Lately in clinic, I have been hearing a lot of concerns regarding painful nails, sometimes accompanied by red, hot and swollen surrounding skin, OUCH! The type of nails that just don’t seem to know where to grow and patients are completely bewildered as to what they have done to deserve this?!

These types of nails are often referred to as involuted or if you’re experiencing the worst type, INGROWN.
Ingrown vs involuted is quite simple. Involuted refers to a nail shape that as it grows, changes shape encroaching on the surrounding skin causing pain. Involuted nails can have varying degrees of pain and curvature in the plates shape. 
​
An ingrown nail is one that has surpassed this and is now cutting into the skin, commonly causing infection or the skin to hypertrophy (increase in size) and envelop the nail plate. These are incredibly painful and can stop you from doing what enjoy such as playing sport or performing the worm on the dance floor, pain free.
​

​What causes this stubborn issue?!
​
Usually there are multiple factors contributing to your nails misbehaving in this way. Until you discuss what you and your feet have been up to with your Podiatrist, it may be hard to put your finger (or toe) on it.

It is all good and well addressing symptoms of pain much like any other problem in the body, however, until you 'nail' the cause, this can stick with you for many new shoes, netball games, trail runs or whatever it's stopping  you from doing.

The main causes include (some more common than others)

• Genetic predisposition
• Trauma to the nail
• Posture of the foot
• Biomechanics of the foot in movement
• Foot deformity e.g. bunions and clawed toes
• Poor cutting technique or picking nails
• Poor fitting shoes and or hosiery
• Sweating
• Brittle/weak nails (this can be due to things like diet or arterial insufficiency)
• Fungal infection
• Medications e.g. beta blockers; Isotretinoin

Depending on whether this is your first one or you’ve had this recurring problem for years, the main message I want you to take away from this blog, is there is hope and your toe/s will be looking and feeling great again before you know it!

Image 1 - http://dubaipodiatry.com/ingrown-toenail-dubai-podiatry-centre/
Image 2 - https://www.palmettostatepodiatry.com/ways-to-prevent-smelly-feet/
Image 3 - http://www.yourpodiatrist.com.au/condition/ingrown-toenails/ 
​​
Written by Anneliese Ball
Podiatrist at Health Associates
Working Monday and fortnightly Saturday

​RISK
Hamstring injuries usually occur due to an imbalance between itself and the quadriceps muscle. The quadriceps are large and powerful group of muscle that extend (straighten) the leg at the knee joint. When there is a powerful contraction of the quadriceps muscle it may over stretch the hamstring and place a large load on the muscle.

• Previous hamstring injury.
• Increasing age of player.
• Sudden change in movement (acceleration or deceleration).
• Poor flexibility.
• Weakness in the muscle.
• Muscle fatigue.
• Muscle imbalances, hamstring to quad ratio.
• Poor or no warm up.
• Body mechanics.
• Psychological factor.
• Poor technique during activity.

PREVENTION

• Proper warm up before exercise including sport specific function movements as well as sport specific skill drills.
• Include speed work within training program to allow the hamstring to sustain high acceleration forces.
• Have a high level of endurance to prevent muscular fatigue.
• Include stretching, functional and strength training within the program.
• Having adequate pre-season preparation prior to competition to ensure readiness to play.
• Gradual increase in training duration and intensity.
• Wearing the right and comfortable protective gear and footwear.
• Adequate recovery times between session to allow the body recover and prevent burning out/over-training.
• Avoid activities that cause pain.

ACUTE MANAGEMENT

• RICER protocol for the first 48-72 hours; rest, ice, compression, elevation and referral. The leg should be elevated when applying ice. The ice should be used for 20 minutes every 2 hours. This protocol will reduce the swelling and bruising of the muscle.
• Another protocol for acute hamstring injuries is the No HARM protocol. This is no heat, no alcohol, no running or activity and no massage. This will also help to decrease bleeding and swelling in the tissue.

REHABILITATION

• Rehab will vary based on the severity of the injury.
• restore flexibility of the muscle.
• Re-activation of muscle fibres.
• Progressive eccentric loading on the muscle.
• Restore endurance.
• Strengthen the hamstring back to usual strength.
• Strengthen other muscles of lower limb and trunk.

RETURN TO PLAY (depending on how well managed the injury is)

• Grade 1 = 1-3 weeks.
• Grade 2 = 4-8 weeks.
• Grade 3 (may require surgery) = approximately 3 months.

Early return to play and/or poor rehabilitation of the injured muscles will increase the chance of re-injury. Full range of motion and strength is required along with the muscles ability to endure full speed training. The player must be able to perform sports related activities such as jumping, sudden change of direction and twisting.

Joshua Hallinan
Chiropractor
Working Tuesday and Thursday at Health Associates

​
References
Prior, M., Guerin, M., & Grimmer, K. (2009). An Evidence-Based Approach to Hamstring Strain Injury: A Systematic Review of the Literature. Sports Health, 1(2), 154–164. 

Hamstring Strain Injuries: Recommendations for Diagnosis, Rehabilitation, and Injury Prevention Bryan C. Heiderscheit, Marc A. Sherry, Amy Silder, Elizabeth S. Chumanov, and Darryl G. Thelen Journal of Orthopaedic & Sports Physical Therapy 2010 40:2, 67-81 

Hamstring strain injuries Opar, D.A., Williams, M.D. & Shield, A.J. Sports Med (2012) 42: 209.

Verrall GM, Slavotinek JP, Barnes PG, et al Clinical risk factors for hamstring muscle strain injury: a prospective study with correlation of injury by magnetic resonance imaging British Journal of Sports Medicine 2001;35:435-439.

Sherry, Marc A., Tyler S. Johnston, and Bryan C. Heiderscheit. "Rehabilitation of acute hamstring strain injuries." Clinics in sports medicine 34.2 (2015): 263-284.

An ankle sprain occurs when the ligaments of the ankle are undergone a force that stretches them beyond their capabilities and tear. Ligaments of the ankle are tough bands of tissue that provide support to hold the ankle bones together and prevent excessive movement. The lateral (outer) part of the ankle is made up of three ligaments the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL). The deltoid ligament supports the entire medial (inner) aspect of the ankle. There is an interosseous ligament, which is tissues that runs between the entire length of the tibia and fibula. Most ankle sprains occur on the lateral aspect of the ankle, affecting the ATFL ligament. Anyone can experience an ankle sprain at any age.
 
There are three different types of ankle sprains:

1. Inversion ankle sprain
   - Usually involves inversion + plantar flexion + rotation
   - Damages the lateral ligaments of the ankle
   - Peroneal muscle and tendon strains (lateral muscles of the leg)
   - Peroneal nerve injury may also occur in serious cases
2. Eversion ankle sprain
   - Rare
   - Most events are severe
   - Damages medial ligaments of the ankle
3. Diastasis/syndesmosis
   - Damage to the distal talofibular ligaments
   - There can be ankle instability
   - Often associated with a fracture

 
There are 3 grades to a sprain:

1. Grade one
   - No bruising, mild swelling and tenderness
   - Mild to no limp, can raise up on toes
   - No joint laxity, pain at end range of motion
   - 1-2 weeks recovery
2. Grade 2
   - Bruising on one side of foot, more extensive swelling
   - Less localised tenderness, i.e. both sides of ankle
   - Visible limp and unable to raise up on toes
   - Slight laxity and pain with most movements
   - 4-8 weeks recovery
3. Grade 3
   - Bruising and swelling both sides of foot.
   - Tenderness on both sides
   - Unable to weight bear
   - Large amount of laxity
   - 2-6-month recovery

Phase 1 - Acute management of ankle sprain (within 24-72 hours of injury):

• RICE protocol – rest, ice (20 min on, 1 hour off), compression, elevation
• Move ankle through pain free active range of motion as soon as possible
• Watch for significant swelling or changes to ankle which means major damage has occurred
• Weight bear when tolerable, use crutches if it is too painful to load the ankle

 
Phase 2 - Post-acute phase management (Recovery time will vary depending on severity):

• Provide support around the ankle when needed.
• Continue to move the ankle through pain free range of motion
• Strengthen muscles that invert (turn foot inwards) and everters (turn the foot outwards), this depends on the type of sprain. This can be achieved with a resistance band.
• Single leg stance with eye close to improve proprioception (perception/awareness of the position and movement of the body). This can be made more difficult with an unstable surface such as a foam matt or folded pillow.
• Ankle manipulations (done by an allied health practitioner) to promote movement and healing within the joint of the ankle.
• Use massage ball to release tight muscles that have compensated because of the injury.
• Increase weight bearing; use pain and swelling as a to guide the intensity
• Heel/calf raises to increase strength and stability of the ankle

  
Phase 3 – Return to play when all of the above is achieve:

• Begin running with focus on agility and side stepping.
• Jump rope/hopping with increase the intensity of bearing weight onto the ankle.
• Return to sports specific drills.
• Return to play if there is no discomfort during the sports specific training.

​
Josh Hallinan
Chiropractor
Available for Appointment Tuesday & Thursday at Health Associates

Vuurberg G, Hoorntje A, Wink LM, et al Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline British Journal of Sports Medicine 2018;52:956.
 
Kerkhoffs GM, van den Bekerom M, Elders LAM, et al Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline British Journal of Sports Medicine 2012;46:854-860.
 
Walls RJ, Ross KA, Fraser EJ, et al. Football injuries of the ankle: A review of injury mechanisms, diagnosis and management. World J Orthop. 2016;7(1):8–19. Published 2016 Jan 18. doi:10.5312/wjo.v7.i1.8
 
Wolfe, Michael W. "Management of ankle sprains." American family physician 63.1 (2001).
 

 A great study titled "Six different football shoes, one playing surface and the weather; Assessing variation in shoe-surface traction over one season of elite football" has recently been released discussing what type of football (soccer) shoes are best for reducing the risk of lower limb injuries such as the commonly experienced ACL damage.

Football involves a high amount of acceleration, deceleration and changing direction. Both require an adequate amount of traction between shoes and surface in order for the movement to be executed quickly, safely and effectively.

Previous studies have shown that compared to other team sports football requires the greatest amount of cutting movements. A player can perform up to 800 cuts per game! 

A players ability to accelerate, decelerate and change direction is influenced majorly by the tractional properties of boots and playing surface.

The components of traction studied in this paper were translational and rotational. Translational relating to the player moving in a straight or side to side pattern.

Previous studies have proven that increased translational movement is linked to improved performance whereas increase rotational movements are associated with an increased risk of lower limb injuries such as ACL damage. 

The study looked at the relationship between:-
Shoe outsole purpose

• Artificial grass
• Firm ground
• Soft ground
• ​Stud cleat configuration

With 

• Playing surface

​
This study was completed to shed some more light on which external factors are contributing to lower limb injury in football players. The external factor here being footwear and the way they interact with the playing surface.

The study was done in Doha, Qatar at the Qatar national team outdoor training pitch. The study was carried out over a single season on the one natural grass football pitch.

6 Nike Shoes were included:-
Artificial grass

• Tiempo (AG)

Firm ground

• Hypervenom
• Tiempo
• Magista
• Mercurial

Soft ground

• Tiempo (SG)

​
​All 6 shoes, one at a time, were attached to a portable traction testing device which is designed to mimic foot movements employed by football players.

This allowed the researchers to pool data about all 6 shoes and their translational and rotational traction qualities.

What were the results?!
Soft ground outsoles showed to have the highest translational traction, however they also showed to have had the highest rotational traction!

Shoe outsoles designed for artificial grass, so the Nike Tiempo (AG) had the lowest rotational traction and came out on top.

So what does all this mean?
Decreased rotational traction in a shoe is proven to decrease lower limb injuries WITHOUT causing any detriment to player performance. 

So YOU want increased translational traction, helping the player move forward and side to side more effectively and safely, and decreased rotational traction, meaning they can rotate and pivot without that increased chance of hurting themselves!

This doesn't mean that if you put the Nike Tiempo on that you're invincible and you'll never hurt yourself. Many things come in to play when aiming to reduce the risk of injury. Adequately strengthening and stretching the correct muscle groups, building the appropriate skills and recruiting safe and effective movement patterns and strategies all compound together to make you a stronger, better player that will be able to stay in the game for longer.

Moving forward towards purchasing footwear, artificial grass shoe outsoles are small round moulded studs vs the screw in metal studs used with soft ground outsole shoes. Also, making sure the fit of the shoe is correct is just as important as getting the appropriate outsole. Having a shoe that is wide enough, deep enough and long enough is crucial!

Moving forward in the world of research they forecast studies looking further into the relationship between shoes and several different playing surfaces, soil types, and grass species to get a more complete understanding of shoe-surface traction.

Stay tuned players!

Access the whole research paper here, hot off the press!
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0216364

References
Taylor JB, Wright AA, Dischiavi SL, Townsend MA, Marmon AR. Activity demands during multi-directional team sports: a systematic review. Sports Medicine. 2017 Dec 1;47(12):2533–51. pmid:28801751

Soccer is the most popular sport on the globe with over 270 million participants and it’s easy to see why. It is fast, dynamic, exciting and crazy, almost every emotion within 90 mins can be experienced. The performance of a soccer player is made up of many different variables such as tactile, mental, technical and physiological. During a game, elite level players run about 10km at an average intensity close to the anaerobic threshold (80-90% of maximal heart rate). Within this time there are a number of explosive movements including jumping, kicking, tackling, sprinting, turning and deceleration. Strength and power are equally as important as endurance in soccer. Now with this large number people playing and the high demands of the game there will be injuries. Let’s analyse to trends of injuries in soccer and how they can be managed and prevented, paying close attention to ankle sprains
Most soccer injuries occur to the lower extremity at approximately 87% and the common injury types include strain, sprain and contusion. The UEFA injury study showed thigh strains makes up 17%, hamstring 12% and ankle sprain 7%. The incidence is higher during the game at 57% making injuries quite high during training at 43%. 16% accounted for more than 28 days away from training and game. 12% with season ending injuries. Another study among amateur soccer players in Spain showed there was an average of 0.11 injuries per player per year. A large number of injuries led to 1 competitive match being missed (87%). Midfielders had the highest injury rate at 34.3%. The knee and ankle making up 42.3% making them the most common injury location. Ligament sprains accounted for 32.1%.
Risk factors:

• Previous injury
• Age (older players tend have a greater number of injuries)
• Play intensity
• Poor rehabilitation to injured area
• Lack of strength and stability
• Increased risk towards end of the game – fatigue
• Inadequate preseason preparation (see more overuse injuries)

 A change in score also has a strong correlation with an increase in injury incidence, this is because it changes:

• Team strategy
• Player precautions
• Players attitudes
• Intensity of the match
• Competitiveness

As mentioned, ligament sprains are common within especially in the ankle. 80-90% of ankle injuries are on the outer aspect of the ankle (lateral) with 69% being on the dominant leg. Most of the time the sprains are uncomplicated, however, 60% suffer from a repeated sprain after the initial event. 63.3% occurs with player contact and most occur to defenders. The mechanism of injuring is due to landing, twisting, turning or running which leads to rolling the ankle.
 How to recognise an ankle sprain:

• Pain or discomfort around ankle post rolling it
• Swelling
• Discoloration
• Limited ROM
• Non-load bearing pain
• Instability
• Weakness
•  

There are 3 grades to a sprain:

1. Grade one;
   - No bruising, mild swelling and tenderness
   - Mild to no limp, can raise up on toes
   - No joint laxity, pain at end range of motion
   - 1-2 weeks recovery
2. Grade 2;
   - Bruising on one side of foot, more extensive swelling
   - Less localised tenderness, i.e. both sides of ankle
   - Visible limp and unable to raise up on toes
   - Slight laxity and pain with most movements
   - 4-8 weeks recovery
3. Grade 3;
   - Bruising and swelling both sides of foot.
   - Tenderness on both sides
   - Unable to weight bear
   - Large amount of laxity
   - 2-6 month recovery

Training is an integral part of any athletes daily routine. It allows the body to cope with the demands of the sport and helps gradually build strength, endurance and improve skill levels. Training helps to gain motivation, ambition and confidence as well as learning about the importance of having a healthy mind and body. Many people believe that to be successful you need to spend hours on hours playing that sport. While part of this is true, time must be devoted to learning the finer principles of movement to excel at the chosen sport. This must be specific to the athlete and their sport and include a range of training types including aerobic exercise, strength training and functional training. This will help to improve endurance, power, speed, co-ordination, flexibility, agility, balance, muscle recovery and decrease the risk of injury. Now how does this relate to young athletes looking to improve in their sport and gain an extra edge over opponents?
 
As mentioned, strength training is just one component of training and not the most important factor but can be very useful for young athletes. Firstly, there is a negative stigma around young athletes and strength training and how it may affect the athletes growth and health. This is because most people immediately think of a young athlete throwing around heavy weights, but this is not the case. Heavy bodybuilding exercises serve little to no purpose for athletes in general. They have little neural requirements and do not improve movements or skill in fact they’ll most likely make the athlete slower and inefficient. Instead it should be focussed on specific movements to activate certain muscles. Strength is a component of what the body requires to perform athletic actions against resistance. Current research highlights that resistance training can be safe, effective and worthwhile for young athletes. This must be under the supervision of a qualified professional with age-appropriate exercises and proper lifting techniques. For best results the athlete should focus on their weaknesses which will show up in a series of tests and skill assessments, it will also help monitor progress. Working on weaknesses will continually challenge the athlete’s ability in those movements and skills.
 
The importance of strength training for young athletes and how to be safe and effective.
 
Strength training has been shown to improve performance which can give an extra edge over opponents. Young athletes may not have the strength, endurance or stability to properly perform the techniques within the sport as their bodies are still developing. Strength training will guide the young athlete for optimal mobility, co-ordination, strength, stability, and movement efficiency. The training should begin with simple light exercises, even body weight and then progress slowly once technique is perfected. This should be done under guidance of a strength coach/professional. If the strength training is completed properly not only will the athlete build strength but also knowledge and understanding of muscle mechanics, body position and proper technique. This will reduce the risk of injury during training and sport. The weight will never injure someone if done properly and safely, improper technique (even with light weight) can lead to injury during the exercise or in the future.
 
Strength training can also help the athlete to create a platform to build on as they go into adulthood with the development and growth of those motor skills and muscle mechanics. Research suggests it can also have a positive effect on self-esteem and self-confidence. A training program allows the athlete to gain focus, attention and dedication. Although, need to take into consideration that young athletes are still kids and must design the program to be fun and enjoyable and also need to avoid burning out or pushing them too hard.
 
So, I know what you’re thinking, is it safe for my child to “lift weights?” or what is the “best age to start?” or “when is it safe?” or “It will stunt my child’s growth?”. Age-specific strength training can begin as early as 8 years old, but most recommendations are during pre-adolescent phase when the athlete has developed some health and skill related fitness. Strength training if done properly it will not stunt growth of the athlete and in fact promote health and growth.
 
Further research on strength training:
 
A research conducted in  AFL showed there was a decrease in the amount of hamstring injuries after adding a training program including anaerobic interval training, stretching and sport specific training drills. This also highlights that balance is important not to just focus on strength, but the training program should encompass endurance, power, speed, co-ordination, flexibility, agility, balance and muscle recovery.  Sprinting for example research has shown that plyometric training, including unilateral exercises and horizontal movement of the whole body elicits significant increases in sprint acceleration performance. Research has also shown that there is a large amount of force travelling through the spine during a golf swing, in fact eight times their body weight. With such force through the spine it is important that the golfer has a training program that improves strength and stability of the core and spine whilst maintain range of motion.
 
 
https://www-sciencedirect-com.simsrad.net.ocs.mq.edu.au/science/article/pii/S1440244012000357
https://journals-humankinetics-com.simsrad.net.ocs.mq.edu.au/doi/abs/10.1123/ijspp.1.2.74
https://bjsm-bmj-com.simsrad.net.ocs.mq.edu.au/content/39/6/363.abstract
https://www.noregretspt.com.au/index.php/resources/blog/43-2014/213-6-must-haves-before-embarking-on-strength-training-for-sports
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3827762/
https://bjsm-bmj-com.simsrad.net.ocs.mq.edu.au/content/44/1/56.short
https://www-ncbi-nlm-nih-gov.simsrad.net.ocs.mq.edu.au/pmc/articles/PMC3105332/
https://www-ncbi-nlm-nih-gov.simsrad.net.ocs.mq.edu.au/pmc/articles/PMC3105332/
https://www-tandfonline-com.simsrad.net.ocs.mq.edu.au/doi/pdf/10.1080/07303084.2001.10605847

Warming up before exercise is vital, it serves two purposes, to enhance performance and prevent injury. A warmup is a period of time devoted prior to doing physical exercise and usually consists of light cardiovascular exercises combined with stretches. Most recommendations for the length of a warm up is between 10-20 minutes. The idea is to prepare the body physically and mentally for the main activity. Keep the warm up mostly at a low intensity at the beginning and then gradually increase as you progress through the warm-up period. Keeping the muscles warm prior to activity has not only shown to decrease the chances of acute injuries such as muscle strains and overuse injuries but it will also decrease muscle soreness post exercise.
 
There is also a mental component to warming up as mentioned, which is very important. It allows the mind to be prepared for the activity. There is evidence suggesting that mentally preparing/visualising for the activity or event can improve technique, skill and co-ordination. It also prepares the athlete for possible discomfort experienced during activity. If the mind is not ready or not focussed, then physical performance may be limited and could increase the risk of injury.
 
What happens to the body during a warm up?

• The muscles increase in temperature which allows the muscle to contract with more force and then relax at a quick rate. It also decreases the risk of muscles over stretching but makes it more elastic. This process can increase the bodies speed and strength during activity
• The temperature of your blood also increases. This allows for oxygen to enter into the muscles more easily and when there is more oxygen available, endurance increases
• As the body goes through the process of a warmup the blood vessels increase in size, this increases blood flow to muscles and places less stress on the heart
• The range of motion of major joints increases which improves flexibility, mobility and general joint function
• Hormone levels through the body change such as cortisol and epinephrine which help with energy production vital for completing the activity
• The mind prepares itself for the activity which increases focus and concentration

 
Tips

• Keeping the warmup between 10-20 mins is the general recommendation. A short warm up may mean that the body is not ready for activity and increase risk of injury. However, a long warm up can cause fatigue and use energy needed for the activity, again increasing injury risk and decreasing performance
• The warm up should be relevant to main activity. This will prepare the body for the movements needed to perform activity
• Make sure the warm up gradually increases intensity as this will prepare the body for higher loads and reduce risk of injury
• Avoid static stretches prior to high intensity activities as they have the possibility of increasing the risk of injury especially if your body temp is cold. Try dynamic stretching which involves continuously moving through a range of motion
• Make sure you focus and visualise during warm ups for the activity
• If you are in a team sport environment and on the bench, you should also continue to run and stretch while waiting to join the game so that the body is prepared​

 
 
https://link-springer-com.simsrad.net.ocs.mq.edu.au/article/10.2165/00007256-198908040-00004
https://link-springer-com.simsrad.net.ocs.mq.edu.au/article/10.2165/00007256-200737120-00006
https://www-sciencedirect-com.simsrad.net.ocs.mq.edu.au/science/article/pii/S0004951407700417
https://www-sciencedirect-com.simsrad.net.ocs.mq.edu.au/science/article/pii/S144024400600051X
https://www-tandfonline-com.simsrad.net.ocs.mq.edu.au/doi/abs/10.1080/15438620802310784
https://www-degruyter-com.simsrad.net.ocs.mq.edu.au/downloadpdf/j/hukin.2012.35.issue-1/v10078-012-0079-4/v10078-012-0079-4.pdf
https://www.active.com/triathlon/articles/the-real-reason-you-should-warm-up-4682
https://www.verywellfit.com/how-to-warm-up-before-exercise-3119266

Cool it down with Ice or turn up the heat?

One of the most common approaches for clinicians and the public alike, to find pain relief for lower back pain, is to apply heat or cold therapeutics. These take the form of heat packs, hot water bottles, wheat bags as well as ice packs, ice gel packs etc. It’s one of those topics that everyone has an opinion on what works for them (and what will work for you).
​
But what does the research have to say on this topic?

Unfortunately there is no high quality research on this subject. There is moderate level evidence to support the use of heat packs for short term symptom relief, and only low levels of evidence that shows minimal benefit from cold therapies for the treatment of lower back pain in acute (< 6 weeks ) and sub-acute patients. There appears to be a benefit of adding exercise to this approach which has ever increasing levels of support in the research.
​
So what can we take away here?

Both heat and cold therapies are commonly used low risk interventions for lower back pain. Heat has moderate evidence demonstrating some benefit in pain reduction and this enhanced with adding exercises.

French, S. D., et al. (2006). "Superficial heat or cold for low back pain." Cochrane Database of Systematic Reviews(1).

Concussion is a disturbance to normal brain function, rather than a structural injury to the brain. A mild/subtle concussion is when the person is seeing stars and a more obvious one will show function deficits. Biomechanical forces of concussion can be linear or rotational. A concussion can occur due to impact to another player, the playing surface or playing equipment (e.g. ball or goal posts). According to data in the US there is reports of 1.6-3.8 million sports related concussions and unreported rates are 6-10 times more than this figure. Rugby league + union show a prevalence of 3.9 rates per 1,000 player hours (horse racing has the most, between 17-95 rates per 1,000 player hours). NRL in the past 4-5 years in elite competitions reports that between 5-7 concussions will be seen per team per season.
 
Signs and Symptoms that a concussion has occurred
Obvious signs may include:

• Loss of consciousness or non-responsive
• Person is on the ground or slow to return to feet
• Person not bracing for the fall to the ground (this usually means they lost consciousness before fall)
• Loss of balance or unsteady on feet
• Poor co-ordination
• Blank or dazed look
• Obvious trauma to face or head

 
Indications during play:

• Unsure of what occurred (most consistent sign is a few moments after event)
• Disorientation (e.g. not knowing who you’re playing, what venue you’re playing at, time of game, which direction your team is going)
• Forgetting structures and team plays
• Feeling slower (decision making, movements, processing information)

 

 

 
 





Management of acute concussion:

• If in doubt sit them out!! Loss of consciousness and memory loss does not have to occur for the person to be concussed
• Management begins as soon as the person is identified as having a suspected concussion. Remove person from play and/or training and should not return to play on the same day and at least 48 hours after, even if there is no signs or symptoms.
• Players are removed to decrease the risk of further injury, allow for examination of injury and reduce the risk of long-term problems related to concussions and injuries.
• CALL AMBULANCE when red flags signs and symptoms are present:

• Neck pain or tenderness
• Numbness or tingles down upper or lower limbs (possible spinal cord injury)
• Headache becoming worse
• Seizure
• Loss of consciousness
• Persistent confusion
• Worsening of symptoms (this can even be hours after the game)
• Vomiting
• Changes in mood
• Double vision

• Unconscious player means using first aid principles (ABC check airways, breathing and perform CPR if needed). They must be removed from the field with care on a stretcher and immobilise the neck as there may be a neck injury and then wait for ambulance.
• A concussed person must not be left alone for at least the initial 2 hours post injury and not to be sent home by themselves, which means no driving as well. Not to take certain medications including anti-inflammatory or strong pain relief medications as this can mask the symptoms of a concussion. It is not safe to drink alcohol during the initial period post injury. Check breathing during sleep that night and even waking to check for a response.
• Concussions usually are resolved within a two-week period without any issues. A small number of athletes can develop post-concussion syndrome which is a continuation of symptoms greater than 3 months. Recovery time for young athletes is longer than adults.
• Complete rest 24-48 hours post event is recommended

 
Return to play:

• Return to normal daily activities such as school or work and then return to sport. Concussions may have an effect with memory and processing information, this could interfere with the person’s ability to learn.
• A medical practitioner should always be the one deciding the timing of return to school and/or play
• If the athletes are still experiencing symptoms, they should not return to play and usually means they have not fully recovered. If the player returns to play early there is a chance for further concussion, increased risk of other musculoskeletal injury and prolonged recovery.
• Slow progression of involvement back into play is needed to reduce the risk of further complications post 24-48 hours of initial rest period. The 6-stage graduated return to sport (GRTS) is a good guide:
  1. Symptom-limited activity – activities that do not aggravate or worsen symptoms.
  2. Light aerobic exercise – walking or light exercise bike (no resistance/weight training)
  3. Sport specific exercise – drills without contact
  4. Non-contact training – resistance/weight training
  5. Full contact training – after clearance by medical practitioner begin skills and tackling
  6. Return to play

Each stage should be a minimum of 24 hours duration, this means that a period of 7-8 days as minimum time for return to contact sport and this period is twice as long for young athletes (18 years and younger). If there is a return of symptoms at any stage, then the athlete should move back to the stage where they were not experiencing symptoms.

 
http://sma.org.au/resources-advice/concussion/
https://playnrl.com/trainer/concussion/

Josh Hallinan - Chiropractor
Tue & Thur 8am - 6pm