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.
What is the HIA?
The piece of the concussion puzzle that I have not yet covered; on-field concussion recognition and the subsequent sideline Head Injury Assessment (HIA). It is very important to recognise a player does not have to lose consciousness (LOC, get “knocked out cold”) to have concussion. In fact, most lack a LOC so these tests/screens are vital in identifying instances of concussion in most cases
The Concussion Recognition Tool is used on the field to help screen for possible instances of concussion. If a player shows one or more of the signs, symptoms or errors in memory questions on the field it is the job of the trainer/club doctor to remove them from play and put them through the more thorough HIA.
Briefly, the Concussion Recognition Tool helps to assess:
- Visible clues of suspected concussion
- Examples include LOC, lying motionless on ground/slow to get up, unsteady on feet, clutching at head, dazed look, confused
- Signs and symptoms of suspected concussion
- Examples include LOC, seizures, balance problems, headache, dizziness, confusion, pressure in head, blurred vision, light sensitivity, neck pain, amnesia
- Memory function
- Questions include:
- What venue are we at today?
- Which half is it now?
- Who scored last in this game?
- Which team did you play last week?
- Questions include:
If a player shows one or more of these signs and symptoms and is removed from play, that does not mean they are ruled out for the rest of the game. They must then undergo the 15 minute HIA performed by the club doctor. This is the Sport Concussion Assessment Tool (SCAT3).
The SCAT3 (http://bjsm.bmj.com/content/bjsports/47/5/259.full.pdf) must be performed within 15 minutes of the player being presented to the doctor. Initially, the player must rest for 5 minutes, as this is when the test is most accurate, before starting the test itself which takes between 8-10 minutes. There are 7 main segments to the SCAT3:
- Glasgow coma scale (GCS) – an assessment of eye response (eyes opening), verbal response (not confused) and motor response (obeys commands) to give a score out of 15
- Maddocks score – Memory function questions similar to those performed on field (What venue are we at today etc)
- Subjective symptom evaluation (how does the player feel) – player is questioned on signs and symptoms of concussions
- Cognitive assessment – orientation (what date is it), immediate memory (given a list of words to remember), concentration (numbers/months in reverse order)
- Neck examination – range of movement, tenderness, strength and sensation of arms
- Balance examination – Player stands with feet together, single leg and tandem stance
- Co-ordination – player touches finer to nose/doctors finger in quick succession
If it is deemed after that examination that the player has suffered a concussion then that player is not allowed to return to the field of play for the remainder of that game. A great video on the HIA was put together by Channel 9 and Dr Ameer Ibrahim, Sydney Roosters chief medical officer:
Thompson did not come back out after halftime of the game on the weekend after aggravating an Achilles tendinopathy (tendonitis) injury he has been suffering from since the pre-season. A tendinopathy is an overuse injury that includes inflammation and micro-tears of the tendon. Your Achilles it the tough rope-like structure that attaches your calf muscles to the back of your heel, and over time repetitive actions involved with running must have caused either inflammation or micro-tearing of Thompson’s.
Unfortunately, this is not a problem that has a set X weeks recovery period. It is an injury that can linger for months but can be managed quite well with exercises and training load modification. This may mean his game time is varied week to week. He could go the rest of the season with no issues, yet could also have an acute aggravation and spend a week or two on the sidelines. He has been named to start this week which is a good sign the pain and inflammation has settled well from the weekend.
Not much to report here, Dugan suffered a grade 1 hamstring strain on the weekend which will see him out for between 2-4 weeks. The main point I wanted to cover here is the reporting of a “grade 1.5 hamstring strain” by some media outlets. A grade 1.5 muscle strain does not exist; it is not even a shorthand or layman term. Grade 1+ is on rare occasions used as an unofficial way to indicate a higher end grade 1 strain, but the grading system is already very specific and does not officially include half grades.
Tyrone Peachey, unfortunately, fractured a rib in the past weekend’s game against the storm. This is different to Blake Ferguson’s injury (rib cartilage), as a fracture is more than a pain tolerance issue. A fractured rib poses a threat to the internal organs, so must be given time to adequately heal before a player can return to play. Peachey should fall somewhere in the 4-6 week recovery range
Dr Ibrahim (Roosters doctor) has confirmed on Twitter Napa suffered a syndesmosis injury and could be out for up to a month. This indicates a grade 1 syndesmosis injury. Every time you take a step the tibia and fibula (lower leg bones) are exposed to forces that want to spread these bones apart, and the syndesmosis acts as a shock absorber to hold them together. These forces are only increased with running and increased further still with cutting and jumping. Considering the alternatives (higher grade, possibility of fracture) this is a good result for Napa, and I would not be surprised to see him back sooner than 4 weeks.
James Roberts played through a hamstring strain on the weekend, which is something I have not seen done in the past. Usually, a player with a muscle strain particularly of the hamstring or calf is removed from play due to the increased risk of further damage. He has been named this week but is yet to train, and there is no guarantee he will play with even the most minor of hamstring strains needing 1-2 weeks to recover.
Farah didn’t last long in the game on the weekend with back spasms. This can be either muscular in nature or due to a nerve/disc injury in his lumbar (lower) spine. No details have been reported on the source as yet, however, Farah has been named to play this week and by reports should play. This would suggest it is purely muscular tightness/spasm (usually a quick return of 1-2 weeks), however, if there is an underlying injury (disc/nerve) it would hold him out for 4+ weeks.
Roberts suffered a suspected PCL sprain/tear after hyper-extending his knee whilst landing. The PCL is a ligament inside your knee, like the ACL, that helps provide important stability to the knee joint. A general guideline for PCL sprain recovery:
Grade 1 - 1-4 weeks
Grade 2 - 4-6 weeks
Grade 3 - 6-8 weeks
Even with a grade 3 (complete rupture) PCL injuries often don't require surgery. The PCL (unlike the ACL) has a great ability to heal itself, which is why even the most severe PCL injuries can recover in 6-8 weeks. The worry would be if any other meniscus or ligament damage is present, as functionally the knee is often very unstable and requires surgery to recover adequately.
Granville believed he had only suffered a cork in the final moments of Friday night’s game, however, scans have since shown a fracture in his fibula (outside lower leg bone). Recovery for this is usually in the 4-6 week range, and rarely has complications with the fibula being a non-weight bearing bone.
I wrote in more detail on Sam McKendry in the preseason, and I was shattered to hear he had to undergo season-ending ACL reconstruction surgery last week. For those who missed it, McKendry suffered a partial tear of his ACL in his first game back from ACL reconstruction this pre-season. A partial ACL tear can sometimes avoid surgery if the knee is still functionally stable (doesn’t give way while running/changing direction). Unfortunately, this must not have been the case for McKendry, and he will now be aiming to be fit for 2018. Best wishes to Sam in his recovery.