VOLUME 26 – ISSUE 2 • WINTER 200 8

Opinions expressed throughout this journal are the Contents contributors own and do not necessarily reflect the views or policy of Sports Medicine Australia (SMA). Members and readers are advised that SMA cannot be DOING THE RIGHT THING 2 held responsible for the accuracy of statements made It’s a fine line between minimising your taxable income and cheating on your taxes in advertisements nor the quality of the goods or services advertised. All materials copyright. Gary Moorhead On acceptance of an article for publication, copyright passes to the publisher. WILL THE AMA EVER EMBRACE SPORTS AND EXERCISE MEDICINE? 4 Publisher “All doctors are members of the AMA – it’s just that some choose to pay their Sports Medicine Australia PO Box 78 Mitchell ACT 2911 membership fees and others don’t” Tel: (02) 6241 9344 Dr J Fax: (02) 6241 1611 Email: [email protected] Web: www.sma.org.au DRAFT CONSENSUS STATEMENT - SPORTS INJURY SURVEILLANCE Circulation: 4000 AND PREVENTION 8 ISSN No. 978-0-9805297-1-5 A draft statement for discussion and response Editors John Orchard & Janelle Gifford ANTI-INFLAMMATORY DRUGS – THEIR ROLE IN SPORTS MEDICINE 10 Managing Editor Lesley Crompton Wider exposure to an important topic Chief Executive Officer Chris Milne Gary Moorhead Subscription Manager WHICH SPORTS MEDICINE CONDITIONS ARE NSAIDS AND CORTISONE Ken Warwick INJECTIONS USEFUL FOR? 11 Advertising Manager The question to ask –”Do I really want to shrink tissue?” Lesley Crompton Design/Typesetting John Orchard Whalen Image Solutions SPORTS INJURY PREVENTION – WHAT’S IT GOT TO DO WITH PHYSICAL SMA STATE BRANCHES ACTIVITY AND HEALTH 13 ACT Physical activity related injuries – uniting physical activity promotion and ACT Sports House, 100 Maitland St Hackett ACT 2602 Tel: (02) 6247 5115 injury prevention to ensure safe active environments for all New South Wales Caroline Finch PO Box 3176 Rhodes NSW 2138 Tel: (02) 8116 9815 SPORTS INJURY PREVENTION AT THE 9TH WORLD CONFERENCE ON Northern Territory INJURY CONTROL AND VIOLENCE PREVENTION 14 PO Box 2331, Darwin NT 0801 Tel: (08) 8981 5362 Bringing together the “Who’s who” of injury prevention and control, Queensland research, policy and practice from around the world Sports House, 150 Caxton St, Milton QLD 4064 Tel: (07) 3367 2700 Caroline Finch South Australia PO Box 219, Brooklyn Park SA 5025 ACL PREVENTION IN NORWAY AND AUSTRALIA 17 Tel: (08) 8234 6369 Raised hopes that the researchers who specialise in intrinsic risks for ACL Victoria and Tasmania injuries are actually on to something. Sports House, 375 Albert Rd, South Melbourne VIC 3205 Tel: (03) 9674 8777 AFL INJURY REPORT: SEASON 2007 23 Western Australia Head and neck injury incidence was at an all-time low in 2007 PO Box 57, Claremont WA 6010 John Orchard and Hugh Seward Tel: (08) 9285 8033 EPODE 29 SUBSCRIPTION RATES 2008 A review by a Sports and Paediatric Dietitian Australia A$35 Overseas A$50 Tanya Lewis SMA members receive Sport Health as part of their membership fee 2008 CONFERENCE PROGRAM AND REGISTRATION FORM 33 Single copies and back copies A$15 (includes postage) A SLAP ON THE SHOULDER 36 PP No. 226480/00028 SLAP lesions are being seen as an almost essential lesion of the athletic shoulder For subscriptions contact Ken Warwick Rod Whiteley Phone: (02) 6241 9344 Email: [email protected] Cover photograph: Photos.com FROM THE CEO Doing the Right Thing

By Gary Moorhead

At some stages in most people’s lives, there are more than 15,000 community to sporting organisations, schools and choices have to be made between volunteers working in sport with current individuals in all parts of Australia. (To actions that will provide material benefit SMA Sports Trainer accreditation. As a download or view the complete resource and “the right thing” – which might volunteer program there is a high level list see http://www.smartplay.com.au). be something completely different. A of attrition and a constant need to train So what impact have we had? The complicating factor is that sometimes the more Trainers. In the last 12 months, struggle to provide an accurate answer distinction can be blurred. For example, SMA branches put a record number of to this question is one of the prime it’s a fine line between minimising your people through courses (more than five motivators behind a renewed “do the taxable income and outright cheating on and a half thousand). right thing” campaign by Sports Medicine your taxes. While “doing the right thing” and Australia to raise the quality of sports In the provision of health services, teaching and promoting sports injury injury prevention in Australia. there often exist situations where a prevention is no doubt reducing the There are many anomalous aspects to profession actively promotes policies number of potential injuries, there is a sports injury that impact adversely on and practices that in the long run have positive quid quo pro in the process for developing a national all-encompassing the potential to “hurt business.” But they SMA members. A basic ethos of sports approach to prevention. In terms of do it anyway because it is “the right medicine is the “team approach” to allocating responsibility at a government thing”. Dentists promoting fluoridation of treatment, with all relevant professions level, recognition of sports injury as water supplies is one obvious example. making a contribution from their area an issue has suffered because while Health professionals involved in the of expertise. Sports Trainers have the incidents and events that cause the treatment of sporting injuries promoting always been embraced as part of injuries largely lie under one department injury prevention is another. Sports the sports medicine team - the “team (Sport) the costs that are an outcome of Medicine Australia (SMA) members fit behind the team”. This has one direct the injuries lie under another (Health). squarely into this latter category, with the benefit to SMA members in that Sports In fact, in recent years this situation added “right thing” of also advocating Trainers provide a reliable referral has received some recognition with all sport and physical activity for their stream of injured players under their support for sports injury prevention at a health promoting/disease preventing care. Anecdotally, many physiotherapy national level in Australia coming from qualities.(For an absolute belting of practices have been built from service the Department of Health and Ageing. another group with possibly different with local sporting clubs to teach skills to In a number of state jurisdictions, most approaches here, read Dr J in this same the club Sports Trainers that led to a later notably Victoria, there seems to be a issue of Sport Health.) referral stream for the physio. greater level of sharing responsibility Sports Medicine Australia and SMA Sports Medicine Australia has also between health and sport departments members have always been at the supported sport in Australia by the and departments of sport and recreation. forefront of campaigns and policies provision of expert advice, policies In the wider area of recreational physical aimed at reducing the incidence and guidelines for safety. These activity and health promotion through and severity of injury in sport and policies and guidelines are constantly physical activity, for many years, injury recreational physical activity. The Safer updated to take into account the latest consequent of this activity was very Sport Program – the Program through research and best practice. This year much an “elephant in the room” – don’t which SMA members turn community SMA has released updated guidelines mention it because it might embarrass or volunteers into Sports Trainers by for preventing injury in hot weather upset. The most extreme manifestation teaching them sports first aid and injury and revised comprehensive “Safety of this attitude was a “promoting injury prevention and thereby providing Guidelines for Children in Sport. prevention will put people off activity” sport in Australia with a unique safety (download at http://www.sma.org.au/ viewpoint. Fortunately, in this country infrastructure – turns 25 this year. (It information/resources.asp ) In addition, at least, there seems to have been a should also be acknowledged that this with assistance provided by a grant breaking down of the barriers between Program has always had some level of from the Commonwealth Department of physical activity promotion and injury government support at either state or Health and Ageing, SMA has been able prevention and recognition by promoters federal level and has had 25 years of to extend the community sports safety of both that the two are closely linked. unbroken support from medical supplies program “Smartplay” nationally. This SMA can take some credit for this by company Beiersdorf.) At the moment means Smartplay resources will be able our promotion of injury prevention and

2 Sport Health FROM THE CEO

physical activity conferences concurrent The Statement will attempt to gather Dr John Orchard and Journal of Science with the SMA national conference. wide support from health and sport and Medicine in Sport (JSAMS) editor, sector organisations for its proposals. To Professor Caroline Finch. Dr Orchard, But failure to recognise the significance date, these include: a Sydney-based Sports Physician with a or potential danger of sports injury is background of practice with both elite no respecter of background. Despite • A national system for monitoring and Australian Rules and Rugby League the plethora of research articles in injury preventing sports injury. football has a long history of working citing the peak danger times for injury • The establishment of a federally- with injury prevention campaigns. For as being when one is beginning or funded body (resourced by both many years he has been one of the recommencing training for a sport or Departments of Sport and Health) authors of the injury report for both the returning from injury, or when one over- to undertake this surveillance and AFL (see elsewhere in this issue) and trains and overdoes it, there have been a prevention task. The rationale for Cricket Australia and he also maintains number of instances where this message federal funding (apart from the fact the legendary www.injuryupdate.com. does not seem to have got home with that it needs to be a national body) au website. Professor Finch is one prominent members of SMA. In recent is that the Federal Government bears of the world’s leading sports injury months we have had the following the bulk of sports injury costs through epidemiologists and probably has a mishaps: Medicare, private health insurance million frequent flyer points earned by • A former national office holder with rebates and hospital subsidies to state attending conferences as a major speaker 20 years in elite sport deciding to governments. on sports injury. There are two reports prepare an aging body for overseas • Initial establishment of programs to: on sports injury prevention elsewhere in trekking by embarking of a daily • Expand the Australian Spinal Cord this edition by Professor Finch. exercise program. Only problem, Injury Register to include a specific If anyone is interested in contributing to as a busy man, he couldn’t manage section on sports injury based on the the campaign, they should make email daily so decided to cram the whole New Zealand model. contact with the author. program into two sessions a week. • Create a national knee Anterior Result? Stress fractures in both feet! Gary Moorhead is the Chief Executive Cruciate Ligament (ACL) register based Officer of Sports Medicine Australia. • A senior manager with direct on the Norwegian model. responsibility for injury prevention • Promote increased mouthguard use. [email protected] programs decides to take up touch football in his forties. Result? Snapped • Compile de-identified injury data from Achilles in his first game! insurers and hospitals. • A long standing sponsor has a surge While there may be some debate about of youthful adrenalin and decides to the choice of these specific programs as the lead-off priorities for the Campaign, return to soccer after a 10 year lay-off. Discipline Group News Result? ACL! there are strong arguments in their favour. Without data collection and The point of these sadly amusing Australian Physiotherapy measurement, we will have no idea anecdotes is that they underscore the Association - Sports of what is working and what is not. importance of getting a balanced level Without adequate resourcing and data Coming up… of injury prevention information into all collection powers, a similar negative Orthopaedic Physiotherapy programs promoting sport and physical outcome is likely. Promoting increased Joint Relations 2008 activity – most particularly those targeting nd mouthguard use will bring in strong 22 August 2008 an older population. There is no doubt partnership support from the Australian Bond University, Gold Coast that the baby-boomers will increasingly Dental Association and mouthguards Ph: (07) 3423 1553 embrace returns to sport and activity are an injury prevention device with as they try and stave off the effect of a proven track record of success. As National APA Aquatic ageing. If we don’t “do the right thing” with all safety equipment, there are Physiotherapy Symposium and make sure they are forewarned arguments mounted against mandating Current Practice – Future Direction about the dangers and forearmed with their use because of the potentially 30-31 August 2008 the right information, sports medicine negative effects on costs of participation Royal Perth Hospital practitioners – and the health system and participation numbers per se. Seat Ph: Karen Guy (08) 9389 9211 – will be choked with crocked oldies. belts added to the cost of cars and were (And yes, I have fallen off my bike twice seen as an attack on civil liberties when Australian college of Sports since returning to cycling after a 30 year their installation and use was first made Physicians lay-off!) mandatory. The next edition of Sport 3rd Football Australasia Conference For the new SMA injury prevention Health will contain a detailed expansion 23-25 October 2008 campaign, the initial focus will be on the on the Consensus Staement and Telstra Dome, Melbourne publication of a “Consensus Statement argument for the other proposals. Ph: 1300 799 691 about Sports Injury Surveillance and Two of the prime movers of this Prevention in Australia.” (see following) campaign are National Board member

VOLUME 26 – ISSUE 2 • WINTER 2 0 0 8 3 D R J Will the AMA ever embrace sports and exercise medicine? Dr J

One of the internal sayings of the AMA the camel’s back for me was a dinner going to happen. The question was: did (Australian Medical Association) is that they were holding in Sydney for my own representative organisation, the apparently that “all doctors are members members to celebrate the Olympics. AMA, actually support the recognition of the AMA – it’s just that some choose I had replied to an invitation for the of sports medicine as a specialty? The to pay their membership fees and others dinner, well before the RSVP date. answer was, sadly, in a word “no”. To don’t.” What they mean by this is that The week before the dinner I arrived add insult, they had the audacity to the AMA is the representative body for home to find a voice mail message on write, “the AMA supports all doctors, not all doctors and they will work for you my answering machine from the AMA, only just those in recognised specialties, whether you are a paid up member or which said words to the effect of “too but also doctors like yourself who not. Unfortunately this is only half of many doctors have RSVP’d to the dinner haven’t undertaken any recognised the truth. It’s true that whether you have function, so we are sorry to tell you training”. In other words, their opinion paid you membership dues is irrelevant. that you can no longer attend”. That (in the year 2000) is that my training The false bit is that they represent all got me thinking, if they are prepared to meant jack and that I may as well have doctors. Unfortunately there is a time- give me the rubber glove treatment as cut out my Fellowship of the ACSP off honoured hierarchy at the AMA, with an individual member without being in the back of a cornflakes packet. They surgeons and other proceduralists at the slightest bit concerned about it, is it didn’t recognise it and they didn’t care the top, followed by non-procedural possible that I am sitting by idly while to inquire whether it was even worth specialists with GPs a long way down they do it on a larger scale to the entire recognising. However they still pointed the food chain. Sports physicians rank specialty of sports medicine? The dinner out that they wanted to represent me right down the bottom at the AMA, along was to celebrate the Olympics and as a as a “doctor-without-any-training”. I of with doctors who trained overseas. The sports physician I was being de-invited course took the only dignified course AMA will defend to the death the right because I obviously was on their list of of action and resigned, vowing to never of surgeons to generate Medicare rebates “less important” members. I would have again consider membership until the for procedures that have been shown bet my house that they weren’t calling AMA fully recognised my training. not to work, or, alternatively, the right up surgeons to tell them not to attend Paradoxically, I have maintained a very of a surgeon who has been successfully the dinner. If they couldn’t value a sports good relationship with their flagship sued dozens of times not to pay an physician as an important member journal, the Medical Journal of Australia. increased liability premium. However, if to look after at a dinner function Fortunately the MJA appears to have you are a sports physician trying to get celebrating sport and medicine, when complete editorial independence (as the advanced four year training program would they ever value me as a member? all good peer review journals do) and that you completed a decade ago I wrote the AMA a letter. I explained has published many sports and exercise recognised by Medicare, then the AMA that I had been a member for my entire medicine articles over the last decade. will brush you off as a non-concern, medical career and that I believed that, I have written a few myself and have whether you are a member or not. all other things being equal, that I should been called upon to review quite a few For balance, I should declare my be a member of the AMA. I briefly more. In fact the MJA currently has 55 personal history with the AMA. I joined mentioned my annoyance at being sports medicine articles in its online the AMA as a medical student in the snubbed at the dinner but then cut to archives, more than any of anaesthetics, 1980s and was a member for my first the chase. I stated that far and away my dermatology, ENT surgery, occupational ten years as a doctor, resigning in 2000, biggest personal issue in medical politics medicine, ophthalmology, orthopaedic shortly after the Sydney Olympics. I was that the Federal government did not surgery, plastic surgery, pathology, believed in the 1990s, as many sports properly recognise my area of specialty, rehabilitation medicine, renal medicine, physicians still do, that the only way to which was sports medicine. Many in my urology or vascular surgery. The irony properly effect change is from within. profession had believed that the Sydney is that the MJA certainly considers By being a member you can vote and Olympics would be the watershed sports medicine to be a specialty area of make internal representations. It is moment when it would become medicine. However its parent body the almost a truism that the AMA should glaringly obvious to the government AMA, like the Medicare system, still does listen to their own members more than that sports and exercise medicine must not appear to consider sports medicine they should listen to outsiders. Why be considered an important specialty in to be a fully legitimate medical specialty. then did I resign? The straw that broke this country. It looked as if this wasn’t In the AMA’s schedule of recommended

4 Sport Health D R J

fees, they recommend that sports has been appalling. The AMA also rates didn’t get a mention. This should be physicians work in only the area of their time as being worth far less than core business for the medical profession sports medicine (as ‘non-specialists’ specialists, with no exception made for and it is amazing that the AMA doesn’t in this area) and charge at a rate far GPs who have undertaken extensive strongly promote exercise prescription. lower than other similar specialists. further education such as Masters or True to form, when it came to the The Medicare system also treats sports PhD degrees. According to the AMA, AMA’s requested changes to the medical physicians in a similar fashion, but if you are a GP this status itself makes system to combat obesity, the AMA at least there are no fee caps under you a less worthy medical practitioner reverted to type as a trade union for Medicare and you can charge what you than a specialist, just as being a sports the proceduralists. Sports and exercise like. The AMA actually does do a deal physician makes you less worthy. It is medicine physicians, exercise physiol with the Worker’s Compensation body one thing for Medicare to not want to ogists, physiotherapists, dieticians and in my state, NSW, to cap all doctors fees pay more, but another for your so-called GPs (and their government funding, at the rates set by the AMA (other than representative body to say that you are or lack thereof) didn’t rate a mention surgeons, not surprisingly, who can worth less than other doctors. I recall in the obesity position statement. But charge above the already lucrative rate). the AMA being part of a relative values bariatric surgeons and bariatric surgery So, whether you are a member or not, study in the 1990s which, amongst did get highlighted and in fact the AMA the AMA still looks after you if you are other things, suggested that specialists called for greater funding for these a surgeon and shafts if you are a sports had greater practice expenses than procedures, including funding for more physician. GPs because they had to drive cars like surgeons to be trained in performing BMWs whilst GPs only had to drive them. Newer forms of bariatric surgery Another example of the disgraceful around in Holden Barinas. (the “laparoscopic band” procedures) treatment of sports physicians by the are certainly the most effective way at AMA was the plan that it mapped out The AMA would not for a minute be reversing super-obesity, but equally with the Howard government (shortly concerned about the fees of non-doctor surgery is not the ‘big picture’ answer before its tragic demise) to give GPs sports medicine practitioners such as for getting the majority of the population access to a limited number of MRI physiotherapists, dietitians, physiologists exercising more. scans (e.g. knee) under Medicare. This or podiatrists, and perhaps nor should is a sensible and legitimate request. they be. But they can be counted With releases like the “Position Statement However, the ALP is far less beholden upon to argue that the government on Obesity”, the AMA is trying to create to the AMA and, as such, it is still doesn’t take a cent out of the pockets the appearance it has evolved from a unclear at the time of writing whether of procedural specialists to support any trade union for procedural specialists Nicola Roxon is going to follow-through of them. The AMA staunchly upholds to a responsible body promoting better with this plan. At the moment, only a Medicare system that funds surgery health for society, but has it really gone ‘specialists’ can order knee MRI scans for patellofemoral pain rather than the whole way? It is certain that the under Medicare and the AMA and physiotherapy and surgery for plantar Royal Australasian College of Surgeons Medicare agree that sports physicians fasciitis rather than podiatry. In other (RACS) would have had some input into aren’t specialists. The deal would have words, the AMA’s vision of a Medicare the AMA’s position statement and call meant that the only recognised doctors utopia is one that funds treatment based for extra surgical funding. It is equally that wouldn’t be able to order knee MRI on the status of the practitioner rather certain that the AMA didn’t consult SMA scans under Medicare would be sports than what actually works for the patient. or the ACSP in drafting the statement. physicians. It is ironic that I have written If SMA were consulted, they would Last but not least, the AMA seems to an article in the AMA’s journal, the MJA, have recommended highlighting the have a relative blind spot on the public on the appropriate use of MRI and other positive messages - exercise and health radar with respect to the value radiology in sports medicine, but I still healthy eating - with less highlighting of exercise itself. To its credit, the can’t order an MRI under Medicare. As of the negative end product, obesity. AMA has been more active with policy far as I am aware, the AMA has never This tends to lead to finger-pointing, statements in recent years in areas such had any concern that sports physicians which was the hallmark of the Howard as smoking, indigenous health and can’t order musculoskeletal MRI scans approach that abdicated government nutrition. The AMA released a “Position under Medicare and has never made responsibility. The AMA’s position Statement on Obesity” in early 2008 any representations to have this anomaly statement is in contrast to an American which has some welcome and timely corrected. program entitled “Exercise is medicine” suggestions, including extra taxes and (www.exerciseismedicine.org). This is a Obviously sports physicians only bans on the advertising of junk food to joint venture of the American Medical represent a small percentage of SMA’s kids. Included in this statement the AMA Association and the American College of members and hence a small part of made brief comment on physical activity, Sports Medicine (ACSM), the analogous the broader field of sports and exercise echoing the recent logical calls for better body to SMA. While the USA hasn’t medicine as a whole. Not surprisingly, urban planning to encourage incidental got all of the answers for obesity, at the AMA’s approach to the broader everyday physical activity. Surprisingly, least this campaign has got the primary family of sports medicine practitioners the phrase “exercise prescription”, which focus where it should be - on exercise is no better. Those doctors who are not is health professionals recommending prescription. sports physicians are mainly GPs and exercise to their patients, either in the AMA’s attitude to them historically addition to or in lieu of medications, >> to Page 9

VOLUME 26 – ISSUE 2 • WINTER 2 0 0 8 5 We put our heart & ‘sole’ into providing your patients with the perfect fit.

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>> to Page 22

VOLUME 26 – ISSUE 2 • WINTER 2008 7 CONSENSUS STATEMENT Draft Consensus statement about Sports Injury Surveillance and Prevention

in Australia By John Orchard, Caroline Finch & Gary Moorhead

This statement is in draft form only, for us to fall further behind world’s best financial incentive for sports to fund discussion and response. It is hoped that practice in this area. We are in a injury surveillance given the reality it can be amended by stakeholders over strong position to copy some or all of that government institutions (along the following months to a version where the system(s) of our close neighbour with individuals) pay for most of the multiple sports medicine and sporting New Zealand. Popular sports in cost of sports injuries. The costs of bodies in Australia would be prepared Australia are also popular in New sports injuries in Australia, whilst not to agree to it. Please direct any feedback Zealand, which has had a national specifically known, are substantial. to John Orchard via SMA at lesley. sports injury surveillance system in In New Zealand the costs of sports [email protected] . place for many years. As a result, New injuries actually exceed those of Zealand is far more advanced than traffic accidents 14. In Australia, traffic 1. The rationale for sports injury Australia in successfully achieving accidents are known to cost A$17 prevention as an important sports injury prevention12. Other billion annually 15. In Switzerland, a contributor to fighting inactivity. countries, in particular those of country with one third of Australia’s Inactivity will soon surpass smoking Western Europe and Scandinavia, population, there was an annual cost as the most costly preventable risk currently have much more advanced for sports injuries in 2003 of €1.3 factor for premature death in Western systems than Australia6. billion with indirect costs being €8 countries 1. Despite this, up to 16 3. The Federal government is billion and with 5.6 million working 50% of the potential health gain of the most appropriate body days lost. Extrapolating from these increased sport and exercise may be to coordinate sports injury recent figures it is very likely that lost because of the effects of injury previous calculations of the costs of 2 prevention. The Federal . Therefore sports injury prevention government, through its Department sports injuries in Australia were gross is a critical component to successful of Health, is in the best position to underestimations. The total annual 3-5 exercise promotion . An increasing set up and fund a national sports cost of sports injuries in Australia number of countries are recognising injury surveillance and prevention would be likely to exceed A$10 this important link and establishing body 6 11 13. This could follow the billion. or improving national sports injury New Zealand (or Scandinavian) 4. The benefits, even in the short 6 surveillance systems . Preventing model, where a government funded term, would easily outweigh the obesity has just been announced body (as opposed to the multitude costs of improved sports injury as a new National Health Priority of sports) is responsible for national prevention in Australia. Sports 7 Area in Australia . Injury prevention coordination of sports injury data. In injuries are already very costly for the and control is already one of the Australia the Federal government is Australian health system and for the seven established National Health the body which bears the greatest individuals who suffer from them. It Priority Areas, although within cost of sports injuries 13 (through, would be even more costly for the this category, sports injury is not collectively, Medicare, private health Federal government to compensate currently considered8. The nexus insurance rebates, and indirectly sports injuries to the level evident in between there two areas should through public hospital subsidies to New Zealand. This would require no longer be ignored. Preventing state governments). Therefore the careful consideration of the huge sports injury should also be seen as Federal government would potentially costs involved and the relative a national priority with respect to have the most to gain financially from benefits. However, in the interim, a both categories: avoiding injury and successful sports injury prevention, as surveillance and prevention body preventing inactivity and obesity. has been the case in New Zealand 12. could be created with a significantly 2. Australia does not currently follow There are very few sports in Australia, more modest budget. It is likely that world’s best practice in sports if any, which would be wealthy such a body would demonstrate, 12 injury surveillance. Australia has no enough to be able to fund their own as in New Zealand , cost savings national system for monitoring and national injury surveillance schemes to the government (far exceeding preventing sports injuries 6 9-11. This as the vast majority of people playing implementation costs) from programs deficiency, whilst it persists, is causing sport are amateurs. There is also little such as:

8 Sport Health CONSENSUS STATEMENT

a. Coordinating expansion of the References: >> Dr J from Page 5 Australian Spinal Cord Injury 1. Mokdad A, Marks J, Stroup D, Gerberding J. Actual Register (ASCIR) 17 to include a causes of death in the United States, 2000. JAMA The Australian Medical Association, by 2004;291:1238-1245. contrast, perhaps wants the focus on section which reports annually on 2. Platen P, Henke T. Joint initiative on sports injury spinal injuries specifically in sport, prevention. Bochum, Germany: Eurosafe, 2007. obesity rather than exercise, because reflecting the success New Zealand 3. Bauman A, Armstrong T, Davies J, Owen N, it fits in nicely with advocacy for Brown W, Bellew B, et al. Trends in physical procedural specialists. If our AMA has had in prevention of spinal activity participation and the impact of integrated cord injury in sports such as rugby campaigns among Australian adults, 1997-99. Aust N wants to cross the road completely to Z J Public Health 2003;27:76-9. becoming socially responsible in the area union 18-20. 4. Finch C, Owen N, Price R. Current injury or disability as a barrier to being more physically of exercise/obesity/nutrition, the next b. Creation of a national knee active. Med Sci Sports Exerc 2000;33:778-782. time it does a release it could consult Anterior Cruciate Ligament (ACL) 5. Finch C, Owen N. Injury prevention and promotion of physical activity: what is the nexus? J Sci Med sports and exercise physicians and registry, modelled on the successful Sport 2001;4(1):77-87. SMA, as well as the College of registries in the Scandinavian 6. Orchard J. Preventing sports injuries at the national Surgeons. Perhaps the best slogan for 21 level: time for other nations to follow New countries . This could use data Zealand’s remarkable success. British Journal of their current campaign on obesity, from Medicare and public and Sports Medicine 2008;42(6):392-93. 7. Roxon N. Obesity a National Health Priority Area which sums up the entire attitude of the private hospitals. ACL injuries under a Rudd Labor Government: http://www.alp. AMA to exercise, would be “Exercise perhaps account for 10% of the org.au/media/1107/mshea201.php, 2007. your right to have an operation”. It is cost of all sporting injuries in 8. AIHW. Injury prevention and control: http://www. aihw.gov.au/nhpa/injury/index.cfm, 2005. sad that, to date, the AMA certainly Australia and therefore should be a 9. Orchard J, Coates J, Moorhead G. How a national hasn’t embraced sports and exercise priority for prevention. A substantial sports injury body could work in Australia. Sport Health 2007;25(4):11-14, 23, http://www. medicine. Shunned is a more apt proportion (estimated at over injuryupdate.com.au/images/research/NSIbody.pdf. description. Given that the AMA has 20%) of the 25,000 or more knee 10. Orchard J, Finch C. Australia needs to follow New Zealand’s lead on sports injuries. Medical Journal of lost its cushy relationship it had with replacements performed annually Australia 2002;177:38-39. the Howard government, it might need in Australia have their genesis in 11. Orchard J, Leeder S, Moorhead G, Coates J, Brukner P. Australia urgently needs a federal government to start looking at ways to re-invent ACL injuries. body dedicated to monitoring and preventing sports itself somewhat (rather than the time- injuries. Medical Journal of Australia 2007;187:505- c. Creation of a program to 506. honoured plan A of just campaigning for substantially increase the rate 12. Gianotti S, Hume P. A cost-outcome approach to a Coalition government). An important of mouthguard usage in contact pre and post-implementation of national sports injury prevention programmes. Journal of Science item on its agenda should be to assess sports, by encouraging rule changes and Medicine in Sport 2007;10(6):436-46. why it has treated an entire branch of and perhaps targeting a rebate for 13. Finch C, Hayen A. Government health agencies need to assume leadership in injury prevention. doctors as outcasts over the last 15 years. dental injury treatment for those Injury prevention 2006;12:2-3. If Medicare finally recognises sports players who are injured whilst 14. Influencing government policies that impact on physicians as specialists, the AMA may sport injury prevention - the implementation of wearing a mouthguard. This would the New Zealand Injury Prevention Strategy. 2nd well follow suit (and how ironic would also replicate the success of New World Congress on Sports Injury Prevention; 2008; it be that the medical union would lag Tromso. Zealand in increasing mouthguard 15. Connelly L, Supangan R. The economic costs of behind the government in this regard?). usage 22. road traffic crashes: Australia, states and territories. Accid Anal Prev 2006;38:1087-93. There are many more bridges that will d. Compulsory compilation, in return 16. Bruegger O. Costs of sports accidents to the Swiss need building before the AMA can be for a fee, of de-identified injury data National Economy [abstract]. British Journal of Sports Medicine 2008;42:495. considered at the forefront of exercise from those bodies which already 17. Cripps R. Spinal cord injury, Australia, 2005-06. medicine. Given that lack of exercise collect sports injury data in Australia Australian Institute of Health & Welfare: Flinders University, 2007:http://www.nisu.flinders.edu. is now Australia’s largest preventable (private health and sports insurers au/pubs/reports/2007/injcat102.pdf. predictor of ill-health, it is still obvious and public hospitals). This data 18. Quarrie K, Gianotti S, Hopkins W, Hume P. Effect of a nationwide injury prevention programme on that the AMA’s prime concern is the would form the basis of an annual serious spinal injuries in New Zealand rugby union: welfare of doctors who make lots of report into trends regarding sports ecological study. BMJ 2007;334:1150-53. 19. Noakes T, Draper C. Preventing spinal cord injuries money out of illness. injuries in Australia. in rugby union. Other countries should follow New e. Arising out of item d., recommend Zealand’s lead. BMJ 2007;334:1122-3. 20. Haylen P. Spinal injuries in rugby union, 1970-2003: and activate research and lessons and responsibilities. Medical Journal of prevention based on annual Australia 2004;181(1):48-50. 21. Granan L, Bahr R, Steindal K, Furnes O, statistics of sports injury in Australia. Engebretsen L. Development of a National Cruciate Ligament Surgery Registry: The Norwegian National Knee Ligament Registry. American Journal of Sports Medicine 2007:Nov 7; [Epub ahead of print]. 22. Quarrie K, Gianotti S, Chalmers D, Hopkins W. An evaluation of mouthguard requirements and dental injuries in New Zealand rugby union. British Journal of Sports Medicine 2005;35:650-654.

VOLUME 26 – ISSUE 2 • WINTER 2 0 0 8 9 ANTI INFLAMMATORY DRUGS Anti-inflammatory Drugs – Their Role In Sports Medicine: A personal viewpoint By Chris Milne

Last year at the SMA conference in lysozyme release and neutrophil only 1.33. It will be no surprise to hear Adelaide I ran a workshop on the aggregation. At the cell membrane level, that those at greatest risk of vascular topic of NSAID and cox-2 agents in they alter ion fluxes. events were older people with adverse musculoskeletal injury. The session was vascular risk factors. The major publicity in the last decade well received and engendered a good or two has been around their toxicity; All of this publicity has led to a lot of level of debate and I was asked to repeat their efficacy is unquestioned. A lot scaremongering, in my view. Patients it again this year. Unfortunately, I cannot of the research effort has gone into have been paranoid about the use of be at the SMA conference on Hamilton making agents that are less toxic to these drugs and doctors have become Island and thought that this article would the upper GI tract. This is because pretty reticent about prescribing them. give wider exposure to this important dyspepsia on standard NSAID affects topic. What is the actual truth of the matter? about 10 per cent of people taking these As readers will be aware, anti- drugs. However, the vast majority of The largest meta-analysis of 138 inflammatory agents have been people with dyspepsia do not have any randomised control trials involving in widespread use for a variety of serious medical consequence of this. 145,373 people found that the absolute conditions since the development of There is a small minority of patients, risk of cardiovascular events, mainly aspirin in 1899. There are four common often with coexistent disease or who myocardial infarction, increased from clinical indications for use of these have had a previous GI bleed or are 0.9% per year to 1.2% per year across agents. taking corticosteroids, particularly those patient populations. This is a risk that over the age of 60, who can have more most people would not worry unduly 1. Inflammatory arthropathies, including serious GI bleeding and this can be fatal about. However, the media reported rheumatoid arthritis plus the in some circumstances. that the relative risk increased by seronegative arthropathies and crystal 42%, which is correct but gives ample arthropathies. Therefore, a lot of effort has gone into opportunity for scaremongering. This developing more “GI friendly” NSAIDs. 2. Osteoarthritis, which is more than data was published in the British Medical These agents selectively inhibit the cox-2 just a simple wear and tear disorder. Journal in 2006. Modern day thinking is that it is a enzyme which affects chondrocytes pan-articular inflammatory process and synovium, whilst sparing the cox- Since then there have been other and, therefore, the use of NSAIDs 1, or “housekeeper”, enzyme which side effects reported regarding other is entirely rational for osteoarthritis. maintains the mucous lining of the cox-2 agents. In particular, Vextra Moreover, our patients tell us that they stomach, among other things. However, (valdecoxib) was found to have adverse are more effective than paracetamol like selectivity for beta blockers, cox-2 skin reactions. More recently, Prexige despite what the published data selectivity is only a relative phenomenon. (lumiracoxib) was found to have adverse effects on the liver. Both of these side would tend to suggest. Importantly, cox-2 agents are no more effects were pretty uncommon but the 3. Soft tissue injuries with a significant effective than traditional agents and their regulatory authorities, in my view, were inflammatory component. This only advantage is that they are better overly cautious and withdrew both includes an effusion in a joint tolerated by the majority of people who of these agents from the market, thus following an injury or inflammatory experience dyspepsia on a traditional denying clinicians the opportunity to use conditions involving muscle or tendon NSAID. However, there is a small them in patients who may have gained attachments. minority of people who experience from their use, and in which other dyspepsia even on cox-2 agents. 4. Anti-inflammatory agents are effective agents had been tried and found to be analgesics in their own right and An additional feature of concern was unacceptable. have been particularly useful for the widely publicised data with regard All of this has led to a situation where post-operative and dental pain and to Vioxx (rofecoxib) which, when used clinicians often feel on the defensive headache. by doctors in the USA at a dose of 50mg with regard to use of NSAIDs. As we all Their mechanism of action has only daily, was found to have over twice the know, time is a commodity which is in been understood following the discovery risk of adverse vascular events. The short supply and rather than detail the of prostaglandins in the 1960s. The actual odds ratio was 2.19. However, in pros and cons of a particular situation, NSAIDs inhibit prostaglandin synthesis. the dosage used widely in Australasia, They also inhibit leukotriene synthesis, i.e. 25mg per day, the odds ratio was >> to Page 12

10 Sport Health ANTI INFLAMMATORY DRUGS Which sports medicine conditions are NSAIDs and cortisone injections useful for?

By John Orchard

One simple way to think about NSAIDs still a great indication for a cortisone an injection. If an ultrasound shows an and cortisone – which can help best injection or NSAID treatment (in intact rotator cuff, it is a green light for a identify the conditions where they superficial cases like these, gel may even cortisone injection into the subacromial are useful – is that they are tissue be preferable to tablets). space. Degenerative tendinopathy may “shrinkers”. By inhibiting inflammation, be an amber light with respect to an Where should NSAIDs and cortisone they also suppress the remodelling injection and a full-thickness tear may be injections be avoided? For degenerative part process involved in turning over a red light. conditions which involve delayed new tissue. Both NSAIDs and cortisone repair of an important tissue, cortisone Imaging may be helpful for determining therefore have catabolic (the opposite injections and even NSAIDs can be which muscle strains might be best of anabolic) properties. The question detrimental. Pure tendinopathies, treated with NSAIDs. A hamstring to ask yourself when considering particularly for heavy load-bearing tear proven on MRI scan may have its treatment with cortisone and NSAIDs for tendons like the Achilles, are a prime healing potentially delayed by NSAIDs musculoskeletal conditions is: “do I really example where the risks and detrimental and lead to a greater risk of recurrence want to shrink tissue?” If the answer effects of anti-inflammatory medications (http://www.richmondphysiotherapycli is yes, then these forms of therapy are may outweigh the benefits. Even in nic.com.au/hamstring_muscle_strain.pdf probably the best option. If the answer is fractures, animal (and some human) ) whereas a back-related hamstring may no, then traditional analgesics may be a studies strongly suggest that repair benefit and have quicker return to play better choice for pain relief. will generally be delayed by NSAID using NSAIDs. Which musculoskeletal conditions are use. Therefore, in acute injuries where It goes without saying that there are ideal for using NSAIDs and cortisone an important tissue is damaged, use many areas of the body where it is injections? For any process that involves analgesics in preference to NSAIDs. important to make a correct diagnosis nerve impingement they will be Similarly, in chronic degenerative (as before automatically reaching for first line therapy. The soft tissues (or opposed to inflammatory) arthritis, NSAIDs. Forefoot pain, for example, even bone) causing the impingement cortisone injections may lead to longer- might be caused by a metatarsal stress may be “shrunk” slightly by the anti- term harm even after good short-term fracture or Morton’s neuroma. Stress inflammatory effect, but nerve, being pain relief. For smaller joints like the fracture healing would probably be a very low turnover tissue, won’t be A/C joint or finger joints, the effect of decreased by the use of NSAIDs or directly affected by the anti-inflammatory a cortisone injection in relieving scar cortisone, whereas Morton’s neuroma action. The result is reduced pressure tissue may outweigh any damage to might respond very well and be on the nerve and, hopefully, better the articular cartilage, but equation may improved with their use. pain relief than you might expect swing around for an important large joint with a pure analgesic. Impingement like the knee. Even for areas where you should be conditions not involving nerves can also cautious with cortisone injections, there The extreme examples are easy to show great improvement with anti- may sometimes be good results. An advise on. The difficult or ‘grey’ zone inflammatory treatment – shoulder and excellent Australian study published in is when you have two competing ankle impingements, in particular, and the BMJ in 2006 shows that cortisone processes which mean the effect of conditions like iliotibial band friction injections are helpful for tennis elbow anti-inflammatory treatment could go syndrome of the knee. Conditions with (which is a tendinopathy) in the short- either way. A classic is in shoulder pain ectopic tissue like myositis ossificans term, but detrimental in the longer – a cortisone injection might help relieve (where calcium deposits are laid term. Reading this study makes you impingement, but if there is a rotator down in muscle following a ‘cork’) think twice about using cortisone in cuff tendon tear associated, it may also also respond well to anti-inflammatory this condition, although there will reduce healing and lead to extension treatment, used to ‘shrink’ the offending be circumstances where short-term of the tear. This is where investigation new tissue. True ‘bursitis’, like those seen improvement can be very important to may be helpful in the decision on using in prepatellar and olecranon bursas, is the patient whose long-term prognosis

VOLUME 26 – ISSUE 2 • WINTER 2008 11 FROMANTI INFLAMMATORYTHE CEO DRUGS

the line of least resistance is just to move these agents in all asthmatics which, Finally, empowerment of patients on and use some agent whose role is I believe, is irrational. However, involves giving them a choice and less controversial but which may, in such a flare may be serious so it providing them with an information itself, have lower efficacy. needs to be looked out for. sheet detailing at least some of the information listed above. By this Ultimately, the experience of the last In summary, most athletes can take means, the clinician can be assured five years is likely to lead to a lower rate standard NSAIDs without getting that the patients have access to relevant of investment in potentially innovative dyspepsia. For those who cannot, there background material and are not medicines in future and, thereby, a are three options: denied use of medicine that could be of lessening of the choice of medicines a. Use of paracetamol 500mg two tablets significant benefit to them. available to clinicians and patients. up to four times daily is the option It needs to be understood that the above What is a logical way through all of this? that no authorities would dispute. This agent is not associated with any is a personal viewpoint but, nevertheless, 1. I would advise clinicians to assess adverse GI effects unless taken in one that is shared by a large number (I the severity of the pain, i.e. mild, overdose, where it can have toxic might even say the majority) of clinicians moderate or severe. effects on the liver. who are well informed about the use of these agents. 2. They should ask about previous b. Use of a standard NSAID with a low adverse drug reactions and relevant GI toxicity profile, e.g. Ibuprofen medical history. Such reactions References: under cover of Losec (omeprazole). 1. Practical Management: Nonsteroidal include: Antiinflammatory Drug (NSAIDs) Use in Athletic c. Use of a cox-2, e.g. Celebrex Injuries a. Dyspepsia (burning abdominal (celecoxib) or Arcoxia (etoricoxib), Mehollo CJ, Drezner JA, Bytomski JR pain) with aspirin or other NSAIDs. however it needs to be understood Clin J Sport Med 2006; 16 : 170-174 2. Cyclo-Oxygenase-2 Inhibitors: Beneficial or b. Reduced blood flow to kidneys can that these agents are more expensive. Detrimental for Athletes with Acute Musculoskeletal occur on NSAIDs. Usually this is In the short term, e.g. one week for Injuries Warden SJ occult but it may present as fluid settling a joint effusion, this is not a Sports Med 2005; 35 : 271-283 retention in older people or those major consideration provided it is Chris Milne with borderline cardiac function. pointed out to the patient prior to is a Sports Physician them leaving the doctor’s office. c. A flare of asthma with NSAIDs is at Anglesea Sports Medicine rare but well publicised and, once Hamilton, New Zealand again, can put people off using

>> from Page 11 Alternatively, for the patient that has a place in the management of sports is good anyway. A high demand patient a solid medial ligament but is getting injuries and musculoskeletal pain. a lot of pain at the insertion (perhaps (ranging from a high level tennis player John Orchard is a Sports Physician, to a car mechanic who gets tennis elbow developing a Pellegrini-Stieda lesion) South Sydney Sports Medicine pain from work) is the type scenario to then NSAIDs and cortisone would be & Sports Medicine at Sydney be wary of injections. This sort of patient beneficial. University will still want to be loading the elbow in It is also worth remembering the 6 months time and won’t appreciate it if systemic side effects of NSAIDs in Correspondence: the cortisone “wears off”. particular. They increase the risk of [email protected] There are some patients who will swear gastric bleeding, increase blood pressure For further reading: by cortisone injections and NSAIDs for and can be harmful for patients with poor kidney function. The upside is that Bisset L, Beller E, Jull G, Brooks P, many conditions and others who claim Darnell R, Vicenzino B. Mobilisation with to get no effect even for conditions they reduce the risk of bowel cancer and reduce clotting. These factors can movement and exercise, corticosteroid where they aren’t meant to be as useful. injection, or wait and see for tennis This is part of the unknown zone help decide which patients should avoid (or may benefit from) NSAIDS. Cox-2 elbow: randomised trial. BMJ. 2006 Nov in medicine. Maybe certain patients 4;333(7575):939. have over-active repair systems which specific NSAIDs in general are better for regularly lay down excessive scar stomach and worse for heart. http://www.bmj.com/cgi/content/ tissue. These patients may do well with Even though NSAIDs and cortisone are full/333/7575/939 cortisone injections and NSAIDs for out of favour for certain conditions, like Paoloni JA, Orchard JW. The use of many conditions. Knee medial ligament tendinopathies and osteoarthritis, it is therapeutic medications for soft-tissue tears are one of many conditions in the fortunate that there are ‘newer’ therapies injuries in sports medicine. Med J Aust body that can alternately heal badly by out there as alternatives. Nitrate patches, 2005; 183: 384-388. being “too loose” or “too scarred”. For shock wave (lithotripsy), glucosamine the patient that is not laying down much and injections of polidocanol, glucose, http://www.mja.com.au/public/ scar tissue and has a medial ligament autologous blood, aprotinin, hyaluronic issues/183_07_031005/pao10246_fm.html that is not tightening up sufficiently, acid and even botulinum toxin may have avoid using NSAIDs and cortisone.

12 Sport Health INJURYFROM PREVENTION THE CEO Sports Injury Prevention – What’s it got to do with Physical Activity and Health?

By Caroline Finch

I was recently honoured to be a keynote environment factors. One of the most disability 6; this percentage is even higher speaker at the Second International important aspects of the physical in older people (e.g. 40% of 40 – 60 year Conference on Physical Activity and environment for physical activity is olds) and in people who are overweight Public Health, held in Amsterdam in its safety, both actual and perceived. or obese. About 5% of adults also cite April this year. There has long been a Ensuring that sports and recreation fear of injury as a reason for why they call, amongst sports injury researchers grounds, for example, are safe for don’t exercise more. This fear of injury at least, for the integration of safety sports play and more general physical has wider implications, with more than promotion with broader efforts to activity has immediate ramifications one in four parents having prevented or promote physical activity. In light of for the safety of individual participants discouraged their child from a particular this, the invitation to present at this and broader community-wide health. sport/physical activity because of safety conference was too good an offer for me Other safety concerns arise in relation concerns 7. to refuse. to settings for active transportation (e.g. An oft-cited reason for the lack of pedestrian areas and bicycle paths) and This paper summarises the key points integration of physical activity and sports the risk of inter-personal violence (e.g. of my presentation entitled “Physical safety strategies is that the word “injury” stranger danger or muggings) whilst activity related injuries – uniting physical associated with such activity may put being active. Physical activity promotion activity promotion and injury prevention some people off sport. However, it efforts are unlikely to be fully successful to ensure safe active environments for is clear from even the limited injury unless significant attention is therefore all”. Recommendations outlined in the statistics quoted above that this is not also given to addressing safety issues presentation for how this unification true. It is the actual experience of being across the full spectrum of physical could be achieved are listed in closing. injured and the subsequent fears that activity from general play to formal sport. arise from these experiences that are As long ago as 1996, the most influential The good news is that injuries are NOT the barriers to physical activity – not physical activity policy document, the US an inevitable part of participation and the mere mention of the word. With Surgeon General’s Report 1, recognised that any risk can be reduced/minimised health promotion approaches such injury as being the major negative or controlled by adoption of safety as SMA’s Smart play Program (www. consequence of increasing physical measures and policies 2. This means that smartplay.com.au) there is no doubt activity. At about the same time, the SAFE physical activity is a positive and that promotion of SAFE physical activity Australian Government recognised the achievable choice! attracts participants – ignoring the importance of sports safety to minimise Australian research has demonstrated “injury” word does not. It is surely time the risk of injury in sport 2. A very recent that injuries during sport are not a rare for physical activity promotion to also statement from Eurosafe 3, states that event, with about 5% of participants incorporate safety promotion strategies. more than 50% of the physical activity affected each year 4. Fortunately, the health benefits are lost due to injury. It To ensure SAFE physical activity, vast majority of these injuries are is somewhat surprising then, that the prevention and promotion measures minor in nature and do not require two fields of physical activity promotion need to be relevant, acceptable, adopted, significant treatment in a hospital setting and sports safety promotion have largely and complied with. Only research 5. Nonetheless, collectively they have evolved in isolation of each other. Being that can be adopted in practice (in the a significant public health impact with “injury free” is just as much a state of physical activity context) will prevent 27% of people sustaining sport/active good health as being of healthy weight injuries 8. This will require significant recreation injuries requiring some form or not having cardiovascular disease investment from BOTH injury and of medical treatment, 35 % adversely risk factors. It is time for efforts using physical activity experts in a united impacting on the injured person’s quality physical activity to promote health to approach. The actions that will need of life and 36 % impeding participation also promote being free of injury. to be taken over the next few years to in further activity 4. Overall, one in five achieve this include: Physical activity participation is adult Australians do not participate in influenced by both social and physical more physical activity because of injury/ >> to Page 16

VOLUME 26 – ISSUE 2 • WINTER 2008 13 CAROLINEINJURY PREVENTION FINCH Sports Injury Prevention at the 9th World Conference on Injury Control and Violence Prevention By Caroline Finch

The biennial, premiere international of effectiveness studies. Such studies This study is the first to compare the rate injury prevention conference (The would provide real-world assessment and patterns of acute injuries in these World Conference on Injury Control of whether or not interventions shown two wrestling styles in juniors. It has and Violence Prevention) was held to be efficacious would actually work led to some suggestions for possible in Merida Mexico in March 2008. As when implemented directly into sporting preventive actions in the two forms of usual, this meeting brought together the contexts. Dr Brent Hagel (University of the sport. Toomas Timpka presented a “Who’s Who” of injury prevention and Calgary, Canada) discussed the vexed study from PhD candidate,Stefan Backe, control research, policy and practice issue of whether or not the introduction which described injuries in competitive from around the world. The contexts of safety measures would lead to an rock climbers in Sweden. Overuse of injury discussed included sport and adverse change in user behaviour with injuries were the most common in this active recreation, the home, work, roads potential negative injury consequences. group of athletes. and other transport, natural disasters, He reviewed the literature specifically Another session describing advances violence and self-harm, amongst others. relating to the use of helmets by cyclists in injury surveillance provided an There was particular discussion about and skiers and wrist guards in sport and opportunity to present a detailed analysis capacity building for injury prevention, recreational activities. In doing so, he of the quality and completeness of new policy imperatives and directions, provided compelling conclusions about the 10th Revision of the International quality data collections and trauma the likelihood of any risk compensation Classifications of Diseases Australian management systems. Pre-conference that might occur. Prof Toomas Timpka Modification (ICD-10-AM) activity meetings also meant that the leading (Linkoping University, Sweden) codes, which are used to identify sports international injury surveillance and data introduced the recently established injury cases in routine collections of coding systems experts also attended. Sports Safe International (SSI) initiative health service data. I demonstrated as a global body for the promotion of This year’s conference included a very that it was possible that up to 1 in 5 sports safety. He concluded that all well attended Invited Symposium injury hospitalisations were for sports athletes have the right to well-being and “Sports Injuries: Challenges for Research injuries, after accounting for missing or health that can only be achieved by a and Action”, a proffered paper section incomplete sports activity codes. balance between sports industry needs and some posters. A number of other and safety-oriented scientific knowledge As is often the case with conferences, papers and posters at this conference and evidence-based actions. Finally, Dr some of the more interesting research were related to active recreational Claude Goulet (Laval University, Canada) was presented as posters. Yard and pursuits, largely associated with water- argued that sports safety initiatives colleagues (Columbus University, USA) based activities such as risk perceptions needed to be fully addressed within a described the use of real time injury in relation to drowning, recreational perspective of broader efforts aimed at surveillance to monitor injuries during boating and use of personal floatation promotion physical activity participation. high school sport. Timpka and his SSI devices. Following is a précis of the He stressed that latter are unlikely to be colleagues discussed the need for a presentations directly related to sports fully effective, if they continue to ignore global sports safety policy in another injury and their prevention. the potential for sports injury risk. poster. Timpka and Finch had a second The “Sports Injuries: Challenges for poster that explained the relationship Two proffered papers described injury Research and Action” began with my between the policy implications of patterns in two quite distinct sports. own presentation in which I argued health promotion versus sports safety Ellen Yard (PhD candidate, Columbus that sports injury prevention and approaches. Abbot and her colleagues University, USA) described injuries in safety initiatives would be significantly (Youthsafe, Australia) described the formal junior championships for freestyle progressed in the future if more formal evaluation of a training program and Greco-roman wrestling injuries. emphasis was given towards the conduct >> to Page 16

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Sports Medicine Aust.indd 1 2/4/08 10:35:08 AM INJURY PREVENTION

>> from Page 13 safety knowledge in relationship to References • The state of being “injury-free” needs transportation, the built environment, 1. U.S. Department of Health and Human Services. workplace safety as well as sports and Physical activity and health: a report of the Surgeon to be fully equated with being healthy General. Atlanta, G.A.: U.S Department of Health leisure. and Human Services, Centers for Disease Control so that when physical activity is and Prevention, National Center for Chronic Disease promoted for health gains, that the • There is a need for a shift in some Prevention and Health Promotion, 1996. prevention of injury is one of the sports injury research to include an 2. Finch C, McGrath A. SportSafe Australia: A national sports safety framework. A report prepared for health goals – delete from here i.e increased focus on a broad physical the Australian Sports Injury Prevention Taskforce. this is not just an issue in the sporting activity context (rather than just Canberra: Australian Sports Commission, 1997. 3. Eurosafe. Eurosafe Sports Safety Statement: http:// context, but there is the opportunity focusing on organised sport) www.eurosafe.eu.com/ 30/10/2007. for the sport and physical activity • Accordingly sports injury researchers 4. Finch C, Cassell E. The public health impact of injury during sport and active recreation. Journal of sector to lead efforts in this direction. will need to pay more attention to Science & Medicine in Sport 2006;9:490-497. • International, national and local understanding the particular contexts 5. Cassell EP, Finch CF, Stathakis VZ. Epidemiology of medically treated sport and active recreation injuries physical activity promotion efforts will of, and influences on, physical activity in the Latrobe Valley, Victoria, Australia. British need to acknowledge the potential and its associated injury risks and Jorunal of Sports Medicine 2003;37:405-409. 6. Finch C, Owen N, Price R. Current injury or for some injury risk and promote hazards disability as a barrier to being more physically proactive steps to minimise or remove active. Medicine and Science in Sports and Exercise • Sports injury intervention effectiveness 2001;33(5):778-782. (where appropriate) these risks. research needs to be well grounded 7. Boufous S, Finch C, Bauman A. Parental safety in the physical activity context, concerns – a barrier to sport and physical activity • Safety promotion needs to be made in children? Australian and New Zealand Journal of fully synonymous with physical particularly when interventions Public Health 2004;28(5):482-486. developed through working with 8. Finch C. A new framework for research leading to activity promotion, and vice versa, sports injury prevention. Journal of Science and from both injury prevention and high performance athletes or very Medicine in Sport. 2006;9(1-2):3-9. organised sports teams need to be health promotion perspectives. Professor Caroline Finch is a translated to, and adopted by, less • New collaborations between physical NHMRC Principal Research Fellow formal, or more community-delivered, activity and “sports” safety researchers, at the School of Human Movement activity settings practitioners and policy makers need and Sport Sciences, University of to be established. • Finally, until sport (in its organised Ballarat, Victoria, Australia forms) is recognised as being an • Effective partnerships will ensure that Correspondence: c.fi[email protected] a) safety promotion is fully understood important part of physical activity and and placed within the understanding health promotion efforts, it will be of the physical activity context hard for researchers working in this and b) physical activity promotion developing nexus area to publish their efforts adopt and capitalise on vast research in high quality journals.

>> from Page 14 they will not learn about innovative importance and quality of the sports aimed at encouraging soccer clubs to implementation and policy actions injury work that is undertaken within adopt how a risk management approach undertaken in other injury contexts that sports medicine circles. to sports safety. could then be translated for the benefits of sports safety. Importantly, the general Professor Caroline Finch is a For some reason that eludes me, injury prevention community will never NHMRC Principal Research Fellow this meeting continues to be poorly learn about the great work that is being at the School of Human Movement attended by people working in sports done in sports injury prevention and will and Sport Sciences, University of injury prevention – this is reflected, in rate both its importance as low and its Ballarat, Victoria, Australia part, by the range of presentations at general scientific worth as being lower Correspondence: c.fi[email protected] this meeting, as described above. This than that in other areas. conference is the major international source about new knowledge on the I personally, would not miss this biennial science of, and research methodologies conference because of the broad for, injury research and implementation. benefits to my own research program. If sports injury prevention researchers I would encourage many more sports do not attend it, they are unlikely to safety experts to consider attending be well-versed in the latest thinking the meetings in future years (the next about how to undertake injury research meeting will be held in 2010 in a place nor will they be exposed to new ideas yet to be confirmed). From a personal that could benefit research in our point of view, it would also be great specific area. Similarly, if sports injury to have many more voices than just practitioners do not attend the meeting, mine, and a couple of my international colleagues, singing the virtues of the

16 Sport Health ACLFROM PREVENTION THE CEO ACL prevention in Norway and Australia By John Orchard

The 2nd World Sports Injury Prevention is an intrinsic but non-preventable risk semitendinosus tendon to fire earlier in a Congress in Tromsø was a great factor. My personal interest has been side-stepping movement 3. Both of these opportunity to become aware of in researching some of the potentially- factors may contribute to decreasing the the latest advances in the field in preventable extrinsic risk factors for valgus force on the knee. It is promising both Norway and around the world. ACL injuries, particularly related to that to date the ACL rate in Norwegian Although many sports injury areas were surface type in outdoor sports. In this women‚s handball may have lowered 4 discussed, prevention of knee anterior sense I am unfashionable, in that the but no major change has yet been seen cruciate ligament (ACL) injuries is still vast majority of researchers in the in women‚s college sports in the USA rightly considered the Holy Grail. ACL field of ACL prevention are firmly such as basketball and soccer 5. injuries are common in many of the focused on studying the potentially- There is some recent published extrinsic world’s most popular sports and they preventable intrinsic risk factors. The risk factor data, not surprisingly also regular lead to knee osteoarthritis later Tromsø conference confirmed my coming out of Norway. Although I have in life. ACLs also disproportionately pessimism that extrinsic risks were argued recently that New Zealand is affect women. The rates of ACL injuries being ignored relative to intrinsic home to the world’s best nationwide appear to have been increasing, partly factors, but raised my hopes that the injury surveillance system 6, the greatest because women worldwide have been researchers who specialise in intrinsic volume of quality of specific studies are increasingly participating in change-of- risks were actually on to something. certainly arising out of the Oslo Sports direction sports in recent years. There seem to be an increasing number Trauma Research Centre (OSTRC). The of trials showing, almost exclusively Traditionally, ACL risk factors are Norwegians have found that wooden in females, that balance exercises can divided into potentially-preventable floors are less risky than artificial floors decrease the risk of ACL injuries 1. and non-preventable risk factors and for ACL injury in handball 7. They have Importantly, some of the mechanisms then into intrinsic (athlete-related) also compared ACL injury rates in by which these exercises work were and extrinsic (non-athlete-related) risk Norway for football (soccer) games on becoming understood. These included factors. As an example, female gender natural grass and artificial turf and found increasing reaction time 2 and getting the no significant difference between the two surface types 8. I attended a session in which one of the most recent papers was presented and asked the author/ presenters which types of natural grass were most commonly used on football fields in Norway. This question seemed to come from left field, so to speak, and neither of the presenters knew anything about natural grass other than it wasn’t artificial. To me this may be a critical omission of observation that may, sadly, lead to bad decision making up to the highest echelons in FIFA. There is no doubt that, in certain circumstances, artificial turf may be a ‘safe’ surface in soccer. However, I am concerned that these ‘circumstances’ might be cold weather and it may be a mistake to give artificial surfaces the green light in warm climates 9. Whether I am right depends on whether you believe the observational data from Europe in soccer Figure 1 – with Willem van Mechelen (Netherlands) under the midnight is a better predictor of outcomes in other sun in Tromsø climates than the observational data from

VOLUME 26 – ISSUE 2 • WINTER 2008 17 ACL PREVENTION

is seen in most years. seasonal changes for the third-generation ACL risk on natural artificial surfaces but I don’t have any grass will always reason to think the pattern would be drop as the season different to Astroturf. progresses unless there Hearing that new generation artificials is growth of new grass in Norway (Figure 3) were of equivalent (which happens in the ACL risk to natural grass, I spent much spring and summer and of trip trying to observe and guess which when new portable types of natural grass they were using on slabs are brought in sporting fields around Scandinavia. I was 14). Some grasses have suspicious that the Norway studies might intrinsically more lateral be comparing artificial surfaces at their growth and lead to best (in cold weather for most of the more shoe-surface year) to natural grass not at its best (i.e. traction than others. not ryegrass). My sample size was pretty Basically of the three small, was conducted in mid-summer Figure 2 – the old gravel surface used in arctic most commonly used only and my identification skills are not natural grass types climates for soccer games expert. However, I concluded that many around the world, sports fields in Norway probably use ryegrass has less lateral other forms of football. Even though a hybrid natural grass surface (Figure growth than the other two 13 and is more there is one study (with a small number 4; maybe fescues, Kentucky bluegrass, likely to result in lower shoe-surface of ACLs) from soccer in the USA 10, the poa annua and a bit of ryegrass thrown traction and lower risk of ACL injuries majority of warm-climate data on surface in). This might make identifying grass (Table 1). condition comes from other football types in Norway akin to identifying codes 11. I personally think it should The situation with artificial turf is grape types in France – difficult because apply for injuries categories such as ACLs different. Traffic doesn’t change the they mix it up so much. Maybe the in soccer. shoe-surface traction at all – if the researchers in Norway couldn’t answer artificial surface was cut up by traction my question about grass type is because In other football codes, rye grass has then it wouldn’t last! However, Astroturf it is such a tough one! The result though been found to have lower shoe-surface seems to lead to a much higher risk of was often a far bit of thatch (Figure traction than other grasses and lead ACL injury in hot temperatures than in 5) and potential for developing high to a lower risk of ACL injuries 12. With cold temperatures 9 15. It is notable that traction. It may be quite likely that the respect to all natural grasses, traffic the actual temperature of an artificial climate in Norway is too cold to support appears to be a protective factor (the surface (like sand at the beach) is much ryegrass and there may be issues with grass roots and lateral growth are cut closer to the ambient temperature in increased shoe-surface traction once a up, which tends to lower shoe-surface hot weather than it is for natural grass natural surface freezes. It might be that, traction) 13. Hence an ‘early-season’ bias (which can stay remarkably cool). In a in Norway, artificial turf in the most for most outdoor football competitions football competition with games played sensible surface for a soccer ground. is observed. Fans of the AFL will have on artificial turf over autumn to winter, noted that seven ACL injuries occurred What about a warmer climate, where this will also produce an early-season in the pre-season period this year but the the risk of playing on a third-generation bias (for slightly different reasons than rate of ACL injury has been much lower artificial surface might be a lot higher? the same pattern seem on natural grass). in the regular season, a pattern which I haven’t seen any soccer data from With Astroturf it is Africa, but I did hear at the conference, simply a matter of the off the record, than the latest NFL data temperature getting might be trending that way. I studied colder; with natural NFL ACL injuries in the Astroturf era and, grass it is the grass whilst this surface was minimally riskier thickness changing. than natural grass, it was a fairly close In temperate-warm comparison. If the NFL data is showing climates on natural the disparity between third-generation grass, there may artificials and natural grass is widening, actually be a change it is a bit of a bombshell. I only hope of grass type (from the that if these rumours are accurate that higher-risk Bermuda someone will come to a major sports to the lower-risk rye) medicine conference and present over the course of the findings (which didn’t happen in the season as well. Norway). As mentioned before, I hope Unfortunately I haven’t that FIFA doesn’t make the presumption seen any data about Figure 3 – artificial turf, a big improvement on that because artificial surfaces in Norway temperature and gravel for soccer in the deep north are safe that they also will be in Africa.

18 Sport Health ACL PREVENTION

Table 1 – relative risk for ACL injuries on the major natural grass species

Grass species Relative Preferred Common distribution risk for ACL climate injuries Kentucky bluegrass (poa Medium-High Cool and dry Northern USA, Canada, pratensis) – also known Continental Europe in UK as smooth-stalked meadow grass Rye grass (Lolium perenne) Low Temperate United Kingdom, New and humid Zealand, Japan, southern Australia & USA (winter) Bermuda grass (cynodon Medium-High Warm Northern Australia, dactylon) – also known in Africa, Southern Asia, Figure 4 – fairly thatchy hybrid Australia as couch. Southern Australia & grass from Tromsø in Northern USA (summer) Norway

One of the non-reversible risk factors have all had knee reconstructions in the from his patellar tendon traditional ACL for ACL injury is previous ACL injury. In past) will break into Sheahan’s Top 50. reconstruction a few years earlier, he particular, ACL injury to the contralateral However, no player has ever won the would have known first hand about the side is a known non-reversible risk. Re- Brownlow medal after having had an missed initial season and the slow return injury to the ACL graft is also known but ACL reconstruction. In the NRL it looks to good form in the season following. potentially modifiable and so is worth slightly better if you create a ‘Top 50’ To date (at the time of writing) his studying in more detail. For the non- group of players from those who have LARS treatment has been a success, in serious athlete, the best way to reduce played Origin or Test football in 2008. that he is already playing games that the risk of re-injury (both to graft, if used, Of these, Justin Hodges, Brent Tate, Joel he would have missed. We know that and contralateral side) and subsequent Monaghan and Ashley Harrison have the older artificial ligaments from the arthritis is to retire from high risk sports. come back from knee reconstructions. 1980s generally led to bad results in Therefore, many non-serious athletes But in all codes there are many players ACL reconstructions, but a good article may not need ACL grafts at all and, if who – even if they aren’t in the 10% from The Age reminded use that Doug they do require or elect to have ACL or so who re-rupture their graft – don’t Hawkins was actually an isolated major reconstruction, they are probably best return to the same standard of play after success with an artificial ligament from advised to seek a surgical technique with an ACL reconstruction. this era 16. We certainly need more than minimum morbidity. The serious athlete These fairly nasty statistics about the small number of 2008 cases to know who needs to keep playing is faced outcomes would have been prominent whether the new generation artificial is with the unfortunate reality that many in the discussions that the Swans had going to be a major advance. ACL grafts don’t hold up in difficult about the fairly radical option of a conditions. In the mid-1990s, particularly One lesson we can immediately take LARS (Ligament Augmentation and after David Schwarz suffered three ACL on board is that surgeons should look Reconstruction System) which they used injuries on the same knee (one primary acutely for preservation of the native for Nick Malceski. Even though he had and two graft ruptures) within 12 months ACL if it has only been torn or avulsed ultimately had a relatively good outcome the belief in AFL medical circles was (as opposed to completely ruptured) that perhaps the problem was that we were letting our players back too soon. However, sadly the rate of graft rupture in the AFL hasn’t improved from the mid-1990s to today despite the average player missing closer to 10 months than the 6 months which was the standard of the 1990s. Even more sadly, ACL injuries are a common cause of career stagnation or regression for the 6% of players who have had one. At the end of the 2007 AFL season, the only two players ranked in Mike Sheahan’s Top 50 who had previously had an ACL reconstruction were Cameron Mooney (no. 22) and Nick Malceski (no. 47). Perhaps at the end of 2008, Richardson, Didak, Hayes and Bradshaw (who Figure 5 – grass on a house in Western Norway with too much thatch?!

VOLUME 26 – ISSUE 2 • WINTER 2 0 0 8 19 ACL PREVENTION

at the initial injury. It sounds like in Justin Hodges had a patellar tendon ACL in early 2000, as the entire country Malceski’s case of 2008 that the LARS graft when at the Roosters and would considered that the injury had cost them ligament was used as a reinforcement of now be in the current top 10 players in a certain Gold medal. Like the genesis the intact part of his ACL. Another similar the NRL competition. I don’t know how of the AIS out of the grief of the terrible case that didn’t get as much publicity much knee pain he still gets, but I do Australian Olympic performance at was Daniel Giansiracusa of the Western know that the most important thing a Montreal, the politicians decided that Bulldogs, who injured his ACL in the professional rugby league centre would something needed to be done about 2008 preseason but apparently had want from a knee reco is to return to the ACL prevention and they funded the no reconstruction at all as the injured highest possible level. Another one of OSTRC. ligament looked as though it may heal our patella tendon reconstructions, Ryan My fi nal anecdote from the many I in a good position with conservative Cross, now plays at the very top level have about the trip comes from the treatment. At the Roosters we had a case of rugby union for the Wallabies, in a Leprosy museum we visited in Bergen. in 2006 where the player concerned similar position. Leprosy has been virtually eradicated in tore all of ACL, PCL and MCL and was When in Norway, I chatted to Oslo’s the Western world and the Norwegians rightly considered a career-threatening top knee surgeon Lars Engebretsen are the most responsible for this. In the injury at the time. However, the surgeon about ACL reconstructions. They have a 1850s, at the time that John Snow was treating him (Merv Cross) made the call national database of ACL reconstructions, working out the cause for cholera in that ACL and PCL had been peeled off which leads the world and is something London, Norway founded the fi rst ever together at femoral end and the main we should try to emulate in Australia national medical register for the disease body of both ligaments was still intact. 18. Ironically Lars doesn’t use the LARS leprosy. Armauer Hansen gets most of He did a direct repair with no graft technique but prefers patellar grafts the credit for conquering leprosy by for all three ligaments and the player for high level athletes, hamstrings for discovering the bacteria responsible came back successfully at 7 months. low level and occasionally he’ll do (actually predating Koch’s discovery As a measure of the success, he is now an allograft. He mentioned though of the tubercle bacillis). Ove Høegh one of the 2008 State of Origin players that 80% of Norway surgeons use should get as much credit for creating listed above. Like the Swans and the hamstring tendon allografts but for his the register, as it was from this that Western Bulldogs, we took an option elite athletes he still isn’t convinced that Hansen was in fact sure that leprosy which had some degree of risk but also they can get the players back to the was an infectious disease and that had the upside of not requiring the same performance level as the patellar therefore he needed to fi nd the agent. player to have any of his own tendons tendon grafts. Hans Mueller-Wolfhart Expanding from this history it is easy to sacrifi ced. Alisa Camplin did something at Bayern Munich, of Actovegin fame understand why the Scandinavians still along the same lines using a donor lately in Australia, sends his German lead the world in both medical registers (allograft) tendon for her reconstruction elite players over to Colorado to get and public contribution towards disease before the 2006 Winter Olympics. I am Richard Steadman to do patellar tendon prevention. aware that some of the Sydney knee autologous grafts for them. Dozens surgeons are getting parents to donate of elite English and European soccer graft tendons to their athlete children for players have been to Steadman to get knee reconstructions. It would not be their ACLs done, including Michael surprising to see professional footballers Owen and Ruud van Nistelrooy. When use either of these techniques in the near you travel, it seems that the patellar future. tendon autograft is still the world gold With respect to the traditional autografts, standard for super-elite athletes, even in Australia at the community level though hamstring autograft procedures the vast majority of patients (or their are now undoubtedly the no. 1 surgeons) are choosing hamstring procedure in the world for Joe Average. grafts for the morbidity advantages Another very interesting thing I learnt mentioned earlier. Matthew Liptak has in Norway was that Lars Engebretsen presented data from AFL reconstructions credits an ACL injury, to Susann Goksør done in the 1990s suggesting that the Bjerkrheim, for the entire formation of hamstring grafts in general do better the Oslo Sports Trauma Research Centre. than the patellar tendon grafts 17, which Previous lobbying for the government supports this trend. However, for my and private sectors to support such a elite players at the Roosters I still tend to Figure 6 – The Broad St pump in centre had failed, but Susann’s ACL recommend patella tendon grafts fi xed Soho, London, where John Snow injury was the catalyst for the powers in with interference screws. I don’t know Norway to change their minds. Susann determined the cause of cholera whether it is the sport itself or other was the top handball player in Norway in the 1850s. About the same time aspects of surgical technique, but our and was thought to be the key to the the Norwegians were determining results have been hard to argue against national team winning a Gold medal the cause of leprosy, bringing in from an observational viewpoint in at the Sydney Olympics. There was the era of modern epidemiology terms of getting back to super-elite level. national mourning when she tore her and public health

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22290 Sustagen ad.indd 1 21/4/06 12:58:14 PM JOHN ORCHARD

1. Renstrom P, Ljungqvist A, Arendt E, B Beynnon TF, W Garrett, T Georgoulis, T E Hewett, R Johnson, T Discipline Group News Krosshaug, B Mandelbaum, L Micheli, G Myklebust, E Roos, H Roos, P Schamasch, S Shultz, S Werner, E Wojtys, and L Engebretsen. Non-contact ACL Australian Association of WA injuries in female athletes: an International Olympic Committee current concepts statement. British Podiatric Sports Medicine Self Management Workshop Journal of Sports Medicine 2008;42:394-412. 9th August, 9.00am – 5.00pm Podiatrist’s education evening 2. Sasaki R, Urabe Y, Yamaguchi O, Ueda Y, Akimoto Perth T. Change of whole-body reaction time by Royal Newcastle Centre performing an anterior cruciate ligament injury 8 CEPs Level 2- Conference Room 2 prevention programme [abstract]. British Journal of Closes 25 July Sports Medicine 2008;42(6):A43. Ranking Park Campus (John Hunter 3. Zebis M, Bencke J, Andersen L, Alkjaer T, Magnusson P, Kjaer M, et al. Neuromuscular training Hospital Site) ACT changes the timing of medial hamstring muscle Lookout Rd, NEW LAMBTON Musculoskeletal Case Studies activity during sidecutting in female elite soccer and Workshop handball players [abstract]. British Journal of Sports Wednesday 4th June Medicine 2008;42(6):A44. 21st September, 8.30am – 5.30pm 4. Myklebust G, Skjølberg A, Bahr R. Anterior cruciate Wednesday 13th August Canberra ligament injuries in female team handball players: Wednesday 26th November national injury trends after the Norwegian injury 8 CEPs prevention study [abstract]. British Journal of Sports SESSIONS START AT 6.30pm Closes 5 September Medicine 2008;42(6):A42. Cost = $10 payment upon entry 5. Dick R, Putukian M, Agel J, Evans T, Marshall S. Descriptive Epidemiology of Collegiate Women’s RSVP for catering purposes the VIC Soccer Injuries: National Collegiate Athletic week prior Pre Surgery Management of End- Association Injury Surveillance System, 1988–1989 stage Osteoarthritis of the Hip Through 2002–2003. Journal of Athletic Training Contact the organiser: 2007;42(2):278-285. & Knee & Early Rehabilitation 6. Orchard J. Preventing sports injuries at the national (ph) 02 4016 4687 level: time for other nations to follow New Following Total Joint Replacement Zealand’s remarkable success. British Journal of 4th October 2008, 9.00 – 4.00pm Sports Medicine 2008;42(6):392-93. Australian Association for 7. Olsen O, Myklebust G, Engebretsen L, Holme I, Exercise and Sports Science Current Treatment and Post- Bahr R. Relationship between floor type and risk of ACL injury in team handball. Scandinavian Journal (AAESS) Operative Management for Articular of Medicine & Science in Sports 2003;13:299-304. Cartilage Defects In The Knee 8. Bjornboe J, Andersen T, Bahr R. Risk of injury NSW 5th October 2008, 9.00 – 4.00pm on artificial turf in elite football [abstract]. British Pre Surgery Management of End- Journal of Sports Medicine 2008;42(6):A14. 7 CEPs each stage Osteoarthritis of the Hip 9. Orchard J, Powell J. Risk of knee and ankle sprains Closes 19 September under various weather conditions in American & Knee & Early Rehabilitation football. Medicine & Science in Sports & Exercise 2003;35(7):1118-23. Following Total Joint Replacement SA 10. Fuller C, Dick R, Corlette J, Schmalz R. Comparison CBD Sydney Pre Surgery Management of End- of the incidence, nature and cause of injuries sustained on grass and new generation artificial turf 23rd August 2008, 9.00 – 4.00pm stage Osteoarthritis of the Hip by male and female football players. Part 1: match & Knee & Early Rehabilitation injuries. British Journal of Sports Medicine 2007;41: Current Treatment and Post- Following Total Joint Replacement i20-i26. Operative Management for Articular 11. Orchard J. Is there a relationship between ground 20th September 2008, 9.00 – 4.00pm and climatic conditions and injuries in football? Cartilage Defects In The Knee Adelaide Sports Med 2002;32(7):419-432. CBD Sydney 12. Orchard J, Chivers I, Aldous D, Bennell K, Seward H. Ryegrass is associated with fewer non- 24th August 2008, 9.00 – 4.00pm Current Treatment and Post- contact anterior cruciate ligament injuries than 7 CEPs each Operative Management for Articular bermudagrass. British Journal of Sports Medicine 2005;39:704-709. Closes 8th August Cartilage Defects In The Knee 13. Chivers I, Aldous D, Orchard J. The relationship of 21st September 2008, 9.00 – 4.00pm Australian football grass surfaces to anterior cruciate QLD Adelaide ligament injury. International Turfgrass Society Pre Surgery Management of End- Research Journal 2005;10(1):327-332. 7 CEPs each stage Osteoarthritis of the Hip 14. Orchard J, Rodas G, Til L, Ardevol J, Chivers I. A Closes 5 September hypothesis: could portable natural grass be a risk & Knee & Early Rehabilitation factor for knee injuries? Journal of Sports Science and Medicine 2008;7(1):184-190. Following Total Joint Replacement TAS 15. Torg JS, Stilwell G, Rogers K. The effect of ambient 1st November 2008, 9.00 – 4.00pm Musculoskeletal Disorders temperature on the shoe-surface interface release coefficient. American Journal of Sports Medicine Brisbane Workshop (case studies – practical 1996;24(1):79-82. workshop) Current Treatment and Post- 16. Quayle E. The crucial link. The Age 2008;http:// 27th July, 2008 www.realfooty.com.au/articles/2008/03/08/1204780 Operative Management for Articular 132545.html?page=fullpage. Hobart Cartilage Defects In The Knee 17. Liptak M. Outcome of Anterior Cruciate Ligament 7 CEPs Injuries in an Elite Sporting Population. A 2nd November 2008, 9.00 – 4.00pm Retrospective Review of Australian Rules Footballers. ISAKOS conference 2007:A229. Brisbane For more information 18. Granan L, Bahr R, Steindal K, Furnes O, 7 CEPs each email: [email protected] Engebretsen L. Development of a National Cruciate Ligament Surgery Registry: The Norwegian National Closes 17 October Knee Ligament Registry. American Journal of Sports Medicine 2007:Nov 7; [Epub ahead of print].

22 Sport Health AFL AFL Injury Report: Season 2007 Released May 28th 2008 By John Orchard

The AFL has conducted and published the data provided by each club after Injury Rates an annual injury survey every season the conclusion of the season with the The major measurement of the number for the past 16 years, since 19921. This is player movement monitoring done in of injuries occurring is seasonal injury the longest running injury surveillance ‘real time’ during the season, in order incidence measured in a unit of new system in Australia. The injury survey to maximise compliance with the injury injuries per club per season (where also has had a pivotal position in guiding survey definition. Individual player injury a club is defined as 40 players and a the AFL Research Board to fund projects details are not revealed in any report season is defined as 22 rounds). The which study injuries that are common, of the injury survey. Player Movement major measurement of the amount of severe and/or increasing in incidence Monitoring has allowed the injury survey playing time missed through injury in AFL players. As the AFL was also to achieve ‘100% compliance’ for all is injury prevalence measured in a the first professional sporting body to instances of missed player games since unit of missed games per club per implement a funded research board, 1997 7. In 2001 this was extended to season, or alternatively percentage of it has distinguished itself as the most include rookie listed players and finals players unavailable through injury. progressive professional sport in this matches. The recurrence rate is the number country with respect to injury research. of recurrent injuries expressed as a Injury surveillance is now universally Injury definition percentage of the number of new considered to be an important obligation The injury survey has defined an injury injuries. A recurrent injury is an injury in of professional sporting bodies 2- as a condition “causing a player to miss a the same injury category occurring on 5. However, the degree to which match”. This decision was made with the the same side of the body in a player it is successfully undertaken varies aim of assuring maximum compliance to during the same season. Therefore, by substantially. Nationally (and even the survey and has enabled the capture this definition, an injury of one type internationally) the AFL injury survey of 100% of defined injury episodes since that recurred the following season was structure is seen as a model of “how 1997. As a result the AFL injury survey is defined as a new injury in that next to get it right”, given that it leads to one of the few sports injury surveillance season. consistent reports and ongoing analysis systems in use that is highly reliable 7-9. All injury rates are adjusted to account of injuries. The first public release of the Injury categories for differing player list sizes and number annual report was following the 1996 of matches per club in each season, so injury survey 6, believed to be the first Injury categories have been slightly that the injury rates reported each season time in the world that a professional changed based on which specific represent a hypothetical club with 40 sport openly tabled its injury data. diagnoses (using OSICS10) are listed players participating in 22 matches. included within each category in the METHODS 2007 analysis. Where changes have been made they have been made RESULTS The methods of the injury survey are retrospectively for all previous survey Key indicators for the past ten years now well established and have been years. Therefore, some of the category (and estimated key indicators for the previously described in detail 7, although data presented in this report for previous previous five years) are shown in Table minor changes to methods are made years varies slightly from what is 1. The injury incidence (number of new on an annual basis. The definition of apparently the same data that has been injuries per club per season) for 2007 an injury is “any injury or other medical published before in the previous reports. was in keeping with the low rates of condition that prevents a player from recent years. However, injury prevalence, participating in a regular season (home One significant change which was made severity and recurrence rates all rose and away) or finals match”. Player to injury categories for the 2008 report slightly in season 2007. movement monitoring essentially was that injuries which specifically requires that all clubs define the status occurred in events outside football were of each player each round to be either: grouped with medical illnesses as part of Injury incidence (1) playing AFL football (2) playing an ‘other conditions’ category, where the Table 2 details the incidence of the major football at a lower level (3) not playing mechanism was not considered related injury categories. The injury profile of football due to injury or (4) not playing to playing AFL football. This change was 2007 shows diverging trends for some football for another reason. The injury applied retrospectively to all previous of the major categories. Incidence of survey coordinator can cross-check data. head and neck injuries (combined),

VOLUME 26 – ISSUE 2 • WINTER 2008 23 AFL

Table 1 - Key indicators for all injuries over the past eleven seasons All injuries 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Incidence (new injuries per club 41.9 40.3 36.9 37.4 35.8 34.4 34.1 34.8 35.3 34.1 34.7 per season ) Incidence (recurrent) 8.4 7.6 5.2 5.9 5.5 4.4 4.6 3.7 4.8 4.1 5.6 Incidence (total) 50.3 47.9 42.1 43.3 41.3 38.7 38.7 38.5 40.1 38.2 40.4 Prevalence (missed games per 159.2 141.9 135.9 131.8 136.4 134.7 118.7 131.0 129.2 139.5 147.5 club per season) Average injury severity (number 3.8 3.5 3.7 3.5 3.8 3.9 3.5 3.8 3.7 4.1 4.2 of missed games) Recurrence rate 20% 19% 14% 16% 15% 13% 14% 11% 14% 12% 16%

Table 2 - Injury incidence (new injuries per club per season) Body area Injury type 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Head/neck Concussion 0.6 0.7 0.5 0.6 0.7 0.7 0.3 0.3 0.7 0.3 0.3 Facial fractures 0.8 0.6 0.7 0.7 0.4 0.4 0.6 0.8 0.6 0.3 0.4 Neck sprains 0.1 0.2 0.2 0.2 0.1 0.0 0.0 0.1 0.2 0.3 0.1 Other head/neck injuries 0.2 0.2 0.2 0.1 0.3 0.2 0.3 0.2 0.1 0.2 0.2 Shoulder/ Shoulder sprains and dislocations 1.0 0.9 0.7 0.7 1.1 0.9 1.3 1.0 1.4 1.6 1.0 arm/elbow A/C joint injuries 0.9 0.9 0.6 1.3 0.9 1.1 0.3 1.1 0.8 1.2 0.8 Fractured clavicles 0.4 0.4 0.3 0.5 0.3 0.3 0.2 0.6 0.3 0.3 0.3

Elbow sprains or joint injuries 0.2 0.1 0.1 0.1 0.2 0.1 0.1 0.3 0.1 0.1 0.1 Other shoulder/arm/elbow injuries 0.6 0.5 0.2 0.5 0.5 0.8 0.5 0.4 0.6 0.3 0.2 Forearm/ Forearm/wrist/hand fractures 1.1 1.7 1.7 1.4 0.8 1.1 0.8 1.1 1.3 1.1 0.9 wrist/hand Other hand/wrist/ forearm injuries 0.4 0.4 0.4 0.5 0.3 0.4 0.7 0.4 0.3 0.3 0.6 Trunk/back Rib and chest wall injuries 1.2 0.6 1.0 0.8 0.4 0.9 0.8 0.7 0.4 1.0 0.4

Lumbar and thoracic spine injuries 1.8 1.4 1.4 2.2 1.4 0.9 0.8 1.6 2.1 1.5 1.3 Other buttock/back/trunk injuries 1.2 1.0 1.1 0.8 0.5 0.4 0.5 0.6 0.4 0.6 0.5 Hip/groin/ Groin strains/osteitis pubis 4.1 3.2 3.1 3.0 3.5 3.8 2.8 3.1 2.9 3.3 4.1 thigh Hamstring strains 6.6 6.4 6.7 5.6 6.0 4.4 5.8 6.3 5.2 6.4 6.7 Quadriceps strains 2.5 3.0 2.4 2.0 1.6 1.7 2.0 1.9 1.9 1.7 1.8 Thigh and hip haematomas 1.3 1.3 1.1 1.1 0.6 1.0 0.3 1.1 1.0 1.1 0.6 Other hip/groin/thigh injuries 0.4 0.2 0.3 0.3 0.3 0.3 0.4 0.3 0.2 0.3 0.8 Knee Knee ACL 1.2 0.8 0.7 0.5 0.9 0.8 0.6 0.5 0.6 1.0 0.7 Knee MCL 0.7 1.3 1.2 0.9 1.2 0.9 1.0 0.7 1.0 0.8 1.4 Knee PCL 0.6 0.3 0.7 0.5 1.0 0.4 0.5 0.7 0.4 0.3 0.2 Knee cartilage 0.9 1.1 1.1 1.2 1.9 1.3 1.7 1.2 1.3 1.0 1.2 Patella injuries 0.2 0.4 0.1 0.2 0.2 0.4 0.1 0.1 0.3 0.3 0.3 Knee tendon injuries 0.5 0.6 0.7 0.7 0.5 0.8 0.7 0.4 0.7 0.4 0.3 Other knee injuries 1.4 0.4 0.9 1.3 0.8 0.5 0.7 0.7 0.9 0.2 0.8 Shin/ankle/ Ankle sprains or joint injuries 2.7 2.8 2.1 2.7 2.0 2.5 2.6 2.5 2.5 2.1 2.2 foot Calf strains 1.9 2.3 1.4 1.9 1.6 2.2 1.6 0.9 1.9 1.6 1.2 Achilles tendon injuries 0.4 0.3 0.5 0.4 0.2 0.4 0.4 0.2 0.3 0.3 0.4 Leg and foot fractures 0.5 0.8 1.1 0.6 1.0 0.8 0.5 0.5 0.4 0.7 0.5 Leg and foot stress fractures 0.8 0.7 0.8 0.5 0.9 0.7 0.9 0.9 0.9 1.1 1.1 Other leg/foot/ankle injuries 1.9 1.7 1.3 1.3 1.7 0.8 1.5 1.7 1.3 1.5 1.3 Other Medical illnesses/ non- football 2.7 2.9 1.7 2.2 2.0 2.6 2.8 2.1 2.3 0.9 2.1 injuries NEW INJURIES / CLUB / SEASON 41.9 40.3 36.9 37.4 35.8 34.4 34.1 34.8 35.3 34.1 34.7

24 Sport Health AFL

Table 3 - Recurrence rates (recurrent injuries as a percentage of new injuries) groin injury prevalence were both at their highest levels since Injury type 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 the commencement of injury Hamstring strains 38% 36% 31% 37% 25% 30% 27% 22% 26% 16% 22% surveillance. Groin strains 36% 31% 6% 16% 20% 23% 20% 24% 23% 28% 38% Ankle sprains 20% 21% 9% 11% 17% 16% 6% 11% 15% 10% 20% ANALYSIS & DISCUSSION Quadriceps strains 35% 20% 20% 18% 10% 17% 9% 6% 20% 19% 18% FOR SIGNIFICANT INJURY Calf strains 15% 15% 17% 32% 17% 13% 14% 6% 12% 7% 9% CATEGORIES ALL INJURIES 20% 19% 14% 16% 15% 13% 14% 11% 14% 12% 16% Hamstring injuries Hamstring strains remain the most common injury in the AFL. lumbar spine injuries, rib injuries and • 3 missing through other reasons Previous analysis of hamstring knee PCL (posterior cruciate ligament) (such as suspension, being used as a and other muscle strain data shows a injuries were at all time lows. However travelling emergency, team bye in a high rate of recurrence 11-14. The current hamstring injury incidence was at its lower grade, etc). AFL data shows that management highest level since 1999 and groin injury Table 5 details the amount of missed of these injuries has become more incidence was at its highest level since playing time attributed to the most conservative over the last decade in the 1997. notable injury categories. In season 2007, AFL, with recurrence tending to decrease hamstring injuries continued as the no. 15 (Table 6). The risk of recurrence Injury recurrence 1 injury in the game with respect to however does remain high and persists Table 3 shows the rate of recurrence missed playing time, surpassing both for three months after return to play of some of the common injury types, groin injuries and knee anterior cruciate because players often return with subtle particularly muscle strains which have ligament (ACL) injuries. Based on injury strength deficits and/or biomechanical a comparatively high recurrence rate. prevalence (missed playing time), these compensations 11. Most contact-mechanism injuries, such as three categories are consistently the fractures, concussions and ‘cork’ injuries highest categories for injury prevalence. Head and neck injuries have a low recurrence rate. The issue With respect to mechanism these injuries Table 7 shows consistently low of recurrence for muscle strains is the are most commonly non-contact. incidence and prevalence for head and 11 subject of ongoing research . The rate As was the case with injury incidence, neck injuries (combined) over the past of injury recurrence has been showing some divergent trends were noted decade. Season 2007 reported the lowest a fairly steady decline over the last 10 in 2007. Knee PCL injuries and facial incidence of head & neck injuries since years, although the rate of 16% in season fractures were at an all time low with the survey was commenced, with a zero 2007 was a return to the long-term respect to contribution to missed percent recurrence rate. average. The recurrence rate for groin playing time. However, hamstring and Reduced tolerance of head-high contact injuries in season 2007 was high at 38%. and stricter policing of dangerous tackles Weekly player status and injury along with the introduction of rules to prevalence penalise a player who makes forceful contact to another player with his head Table 4 details player status on a weekly over the ball may have contributed to basis over the past ten seasons. The these positive trends. ‘average’ status of a club list of 44 players in any given week for 2007 was: Knee ligament injuries • 34 players playing football per week; Knee ligament injury incidence fell in • 7 missing through injury; and 2007, particularly with respect to PCL

Table 4 - Average weekly player status by season Status 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Playing AFL 21.0 22.0 22.0 22.0 22.0 22.0 22.0 22.0 22.0 22.0 22.0 Playing lower grade football 11.8 11.4 11.4 11.3 12.9 12.1 12.0 11.9 12.2 11.8 11.9 TOTAL playing 32.8 33.4 33.4 33.3 34.9 34.1 34.0 33.9 34.2 33.8 33.9 Not playing because of injury 7.7 6.7 6.4 6.2 6.7 6.6 5.7 6.4 6.4 7.0 7.4 Not playing for other reasons 1.9 1.6 1.8 1.8 1.8 2.3 2.5 2.5 2.8 3.1 2.9 TOTAL not playing 9.6 8.3 8.3 8.0 8.5 8.9 8.2 8.9 9.1 10.1 10.4 Players in injury survey (per club) 42.3 41.7 41.7 41.4 43.4 43.0 42.2 42.8 43.3 43.9 44.2 Injury prevalence (%) 18.1% 16.1% 15.4% 15.0% 15.5% 15.3% 13.5% 14.9% 14.7% 15.9% 16.8%

VOLUME 26 – ISSUE 2 • WINTER 2 0 0 8 25 AFL

Table 5 - Injury prevalence (missed games per club per season) Body area Injury type 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Head/neck Concussion 0.7 0.7 0.5 0.7 1.3 2.0 0.6 0.3 0.9 0.3 0.3 Facial fractures 2.5 2.0 2.2 2.0 1.3 1.4 1.0 2.2 1.4 0.8 0.7 Neck sprains 0.6 0.7 1.6 0.3 0.2 0.0 0.0 0.6 0.3 0.3 1.1 Other head/neck injuries 0.3 0.2 0.4 0.8 1.5 0.2 0.7 0.2 0.2 1.1 1.6 Shoulder/ Shoulder sprains and dislocations 5.3 5.9 5.6 4.0 5.4 5.9 5.7 5.9 7.7 10.8 6.4 arm/elbow A/C joint injuries 2.2 2.1 0.9 3.1 2.1 2.4 0.7 2.5 1.9 2.7 1.4 Fractured clavicles 1.4 1.6 1.2 3.0 1.6 2.0 1.0 3.5 1.3 1.7 1.8 Elbow sprains or joint injuries 0.7 1.2 0.2 0.1 0.4 0.3 0.4 0.7 0.4 0.7 0.8 Other shoulder/arm/elbow injuries 2.4 1.9 0.3 1.3 1.3 3.4 1.6 1.6 2.4 1.7 0.7 Forearm/ Forearm/wrist/hand fractures 4.1 5.4 5.9 5.6 2.7 3.1 2.5 3.9 3.8 4.3 2.3 wrist/hand Other hand/wrist/ forearm injuries 0.6 1.3 0.9 1.4 0.3 2.2 2.9 1.2 1.2 0.5 3.1 Trunk/ Rib and chest wall injuries 2.8 1.0 2.0 1.3 0.7 1.5 1.7 1.3 0.6 2.2 1.9 back Lumbar and thoracic spine injuries 9.7 4.3 7.9 8.4 5.6 5.8 2.1 5.4 6.4 5.4 2.8 Other buttock/back/trunk injuries 6.0 1.6 2.3 2.6 1.5 1.6 1.6 2.3 0.7 1.3 1.7 Hip/groin/ Groin strains/osteitis pubis 17.4 13.6 9.4 7.5 13.6 15.7 13.6 13.3 11.2 14.0 18.0 thigh Hamstring strains 20.9 21.0 22.3 22.4 21.3 15.6 18.7 21.6 18.6 21.8 24.3 Quadriceps strains 8.6 9.5 6.7 5.6 3.8 4.3 6.0 4.2 6.4 5.5 5.6 Thigh and hip haematomas 2.4 1.8 1.5 1.8 0.6 1.9 0.5 1.7 1.6 1.4 1.0 Other hip/groin/thigh injuries 1.7 0.5 2.3 1.4 1.7 1.2 1.5 2.6 1.0 2.3 4.5 Knee Knee ACL 19.8 15.8 10.8 4.8 13.6 15.3 10.8 10.1 9.3 15.3 15.9 Knee MCL 3.3 4.3 3.3 3.5 4.8 2.8 2.9 2.9 3.0 1.7 4.7 Knee PCL 1.9 2.2 5.2 2.3 5.9 2.3 2.0 6.5 2.7 1.8 1.6 Knee cartilage 4.0 5.6 5.3 8.6 12.5 6.0 7.0 6.1 7.8 5.7 9.1 Patella injuries 0.9 1.6 0.8 1.8 0.8 2.5 0.6 0.1 0.8 1.2 2.7 Knee tendon injuries 2.4 1.6 3.9 3.9 2.5 3.7 2.9 0.9 2.6 1.8 0.7 Other knee injuries 3.9 0.8 2.2 3.6 2.5 1.0 2.4 1.3 3.8 0.2 2.6 Shin/ Ankle sprains or joint injuries 7.2 6.9 3.9 6.8 4.3 5.9 5.3 6.4 9.2 8.1 7.1 ankle/foot Calf strains 5.8 6.4 3.4 5.7 3.4 4.4 3.8 1.7 4.5 3.4 3.1 Achilles tendon injuries 1.3 1.4 1.3 1.6 0.7 0.9 1.5 0.8 1.9 2.1 2.2 Leg and foot fractures 2.6 5.4 8.8 4.6 7.0 7.9 2.9 3.7 2.7 5.7 2.7 Leg and foot stress fractures 4.9 4.0 6.7 3.8 4.4 3.9 5.3 6.3 5.1 8.2 6.8 Other leg/foot/ankle injuries 6.4 5.1 3.1 3.9 4.2 2.3 3.7 4.3 4.2 4.1 4.2 Other Medical illnesses/ non- football injuries 4.3 4.5 3.4 3.4 2.8 5.4 4.8 4.6 3.7 1.2 4.1 MISSED GAMES / CLUB / SEASON 159.2 141.9 135.9 131.8 136.4 134.7 118.7 131.0 129.2 139.5 147.5

Table 6 - Key indicators for hamstring strains over the past eleven seasons Hamstring strains 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Incidence 6.6 6.4 6.7 5.6 6.0 4.4 5.8 6.3 5.2 6.4 6.7 Prevalence 20.9 21.0 22.3 22.4 21.3 15.6 18.7 21.6 18.6 21.8 24.3 Severity 3.2 3.3 3.3 4.0 3.5 3.5 3.2 3.4 3.6 3.4 3.6 Recurrence rate 38% 36% 31% 37% 25% 30% 27% 22% 26% 16% 22%

Table 7 - Key indicators for head & neck injuries over the past eleven seasons Head and neck 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Incidence 1.8 1.6 1.6 1.6 1.5 1.2 1.2 1.4 1.6 1.0 0.9 Prevalence 4.1 3.5 4.6 3.8 4.2 3.7 2.2 3.3 2.7 2.5 3.7 Severity 2.3 2.2 3.0 2.3 2.9 3.0 1.8 2.4 1.7 2.6 4.0 Recurrence rate 0% 4% 4% 0% 0% 5% 9% 0% 3% 0% 0%

26 Sport Health AFL

Table 8 - Key indicators for major knee ligament injuries over the past ten seasons Acknowledgments: Category 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 The authors and AFL Medical PCL incidence 0.6 0.3 0.7 0.5 1.0 0.4 0.5 0.7 0.4 0.3 0.2 Officers would like to acknowledge the following PCL prevalence 1.9 2.2 5.2 2.3 5.9 2.3 2.0 6.5 2.7 1.8 1.6 people who contributed to the PCL severity 3.3 7.4 7.2 4.8 5.9 5.9 4.4 9.0 7.0 6.8 9.7 survey in 2007: David Binney, Number of centre bounce Dr Andrew Potter (medical PCL injuries (compared to services coordinator and total injuries) 0/10 2/5 3/12 4/8 4/18 3/7 2/8 5/13 1/9 0/5 0/3 doctor, Adelaide), Victor Popov ACL incidence 1.2 0.8 0.7 0.5 0.9 0.8 0.6 0.5 0.6 1.0 0.7 (physiotherapist, Brisbane), Dr Ben Barresi (doctor, Carlton), Dr ACL prevalence 19.8 15.8 10.8 4.8 13.6 15.3 10.8 10.1 9.3 15.3 15.9 Andrew Jowett, Gary Nicholls Number of graft ruptures (doctor and physiotherapist, (compared to total ACL Collingwood), Bruce Connor injuries) 3/21 2/15 0/8 1/8 1/17 4/15 0/11 2/9 1/10 4/19 2/13 (physiotherapist, Essendon), Jeff Boyle and Norm Tame injuries. New rules were introduced in (1) the new centre circle rule to limit the (physiotherapist and football 2005 to limit the ruckman’s run up, with run-up of ruckmen at the centre bounce; staff, Fremantle), Dr Chris Bradshaw the introduction of a 10 metre outer (2) the program of ground condition (doctor, Geelong), Dr Peter Baquie + circle at centre bounces. There have testing and surveillance; Nick Russell (doctor and football staff, been no centre bounce ruck mechanism Hawthorn), Dr Andrew Daff (doctor, (3) video surveillance and non tolerance PCL injuries in 2006 or 2007, indicating Melbourne), Dr Con Mitropolous (doctor, of illegal play; success with this rule change (Table 8). Kangaroos), Dr Peter Barnes and Michael The trend of higher PCL injuries amongst (4) the introduction of specific rules, Heynan (doctor and football staff, Port ruckmen has been eliminated and there such as the rule to protect players from Adelaide), Dr Greg Hickey (doctor, also appears to be a drop in ‘ground- forceful contact when their head is over Richmond), Dr Ian Stone (doctor, contact’ PCL injuries. the ball; St. Kilda), Dr Nathan Gibbs (doctor, Knee ACL injuries were at average rates (5) the establishment of a research Sydney), Paul Tucker (physiotherapist, for season 2007. There was a smaller board which funds research projects to West Coast Eagles), Dr Gary Zimmerman number than usual occurring in the improve our knowledge base; (doctor, Western Bulldogs), Dr Peter Harcourt and Dr Harry Unglik (AFL AFL Premiership Season matches, but (6) improved management and Medical Commissioners), Rod Austin, a relatively high prevalence due to prevention of injuries at club level. pre-existing ACL injuries where the Jill Lindsay and Adrian Anderson (AFL player had not yet recovered from his The AFL injury profile continues to be administration), Champion data and all reconstruction. These injuries are the consistently defined and published in those acknowledged in the injury reports subject of further research16 and due to sports medicine scientific literature and for previous years (particularly Dr Tim 7 their regular occurrence and devastating in public media releases . Hamstring Wood who had a major administrative impact on footballers will continue to be injuries, knee ACL injuries and groin role during the early years of the injury a priority topic. injuries (including osteitis pubis) are survey). consistently the most prevalent injuries in AFL players. CONCLUSIONS REFERENCES • Historically, the AFL injury survey is 1. Seward H, Orchard J, Hazard H, Collinson D. The AFL injury profile is moving Football Injuries in Australia at the elite level. the world’s longest running publicly- Medical Journal of Australia 1993;159:298-301. further towards being predominantly released injury survey in sport1 7 17; 2. Finch C. A new framework for research leading to one of non-contact injuries as key sports injury prevention. Journal of Science and contact injuries such as head and • The survey has run for 16 seasons, Medicine in Sport 2006;9:3-9. achieving 100% participation and 3. van Mechelen W, Hlobil H, Kemper H. Incidence, neck injuries, rib injuries and knee Severity, Aetiology and Prevention of Sports compliance over the last 11 seasons; Injuries: A Review of Concepts. Sports Medicine PCL injuries continue to reduce in 1992;14(2):82-99. incidence. However, there still remains • The survey defines an injury as a 4. van Mechelen W. Sports Injury Surveillance Systems: an enormous challenge in controlling ‘condition which causes a player to ‘One Size Fits All?’ Sports Medicine 1997;24(3):164- miss a game’ striking a balance which 168. key non-contact soft tissue injuries such 5. Meeuwisse W, Love E. Athletic Injury Reporting: as hamstring and groin strains, which has enabled comprehensive analysis Development of Universal Systems. Sports Medicine without sacrificing compliance9; and 1997;24(3):184-204. showed rates in 2007 which were high 6. Orchard J, Wood T, Seward H, Broad A. AFL Injury by historical standards. • The survey has led directly and Report 1996. Football record 1997;86(8):S14-S23. indirectly to dozens of published 7. Orchard J, Seward H. Epidemiology of injuries in The ongoing trends in the injury the Australian Football League, seasons 1997-2000. studies and interventions which British Journal of Sports Medicine 2002;36:39-45. incidence vindicate the approach the have improved the safety of the AFL 8. Orchard J, Seward H. AFL Injury Report 2003. AFL is taking towards injury surveillance competition 1 7 11 14 16-29 (e.g. ruck rule Journal of Science and Medicine in Sport 2004;7(2):264-5. and research3. Possible variables that changes to decrease PCL injuries and may have (or in some cases certainly changes in ground preparation to have) reduced injury incidence over the reduce ACL injuries). >> to Page 38 past decade includes:

VOLUME 26 – ISSUE 2 • WINTER 2 0 0 8 27 MORE FUEL MEANS MORE ENERGY.

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EPODE stands for “Ensemble, Prevenons, L’obesite des Enfants” this When EPODE? What else? is French for “Together We Can Prevent The South Australian Government The September 2007 edition of “Nutrition Childhood Obesity” an acronym given announced the decision to put funds and Dietetics”, Journal of the Dietitians to a healthy eating and physical activity into EPODE in late in March 2008. It Association of Australia, including the program born in France. is estimated that almost $2million will Journal of the New Zealand Dietetic be put into setting up the first five sites Association reported on some of the “Together” is a key element of EPODE which will reportedly be named later current programs and interventions for as the program encompasses community in June. childhood obesity in Australia. One organisations, local government, parents, study to note is the PEACH (Parenting, schools, businesses and health services There has been some controversy from Eating & Activity for Child Health) study5. all working together. Each healthy the opposition, who argue that this This is a multisite, Randomised Control community ‘site’ uses coordinated program is so personalised the majority Trial in Adelaide and Sydney and has approaches and strong local leadership of students will miss out. However, proven to significantly reduce BMI and to promote healthy eating and activity. the extended plans are to increase the waist in overweight and obese 5-9 year number of communities involved by five Children have growth monitored on a olds5. This intervention examines the per year to approximately twenty sites in regular basis and parents are advised of importance of parenting skills training. 2011-12 which will incorporate around any concerns and also provided with 200 schools. This is an appropriate Sports Dietitians Australia (SDA) also nutrition and exercise advice. A number amount of students to pilot effectiveness supports the importance of having a of programs and activities are set up and if successful, it would be good to family approach to manage overweight with in the community to make healthy see the program made available to more children. SDA has a fact sheet available choices easier choices. communities. which offers some practical advice for parental involvement and encouraging Why EPODE? What next? activity: http://www.sportsdietitians.com. EPODE has shown to be a successful au/asset/1/upload/Fact_sheet18.pdf. Time will tell if the South Australian program in France with over 100 1. Booth ML, Dobbins T, Okely AD, Denney- version of EPODE is successful and communities involved and has also since Wilson E, Hardy LL.. Trends in the prevalence of sustainable in Australia. overweight and obesity among Australian children been introduced to Belgium and Spain. and adolescents 1985–1997–2004. Obesity 2007; 15: There has been limited information 1089–95. The need for a program to fight 2. Wake M, Hardy P, Canterford L, Sawyer M, Carlin made available since the media release JB. Overweight, obesity and girth of Australian obesity is clear with the most recent last March. The program may not retain preschoolers: prevalence and socio-economic representative data from Australia correlates. Int J Obes 2007; 31:1044–51. the “EPODE” title here so keep watching 3. Government of South Australia. Right Bite. Easy indicating that around 25% of school- the media and health reports for further guide to…Healthy Food and Drink Supply for aged children and adolescents1 and 20% South Australian Schools and Preschools. Available information about health promoting at http://www.brightonss.sa.edu.au/right_bite/ of preschool children2 are overweight or communities. accessed 2 July 2008. obese, and that this figure continues to 4. Government of South Australia. Start Right Eat Right. Available at http://www.dh.sa.gov.au/pehs/ increase. startrighteatright.htm accessed 2 July 2008. 5. Golley R, Perry R, Magarey R, Daniels LA. Family- The South Australian version of EPODE focused weight management program for five- to will take a preventative approach to nine-year-olds incorporating parenting skills training with healthy lifestyle information to support obesity. This would appear to link in behaviour modification. Nutr Diet 2007; 64:144–50. effectively with other pre-existing health promotion programs in South Australia including; “Right Bite”3, a school canteen healthy eating policy, “Start Right Eat Right”4 a policy for child care centers and also the recent efforts toward modifying television advertising of “occassional” foods in children’s viewing times.

VOLUME 26 – ISSUE 2 • WINTER 2008 29 be active ’09

In October 2009, Sports Medicine Australia will host the paramount sports medicine, sports science, sports injury prevention and physical activity promotion conference event in Australia. be active ‘09 is a multi-disciplinary event, combining the 2009 Australian Conference of Science and Medicine in Sport, the Seventh National Physical Activity Conference and the Sixth National Sports Injury Prevention Conference. be active ‘09 brings together some of the finest speakers from Australia and around the world to present a comprehensive scientific forum on all facets of these fields - from elite performance to community participation in sport, physical activity and their impact on individual and public health. be active ‘09 showcases the latest developments through keynote and invited presentations, symposia, practical workshops, free papers, posters and a trade exhibition. It will also provide extensive networking opportunities.

The anticipated outcome of be active ‘09 is to assimilate, interpret and share scientific evidence with key stakeholders who are in a position to develop recommendations concerning effective policies and programs within their own jurisdictions.

Submission of Abstracts will open in January 2009 and close 31 March 2009. be active ‘09 will be held 14 – 17 October 2009 at the Brisbane Convention & Exhibition Centre.

More information will be made available on www.beactive09.com or contact the Conference Secretariat on [email protected]

be active ‘09 is proudly supported by the following groups Don’t miss the boat ACSMS 08 Conference 16-18 October 2008

Pack your bags and grab your sunblock, • Mrs Trish Wisbey-Roth (Physiotherapy Many aspects of cricket still exist as as this year Sports Medicine Australia’s Practitioner & Researcher) relics of the past – a dinosaur within national conference takes you to • Dr Susan Backhouse (UK Anti-doping the modern era. For cricket to make breathtaking Hamilton Island. expert) significant strides of change, it needs to not only embrace research and science, Situated on one of the 74 tropical • Dr Michael Kellmann (Sports but also harness the power of these tools islands in the Coral Sea, between the Psychologist, University of Queensland) of change and create the new Jurassic Queensland coast and the Great Barrier • Dr Kristiann Heesch (School of Park of modern sport. John Buchanan Reef, Hamilton Island will provide the Human Movement Studies, University briefly touches on some of the areas that perfect backdrop to catch up on the of Queensland) he has seen where research and science latest in sports science and medicine, • Professor Caroline Finch (University of can greatly assist the acceleration of this sports injury prevention and physical Ballarat) evolution. activity promotion. • Dr Steven Bird (Charles Sturt Michael Kellmann - Is recovery Here is a taster of what to expect to University) important? whet your appetite. • Professor Tim Cable (John Moores Coaches and researchers suggest that University, Liverpool) enhanced recovery allows athletes to What is ACSMS 08? train more, and thus improves their ACSMS 08 is the Asics Conference of Sessions overall fitness (aerobic, strength and Science and Medicine in Sport which is a Conference sessions will focus on a power), technique and efficiency. multidisciplinary meeting and its purpose range of topics including the shoulder, Although most coaches recognise is to ‘promote knowledge and practice knee/ACL, tendon foot and ankle, that recovery is crucial within the in sports science and sports medicine biomechanics, recovery, nutrition, sport setting, they often have limited by providing an interactive educational paediatric exercise science, physical knowledge of what recovery modalities forum of the highest standard so that the activity (and young people, adults and and monitoring tools are available. This participation, performance and wellbeing environments), measurement, diabetes/ introductory paper will briefly provide of Australians engaged in sport and peripheral vascular disease, sports injury an overview of physiological and physical activity may be ultimately and drugs in sport. psychological aspects of recovery. It will enhanced’. Hands-on workshops will include: then be followed by the research papers Mobilisation techniques to augment foot in this session. What’s on the function; Dental first aid; Knee exam; Trish Wisbey-Roth – The lumbo- ACSMS 08 menu? Assessment of cycling biomechanics pelvic hip complex – The challenge to optimise performance and minimise Speakers of optimizing intervention to injury; 100% ME - drugs in sport maximise dynamic activity A plethora of speakers from varying program; Assessment of core stability Leading physiotherapy researcher and disciplines and backgrounds will impart and proximal muscle function to founder member of the Low Back the latest knowledge in sports science optimise dynamic activity; Holistic Interest Group Australia will give and medicine. treatment: more than body and mind; delegates insights into research outcomes Keynote and invited speakers will Groin injury examination; Ultrasound from the group’s research over the last include: imaging in sports medicine and CPR three years. accreditation. • Mr John Buchanan (Former Stephen Bird – Exercise physiology: Australian Cricket Team Coach) Conference session highlights, on a day Current trends in enhancing athletic to day basis, are outlined below: performance” • Professor Wendy Brown (University of Resistance exercise researcher provides Queensland) Day One insights from his work as a lead paper • Mr Craig Purdam (Head, AIS to the exercise physiology free papers Physiotherapy) Major speakers include: session. • Mr Dean Robinson (High John Buchanan – Jurassic park Performance Manager, Geelong revisited: research and science meets Football Club) the dinosaur

VOLUME 26 – ISSUE 2 • WINTER 2008 31 FROM THE CEO

Free Papers include: Free Papers include: Kristiann Heesch – Qualitative methods in physical activity research Overweight children have poor bone Effects of static stretching in warm – an overview strength relative to body weight, up on repeated sprint performance Explains how qualitative research can placing them at greater risk for This study looks at how repeated sprint better our understanding of people’s forearm fractures ability may be compromised when static perceptions and beliefs about physical Overweight children have stronger stretching is conducted after dynamic activity, physical activity interventions, bones due to greater muscle size. activities and immediately prior to and physical and social environments However, children with high fat mass performance. that impact their physical activity. relative to muscle mass (increased Measuring children’s sport adiposity) have poorer bone strength, participation, risk perceptions and Free papers Include independent of weight, which may injury history: development and Athletic burnout in regional, rural contribute to the increased risk of validation of a survey instrument and remote adolescent athletes fracture in obese children. This study determines the influence of This paper will introduce a current study Handgrip strength and future child and parent injury perceptions on that is investigating the prevalence of dementia in elderly men: The sport choice and participation. burnout in Australian adolescent athletes Honolulu-Asia Ageing Study who live in regional, rural and remote Do hard playing fields increase the Handgrip strength is a predictor of areas and who are competing at non- risk of injury in community level disability, mortality and cognitive decline. elite and pre-elite levels. Australian football? This study examined the association of Presently, sporting grounds are being mid-life to late-life grip strength, and Still want more? closed due to hardness readings. The change between mid-life and late-life, The ACSMS 08 Social Program will results of this study provide some with future risk of dementia. provide delegates with a unique evidence to challenge this. opportunity to network with other sports Day Two Special Seminar on Business Skill medicine professionals while soaking Development – presented by the SMA up the latest in sports medicine, and of Major Speakers include: National Board Business Advisers – a course, the idyllic surroundings. The conference program has been designed Refshauge Lecture: Wendy Brown lawyer, HR consultant, marketing expert so that delegates can maximise their – Stand up, sit down, keep moving: and economist/finance expert. leisure opportunities on the beach, in the how much activity for a merry and pool, at the marina, on the Great Barrier bright old age?” Day Three Reef – or at the bar. This year’s Refshauge Lecture showcases one of Australia’s leading researchers in Major Speakers include: The social calendar will kick off on the the field of physical activity and health Craig Purdam – Short cuts, potholes Wednesday night with the Welcome giving a definitive lecture on dose and dead ends: the race against Reception followed by the Poster Session response to exercise and physical activity nature in injury management on Thursday afternoon. The Poster drawing on the latest research in the In sport, clinicians face an ongoing Session will be a stand alone session at field. challenge in returning players to train the conference, with discussion fueled by a complimentary drinks service. and compete following injury in the Caroline Finch – Using behavioural Senior members of SMA will provide shortest possible time. This paper will and health promotion theories to feedback to individual researchers and explore a number of legal opportunities guide sports injury prevention and discuss their research. Further, all poster and constraints to reducing injury safety promotion abstracts accepted are published in the downtime using examples drawn from This session will present the review December supplement of the Journal of common injuries. findings and provide an overview of the Science and Medicine in Sport and will theories most relevant to sports injury Dean Robinson - Development, have the chance to share in one of the prevention. Some suggestions for the integration and technologies of a four poster awards on offer, each valued design of future sports injury studies that high performance unit at $500. could benefit from the incorporation of The management practices and the However, the highlight of the Social principles from behavioural and health sports science technologies that Program will be the Saturday evening promotion theory will be given. enable Geelong Football Clubs High Conference Dinner in the Bougainvillaea Performance Unit to monitor and Marquee on the shores of Catseye Tim Cable - Exercise, ageing and develop the athletes to their full Beach where delegates will enjoy local cardiovascular function potential. entertainment, dancing and fine food. Leading UK researcher with interests in exercise and cardiovascular control, post- Susan Backhouse – Anti-doping The ACSMS 08 Conference will exertional hypotension and orthostasis, policy and practice: state of the social surely be one to remember. So exercise, ageing and the peripheral science don’t miss the boat on catching up vascular circulation and exercise and UK expert in the development of anti- on the latest in sports science and thermoregulation. doping programs for UK Sport. medicine…jump on www.sma.org. au/acsms/2008 to register, or for further details.

32 Sport Health Conference Program

Wednesday 15th October 1330 - 1500 SMA Board Meeting (Chart Room) 1730 - 1900 Welcome Reception (Main Pool)

Thursday 16th October Time MR 1 & 2 Endeavour Room 1 MR 3 & 4 Chart Room Workshop: Workshop: (0730 - 0900) Workshop: 0800 - 0900 Craig Purdam “Mobilisation Bill Vicenzino Workshop: John Banky techniques to augment foot function” Elbow CPR Accreditation “Dental First Aid - What’s this?” 0900 - 0930 Change Over Free Papers: Free Papers: Free Papers: 0930 - 1030 Ageing and Arthritis Shoulder Paediatric Exercise Science 1030 - 1100 Morning Tea (Trade Exhibition Opens) Invited: Trish Wisbey-Roth Invited: Stephen Bird “The lumbo-pelvic hip complex-The “Exercise physiology: Current trends challenge of optimising intervention Free Papers: in enhancing athletic performance” 1100 - 1230 to maximise dynamic activity” Young People and Physical Activity and and Free Papers: Free Papers: Exercise Physiology Low Back Pain 1230 - 1400 Lunch (Trade Exhibition) Invited: Michael Kellmann ASADA Session “The Role of Health “Is recovery important?” Free Papers: Free Papers: Professionals in Australia’s Anti- 1400 - 1530 and Adults and Physical Activity Achilles Tendinopathy Doping Framework” and Respondent: Susan Backhouse Free Papers: Recovery 1530 - 1600 Afternoon Tea (Trade Exhibition) 1600 - 1615 Official Opening Ceremony (Auditorium) Plenary Keynote: 1615 - 1715 John Buchanan “Jurassic Park Revisited: Research and science meets the dinosaur” (Auditorium) 1730 - 1900 Poster Session (Endeavour Room 2) 1930 - Late ASMF Fellows Dinner (Barge Pier, Hamilton Island Marina) Friday 17th October Time MR 1 & 2 MR 3 & 4 Endeavour Room 1 Endeavour Room 2 Chart Room Workshop: Workshop: Trish Wisbey-Roth (0730 - 0900) Workshop: Leo Pinczewski “Assessment of Cycling 0800 - 0900 Workshop: Susan Backhouse “Clinical examination of the Biomechanics to optimise CPR Accreditation 100% ME program Knee” performance and minimise injury” 0900 - 0930 Change Over Refshauge Lecture: Wendy Brown 0930 - 1030 “Stand up, sit down, keep moving: how much activity for a merry and bright old age?” (Auditorium) 1030 - 1100 Morning Tea (Trade Exhibition) Invited: Caroline Finch “Using behavioural and health promotion theories to guide sports injury Free Papers: Symposium: prevention and safety Free Papers: 1100 - 1230 Diabetes and Peripheral Management of the ACL Poster Display promotion” and Neuromechanics Vascular Disease Injured Knee Free Papers: The use of behavioural and health promotion theory to guide sports safety 1230 - 1400 Lunch (Trade Exhibition) Free Papers: SMA Board Advisors Session Free Papers: Free Papers: 1400 - 1530 Quantifying and describing “How to run a successful Poster Display Knee Nutrition and Physiology injury risk business” 1530 - 1600 Afternoon Tea (Trade Exhibition Closes) Invited: Tim Cable Free Papers: Free Papers: Environments Free Papers: 1600 - 1730 “Exercise, ageing and Poster Display Closes Hot Topics in and Physical Activity Foot and Ankle cardiovascular function” Neuromechanics 1930 - Late Discipline Group Dinners

Saturday 18th October Time MR 1 & 2 MR 3 & 4 Chart Room Workshop: Workshop: Workshop: Trish Wisbey-Roth 0800 - 0900 Stephanie Hanrahan Neville Blomeley and Brendan de Morton “Assessment of core stability and proximal “Holistic Treatment: More than Body and Mind” “Examination techniques for groin injuries” muscle function to optimise dynamic activity” 0900 - 0930 Change Over Invited: Kristiann Heesch Invited: Susan Backhouse and “Qualitative Methods in Physical Activity Free Papers: Symposium: 0930 - 100 Research: An Overview” and Sports Psychology Anti-Doping Policy and Practice: State of the Free Papers: Social Science Qualitative Physical Activity Research 1100 - 1130 Morning Tea (Asics Trade Exhibition) Invited: Dean Robinson 1130 - 1300 “Development, Integration and Technologies of a High Performance Unit” (Auditorium) 1300 - 1400 Lunch (Asics Trade Exhibition) Keynote: Craig Purdam 1400 - 1500 “Short cuts, potholes and dead-ends: the race against nature in injury management” (Auditorium) 1500 - 1530 Afternoon Tea (Asics Trade Exhibition Closes) “Best of the Best” 1530 - 1630 Best paper winners re-present to determine Asics Medal winner for Best Conference Paper (Auditorium) 1630 - 1700 SMA AGM (Auditorium) 1830 - 2230 Conference Dinner (Bougainvillea Marquee) Registration Form Contact Details

Title...... First Name...... Last Name...... PProfession/Position...... rofession/Position...... Organisation/Discipline Group...... Group...... Mailing AAddress...... ddress...... SSuburb...... State...... uburb...... State...... PostPost CCode...... ode...... Country...... Country...... PPhone...... hone...... Fax...... Fax...... MMobile...... obile...... Email...... Email...... Special Requirements - Dietary, PPhysicalhysical eetc...... tc...... Registration Fees SSportsports MMedicineedicine AAustraliaustralia MMembership*embership*

Join SMA now to be eligible for the ddiscountediscounted mmemberember rregistrationegistration rrateate oorr oonene ooff tthehe AASMFSMF FFellowsellows awards. Conference awards are only available to SMA members. Joining ffeeee ooff $$4040 wwaivedaived fforor CConferenceonference ddelegates.elegates.

*SMA membership is open to aanyonenyone wwithith aann iinterestnterest iinn oorr ddirectirect iinvolvementnvolvement wwithith ssportsports mmedicine,edicine, sports science, physical activity promotion or sport injury ppreventionrevention aandnd a mminimuminimum threethree yearyear fullfull timetime tertiarytertiary degreedegree (or(or studyingstudying for a degree for student membership).

Sub Total AUD$  FFullull MMemberember - $$180180  SStudenttudent MMemberember - $45 ......

Conference Registration

EEarlyarly BBirdird RRegistrationegistration Late Registration O Onn oorr bbeforeefore 3311 JJulyuly 22008008 O Onn or after 1 August 2008 SMA Member - FFullull $ $620620 $ $720720 ...... SMA Member - SStudent^tudent^ $ $490490 $ $590590 ...... Non Member - FFullull $ $820820 $ $920920 ...... Non Member - SStudent^tudent^ $ $580580 $ $680680 ......

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Registered delegates receive aaccessccess ttoo allall ssessionsessions bbeingeing offeredoffered duringduring tthehe conference.conference. DDelegateselegates aalsolso receive entrance to the Welcome Reception, Poster Session and CConferenceonference DDinner,inner, llunch,unch, mmorningorning aandnd aafternoonfternoon tteas,eas, eentrancentrance ttoo tthehe trade exhibition, a Book of Abstracts, which includes a detailed CConferenceonference PProgram,rogram, aandnd a CConferenceonference bbag.ag.

Costs are included in the rregistrationegistration ffeeee uunlessnless ootherwisetherwise nnotedoted aabove.bove. FForor ccateringatering ppurposesurposes ppleaselease Tick  if attending. D Delegateelegate TicketTicket A Additionaldditional TicketTicket # Required Welcome Reception (Wed 15 October)October) $nil$nil  $ $6060  ...... ASMF Fellows Dinner (Thurs 16 October)October)> $ $6060  $ $6060  ...... Conference Dinner (Sat 18 October)October)> $ $nilnil  $ $100100  ......

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 I wish to pay by  MMastercardastercard  VVisaisa Please forward this completed form to: Card # ...... /...... / ...... / ...... ACSMS Conference Secretariat C/- Sports Medicine Australia Expiry Date ...... / ...... PO BOX 78 Cardholder’s Name...... Mitchell ACT 2911 Phone +61 2 6241 9344 Cardholder’s Signature...... Fax +61 2 6241 1611 Email [email protected] PHYSIOTHERAPY A SLAP on the shoulder

If you follow the popular press in US articular fibrocartilaginous extension of anterior translation in the cocking sports, you’d be excused for thinking of the insertion of the long head of or acceleration phases of throwing, that throwing athletes attract SLAP biceps. For an elegant description then surely at least some of these lesions like dogs attract fleas. Well, of the anatomy of the labrum of the individuals would be unlucky enough maybe they are not that common, but glenoid, and its relation to the long to have their shoulder progress from increasingly SLAP lesions are being heads of the biceps and triceps, the a subtle anterior instability to a frank seen as an almost ‘essential’ lesion of interested reader is directed elsewhere. dislocation. However, the incidence of the athletic shoulder, so it serves those In short, however, the circumferentially anterior instability in the throwing arm of us who see injured throwing athletes placed fibrocartilaginous labrum is the of these athletes displays the opposite, well to be familiar with the presentation, intermediate structure between the with a marked reduction in frank pathology, contributing factors and tendons of the long heads of the biceps anterior instability in throwing arms rehabilitation of these athletes. (superiorly) and triceps (inferiorly) in comparison to non-throwing arms. and the insertion of the fibres into the Clearly there is some systematic effect There is a growing body of thought that scapula. going on here, but it is not anterior a significant early symptom of a superior translation. labral lesion from anterior to posterior The essential thing to understand then (SLAP) lesion will be a sense of lost is that a common mechanism of failure Another body of work suggests it throwing velocity—a symptom that both of this insertion is a tensile overload might, in fact, be a postero-superior the athlete and the coaching staff will of the associated tendon wrenching translation that is a more common be immediately and acutely aware of. the attachment from the glenoid. This occurrence in throwing athletes. The It is worth noting that often the athlete can occur in a number of ways, but genesis of this is a tightening of the will describe this as a ‘dead arm’. Those in throwing athletes it is thought to posterior inferior glenohumeral ligament, of us who more commonly deal with be associated with the extremes of probably due to an abbreviated follow- impact sports can mistakenly interpret shoulder rotation regularly displayed through phase, or an insufficiency of this as a sign of frank shoulder instability, during their sport. At first this may seem the decelatory musculature increasing and it pays to clarify this with the athlete incongruous if you thought the main the load on the passive elements such in some detail. Rarely, if ever, will the role of the long head of the biceps as the posterior capsule. The influence athlete describe signs or symptoms of is in elbow movements; however, if of throwing mechanics on pathology true instability (shoulder ‘popping out’ you recall that the proximal long head and performance in these athletes is or true neurological deficit in the upper of biceps is relatively trapped in the hotly debated and a long way from limb). bicipital groove between the greater and being resolved; however, the interested lesser tuberosities then you can envision reader is directed to a review of these Pathology that humeral rotation will then place factors which are useful to address a marked increase in tension between during rehabilitation. Therapeutically, the The SLAP lesion was first described the glenoid origin and the initial few implications are that an improvement by Snyder, who further sub-defined millimetres of tendon during rotation in the strength of the external rotators his original series of 27 subjects of the humerus. Any translation of the will assist in reducing the load on the from a retrospective review of 700 humerus away from the centre of the posterior capsule during the decelatory arthroscopies into four subtypes. This glenoid can then change this tension on phase. classification system has been further the origin. refined (delineating three subtypes of Interestingly, I have now collected Type II SLAP lesions) and extended to Traditionally, the translation associated a series of close to 1000 consecutive include an increased variation in SLAP with perceived instability in the throwing measures of isometric break force for lesion types such that there are now shoulder has been suggested to be internal and external rotation (measured at least an unwieldy 10 types of SLAP antero-inferior; however, as alluded by the side), and those with SLAP lesions lesion described, which doesn’t include to above, there is a growing body of regularly display a marked reduction (>1 subtypes. I’m entirely incapable of thought that this may not be the case. S.D. from average strength ratios) in their recalling the vagaries of these evolving The incidence of shoulder pain in external rotation strength. I have had subtypes, and in a practical sense I now the throwing athlete is very high; if a several subjects who have had their cuff consider SLAP lesions by their essential significant subset of this shoulder pain strength measured and in the subsequent manifestation: an incompetence of the were being caused by some degree two years have been unlucky enough

36 Sport Health PHYSIOTHERAPY to suffer a throwing-related SLAP Rotational range of motion in restoring rotational ROM, and while lesion—they, too, had a similar reduction we have no reliable way of predicting When discussing shoulder rotational in external rotation strength. Such small the order of magnitude of these changes range of motion (ROM), a couple of numbers make for a statistically invalid according to the thrower’s playing related concepts are important to keep in leap of faith to suggest that it is the history, anthropometrics or kinematics, mind. First, rather than passive shoulder external rotation weakness that caused we now have a non-ionising method of external or internal rotation range per the SLAP lesion, but combined with the reliably measuring this value. se, the important concept is the total proposed mechanism described is some rotational ROM, or the sum of these two kinetic evidence that suggests improved values. For any given individual, these Clinical assessment external rotation strength reduces are thought to be constant from side- The clinical assessment of SLAP lesions harmful loads at both the shoulder and to-side, but the same cannot be said for has had a chequered past. Some of elbow of throwing athletes. between individual comparisons. While the early examination techniques Also of consideration here is the this averages to about 180°, the variation were hampered by an incomplete finding that a SLAP lesion is regularly is large (the highest total rotational ROM understanding of the normal anatomy of associated with a collection of oedema I’ve seen was 270°). Throwing athletes the biceps origin at the time, from which in a pouch superior to the glenoid, with tightening of their posterior capsule arose inaccuracy when comparing to which can directly impinge on the will usually have a reduction of internal arthroscopic examination. course of the suprascapular nerve, rotational ROM associated with this, The initial analysis of any reported thereby further reducing the integrity of and restoration of these ROM losses is physical examination technique needs to at least the infraspinatus muscle which associated with a marked reduction in be tempered by the light of subsequent it subsequently innervates. Of concern the incidence of SLAP lesions in these analyses of the same technique is that due to the lack of a cutaneous athletes. Second, humeral torsion is a performed by different investigators. The distribution, the motor loss may be the confounder that must be considered. outstanding Likelihood Ratios described only sign of such an injury. It turns out that the amount of twist by O’Brien’s initial report of the Active about the long axis of the humerus (the Tightening of the posterior capsule has Compression Sign were cast aside when ‘humeral torsion’) will effectively ‘shift’ previously been implicated in the genesis subsequent investigations reported a this rotational ROM. So if an individual of shoulder pathology, but subacromial less rosy picture. Unfortunately in this has a 15° retrotorsion increase in their impingement and the tight posterior case, O’Brien and colleagues would dominant arm, then you should expect capsule has shown to be associated have cause for objection when papers to find 15° more external rotation and with a superior migration of the humeral investigating this sign don’t perform the 15° less internal rotation ROM when you head. The cadaveric evidence certainly test as it was originally described, and assess. Confusingly in my opinion, the showed this, but it was during passive then conclude that the test is of little US literature continue to separately refer forward flexion that this occurred, and clinical utility. Further review papers to lost internal rotation (Glenohumeral some of us had mistakenly extrapolated will often state performance of O’Brien’s Internal Rotational Deficit or ‘GIRD’) and this to all shoulder movements, including Active Compression Sign in their abstract, an increase in external rotation (External the cocking phase where abduction and but a more careful perusal of their Rotational Gain or ‘ERG’) which are external rotation occur. The suggestion methods shows a different test being viewed in isolation from humeral torsion. is that during the extreme shoulder performed than that which was originally Perhaps, though, it is only confusing external rotation displayed during the described. It benefits all of us to be to me as I find the notion of a total cocking phase of throwing (up to 210° accurate in our examination technique rotational arc of motion more intuitive of external rotation have been recorded), and reliable to the original description where the arc is shifted by the difference the posterior capsule ends up antero- if we’re trying to make inferences from in torsion, and then real differences in inferior to the glenoid, and if this capsule the original work. That said, there are internal and external rotational range has been significantly thickened and now a number of techniques available to are obvious. Of great clinical use from tightened the resultant translation at the the clinician, along with O’Brien’s Active these papers is the finding that losing glenohumeral joint is postero-superior. Compression sign, showing promising 25° or more of total rotational ROM to The net result is now a double whammy predictive ability, such as the Crank be associated with a significant increase of tension on the proximal long head of Sign, the Biceps Load II, the Resisted in the incidence of SLAP lesions, thereby the biceps and its associated investment Supination External Rotation Test, and giving clinicians a useful clue for in the superior labrum—first, by the the Passive Compression Test. The true screening purposes and some direction humeral rotation, and, second, by the utility of these techniques will be clearer to their immediate treatment aims. translation associated with the capsular when all these tests are performed The average side-to-side difference for thickening. This also helps explain the prospectively by a second group, and humeral torsion in throwing athletes reduction in anterior instability incidence this is something we should all be is about 13° but the range is large: our as the posterior capsular tightening will eagerly awaiting. series of over 200 throwing athletes has thus be protective of this. shown a variation from 48° retrotorsion In summary, a SLAP lesion should be increase to 30° retrotorsion decrease— suspected in the athlete who presents almost 80° range. Clearly such a with an unexplained loss of throwing difference will need to be accounted for velocity. The index of suspicion would

VOLUME 26 – ISSUE 2 • WINTER 2 0 0 8 37 ROD WHITELEY

rise if a true reduction in internal rotation 7. Whiteley, R., Baseball throwing mechanics as they 18. Crockett, H.C., et al., Osseous adaptation and range relate to pathology and performance - a review. of motion at the glenohumeral joint in professional ROM is found once their humeral torsion Journal of Sports Science & Medicine, 2007. 6(1): p. baseball pitchers. Am J Sports Med, 2002. 30(1): p. is accounted for, and probably more so 1-20. 20-6. 8. Moore, T.P., et al., Suprascapular nerve entrapment 19. Osbahr, D.C., D.L. Cannon, and K.P. Speer, if a relative reduction in their external caused by supraglenoid cyst compression. J Shoulder Retroversion of the humerus in the throwing rotation strength (in comparison to Elbow Surg, 1997. 6(5): p. 455-62. shoulder of college baseball pitchers. Am J Sports 9. Harryman, D.T., 2nd, et al., Translation of Med, 2002. 30(3): p. 347-53. their internal rotation strength) is found. the humeral head on the glenoid with passive 20. Whiteley, R., et al., Indirect ultrasound Conservative rehabilitation would involve glenohumeral motion. J Bone Joint Surg Am, 1990. measurement of humeral torsion in adolescent addressing these strength and flexibility 72(9): p. 1334-43. baseball players and non-athletic adults: reliability 10. Werner, S.L., et al., Relationships between throwing and significance. J Sci Med Sport, 2006. 9(4): p. deficits, along with their throwing mechanics and shoulder distraction in professional 310-8. baseball pitchers. Am J Sports Med, 2001. 29(3): p. 21. O’Brien, S.J., et al., The active compression test: a volume and throwing mechanics in 354-8. new and effective test for diagnosing labral tears concert with their coaches. If this were to 11. Burkhart, S.S., C.D. Morgan, and W. Ben Kibler, and acromioclavicular joint abnormality. Am J fail then surgical intervention would be The disabled throwing shoulder: Spectrum of Sports Med, 1998. 26(5): p. 610-3. pathology Part I: Pathoanatomy and biomechanics. 22. Parentis, M.A., et al., An evaluation of the warranted, otherwise the outcome is not Arthroscopy - Journal of Arthroscopic and Related provocative tests for superior labral anterior posterior good in the throwing athlete—surgery Surgery, 2003. 19(4): p. 404-420. lesions. Am J Sports Med, 2006. 34(2): p. 265-8. 12. Meister, K., et al., Rotational Motion Changes in 23. Guanche, C.A. and D.C. Jones, Clinical testing for followed by appropriate rehabilitation the Glenohumeral Joint of the Adolescent/Little tears of the glenoid labrum. Arthroscopy, 2003. seems to have a good clinical outcome. League Baseball Player. Am J Sports Med, 2005: p. 19(5): p. 517-23. 0363546504269936. 24. Parentis, M.A., et al., An anatomic evaluation of 13. Burkhart, S.S., C.D. Morgan, and W.B. Kibler, The the active compression test. 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Part II: Evaluation and treatment of SLAP lesions in 17(2): p. 160-4. 3. Huber, W.P. and R.V. Putz, Periarticular fiber system throwers. Arthroscopy, 2003. 19(5): p. 531-9. of the shoulder joint. Arthroscopy, 1997. 13(6): p. 27. Myers, T.H., J.R. Zemanovic, and J.R. Andrews, The 680-91. 15. Burkhart, S.S., C.D. Morgan, and W. Ben Kibler, The resisted supination external rotation test: a new test disabled throwing shoulder: Spectrum of pathology for the diagnosis of superior labral anterior posterior 4. Montgomery, W.H., 3rd and F.W. Jobe, Functional part III: The SICK scapula, scapular dyskinesis, the outcomes in athletes after modified anterior lesions. Am J Sports Med, 2005. 33(9): p. 1315-20. kinetic chain, and rehabilitation. Arthroscopy, 28. Kim, Y.S., et al., The Passive Compression Test: A capsulolabral reconstruction. Am J Sports Med, 2003. 19(6): p. 641-61. 1994. 22(3): p. 352-8. New Clinical Test for Superior Labral Tears of the 16. Pieper, H., Humeral torsion in the throwing arm Shoulder. Am J Sports Med, 2007 5. Walch, G., et al., [Postero-superior glenoid of handball players. American Journal of Sports impingement. Another shoulder impingement]. Rev Medicine, 1998. 26(2): p. 247-53. Chir Orthop Reparatrice Appar Mot, 1991. 77(8): p. By Rod Whiteley, Specialist Sports 571-4. 17. Reagan, K.M., et al., Humeral retroversion and its relationship to glenohumeral rotation in the Physiotherapist 6. Burkhart, S.S., C.D. Morgan, and W.B. Kibler, shoulder of college baseball players. Am J Sports Shoulder injuries in overhead athletes. The “dead Med, 2002. 30(3): p. 354-60. arm” revisited. Clin Sports Med, 2000. 19(1): p. 125- 58.

>> from Page 27 17. Seward H, Orchard J, Hazard H, Collinson D. 27. Seward H, Orchard J, Jowett A. Football Australasia: Football Injuries in Australia. Canberra: Australian controversies in 2003. Medical Journal of Australia Sports Commission, 1995. 2004;180(7):in press. 9. Orchard J, Hoskins W. For Debate: Consensus injury definitions in team sports should focus on missed 18. Orchard J, Wood T, Seward H, Broad A. 28. Norton K, Schwerdt S, Lange K. Aetiology of injuries playing time. Clinical Journal of Sport Medicine Comparison of injuries in elite senior and junior in Australian football. British Journal of Sports 2007;17(3):192-196. Australian football. Journal of Science and Medicine Medicine 2001;35:418-423. in Sport 1998;1(2):82-88. 10. Rae K, Britt H, Orchard J, Finch C. Classifying 29. Norton K, Craig N, Olds T. The evolution of sports medicine diagnoses: a comparison of the 19. Orchard J, Seward H, McGivern J, Hood S. Intrinsic Australian football. Journal of Science and Medicine International classification of diseases 10-Australian and Extrinsic Risk Factors for Anterior Cruciate in Sport 1999;2(4):389-404. modification (ICD-10-AM) and the Orchard sports Ligament Injury in Australian Footballers. American injury classification system (OSICS-8). British Journal of Sports Medicine 2001;29(2):196-200. John Orchard is a Conjoint Journal of Sports Medicine 2005;39:907-911. 20. Orchard J, Seward H, McGivern J, Hood S. Rainfall, Senior Lecturer at the 11. Orchard J, Best T. The Management of Muscle evaporation and the risk of non-contact Anterior Strain Injuries: An Early return Versus the Risk of Cruciate Ligament knee injuries in the Australian University of New South Wales Recurrence [guest editorial]. Clinical Journal of Football League. Medical Journal of Australia 1999;170:304-306. Sport Medicine 2002;12:3-5. Correspondence: 12. Verrall G, Slavotinek J, Barnes P, Fon G, Spriggins 21. Orchard J, Marsden J, Lord S, Garlick D. Preseason A. Clinical risk factors for hamstring muscle strain Hamstring Muscle Weakness associated with [email protected] injury: a prospective study with correlation of injury Hamstring Muscle Injury in Australian Footballers. by magnetic resonance imaging. British Journal of American Journal of Sports Medicine 1997;25:81-85. Sports Medicine 2002;35:435-439. 22. Orchard J, Chivers I, Aldous D, Bennell K, Dr Hugh Seward is President 13. Bennell K, Wajswelner H, Lew P, Schall-Riaucour Seward H. Ryegrass is associated with fewer non- of the AFL Medical Officers A, Leslie S, Plant D, et al. Isokinetic strength testing contact anterior cruciate ligament injuries than does not predict hamstring injury in Australian bermudagrass. British Journal of Sports Medicine Association Rules footballers. British Journal of Sports Medicine 2005;39:704-709. 1998;32:309-314. 23. Orchard J. Is there a relationship between ground 14. Orchard J. Intrinsic and Extrinsic Risk Factors for and climatic conditions and injuries in football? Muscle Strain Injury in Australian Footballers. Sports Med 2002;32(7):419-432. American Journal of Sports Medicine 2001;29(3):300- 24. Orchard J. The AFL Penetrometer study: work in 303. progress. Journal of Science and Medicine in Sport 15. Orchard J, Best T, Verrall G. Return to play 2001;4(2):220-232. following muscle strains. Clinical Journal of Sport 25. Orchard J. The ‘northern bias’ for injuries in the Medicine 2005;15(6):436-441. Australian Football League. Australian Turfgrass 16. Cochrane J, Lloyd D, Buttfield A, Seward H, Management 2000;23(June):36-42. McGivern J. Characteristics of anterior cruciate 26. Orchard J. Orchard Sports Injury Classification ligament injuries in Australian football. Journal of System (OSICS). In: Bloomfield J, Fricker P, Fitch Science and Medicine in Sport 2007;10(2):96-104. K, editors. Science and Medicine in Sport. 2nd ed. Melbourne: Blackwell, 1995:674-681.

38 Sport Health FROM THE CEO

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������������������� VOLUME 26 – ISSUE 2 • WINTER 2 0 0 8 39 FROM THE CEO Notice of Annual General Meeting and Call for Nominations

Notice is hereby given that the Annual General Meeting of Sports Medicine Australia will be held at the Convention Centre, Hamilton Island on Saturday 18 October 2008 at 5.00PM. Agenda 1. President’s Welcome 2. Roll Call, Apologies and Proxies 3. Minutes of the Previous AGM 4. Reports 5. Financial statements & audit report 6. Board Election (if required) 7. Appointment & remuneration of auditors 8. Special Business 9. Close Call for Nominations – Board of Directors Members are asked to provide nominations for positions on the Board of Directors of Sports Medicine Australia. National Directors for: • Queensland • WA • ACT • Tasmania • Victoria • NT

I of

hereby nominate

for the position of

on the National Board of Directors of Sports Medicine Australia

Proposer’s Signature Date

Seconder (full name)

Seconder’s signature Date

Nominations should reach: Sports Medicine Australia, PO Box 78 Mitchell ACT 2911 or fax to (02) 6241 1611

BY NO LATER THAN 5.OO PM (EST) ON Friday 26 SEPTEMBER 2008

Note to the validity of nominations to the Board of Directors of SMA

Appointment and Election of National Directors

a) Each State Branch shall elect a National Director from and by the Federation membership in their state.

40 Sport Health