Common Rugby League Injuries

INJURY CLINIC Sports Medicine 18 (6): 438-450. 1994 o I 12- I 642/94/00 I 2-0438/S06.50/0

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Common Rugby League Injuries Recommendations for Treatment and Preventative Measures

Nathan Gibbs

South Sydney Orthopaedic and Sports Medicine Centre, Maroubra, New South Wales, Australia

Contents Summary . . . . . . . . . . . . . . . . . . 1. Ankle Ligament Tears . . . . . . . . . . .

1.1 Anatomy and Mechanism of Injury 1.2 Diagnosis . 1.3 Testing . . 1.4 Treatment 1.5 Prognosis . 1.6 Prevention

2. Knee Ligament Tears. 2.1 Anatomy and Mechanism of Injury 2.2 Diagnosis ..... ... . . 2.3 Testing . . ........ . 2.4 Treatment and Prognosis 2.5 Prevention .. ... .. . .

3. Head Injury . . . . . . . . . . . 3.1 Lacerations and Fractures . 3.2 Concussion ..... 3.3 Prevention . . . . . . . . . .

4. Shoulder Ligament Tears .... 4.1 Anatomy and Mechanism of Injury 4.2 Diagnosis and Testing 4.3 Treatment ...... .

5. Musculo-Tendinous Injuries 5.1 Groin Injuries . . . . . . 5.2 Hamstring and Calf Muscle Injuries. 5.3 Quadriceps Muscle Injuries

6. Conclusions . . . . . . . . . . . . . . . . .

438 439 439 439 441 441 442 442 442 442 443

. 443 443 444 444 445 445 445 446 446 446 447 447 447 448 448 449

Summary Rugby league is the main professional team sport played in Eastern Australia. It is also very popular at ajunior and amateur leveL However, injuries are common because of the amount of body contact that occurs and the amount of running that is required to participate in the game. Injuries to the lower limbs account for over 50% of all injuries. The most common specific injuries are ankle lateral ligament tears, knee medial collateral and anterior cruciate ligament tears, groin musculotendinous tears, hamstring and calf muscle tears, and quadriceps muscle contusions. Head injuries are common and consist of varying degrees of concussion as well as lacerations and facial fractures. Serious head injury is rare.

Common Rugby League Injuries 439

Some of the more common upper limb injuries are to the acromioclavicular and glenohumeral joints. Accurate diagnosis of these common injuries using appropriate history, examination and investigations is critical in organising a treatment and rehabilitation plan that will return the player to competition as soon as possible. An understanding of the mechanism of injury is also important in order to develop preventative strategies.

Rugby league is the main professional bodycontact team sport played in Eastern Australia. It is also played at a junior and amateur level with an estimated 150 000 participants) J] It is an

extremely physical game whereby the players require a combination of speed, stamina, strength and agility. Each team has 13 players with a maximum of 6 interchange players allowed. The game is played in 2 nonstop halves, each of 40 minutes. Each team is allowed 6 tackles with the ball, after which the opposition team is allowed to use the ball for 6 tackles and so on. Thus, the same players are both offensive and defensive players depending on which team has the ball.

The ball cannot be thrown or knocked forward but must be carried forward or kicked downfield. The defensive team has to stop the offensive player with the football from making forward progress. Points are scored when the offensive player places the ball over the opposition try-line. The players wear minimal protective equipment. Injuries are common both from direct trauma and from twisting/straining mechanisms. The few studies that have been done on professional rugby league football show a high injury rate (44.9 injuries per 1000 player-position game hours)[2] and an injury rate greater than the other main body-contact sports played in Australia at an elite level (for example, Australian football, rugby union and soccer))3]

Common injuries sustained from playing professional rugby league are listed in table I. These findings are based on a study of the South Sydney professional rugby league club. The injury statistics for 1989-1991 have previously been published[2] with the continuation of the study (1992-1993) unpublished. An injury has been defined as any injury sustained whilst playing in a

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competition game that required the player to miss the subsequent week's game. This article will discuss the diagnosis, treatment and preventative measures for the common injuries from rugby league.

1. Ankle Ligament Tears

Ankle ligament injuries are very common in rugby league and accounted for 11 % of all injuries over the 5 years of the Gibbs study[2] (and unpublished personal observations).

1.1 Anatomy and Mechanism of Injury

Anatomically, the ankle is stabilised laterally by the anterior and posterior talo-fibular and calcaneo-fibular ligaments (ATF, PTF, CF), medially by the fan-shaped deltoid ligament (OL) and superiorly by the syndesmosis, comprising the distal anterior and posterior tibio-fibular ligaments (DATF, OPTF) and the interosseous membrane. The lateral ligament complex is more commonly injured and occurs by an inversion/plantar flexion mechanism. The OL and syndesmosis are usually injured from an external rotation/abduction or dorsiflexion mechanism. Either of these types of mechanisms can occur in rugby league because the players wear boots with cleats to improve traction and the ankle can be twisted when tackled by 2 to 3 players, whilst the foot remains fixed.

1.2 Diagnosis

Injury to the lateral ligament complex from rugby league usually results in sprains or partial or complete tears to either or both of the ATF and CF ligaments. With the ankle held in neutral dorsiflexion/plantar flexion, the ATF ligament forms approximately a 90° angle from the anterior border

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Table I. Most common specific injuries in rugby league players (South Sydney football club, 1989-1993)[2)

Specific injury % of all injuries

Ankle ligament tear 11

Knee medial collateral ligament 8 tear

Groin muscle/tendon tear 8

Concussion 6

Acromioclavicular joint tear 5

Metacarpal fracture 5

Costochondral joint tear 5

Glenohumeral joint instability 4

Hamstring muscle tear 4

Anterior cruciate ligament tear 3

Lumbosacral spine ligament 3 tear

Neck burner 2

Wrist fracture 2

Facial fracture 2

Thigh muscle contusion 2

Calf muscle tear 2

Other injuries 28

Total 100

of the fibular shaft in a clockwise direction, whilst the CF ligament forms a 2300 angle as it runs in a posterior/inferior direction to attach to the calcaneus)4] Hence, when the ankle is plantar-flexed, the ATF ligament is the main restraint to inversion as its angle with the fibula approaches 1800 while dorsiflexion causes the CF ligament's angle with the fibula to approach 1800 , thereby becoming the main restraining force to inversion stress.

Following an inversion injury to the ankle, the examination should be aimed at determining whether there is a single or double ligament injury to the lateral ligament complex and the degree of damage. Initial haematoma formation within several minutes and the inability of the player to continue in the game usually indicate partial or complete tears. The degree of restricted joint range of movement and swelling over the following 24 to 48 hours also indicate the degree of damage. Tenderness over the antero-inferior lateral malleolus border suggests ATF ligament injury, whereas CF ligament injuries are tender over the inferior tip of the lateral malleolus. The anterior drawer test, with the ankle in a neutral position, is more specific


Gibbs

for instability from an ATF ligament partial or

complete tear. Ankle inversion stress testing in

the neutral position is more specific for examining

instability from a CF ligament partial or complete tear. If only I of the tests is positive a single liga

ment injury is likely. Rupture of both the ATF and

CF ligaments causes gross laxity in both the

anterior drawer and inversion stress tests. Injuries to the DL and syndesmosis are less

common in rugby league than lateral ligament

injuries; however, they usually take longer to

resolve. External rotation/abduction and dorsiflexion stress can lead to isolated DL or DATF liga

ment injuries, as well as producing combinations of injuries, including medial malleolus avulsion,

vertical posterior tibial, lateral malleolus spiral fractures and diastasis of the ankle joint.

Associated injury to the structures in the poste

rior talar region, such as the flexor hallucis longus

tendon, an os trigonum or a prominent posterior

talar tubercle, can occur as a result of forced plantar

flexion. Testing with forced passive plantar flexion causing pain posteriorly suggests posterior impingement of these structures. Resisted inversion and eversion should be tested to assess the function and stability of the tibialis posterior and peroneal tendons.

Examination will usually find less swelling than with lateral ligament complex injuries. In DL

injuries, tenderness will generally be localised to

the anterior aspect of the DL over the antero

inferior medial malleolus. Injuries to the DATF

ligament will be tender over the tibio-fibular joint

which is anatomically located superiorly on the anterolateral aspect of the ankle joint. External rotation to the foot will reproduce pain over the DL or the DATF ligament, depending on the injuryJS]

The results of anterior drawer and inversion stress testing will be normal. Squeezing the proximal tibia and fibula together can stress the syndesmosis in the ankle reproducing pain if injury here has

occurred.

Sports Med. 18 (6) 1994

Common Rugby League Injuries

1.3 Testing

Radiographs are not routinely necessary for lateral ligament tears; however, they are useful in clinically severe cases or in those that are slow to resolve. With radiographs, associated avulsion or spiral lateral malleolus fractures can be excluded, the presence of an os trigonum or prominent posterior talar tubercle and (sometimes) any associated talar dome injury can be seen. However, if suspected, a talar dome injury is best detected by nuclear medicine bone scanning and computed tomography (CT) or by magnetic resonance imaging (MRI).l6,71 Persistent activity-related pain and swelling following an ankle ligament injury can suggest an associated talar dome injury.

Stress radiographs and arthrograms have been shown to be accurate in assessing the degree of injury in lateral ligament complex tears.!81 Using the anterior drawer test, an opening of the posterior tibio-talar joint of 6 to lOmm indicates an ATF ligament tear, whilst opening greater than lOmm indicates injury to both the ATF and CF ligaments. Arthrography showing leakage of contrast material antero-inferiorly to the lateral malleolus indicates an ATF ligament rupture, and leakage into the peroneal sheath indicates a CF ligament rupture. MRI has also been shown to be accurate in detecting the degree of damage in lateral ligament injuries.!91 Routine use of stress radiography, arthrography and MRI to assess lateral ligament injuries is only necessary if acute surgical repair of ruptured ankle ligaments is a consideration.

Radiographic examination is more important with injuries to the DL and DATF ligaments because of the commonly associated bony injury. Radiographs can detect avulsion medial malleolus and spiral lateral malleolus fractures. Nuclear medicine scanning and/or CT are often needed to assess vertical tibial fractures or acute medial malleolus stress fractures, if suspected, as these can be missed on plain radiographs. Radiographic features of ankle diastasis include widening of the tibio-fibular and tibio-talar spaces and loss of the continuity between the lateral border of the tibia and the lateral border of the talus. Calcification of

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441

the interosseous membrane is a late radiographic change suggesting syndesmosis injury.!51

1.4 Treatment

Initial treatment of ankle ligament injuries, as with other soft tissue injuries, is aimed at minimising swelling and preventing aggravation of the injury. The decision as to whether the player is removed from the game following a minor ankle ligament injury is a difficult one. By continuing on in pain, the athlete can risk further injury and the commencement of treatment is delayed. The importance of a particular game, the importance of the game the following week that the player may miss by remaining on the field, the importance of the injured player to the team, the ability of that player to play with the injury at their normal performance level and the understanding the player has of the risks of continuing playing are issues that have to be considered. More serious ligament injuries generally result in the immediate removal of the player from the game for proper assessment and treatment. Regular use of ice or cold packs, elevation and compression of the injured ankle, the use of nonsteroidal anti-inflammatory medications and the avoidance of excessive heat, alcohol or massage will help minimise pain and swelling in the first 24 to 48 hours after injury. Strapping or bracing for an unstable ankle is also important. This should allow doriflexion and plantar flexion while restricting excessive inversion and eversion.

Controversy exists as to whether surgical repair of acute ankle ligament ruptures should be performed. Some authors[IO-121 advocate early surgery to restore normal anatomy and prevent chronic ankle instability, whereas others[13-15j consider early mobilisation as the treatment of choice. In my experience with rugby leaguerelated ankle injuries, aggressive conservative treatment yields excellent results, getting the player back to competition sooner than if surgical repair were performed and without the potential complications that can occur from surgery. Treatment of stable and unstable ankle ligament tears involves the use of electrotherapy to help reduce

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pain and swelling, combined with a graduated pain-free mobilising, stretching and strengthening programme to restore full range of movement and strength. Unstable injuries are braced or strapped continuously for the first 3 weeks, and thereafter during sporting activities for at least 3 months, allowing plantar and dorsi flexion but restricting excessive inversion/eversion. Complete immobilisation is avoided as, although the end result is the same as early controlled mobilisation, the recovery for the player is prolonged due to the joint stiffness and muscle atrophy associated with complete immobilisationJ 16]

Weightbearing is not permitted until relatively pain-free walking without limping is possible. Pool exercising can be performed during this non-weightbearing stage as it will often be painfree. Weightbearing strengthening and stretching exercises are then incorporated into the rehabilitation. Balancing and coordination drills are also commenced at an early stage to help regain proprioception deficits that occur from ankle ligament injuries. Jogging is commenced as soon as it is pain-free. The player's return to competition is dependent on their ability to complete normal team training as well as completing a fitness test designed to simulate game situations. For example, the player has to be able to accelerate and decelerate from a standing start, change direction at full pace, perform hopping and jumping plyometric drills with equal power in both legs and perform kicking and tackling drills.

1.5 Prognosis

The recovery from an ankle ligament sprain with no instability takes approximately 1 to 2 weeks, whereas an injury resulting in instability takes 3 to 6 weeks before the player is fit to resume playing. Double ligament tears take longer to resolve than single ligament tears. Ankle strapping or bracing is critical for at least 3 months until nearnormal proprioception has returned. Clinically, the laxity from an acute ankle ligament rupture may never completely return to normal; however, functionally, the ankle may have no further

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Gibbs

episodes of instability due to the stabilising effect of the lower leg musculature. For those few players in whom chronic ankle instability becomes a problem despite appropriate proprioceptive retraining, then ankle reconstructive surgery can be performed. Arthroscopic surgery is sometimes required to treat an associated talar dome lesion or the more common meniscoid lesion whereby a thickened, fibrotic capsular/synovial mass occurs as a result of the ligament damage and causes anterior impingement between the fibula and talusJI7,18]

1 .6 Prevention

Preventative measures for ankle twisting injuries in rugby league have mainly involved strapping or bracing to restrict excessive inversion and eversion stress . Most professional clubs enforce mandatory strapping or bracing for all players during competition. The effectiveness of ankle strapping has been shown to decrease by up to 50% after as little as 10 minutes of exerciseJ 191 However, its proven success in preventing ankle injuries[20] is probably due to its associated effect on improving ankle proprioception through improved feedback from cutaneous receptorsJ21 1 Research comparing strapping and bracing shows that bracing does not lose its effectiveness as quickly and has the advantage of being able to be tightened easily during the competitionJ22)

2. Knee Ligament Tears

The medial collateral ligament (MCL) and anterior cruciate ligament (ACL) are the areas in the knee most commonly injured when playing rugby league. In the Gibbs[21 study (and personal observations), they comprised 8% and 3%, respectively, of all injuries.


The MCL of the knee is the primary restraint to valgus/external rotation stress. The MCL is di vided into a superficial part and a deep part, with the deep part fusing to the medial joint capsule and

Sports Med. 18 (6) 1994


adjoining medial meniscus. The ACL prevents anterior displacement of the tibia on the femur. It is an intra-articular extrasynovial ligament with distinct anteromedial and posterolateral bundles. The ACL tightens with end extension and end flexion, and also with internal rotation. It is a secondary restraint to valgus/external rotation. It has also been likened to the MCL of the lateral compartment. [23]

Injury to the MCL and ACL is common in rugby league because of the injury mechanism whereby a player's foot is fixed whilst their body is twisted in the opposite direction in a tackle. A direct blow to the lateral aspect of the knee during a tackle can also injure the MCL with or without associated ACL injury. Isolated ACL injuries can occur from noncontact hyperextension or sidestepping mechanisms,l24]

2.2 Diagnosis

Injuries to the MCL can be classified as sprains and partial and complete tears. Sprains do not produce any instability and there are minimal initial symptoms. Partial and complete tears result in some degree of instability, with complete tears losing the normal end-point feeling on valgus stress testing. Initial disability is more apparent, with significant localised tenderness and swelling over the MCL at the site of the tear. The MCL more commonly tears from its femoral attachment. Restriction of the end range of extension and flexion is common within 24 to 48 hours of injury. A MCL tear is from a contact situation and does not occur from a noncontact injury as can occur with ACL injuries. However, if sufficient valgus stress is applied, the ACL can also tear but only in association with a MCL injury. Likewise, players falling after rupturing their ACL from sidestepping can land in a valgus position and also damage their MCL. Hence, the examination of any player with a MCL injury must also include an assessment of the ACL. This is not always easy as the anteromedial rotatory instability associated with a complete MCL tear can make the performance of the jerk or pivot shift test difficult.l25] A solid end-point on

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Lachman's testing is the best indication that the ACL is intact.[26] Complete ACL and MCL tears result in gross valgus instability as well as causing valgus instability in full knee extension which does not occur with an isolated MCL rupture. A significant or persistent joint effusion is also suggestive that there may be associated ACL, meniscal or chondral injury as such effusion is uncommon even with complete MCL tears.

Isolated ACL tears have a typical history whereby the player has changed direction or hyperextends the knee and the knee gives way, often with no contact with opposition players. A noise such as a pop or snap is often felt or heard, and early joint swelling indicative of a haemarthrosis is usual. Examination showing a positive jerk or pivot shift test indicates anterolateral rotatory instability. Loss of the end-point on Lachman's testing also is suggestive of an ACL rupture. The posterolateral capsule is usually tender because of the damage sustained here as the knee subluxes anteroiaterally·

2.3 Testing

Radiography is of limited value in the initial assessment of acute knee injuries; however, it may detect associated osteochondral fractures, or lateral capsule and tibial avulsion fractures that can occur in association with an ACL injury. MRI is a useful investigation to determine if MCL or ACL injury has occurred, as well as to determine if there have been any associated intra-articular chondral or meniscal injuries . Radiography for slowly resolving MCL injuries can detect if a pellegrini-steida lesion (ossification of the resolving haematoma within the injured MCL) is the cause for the delay in recovery. Such changes are usually not evident for at least the first 3 weeks following injury.

2.4 Treatment and Prognosis

Isolated MCL injuries are best treated with early mobilisation. Animal studies[27,28] have shown the beneficial effects of early motion compared with immobilisation on the histological healing of surgically transected MCLs. Clinical

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studies[29,30] have also found that MCL injuries in

American football players heal quickly and without an increased likelihood of reinjury when they are treated with early protected motion rather than immobilisation or surgical repair.

My preferred treatment of MCL injuries in professional rugby league players, is aggressive nonoperative treatment. Active early motion within the pain-free range is begun together with electrotherapy to help decrease the pain and swelling. Hinge braces are used for 3 weeks if valgus instability is present. These allow extension and flexion but protect the knee from valgus stress. Weightbearing is allowed when pain-free. Light jogging is commenced in the fourth week following brace removal. This is gradually increased to full training, incorporating twisting, sidestepping and body contact drills by the sixth week. Most players resume competition at the end of the sixth or seventh weeks, missing only 5 or 6 games. Reinjury is very uncommon. Clinically, a complete MCL tear will have regained an end-point but still have an increased laxity by 3 weeks after injury. The increased laxity will tighten over 6 to 12 weeks after injury. Returning to competition is dependent upon pain-free, full training with no subjective valgus opening. Subjective valgus opening is usually due to loss of an end-point rather than any residual laxity which is normally asymptomatic.

Unstable ACL injuries in rugby league players are best treated with reconstructive surgery because of the twisting and body-contact nature of the game. Conservative treatment programmes do not have a high success rate at returning the recreational sports person to their normal level of sporting performance, [31 ,32] let alone returning the professional sports person to the intensity of their competition. Partial ACL injuries which have a negative jerk or pivot shift test and an end-point on Lachman's testing with some increased anterior tibial translation can be successfully treated conservatively. There will be an increased risk of further tearing to the remaining, intact ACL fibres from the same injury mechanism, as the ACL strength will be less. A partial ACL tear which has

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Gibbs

a positive jerk or pivot shift test should be treated as an unstable ACL tear. Arthroscopically assisted reconstructions, using patella tendon or hamstring tendon autografts with or without a lateral capsular augmentation procedure, are the common methods used for ACL reconstructive surgery.[33-35] Early postoperative motion and rehabilitation allow the player to resume full competition within 6 to 9 months.

2.5 Prevention

Preventative braces have been used with varying success in American football, with some studies showing a reduction in MCL injuries while others actually showing that the braces increased the risk of MCL injury,l36] Rugby league rules in Australia currently do not allow the use of preventative braces because of possible injury to other players from contact with the brace. Players often tape their knees or wear soft braces when returning from an MCL injury as this may improve proprioception via cutaneous and visual sensory feedback. Gang tackling, where the player with the ball can be hit by several tacklers at once, increases the risk of twisting injuries to the knee. Administrators are hesitant to outlaw this type of tackle as it would affect the nature of the game.

3. Head Injury

Although head injuries are common in rugby league, luckily serious head injuries are rare. Gibbs[2] (and in unpublished results) found that concussion, causing a player to miss a subsequent game, occurred at a rate of 6% of all injuries. Only 3 of the players injured had recurrent episodes of concussion, with 2 players having 2 episodes and 1 player having 3 episodes in a season. 44 other players were treated for minor concussion on the field but did not miss any games and were not included in the findings. No players suffered any intracranial haemorrhage (lCH) as a result of head injuries; however, 1 player's concussion precipitated an episode of transient post -traumatic cortical blindness as a result of migrainous vasospasm.l37]

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3.1 Lacerations and Fractures

Lacerations which required suturing rarely caused a player to miss a game, but were very common, with 101 players suffering lacerations to the head over the 5 years of the study. Facial fractures were also a common head injury, occurring at a frequency of 2% of all injuries. These mainly involved orbital blow-out, nasal or zygoma fractures.

3.2 Concussion

3.2. 1 Definition and Mechanism Concussion is defined as an immediate and tran

sient post-traumatic disturbance in neural function, with symptoms such as altered consciousness, unsteadiness, aggression, poor coordination, visual disturbance, dizziness, amnesia and poor concentration. Acceleration of the brain within the skull is the main cause of concussion and can occur from a direct hit to the head or the sudden movement of the head from a hit to another part of the body.

3.2.2 Initial Treatment and Testing Initial treatment of the semiconscious or uncon

scious concussed player is to maintain an airway and stabilise the cervical spine in case there has been an associated neck injury. The player should be removed from the field of play for a more detailed neurological assessment. Testing for concussion recovery should include memory, orientation, coordination and information processing ability. Simple neuropsychological tests such as the digit symbol substitution test[38j can be a useful aid in determining full recovery and return of normal information processing speed. This test requires baseline levels to be obtained for each player in the pre-season period. Players must always be kept under observation by a responsible adult for 4 to 6 hours following any concussion. If symptoms of worsening severe headache, vomiting, decreasing level of consciousness, unequal pupils or neck stiffness develop, then urgent hospital admission and CT or MRI scanning is needed to exclude an ICH. Post-traumatic migraine may mimic an ICH and so should also be assessed at a hospital.


445

3.2.3 Prognosis Players should not resume playing until they are

fully recovered from their concussion. This can sometimes take several weeks as postconcussive symptoms of headache, drowsiness and poor concentration can persist. Neuropsychological testing can show varying recovery rates between individuals with the same degree of initial concussive symptoms,l39j Hence, each case should be judged individually with regard to the resumption of contact sport. For a first concussion, the player should not play until they have been symptom-free for at least I week. Subsequent concussions usually require the player be inactive for longer periods. It is normally recommended that players should not play any further games in a season after sustaining 3 concussions.[lJ The belief that there may be cumulative effects from repeated concussions in rugby league with resultant chronic brain damage is based on the evidence from boxing. However, head injury in boxing is much more common than in rugby league, as the aim of the former sport is to render your opponent unconscious and helpless through successive blows to the head. Numerous studies[40-42J have shown the development of dementia pugilistica, or chronic boxers' encephalopathy, as a result of repeated head trauma from boxing. Further research in contact sports such as rugby league is required to see if chronic brain changes can also occur.

3.3 Prevention

Prevention of head injury in rugby league is mainly achieved through the administrative bodies taking a strong stance against head-high and spear tackling techniques. Players need to be penalised for such offences with suspensions from the game. Protective headgear is useful for helping prevent facial fractures and head lacerations, but may not necessarily prevent concussion. The headgear will help soften the blow at the point of impact, but it does not protect the brain from acceleration forces within the skull. The headgear can theoretically increase the risk of head injury by increasing the size of the head target area, as well as increasing its

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mass and subsequent momentum when struck. The effectivenes of headgear for prevention of injuries needs to be investigated. Properly fitted mouthguards should be compulsory for all rugby league players because of their proven effect in decreasing the incidence of orofacial injury as well as concussion from blows to the jawJ431

4. Shoulder Ligament Tears

Injuries to the acromio-clavicular (AC) and gleno-humeral (GH) joints are common in rugby league, and comprised 5% and 4% of all injuries, respectively, in the Gibbs study[2] (and unpublished data).


The AC joint is stabilised by the AC and coracoclavicular ligaments. Minimal movement occurs at the AC joint until the scapula begins to rotate superiorly as the arm abducts past 60°. Most of the superior rotation of the clavicle occurs at the sterno-clavicular joint, while the AC joint undergoes mainly posterior rotation. Injuries usually occur when the acromion is forcibly compressed in a medial direction, such as when the point of the shoulder is struck by the ground or by an opposing player. The GHjoint is the most mobile in the body. As such, bony stability is minimal with the humeral head being approximately 3 times as big as the glenoid fossa in which it sits. As the glenoid fossa is directed anterolaterally, the GH joint is more stable posteriorly than anteriorly. The fibrocartilaginous glenoid labrum which attaches the joint capsule to the glenoid rim improves the socket for the humeral head to sit and so provides important stability.

The GH ligaments fuse with the joint capsule and provide restraint to excessive external rotation, with the inferior GH ligament being an important anterior stabilising force with the arm abducted and externally rotatedJ441 The rotator cuff group of muscles is important for dynamic stability. Landing on an outstretched arm or holding an opposition player as they pull away can cause an abduction/extension/external rotation force to the


Gibbs

arm that results in injury to the anterior GH joint structures. This is the common mechanism for anterior GH joint subluxation or dislocation. A less common mechanism is a direct blow to the posterior shoulder.

4.2 Diagnosis and Testing

AC joint injuries cause pain, tenderness and swelling localised to the AC joint itself. Referred pain is not common and suggests associated injury. End abduction and horizontal flexion are painful and often restricted following AC joint injury. Injuries are classified as sprains, subluxations or dislocations. Associated soft tissue swelling may mask a small subluxation initially. AC joint instability is more apparent with the arm horizontally flexed. Radiological confirmation of the diagnosis is not usually necessary as the treatment for subluxations and dislocations is usually conservative. X-rays, if performed, can show widening of the AC joint, subluxation or dislocation of the AC joint (this can be accentuated by downward pressure on the arm) and, on rare occasions, a fractured distal clavicle which can mimic an AC joint injury.

GH joint injuries vary from the obvious dislocation to the more subtle subluxation. A dislocation causes severe pain and disability especially if it is a first time dislocation. The humeral head usually dislocates antero-inferiorly such that there is a loss of the normal lateral deltoid contour and a palpable bony prominence lateral to the coracoid process. The arm is usually held fixed at about 45° of abduction and flexion. Reduction is best achieved as soon as possible before swelling and significant muscle spasm occur. Intravenous narcotics can be useful to reduce pain and muscle spasm prior to attempting a reduction. The player should be supine whilst gentle traction is applied in a longitudinal direction along the line of the humeral shaft. The humerus should also be slowly externally rotated. Counter-traction should be applied against the player's lateral chest wall. Reduction will usually occur within several minutes. X-rays prior to reduction are useful if the direction of the dislocation is uncertain or if attempted reduction is

Sports Med. 18 (6) 1994


unsuccessful after several minutes. X-rays can show associated fractures to the glenoid rim (Bankart lesion), posterior humeral head (HillSachs lesion) or greater tuberosity.

GH joint subluxation is harder to diagnose as the player may not necessarily feel any joint movement but rather complain of pain (often posteriorly as the posterior capsule is stretched when the humeral head moves anteriorly) or complain of a dead-arm feeling. The position the arm is in when the injury occurs can help differentiate the dead-arm of a subluxation from that of a neck burner, which tends to occur from depression of the shoulder girdle and lateral flexion of the neck to the opposite side. The apprehension and relocation tests[45] are useful to help make the diagnosis of subluxation.

4.3 Treatment

Treatment of sprains and subluxations initially involves avoidance of painful movements, with sling immobilisation if necessary. The use of ice, electrotherapy and anti-inflammatory medications can help minimise swelling and pain. Isometric and pain-free-range isotonic exercises should be commenced immediately and gradually upgraded as symptoms subside. Return to competition usually takes 1 to 2 weeks for a sprain and 3 to 4 weeks for a subluxation. AC joint dislocations, when treated similarly, result in a quicker return to competition (6 weeks) with negligible effects on shoulder function and strength [46] than if surgically treated with reduction and internal fixation. However, severe AC dislocations may occasionally require surgery because of tenting of the skin or for cosmetic reasons.

The treatment of a first-time anterior GH joint dislocation in a rugby league player is controversial. Conservative treatment, possibly involving sling immobilisation followed by a scapular and rotator cuff strengthening programme, is not very successful[47,48] in preventing recurrences, particularly if the glenoid labrum has been damaged. CT arthrography,[49] MRI[50] or arthroscopy[51] are useful investigations to determine the extent of any labral damage. Surgical repair of a labral


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detachment[52] is a successful procedure which can even be considered after a first time dislocation especially in a professional athlete.

GH joint sublaxation often requires an arthroscopic assessment to determine the degree of glenoid labral damage, as small detachments can sometimes be successfully managed with a strengthening programme and even bracing (to restrict the amount of shoulder elevation and external rotation) . Arthroscopy can also detect and remove chondral and superior labrallesions.l53] These can cause catching and pain which can mimic the symptoms of minor instability. Recurrent episodes of subluxation are best treated surgically with a capsulolabral reconstruction.152]

5. Musculo-Tendinous Injuries

Musculo-tendinous injuries in rugby league are common, because of the speed with which the game is played and the body contact and twisting that occurs. Groin musculo-tendinous tears (8%), hamstring muscle tears (4%), calf muscle tears (2%) and quadriceps muscle contusions (2%) were found to be the most common specific musculotendinous injuries in the Gibbs study[2] (and personal observations).

5.1 Groin Injuries

Groin pain is common in rugby league players and has a variety of causes. It can occur acutely, from a twist, or have a more gradual onset related to excessive running or kicking. In assessment of the player with groin pain, referral from the upper lumbar spine needs to be excluded. Pelvic imbalance from a hyperlordotic lumbar spine, with its resultant hip flexor muscle tightness and abdominal muscle weakness, can also lead to groin pain. Other causes of pelvic imbalance include asymmetrical lower limb length, flexibility or strength. Hip joint pathologies such as arthritis, capsular sprain, neck of femur stress fracture, femoral head avascular necrosis and hip flexor tendinitis need to be excluded . Osteitis pubis, pubic rami stress fractures and sacro-iliitis are possible causes of groin pain. Pathological conditions

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of the genito-urinary system can refer pain into the groin. Tearing of the conjoint tendon, with or without a hernia, and tearing of the adductor longus tendon are the main musculo-tendinous causes of groin pain in rugby league players.

Nuclear medicine bone scanning is a useful test to exclude many of the possible bone and joint causes of groin pain while ultrasonography[54] has been shown to be useful in assessing groin tendon pathology. Pain that is localised to the pubic tubercle and is aggravated by coughing or abdominal muscle contraction is usually due to a conjoint tendon tear. A hernia may be present if the tear is large enough. Adductor longus tendon tears usually occur at the musculo-tendinous junction causing maximal pain and tenderness approximately 2 to 3cm distal to the pubic bone attachment. Pain can be reproduced with hip abduction stretching or resisted hip adduction. Conservative treatment consists of resting from painful activities, gentle stretching and strengthening exercises, anti-inflammatory medications and attention to any other contributing factors in the lower back or pelvis. Unfortunately, for some players this proves to be ineffective or requires too long an absence from competition. In such cases, surgery in the form of adductor tenotomy[55] or inguinal herniorrhaphy[56] produces good results with the player returning to competition within 2 to 3 months.

5.2 Hamstring and Calf Muscle Injuries

Hamstring and calf muscle tears usually occur acutely from a sudden forceful contraction. They are graded as strains, partial tears and complete ruptures. Strains result in less initial disability and subsequent pain and swelling due to the muscle fibres remaining intact. Partial and complete tears cause disruption of muscle fibres with more significant pain, swelling and disability. Clinically, a loss of continuity of the contracted muscle can be felt at the site of a significant partial or complete tear. An increase in flexibility can sometimes occur with complete tears.


Gibbs

Ultrasonography and MRI[57] are useful in assessing the severity of a muscular injury. Strains and partial tears can be treated effectively with anti-inflammatory measures followed by muscular rehabilitation. Recovery from a strain can take 2 to 3 weeks whilst a partial tear 4 to 6 weeks. It is critical to regain full recovery of muscle strength and flexibility prior to resumption of competition as this is a common cause for re-injury.f58,59] Attention to adequate warm-up is important as cold muscles tear more easily.[60,61 1 Complete hamstring muscle tears usually occur near the proximal attachment to the ischial tuberosity and require surgical repair in the athlete. Complete calf muscle tears usually involve the medial gastrocnemius muscle, and a good functional result is achieved via conservative treatment with surgery not being required. Recurrent hamstring or calf muscle injuries, or those that have a gradual onset, often have nerve involvement and will not resolve fully until the nerve irritation is corrected. This can occur with impingement of the lower lumbar and sacral nerve roots at the level of the lumbosacral spine, or with sciatic nerve compression by the piriformis muscle in the buttock or fibrous bands attaching to the ischial tuberosity.l621

5.3 Quadriceps Muscle Injuries

Quadriceps muscle contusions are common in rugby league, as the first point of contact when defending is often the attacking player's thighs. The majority of these contusions are minor; however, care must be taken in treating these to prevent secondary bleeding and the potential for myositis ossificans. Applying heat or massaging a muscle contusion within the first 48 to 72 hours can cause further bleeding, as can running before full painless flexibility has returned. Normally a minor contusion prevents a player from running for 3 to 4 days, whereas a more severe injury may cause a player to miss a game. The development of myositis ossificans is initially indicated by worsening pain and flexibility, with radiological evidence of ossification being present after 3 to 6 weeks. Recovery from this can take 3 to 6 months. An

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acute thigh compartment syndrome can develop following a quadriceps contusion. This occurs within 8 to 12 hours of the injury and results in a very tense, swollen thigh. The pain is severe and made worse by attempted knee flexion. Peripheral pulses usually remain unaffected. Urgent compartment pressure measurements are required, and, if they are above 50mm Hg, surgical fasciotomy and delayed wound closure must be performed.l63 ]

6. Conclusions

Injuries in rugby league are inevitable due to the inherent nature of the game whereby hard body contact repeatedly occurs. The most common specific injuries are ankle ligament tears, knee medial collateral and anterior cruciate ligament tears, groin musculotendinous tears, hamstring and calf muscle tears, quadriceps muscle contusions, shoulder acromioclavivular and glenohumeral joint injuries and injuries to the head in the form of concussion, lacerations and fractures.

Fortunately, catastrophic and fatal injuries rarely occur. The aim of a treating sports physician is to quickly and accurately diagnose injuries, so that a management plan can be instituted to return the injured players to competition as soon as possible. An understanding of the injury mechanism is important when designing preventative strategies.

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Correspondence and reprints: Dr Nathan Gibbs, South Sydney Orthopaedic and Sports Medicine Centre, 315 Bunnerong Road, Maroubra, NSW 2035, Australia.

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Documents

Common Rugby League Injuries