step out onto the field, there are a number of factors and guidelines that can ensure the risk of returning to footy is acceptable. These are often assessed in 2 main categories; physical and functional.
The number one priority in this whole process is the health of the player. There may be external pressures coming from the coach and even from Thurston himself, but it is the job of the medical staff in consultation with these parties to indicate when an injury is sufficiently healed and stable for a safe return. This is part of the physical assessment. Pain would seem to be the most obvious indicator; this is not always the case. The absence of pain does not always signify adequate healing of an injury, which is why it is important for the medical staff to be aware of the expected healing and recovery times of all tissues and structures affected by an injury. Pain is also a subjective measure, meaning what Thurston deems as “painful” can be extremely variable when compared to other players. As well as pain other physical factors such as muscular strength, tissue/bone healing, joint stiffness, swelling and range of movement need to be assessed and compared to pre-injury measures. Thurston has indicated in interviews this week he is still suffering pain and does not have the full range of movement or strength, but with his history of shoulder problems, this may not be far from normal. Individualised assessment and management is key, and another indication of the challenging nature of the return to play decision.
Even if a JT is cleared in his physical assessment prior to Origin 1, using this in isolation without including a functional assessment is fraught with unnecessary risk; both of re-injury and poor performance. A functional assessment would be heavily based on the physical nature of rugby league, as well as the position Thurston plays on the field. It will be essential to try and replicate the challenging components of the game Thurston will face when he plays; so tackling as well as being tackled are of great importance. It is the purpose of these tests to put his shoulder under the stresses it will encounter during an in-game situation and see if it handles this without aggravation. Fatigue is also important to assess, as it is often under fatigue muscular injury will occur (his current injury occurred in the final 15 minutes of the Test match 4 weeks ago).
In an ideal world, rehab would return a player to equal to or better than pre injury levels in both physical and functional testing. However, it is often unrealistic to expect a player to be at 100+% returning from an injury. For example, many players return from ACL reconstructions in the 6-9-month range, which evidence shows still holds an increased risk of re-injury. Long term health will be considered along with short-term benefits, and Thurston must always be fully informed of any risk he is taking by returning before reaching full fitness. Although the decision is ultimately Thurston’s, many cases will still require medical clearance from the team Dr, and with the history and severity of his injury, this will likely be the case. Thurston’s return to the field will be a natural progression in his recovery rather than a time-determined event, and hopefully it will involve no further time on the sideline in an already interrupted season for JT.
Everyone thought "interchange rort" when Graham came from the field after a tackle with his head in an awkward position caused him to clutch at his right arm. This was likely due to a nerve injury that originated in the right side of his neck (stinger/burner). He was able to stay on the field momentarily before being taken off for a HIA.
This was definitely the right call, as the mechanism of injury involved both trauma to the head and whiplash in his neck; both are common causes of concussion. Provided he passes through concussion protocols he should be fine to play this week.
Mechanism is all head and neck, so shoulder symptoms will be nerve related from neck. No vision of shoulder being popped back in either... pic.twitter.com/iKtTW9CIcR
— NRL PHYSIO (@nrlphysio) May 22, 2017
Bryce Cartwright suffered a lateral meniscus tear after hyperextending his knee in the Panthers’ game on the weekend. He will be visiting an orthopaedic specialist this week to see if surgery is required.
The meniscus is the cartilage that sits between your thigh and shin bone that provides stability and shock absorption to your knee. Blood supply to the meniscus is limited, and to avoid surgery Cartwright’s meniscus tear will need to be minor and preferably located in a section on the outer rim of his lateral meniscus where blood supply exists.
In rare cases, this could allow for the tear to heal naturally and result in a return over the next 2-3 weeks. However, if the tear is in an inner section of the meniscus, or significant in nature in any location within the meniscus, surgery will be required. There are commonly 2 types of surgery used for meniscus tears:
- Meniscectomy (trim) – removal of the torn portion of the meniscus to decrease symptoms, leaving as much of the normal meniscus as possible. 4-6 week recovery
- Meniscal repair – stitching the torn meniscus back together, used to preserve as much of the meniscus as possible. Is often said to be a better long term option, but recovery is 4-6 months
We will no doubt hear which option Cartwright has opted for in the coming days.
Latrell Mitchell and Nathan Brown
Mitchell was struck in the sternum, which is sensitive and can make it extremely painful to breathe and rotate (turn). Provided there is no structural damage (this appears to be the case with Mitchell) he should be fine to play this week. It will be a pain tolerance issue so he may play with pain relieving injections or padding to assist him.
Similarly, Nathan Brown suffered a direct blow to his ribs, which caused severe pain and he was even taken to hospital to assess for further damage. There has been little to no information from the Eels about Brown’s injury (he was not even included on the injury report), so it is likely his injury involved minor damage to his rib cartilage. Like Mitchell’s injury this is often a pain tolerance issue, so he should be able to play this week.
Wallace suffered a grade 2 adductor (groin) strain and has been given a 4-6 week return date by the Panthers. He has been undergoing treatment in a hyperbaric chamber over the past 48 hours, which is used in an effort to increase the supply of oxygen to the injured tissue and speed up recovery. Some players have returned from this injury having only missed 2 weeks of footy, so I am confident Wallace’s goal of a 4-week recovery is achievable.
Jennings has been ruled out for the next 4 weeks with a quadriceps strain. With that timeline he is likely looking at a grade 2 injury which usually falls in the 4-6 week range for return to play.
Michael Jennings mechanism, slows up in last few strides. Fits quad strain (likely Gr1-2)
Gr3: 6-8wks pic.twitter.com/ktskWnda25
— NRL PHYSIO (@nrlphysio) May 20, 2017
After quite significant trauma to his head, McCullough seemingly lost consciousness and was seen gasping for air. This was quite confronting, and it took quite a while for him to leave the field on a medicab. As he left the field he was not put in a neck brace, but rather his neck was manually stabilised by the club doctor.
This practice is now the norm after a report from the Australian Resuscitation Council was handed to the NRL last year recommending against the use of a cervical collar (neck brace). It was found that the benefits of wearing a cervical collar were outweighed by the risks, such as increased pressure inside the skull, pressure injuries and pain/unnecessary movements. Another point to consider with McCullough’s case is trying to grade or predict a concussion prognosis in the early stages of injury is no longer an accepted practice.
Wayne Bennett was quoted after the game stating: "You don’t see those occasions have too many great consequences apart from a bit of a headache and loss of consciousness”.
Whilst he no doubt had the best of intentions, this statement was used prematurely and only downplays the unpredictable nature of mild traumatic brain injuries. The severe traumatic blow along with McCullough’s symptoms immediately post match are not indicative of the path his concussion injury would take.
To use an excerpt from an article I wrote earlier in the season:
Concussions used to be graded, but as more has been discovered about the course of symptoms and risk of long term complications these grading systems have been abandoned in favour of more individualised management. Many grading systems centred on loss of consciousness (LOC); if the athlete suffered LOC they were considered to have a higher grading concussion than those that did not. But medical professionals were finding LOC did not determine length of recovery. Athletes who were knocked unconscious sometimes recovered quicker than who did not lose consciousness at all. When making decisions about return to footy for players suffering concussion clinicians will treat each case individually, using tools to assess the clinical signs and symptoms, cognitive dysfunction and physical deficits.
McCullough has been ruled out for this week’s game, and the question many will want an answer to is “how long will he be out for?”. This is quite impossible to answer at this stage. It will be in the hands of the treating doctor, and with the unpredictability of concussions it would even be difficult for them to produce a definite timeline.
The opinions given by the author of this article are given by a qualified physiotherapist, HOWEVER they are based on the information available to the author at the time of publication; are general; and are not based on any formal physical assessment and/or diagnosis by the author. If you believe you may be suffering from an injury similar to one commented on by the author, do not rely on the author’s advice as it may not apply to you – see a qualified physiotherapist for a full assessment, diagnosis and treatment plan.