Based on a survey that was done at the end of Winter season 2013, the three most common
injuries experienced by the players and referees at Southern Districts Touch Association are
lateral ankle sprains, anterior cruciate ligament ruptures and hamstring injuries. The
information provided aims to reduce the risk and number of injuries on the field; it also provides
the players and referees with more detail surrounding the injury.
WARM UP
A warm up is performed to prepare your body physically to participate in sport. The benefits of
warm up include:
1. Increase body temperature, blood circulation and oxygen supply to the peripheries.
2. Improves muscle extensibility, therefore reducing the risk of injuries and muscle strains.
3. Increase speed of contraction and relaxation of the muscle.
General Warm Up
General warm up increases the cardiovascular rate in preparation for more vigorous activity. As
a general warm up, you may choose to jog or brisk walk for 5-10 minutes. Once the large
muscle groups have warmed up and your body temperature has increased, you can continue
your sport specific warm up.
Sport Specific Warm Up
Sport specific warm up mimics the movements in the game. In touch football, you will be
required to do a lot of running/sprinting, jumping and throwing. Therefore, you can spend
about 5 minutes throwing and catching a ball forwards, sideways and diagonally. To replicate
the action of running and jumping, dynamic stretching can be performed. When performing a
dynamic stretch, you are taking the joint through its’ active range of motion in a controlled
manner. As you keep taking the joint through motion, you may gradually increase the range.
Keep in mind that you should not hold the stretch (static stretch), or take it through to the end
range in a quick motion (ballistic stretch).
COOL DOWN
The cool down after the game is important because it reduces the effects of delayed onset
muscle soreness (DOMS) as well as assists in the removal of lactic acid, which causes muscle
fatigue. Static stretches can be performed as part of cooling down after the game. When
performing a stretch, you need to hold the muscle in a stretched position for at least 30
seconds.
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References:
1. Behm D, Chaouachi A (2011) A Review of the Acute Effects of Static and Dynamic
Stretching on Performance. Springer: Canada. pp 2633-2651
2. Manoel M, Harris-Love M, Danoff J, Miller T ( 2008) Acute Effects of Static, Dynamic and
Proprioceptive Neuromuscular Facilitation Stretching of Muscle Power in Women.
Journal of Strength and Conditioning Research; Proquest. pp 1528-1533
3. Kirkendall D, Junge A, Divorak J (2010) Prevention of Football Injuries: A Systematic
Review. Asian Journal of Sports Medicine (Volume 1, Number 2), pp 81-92
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Ankle Sprains
Anatomy of the Ankle Joint
Tibia
Fibula
Deltoid ligament
(on medial aspect)
Posterior
talofibular
ligament
Calcaneum
Calcaneofibular
ligament
Anterior
talofibular
ligament
Mechanism of Injury
The most common mechanism of injury for an ankle sprain is when a player is running or
landing on an uneven surface which causes the foot to be rolled inwards (inversion sprain).
Here, the foot is stretched past its’ normal range of movement. The most common ligament to
be affected in an inversion sprain is the anterior talofibular ligament (ATFL), however,
depending on the severity of the sprain, the calcaneofibular ligament (CFL) may also be affected
along with the ATFL.
Eversion sprains can occur, but are less common. This is when the foot is turned outwards.
When this happens, the deltoid ligament located on the medial (inside) of the foot is affected.
An X-Ray may be indicated if pain is felt higher up in the ankle joint or deep in the foot to rule
out the possibility of a fracture.
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Classifications
Grade
Pathophysiology
Signs and Symptoms
Grade I
Some damage to collagen fibers
Minimal pain and swelling present, weight bear
as tolerated.
On examination, nil instability noted.
Grade II
Partial rupture
Moderate pain, swelling and bruising present,
decreased active range of motion may be
present.
On examination, possible joint instability.
Grade III
Full rupture
Significant swelling and tenderness. Bruising
may extend around the whole ankle joint,
feeling of instability or “giving way”, may not be
able to weight bear.
On examination, joint instability present.
Immediate Management
The following management strategies aim to reduce the inflammatory component of the injury.
SPRICEMM:
Support – When you experience a ligament injury, it is important to keep it supported in a mid
to shortened range to allow healing to take place. You may use a brace, bandage or tape the
ankle joint for support.
Protect – After applying support to the joint, you need to protect the joint from further injury.
With an ankle sprain, you may use crutches in the short term to prevent full weight bearing on
the joint as it heals. When walking with crutches, make sure your heel is touching the floor, only
allowing minimal weight through the limb.
Rest – Rest the ankle joint to allow for healing. This does not mean complete immobilization.
You may move the joint gently through range, however, do not push into pain.
Ice – Ice assists in reducing the inflammatory reaction and most importantly provides pain
relief! You may use an ice pack, ice cubes wrapped in towel/pillow case, a bag of frozen peas
etc. as often as possible especially in the first 24-48 hours post- injury.
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Compression – Applying compression to the ankle joint helps to reduce the swelling and
oedema response.
Elevation – It is important to elevate the ankle joint as it reduces the swelling response and
encourages flow of the oedematous fluid back to the heart. In sitting, you may elevate your leg
onto a stool or chair and in lying, place your leg on a pillow.
Medication – If the pain is severe, you may choose to visit your doctor or chemist to get some
anti-inflammatory medication.
Mobilisation – Gentle movement of the ankle joint is encouraged as long as it is within your
pain limits.
Avoid HARM.
Heat – Heat increases blood flow to the area, therefore promoting the inflammatory reaction.
Alcohol – Avoid alcohol in the acute phase as it causes vasodilation (expansion of your blood
vessels) which also increases blood flow to the area.
Running – Avoid running or any vigorous exercise as it may cause further injury to your ankle
and affect the healing process.
Massage – Massage and stretching should be avoided in the acute phase (48-72 hours) as it
may disrupt the development of connective tissue.
If you have followed all these managements and your symptoms still persist or are getting
worse after one week, do consult your doctor or physiotherapist as there may be a more severe
injury underlying the sprain such as a fracture. They will be able to refer you for an X-Ray if
required.
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Physiotherapy Rehabilitation Exercises
According to research, mechanical stability is present only after 6 weeks – 3 months after an
ankle ligament rupture. Therefore, it is important that you consult a physiotherapist to ensure a
proper exercise program is developed, tailored to your needs. This will depend on a number of
factors such as your age, previous level of physical activity and the severity of the ligament
rupture. Although it is important to start exercising the joint as soon as possible to prevent any
stiffness to develop, it is also important to ensure proper healing to prevent chronic ankle
sprain. This is when the ligament has not fully healed and the joint is unstable, and an injury
reoccurs. The aim of the exercise program is to prevent re-injury and also to prevent the
ligament to heal in an elongated position; resulting in joint laxity or instability. An example of a
structured exercise program is as below. The progression of these exercises will be modified by
your physiotherapist according to the rate of improvement and healing process.
Proprioception Exercises:
1. Standing on one leg for as long as you can
2. Standing on one leg whilst performing upper limb movements eg. throwing and catching
ball
3. Standing on one leg on a foam or pillow for as long as you can
4. Single leg mini squats
Strengthening exercises:
1. Active range of motion exercises with a resistance band/theraband
2. Calf raises on the edge of a step (double leg, then progress to single leg)
Once your pain has decreased, you may progress to activities that do not require any sharp
twisting and turning movements such as jogging or running. After complete healing of the
ligament, you may then progress to running, stopping and changing directions.
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References:
1. Picture sourced from: Tiemstra J (2012) Update on Acute Ankle Sprains: American
Family Physician (Volume 85, Number 12), pp 1171
2. Hubbard, Tricia J, Charlie A (2008) Ankle Ligament Healing After an Acute Ankle Sprain:
An Evidence-Based Approach. Journal of Athletic Training: Proquest Central (Volume 43,
Number 5), pp 523-529
3. Gino M et al (2012) Diagnosis, Treatment and Prevention of Ankle Sprains: An EvidenceBased Clinical Guideline. Amsterdam, Br J Sports Med. Pp 854-859
4. Website: http://orthoinfo.aaos.org/topic.cfm?topic=a00150
5. Musculoskeletal Science 252/554 Guide, School of Physiotherapy, Curtin University
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Anterior Cruciate Ligament Rupture
Anatomy of the Knee
The collateral ligaments of the knee support the knee from moving sideways. The medial
collateral ligament (MCL) is located on the inside of your knees and the lateral collateral
ligament (LCL) is located on the outside of your knees.
The cruciate ligaments of the knee form an ‘X’ shape, and it supports back and forth
movements of the knee. The anterior cruciate ligament (ACL) prevents excessive forward
movement of the tibia (shin bone) in relation to the femur (thigh bone), and also prevents
excessive rotational movement of the knee joint. The posterior cruciate ligament (PCL) prevents
the tibia from moving too far back in relation to the femur.
The muscles that are in charge of movement in the knee are the quadriceps, which are located
at the front of the thigh, and the hamstrings which are located at the back of the thigh. The
main action of the quadriceps is to straighten the knee and the hamstrings act to bend the
knee.
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Mechanism of Injury
The most common mechanism of injury for an anterior cruciate ligament (ACL) tear is:
1. Hyperextension of the knee joint. This may occur when there is a force or blow to the
front of the thigh when the foot is planted on the ground.
2. Rotation or twisting at the knee. This may occur when the foot is planted firmly on the
ground and the femur (thigh bone) rotates around the knee, or when the foot is planted
inwardly. This usually happens in touch football when a player is running and tries to cut
and change directions quickly.
An ACL injury may occur in isolation. However, it is common for the medical collateral ligament
and the medial meniscus to be damaged along with the ACL. This is known as the
“O’Donaghue’s triad”. When a player experiences an ACL injury, they may report hearing a
“pop” or a “crack” at the knee, followed by immediate swelling and pain around the knee joint.
It may be difficult to walk off the field due to the feeling of instability at the knee.
An ACL rupture is diagnosed using ‘special tests’, carried out by your physiotherapist or doctor.
If your physiotherapist or doctor thinks you have an ACL rupture, they will refer you on for a
magnetic resonance imaging (MRI) to confirm their diagnosis and establish the severity of the
rupture.
Immediate Management
The following management strategies aim to reduce the inflammatory component of the injury.
SPRICEMM:
1. Support – When you experience a ligament injury, it is important to keep it supported in
a mid to shortened range to allow healing to take place. You may use a brace, bandage
or tape the knee joint for support.
2. Protect – After applying support to the joint, you need to protect the joint from further
injury.
3. Rest – Rest the knee joint to allow for healing. This does not mean complete
immobilisation! You may move the joint gently through range, however, do not push
into pain.
4. Ice – Ice assists reducing the inflammatory reaction and most importantly provides pain
relief! You may use an ice pack, ice cubes wrapped in towel/pillow case, a bag of frozen
peas etc. as often as possible especially in the first 24-48 hours post- injury.
5. Compression – Applying compression to the knee joint helps to reduce the swelling and
oedema response.
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6. Elevation – It is important to elevate the knee joint as it reduces the swelling response
and encourages flow of the oedematous fluid back to the heart. In sitting, you may
elevate your leg onto a stool or chair and in lying, place your leg on a pillow.
7. Medication – If the pain is severe, you may choose to visit your doctor or chemist to get
some anti-inflammatory medication.
8. Mobilisation – Gentle movement of the knee joint is encouraged as long as it is within
your pain limits.
Avoid HARM.
1. Heat – Heat increases blood flow to the area, therefore promoting the inflammatory
reaction.
2. Alcohol – Avoid alcohol in the acute phase as it causes vasodilation (expansion of your
blood vessels) which also increases blood flow to the area.
3. Running – Avoid running or any vigorous exercise as it may cause further injury to your
knee and affect the healing process.
4. Massage – Massage and stretching should be avoided in the acute phase (48-72 hours)
as it may disrupt the development of connective tissue.
Treatment
Like any other ligament injury, the ACL may be partially or fully ruptured. Unfortunately, the
ACL does not receive adequate blood flow to promote effective healing and the ACL usually
stays disconnected after the injury. There are two options for treating an ACL rupture;
conservatively or surgically. There are a few factors to take into consideration when making this
decision.
1. Age
2. Functional requirements; Do you regularly perform high level sports?
3. Functional disability; Are you experiencing an unstable knee?
Conservative Treatment
If you have decided to treat the injury conservatively, consult your physiotherapist for a
structured exercise program. As the ACL keeps your tibia from moving forwards in relation to
your femur (especially in a standing position), the exercise program will focus on strengthening
your quadriceps and hamstring muscles to take over the action of the ACL and prevent
instability or ‘giving way’ at the knee. This will not assist in the healing of the torn ACL.
However, some people are still able to function normally without their ACL.
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Surgical Treatment
An ACL reconstruction is performed by using tissue from the patient’s own body (autograft) or
by harvesting tissue from a donor or cadaver (allograft). ACL reconstruction is done
arthroscopically. This is a minimally invasive surgery where instruments used to reconstruct the
ACL are inserted into the knee joint via small incisions. This results in less trauma compared to
an open surgery and allows for a quicker recovery time. The most common tendons used in an
autograft ACL reconstruction are the quadriceps tendon, hamstring tendon and the patella
tendon.
After the surgery, you will be referred to a physiotherapist for a structured exercise program
aimed to return to work or sport. The structure and progression of the exercises may vary
depending on your age, previous functional ability, physiotherapy goals and surgeon’s orders.
You are most likely given a knee brace and crutches to use for the first few weeks. An overview
of the physiotherapy rehab is given below. These exercises are variable and may be modified by
your physiotherapist.
Week 0-2
1. Education and management of pain and inflammation
2. Protect graft whilst avoiding complications of bed rest; application of brace and
education of walking with crutches
3. Regain knee range of motion toward 0⁰ extension and 90⁰ flexion
4. Hamstring and quadriceps co-contraction exercises and proprioception exercises
5. Avoid open kinetic chain knee extension
Week 2-6
1.
2.
3.
4.
5.
Increase knee range of motion to 90⁰-120⁰ flexion
Improve gait; patient should be off crutches
Patella mobilization
Lower limb strengthening exercises (low load)
Continue proprioception exercises
Week 7-12
1. Full knee flexion to 145⁰
2. Increase resistance for lower limb strengthening exercises and continue proprioception
exercises
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Week 13-26
1. Running forwards and backwards. Caution when running sideways.
2. Jumping to work on force absorption
3. Progress lower limb strengthening exercises
Week 26- return to sport
1. Interval training to improve speed, acceleration and deceleration
2. Sport specific training; running and cutting directions
3. Patient should be pain and symptom free when returning to sport
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References:
1. Picture sourced from: http://ehealthmd.com/acl-tears/wha#axzz2fJdkNXtjt-anteriorcruciate-ligament
2. Linko E et al (2009) Surgical versus Conservative Interventions for Anterior Cruciate
Ligament Ruptures in Adults (Review) The Cochrane Collaboration. John Wiley and Sons:
Finland. pp 1-7
3. Frobell R et al (2013) Treatment for Acute Anterior Cruciate Ligament Tear: Five Year
Outcome of Randomised Trial. BMJ; Sweden. pp 1-12
4. Musculoskeletal Science 252/554 Guide, School of Physiotherapy, Curtin University
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Hamstring Strain
Location of the Hamstring Muscle
The hamstring muscle is made up of three different muscles; biceps femoris (laterally),
semitendinosus and semimembranosus (medially). These muscles act to bend the knee and
straighten the hip.
Mechanism of Injury
Hamstring tears are a result of stretch induced injuries, not from direct trauma. Hamstring tears
commonly occur at the end of swing phase, for example when a player is sprinting or kicking a
ball. When a player swings their leg forward, the hamstring muscle is working eccentrically to
decelerate hip flexion and knee extension. Eccentric contraction of a muscle produces higher
tension compared to a concentric contraction therefore damage to the muscle results in loss of
eccentric control.
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Hamstring injury may also occur at the initial phase of stance. This usually occurs in athletes
who have low back pain or weak glutes, leading to over activity of the hamstring muscle,
leaving it more susceptible to injury.
The rate of recovery for a hamstring strain relies on the location of tear. A tear in the muscle
belly has a faster recovery rate compared to a tear at the myotendinous junction (where the
muscle connects to the tendon) due to the amount of blood supply.
Diagnosis of the grade of hamstring injury may be confirmed via magnetic resonance imaging
(MRI).
Classification
Grade
Pathophysiology
Signs & Symptoms
Grade 1
Overstretched muscle, no
tearing of the muscle fibers
Minimal pain and swelling, tightness when
muscle is put on stretch, player may not
notice pain till after game is over
Grade 2
Partial tear in muscle
Reduce strength and flexibility of muscle,
immediate pain, pain on touch and when
bending the knee with resistance or
straightening the knee, limping when
walking
Grade 3
Severe or complete rupture
Sudden, sharp pain at back of thigh, unable
to weight bear without pain, may be
depression where the tear is, swelling and
bruising may be present after a few days
due to bleeding in the tissue
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Immediate Management
These management strategies aim to reduce the inflammatory component of the injury.
SPRICEMM:
1. Support – Provide support to the injured area to prevent further strain or tears from
vigorous activities. You may apply a bandage or tape in a circular pattern around the
hamstring muscle with some compression.
2. Protect – After applying support to the area, you need to protect the area from further
injury.
3. Rest – It is important to rest the muscle to allow for healing. However, this does not
mean complete immobilisation! Immobilisation for more than a week will result in
muscle wasting. Consult your physiotherapist for a structured exercise program before
you return to sport.
4. Ice – Ice assists reducing the inflammatory reaction and most importantly provides pain
relief! You may use an ice pack, ice cubes wrapped in towel/pillow case, a bag of frozen
peas etc. as often as possible especially in the first 24-48 hours post- injury.
5. Compression – Applying compression helps to reduce the swelling and oedema
response.
6. Elevation – It is important to elevate your leg as it reduces the swelling response and
encourages flow of the oedematous fluid back to the heart. In sitting, you may elevate
your leg onto a stool or chair and in lying, place your leg on a pillow. You may need to
place a small pillow or rolled up towel under your knee to prevent the hamstring from
being in a stretched position.
7. Medication – If the pain is severe, you may choose to visit your doctor or chemist to get
some anti-inflammatory medication.
8. Mobilisation – Gentle movement of the knee is encouraged as long as it is within your
pain limits. Do not stretch into pain.
Avoid HARM.
1. Heat – Heat increases blood flow to the area, therefore promoting the inflammatory
reaction.
2. Alcohol – Avoid alcohol in the acute phase as it causes vasodilation (expansion of your
blood vessels) which also increases blood flow to the area.
3. Running – Avoid running or any vigorous exercise as it may cause further injury to your
knee and affect the healing process.
4. Massage – Massage and stretching should be avoided in the acute phase (48-72 hours)
as it may disrupt the development of connective tissue.
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Treatment
The duration and progression of treatment will depend on the severity of the hamstring tear
and rate of recovery. The treatment will focus on the acute management of inflammation, then
progressing to a structured exercise program to increase strength and endurance of the
hamstring and glutes muscles, increase proprioception, achieve lumbo-pelvic control and
increase cardiovascular fitness for return to sport. It is important to perform exercises
prescribed by your physiotherapist and progress accordingly to prevent re-injury. It takes at
least 2-3 weeks for a low grade hamstring injury to heal. An example of the exercises are as
below:
Strengthening exercises:
1.
2.
3.
4.
Double leg Roman Deadlifts, progressing to single leg Roman Deadlifts
Lunges, progressing to lunges with weights
Double leg bridging, progressing to single leg bridging
Double leg squats, progressing to single leg squats
Proprioception exercises:
1. Standing on a wobble disc, progressing to standing on a wobble disc with eyes closed
2. Standing on one leg, progressing to single leg stand with upper limb movements
Cardiovascular fitness:
1. Graduated running program, progressing distance of run
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Return to Sport Criteria
Before returning to sport or any vigorous activities, it is important to have achieved all these
criteria and get the ‘green light’ from your physiotherapist. This is to lower the risk of re-injury.
1. Hamstring strength and endurance compared to the unaffected side (› 90% strength)
2. Pain free muscle contraction on length and in shortened position (knee straight and
knee bent)
3. Full range of motion, with no pain in stretched position
4. No pain on palpation when hamstring is contracted, and no tone or texture changes
5. Functional tests; box jump, sprinting with forward lean, kicking whilst running, single leg
jump
These are a few examples of the return to sport criteria. However, your physiotherapist may
have different activities or criteria he/she would like you to achieve before returning back to
sport. You need to train full sessions for a few weeks with your team before participating in a
game.
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References:
1. Picture sourced from: http://runnersforlife.com/profiles/blogs/rehabilitating-hamstringinjury
2. Hoskins W, Pollard H (2005) The Management of Hamstring Injury – Part 1 : Issues in
Diagnosis. Elseiver : Australia. pp 96-104
3. Hamstring Strain: A Guide to Prevention and Management (2010). Sports Medicine
Australia.
4. Wilson A, Myers P. Hamstring Injuries. Brisbane Orthopaedic and Sports Medicine Clinic.
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