Inside features20

InsIde Football Wednesday, august 29, 2012

AS WELL AS carrying the weight of expectation of

supporters, the shoulders of AFL players constantly bear the brunt of high forces from bumps, tackles and falls.

The past two AFL Injury Reports have identified a steady increase in shoulder injuries for players.

Twice as many games are missed due to shoulder injury now compared with 10 years ago.

The injury report also clearly shows that over the past decade there has been a parallel increase in the number of tackles per game, which would expose the tackling and tackled player to greater risk of shoulder injury.

In light of the statistics also showing increases in player density around the ball, it all makes sense.

However, there’s a bit more to it, and besides, what can be done about it?

It’s worth having a closer look at the

shoulder joint first to get a better understanding about why it is so susceptible to injury.

The shoulder is a ball-and-socket joint where the top end of the upper arm bone is rounded (ball) and sits in a shallow cup-like cavity (socket) to create the joint.

Ligaments, fibrous tissue and muscles stabilise the joint but the shallow cavity in which the ball sits, while it makes the joint fundamentally unstable, gives it the largest range of motion than any joint in the body. In short, stability is sacrificed for mobility.

A loose shoulder joint is more likely to dislocate but is better at producing power for athletes in sports such as tennis and baseball, and allows for great range of motion for sports like gymnastics.

But for a player in a contact sport, a loose shoulder joint spells trouble.

Sports physician and co-author of the AFL Injury Report, Associate Professor John Orchard explains that the shoulder is susceptible to both subluxation and dislocation, with different consequences.

“When the shoulder joint is injured, if the ball remains in any contact with the socket then it’s called a subluxation,” Dr Orchard said.

“With a subluxation the ball can partly pop out of the socket but will often pop back in without help, whereas with a dislocation, the ball moves out of the socket and stays out.”

Players can often complain of a dead

arm after a subluxation as some of the nerves have been stretched. They usually keep playing but not necessarily well.

With a dislocation on game day, the player has to come off and his shoulder must be put back in or in medical terms “reduced” (although former Swan Tadhg Kennelly dislocated his shoulder so often he would get a teammate on the field to help put it back for him. Ouch!)

Orthopaedic surgeon Dr Greg Hoy has been conducting shoulder instability research for the AFL, investigating the size of the problem, injury management and performance outcomes for players.

His extensive preliminary research, soon to be published in the British Journal of Sports Medicine, shows that if a complete dislocation of the shoulder joint has to be put back in, an AFL player will miss an average of eight games. That’s a whopping one third of the season.

However, surgery is season ending as four to six months of rehab is needed to return to match fitness.

Chris Judd suffered chronic shoulder problems before he was drafted and kudos to West Coast for this decision as his extraordinary talent has far outweighed his injury struggles. But due to the high risk of recurrence of problems in shoulder instability, players may be passed over as recruits if they have a history of dislocation.

“If a player has a dislocation followed by a soft-tissue reconstruction, we have to warn them when they come back that the recurrence rate for re-injuring that shoulder is up to 30 per cent,” Dr Hoy said.

“On top of that, the risk of injuring their ‘good’ shoulder is almost as much as a re-injury on the previously injured side.

“There are some clubs that use that information in their recruiting philosophy and are careful not to preferentially draft players that have sloppy shoulders.”

AFL players often carry injuries and it is commonplace for AFL medical staff, in consultation with players, to constantly consider the pros and cons of carrying a player through a season or ending his season early for surgery.

For some injuries, players can get by with a revised training program and a jab of local anaesthetic on game day without the risk of major repercussions, but this is not the case when it comes to shoulder instability. Clubs are faced with a choice about how to manage a player’s shoulder and the decision is understandably linked to their contention for a flag.

Lance Franklin carried a shoulder injury through much of the 2008 season when the Hawks went on to become premiers and Franklin won the Coleman

Medal. He’s such an important player and arguably the Hawks wouldn’t have won the flag without him but with each game he played injured, the club and Franklin took the risk of full dislocation of his unstable shoulder.

“Clubs and players are weighing up all the time how bad is the shoulder instability,” Dr Orchard said.

“If the team is still in contention and the shoulder of a key player is in question, a club can choose to take the risk in delaying the operation; but if a team is in the bottom four, they can do what’s best for the shoulder and get the surgery done straight away.”

As with Judd, the unstable shoulder of a player being carried through a season needs to be taped for training and matches. The player needs to avoid activities that cause shoulder instability in training including tackling, and focus on strength training exercises with their arms by their sides to add strength of the joint without risking the shoulder popping out.

Taken at face value, the proportionate increase in tackles recorded along with the increase in shoulder injuries makes for a tidy conclusion, but the problem with shoulder injuries may not be as bad as the figures suggest, even accounting for more injuries than recorded in the AFL report. For a shoulder injury to be recorded in the AFL Injury Report,

WINGED: North’s Leigh Adams.

HI-REZ TO BE DOWNLOADED - NEED TO BUY MORE CREDITS

The risk of injuring their good shoulder is almost as much as a re-injury on the previously injured side.’ – SURGEON GREG HOY

The coldSHOULDER

Shoulder injuries are increasing in line with tackle numbers, but the problem is far from that simple, writes DR JODI RICHARDSON

InsIde Football Wednesday, august 29, 2012

‘ ’Dylan has to work through his hamstring injury. He is like his brother and his body type is predisposed to that type of injury.

– Damien Hardwick on Dylan Grimes on Crunch Time

the player has to miss a game. This is one of the criteria used to define injury in the report and having this clear definition is one of the reasons the report is considered one of the best of its kind in the world. But, this doesn’t capture those shoulder instability problems that are carried week to week.

“There are some people that have injuries that allow them to play out the season and have treatment at the end,” Dr Hoy said.

“The number of injuries we deter­mined in our research doubled the reported incidence in the official AFL injury reports as we included those players not missing games.

“Part of that increase is likely the recognition that shoulder instability does create long­term problems so it might be that the injuries are better understood and players are rested for longer than they otherwise would, so more missed games are registered.”

Some clubs will also choose to send

a player for a reconstruction before the season’s end, sacrificing that player for the remaining games but looking to have him fresh for the following season.

This also gives the appearance of extra games being missed. They do this because the rehabilitation for a shoulder reconstruction generally takes longer than the off­season to get the best result.

Between 1992 and 2002 the incidence of shoulder injuries in the AFL remained stable but the management of these injuries was quite different then as explained in the 2011 AFL Injury Report.

“In the 1990s, the standard manage­ment for a shoulder instability episode was to return the player back to comp­etition as soon as possible. If a player had suffered multiple shoulder instability episodes during the season, then once the season had finished a specialist’s opinion was sought and the player considered for shoulder reconstruction,” Orchard revealed in the report.

“In the last 10 years, there have been far more players missing in the final round than mid­season. Many of these will have elected to end their season early to undergo shoulder surgery in order to be fully fit for Round 1 of the following year.”

To get a better understanding about how a player performs after a shoulder instability episode, Dr Hoy and his colleagues compared tackle and overhead marking stats on players before and after their injuries.

They found that in the five games back after their injuries, the tackle count for players was reduced compared to pre­

injury data, so even though the players are still in the game, their injury has a marked effect on their efficiency as a player. Marking was unaffected.

To address the AFL’s concerns about the types of tackles causing shoulder instability episodes, Dr Hoy reviewed video of around 40 injuries and found that 40 per cent were caused by tackles and the remainder by bumps (27 per cent) and marking contests (17 per cent), ruck injuries and falls.

Ultimately, this means that any modification of tackling rules going to make little difference.

“We found that if a player tackles and takes the other player to ground, there is a higher incidence of getting a shoulder injury,” Dr Hoy said.

“The problem is that we don’t have a record of every tackle in the AFL so we can’t establish what percentages of the tackles are causing these injuries, but the common denominator in more injuries than any other was the factor of the tackle going to ground.”

This data does help the AFL and medicos to better understand the risk for players but given the nature of the game, little could be done to reduce or prevent injury under these circumstances.

Part of Dr Hoy’s research is the difficult task of developing an AFL tackling classification system so that types of tackles can be assessed in relationship to injuries.

The AFL recently approved another level of research to determine the outcomes of the three types of shoulder reconstruction used by surgeons.

FRANKLIN: Carried shoulder.

Listed players missing with shoulder injuries in Round 11 compared to the last round of the season over a 20-year period.

Correlation between tackles/team game and shoulder injury incidence from 2002-2011 inclusive.

TACKLE COUNTS AND SHOULDER INCIDENCE

AFL INJURY REPORT

Don’t do it yourself. For simple, speedy tax returns, leave it to the Professionals. The Income Tax Professionals.

ITP Final.indd 1 20/07/12 1:13 PM