Injury tests on the field – Corey Norman
Occasionally coaches do give an indication of the suspected diagnosis of an injured player post game. When asked about Corey Norman’s injury Brad Arthur said he thought it was a “grade 2 medial” and that the recovery time was “maybe 4 weeks”. This is actually quite accurate if the suspected diagnosis is confirmed, but how did Arthur know these details when Norman was not able to get scans until Monday? There are many tools used to assess an injury on game day, with one of the most important being the physical examination.
Any player who has suffered an injury on the field should be assessed by a member of the medical staff quickly, either on the field or if severe enough in the dressing sheds. It is ideal for this to happen quickly as muscle guarding (tensing) can set in around an injury and interfere with the physical examination results. Initially the player may be asked some questions about the mechanism of injury, and particularly with the knee this will often revolve around contact. If the injury was non-contact, knowing he position of the joint or limb is relevant. For contact injuries it is important to know the location and direction of force.
The on field testing usually includes some/all of the following:
- looking for bony deformities or a loss of skin integrity which could indicate fractures or dislocations
- sensation/strength/pulse testing to assess nerve or vascular involvement
- range of movement tests (comparing to the uninjured side)
- special tests assessing ligament laxity (looseness), isolated muscle strength, cartilage integrity/damage, and neural sensitivity (some of these test will be performed on the sideline/in the dressing sheds as a more controlled setting is preferable)
Accurate and comprehensive physical testing done on field can give valuable information on the location and severity of an injury. Making a decision regarding if the player is fit to return to play is of vital importance, and information from these tests allow the medical professional to protect the short and long term health of the player.
For Corey Norman, it was shown that the trainer was performing a valgus stress test on his knee to test the laxity (looseness) of his medial collateral ligament (MCL). Many skilled/experienced medical professionals will be able to gain a fair idea of the severity of an MCL strain with this test by observing the amount which the joint line opens on the inside of the knee when pressure is applied to the outside. In this case the valgus stress test (and other signs/symptoms) would have given the medical staff a suspected diagnosis to pass onto Brad Arthur, which will either be confirmed or altered (damage to other structures?) pending scan results in the next few days. The video below shows on field testing performed on Norman (MCL), Greg Inglis (ACL) and Lachlan Fitzgibbon (meniscus).
These early indications for Norman suggest an approximate 4-week recovery time, and the majority of grade 2 MCL injuries in the NRL cause 2-5 missed games. Some recent examples of grade 2 MCL injuries and recovery times include:
James Segeyaro (2015) – 3 weeks
Sam Perrett (2014) – 5 weeks
Paul Gallen (2013) – 4 weeks
Considering the traumatic injury mechanism for Trbojevic, 6-8 weeks is considered good news and was almost best case scenario after he was tackled mid-air and came down heavily on his right leg. With this recovery timeframe scans likely revealed a grade 2 syndesmosis injury and grade 1-2 MCL sprain. Neither of these injuries will require surgery which is a big relief for Trbojevic and the Sea Eagles. If he had suffered further damage to his syndesmosis (a grade 3 injury requiring surgery is a 12-14 week recovery) or to other ligaments in his knee (ACL rupture is 6+ months recovery) this would have likely ended his season. Trbojevic had surgery in the offseason on his right ankle, so this new injury is to his “good” ankle.
Reviewing ankle mechanism, high ankle (syndesmosis) injury of concern for Tom Trbojevic. Still hoping for MCL/meniscus & no ACL involvement pic.twitter.com/OkiboW8hCf
— NRL PHYSIO (@nrlphysio) May 13, 2017
Coote appeared to roll his ankle in the last minute of the game last week. Paul Green was quoted after the game clearing Coote of injury, and with the video of the injury mechanism not appearing severe I would expect him to be fine for this week’s game
Hayne copped a blow to the outside of the knee, causing his foot to “go dead” and him struggle to run. This was likely due to the trauma causing injury to the peroneal nerve, or the “funny bone” of the knee. The peroneal nerve works to pull the foot upward and outward, and runs very close to the skin near the knee. If the traumatic blow occurs near the nerve it can cause pins and needles, weakness, numbness and in severe cases foot drop (where the foot cannot be lifted to clear the ground when walking). These are often short term injuries, and the Titans indicated Hayne was “80% right” by post match. Barring any aggravation at training this week he should be fine for round 11.
Euan Aitken, Simon Mannering, James Fisher-Harris
Aitken, Mannering and Fisher-Harris all suffered hamstring injuries last week. Mannering and Fisher-Harris both are reported to be minor (grade 1) strains, which usually carry a 2-4 week recovery. Aitken has unfortunately suffered a grade 2 hamstring tendon strain. Tendon injuries tend to have a slightly longer recovery than muscles in the hamstring, and he will be looking at 6-8 weeks on the sideline.
Dan Sarginson and Chris Grevsmuhl
Interesting to note for shoulder dislocations, the prognosis (likely course of injury/recovery time) is not always obvious right away. For Grevsmuhl, it is now 3 weeks since he dislocated his shoulder and the Titans are still letting the injury settle before deciding on conservative (rehab/physio) or surgical treatment. As indicated last week, scan results don’t always tell the full story so it is important to assess function and pain thoroughly. For Sarginson, even a “clean dislocation” (popped out and straight back in, no major damage) will still require 2-4 weeks’ recovery. If there is labrum (cartilage) or extensive rotator cuff damage and surgery is required, the recovery time extends to 4-6 months.
There has been no confirmation for the Titans yet, but considering the non-contact mechanism of injury with valgus (knee collapses in) force it is highly likely Simpkins has suffered an ACL rupture. If so he will undergo reconstructive surgery and return in 7-12 months time (pending ACL graft type).
Unfortunately for Ryan Simpkins mechanism looks ominous here. Non-contact, valgus force (knee collapses in). Not looking good for his ACL pic.twitter.com/YZmQ7bXJc3
— NRL PHYSIO (@nrlphysio) May 14, 2017
Solomone Kata only played 70 minutes for the Warriors before coming off with a suspected calf strain. No official word on severity yet, but by video looked minor (grade 1) which usually involves a 1-3 week recovery.
Scotland’s Greig Laidlaw breaks fibula-Dr. Parekh
Scotland will be without Greig Laidlaw after he broke his fibula Sunday. Surgery not needed. 8-12 weeks RTP.
Wales winger George North suffers knee sprain-Dr. Parekh
Wales will be without star winger George North suffered a “sprain to his posterior cruciate ligament” in their defeat to Saracens on Sunday. Surgery not usually needed but typically 8-12 weeks RTP.
Jack Clifford dislocates shoulder-Dr. Parekh
Jack Clifford is a doubt for England’s autumn series after dislocating his shoulder. If there is no associated injury, could return to play within two to four weeks.