Artificial Surfaces- The burning questions

Artificial Surfaces and new injury challenge.

 This blog serves to provide the reader with greater understanding and information on how friction burns occur on an artificial playing surface and how that this new surface is proving challenging to the medical teams that manage the player’s week on week.

In all there are 4 major Clubs within South Wales that have reverted from the traditional grass root based pitch to the 3/4Generation pitches. Although the advantages (all season pitch, multiple use, faster free flowing game) outweigh the disadvantages (friction burns, new injuries, harder surface) the friction burns can cause some severe risks. It’s the purpose of this blog to discuss what the injuries are, how they occur and how to best manage and prevent them.

Merthyr 3G surfaceArtificial playing surface

The introduction of the new surface into rugby has seen a change in the injuries sustained by players. The common injuries such as ankle sprains, hamstring strains and concussion still remain evident in the game but theres a new kid in town (Abrasions injuries) and its proving difficult to manage.

Now following on from the media hype Wales online, BBC Wales this isn’t a blog that serves to slander  artificial pitches. Yet, what its meant to do is understand the injuries specifically abrasions that may be sustained whilst using an artificial surface. As a medical person I want to know the best way to treat these injuries and allow the players to continue playing without putting themselves at further risk??

Firstly, we need to understand these new injuries (abrasions) and how they occur. As a physiotherapist I except the broken bones and ligament sprains and muscle tears in rugby and undertake rehab sessions with players on a weekly basis to facilitate a safe return to play but the abrasions sustained from such artificial surfaces are time demanding on the medical team and expensive to manage.

What are Abrasions?

Are more commonly seen in cyclists and track and field athletes and are usually caused by a fall on a hard surface. Abrasions are also known as ‘Road Rashexcoriation or “brush burn”.  As the athlete falls then the impact with the ground and coinciding with the frictions causes layers of skin to be removed (Fig 1.)

An abrasion means the superficial surface of the skin (epidermis) has been broken or damaged. Its commonly seen around the extremities where bony and less fleshy parts of the body such as (knees, Ankles, Elbows and hips)

Whilst cyclists, track and field athletes and more recently rugby players have the potential to cause painful abrasions due to the high speed of the sport and impact when falling. Abrasions do not extend into the dermis and do not cause a great deal of bleeding. However, whilst there is little blood loss from an abrasion they can often be painful due to nerve endings being exposed.

Layers of the skin

Layers of the skin

Fig 1: Layers of the skin

The epidermis provides protection, and a deep inner layer (Dermis), which provides the firmness and flexibility of the skin. These Abrasive type injuries would typically be classified as a first degree burn (Classification of Burns-Fig 2). Nonetheless, the risk from infections of these injuries if not managed correctly can be high.

Burns degree classification.jpg

Fig 2: Classification of Burns

 Risk from Abrasions?

The abrasion can contain elements of dirt and in this case rubber crumb from the artificial surface. This may lead to an infection or other complications if not cleaned and attended to. Most abrasions can be treated at home, and a trip to the emergency room is typically not necessary.

  1. Wounds may interfere with function of the injured body part (knee when bending to walk up the stairs).
  2. Wounds may become infected, usually with bacteria if not irrigated properly.
  3. If wounds don’t heal properly they may leave scars.

 

Acute management and Treatment for Abrasions

  • Clean the wound with a non-fiber shedding material or sterile gauze, and use an antiseptic such as Chlorhexidine is a disinfectant and antiseptic that is used for skin disinfection before surgery and It may also used for cleaning wounds.
  • If there is embedded dirt, chlorhexidine may be used as it contains an antiseptic and a surfactant to help remove debris. Rinse the wound after five minutes with sterile saline or flowing tap water. Ideally, you want to irrigate the area with a nontoxic surfactant such as Chlorhexidine or Shur-Clens with a bit of pressure (use a syringe if possible).
  • Don’t scrub at embedded dirt, as this can traumatize the site even more.
  • Cover the cleaned wound with an appropriate non-stick sterile dressing. Use a semi permeable dressing such as Tegaderm, Bioclusive or second skin. Cover the wound and attach the dressing to the clean dry unaffected skin. Whilst brand names have been mentioned here we are aware there may be other products available.
  • Another product that is said to be useful to help heal minor skin abrasions is Antiseptic Healing Ointment made by Brave Soldier. This unique blend of natural botanicals (Tea Tree Oil, Aloe, Jojoba Oil, Vitamin E/Comfrey) helps wounds heal quickly and reduces the likelihood of scarring. It includes 4% Lidocaine which reduces the pain and abrasions can certainly is painful. This ointment is becoming a favorite healing ointment of triathletes and cyclists and works well on road rash, minor cuts, burns, blisters, and even saddle sores.
  • Change the dressing according to the manufacturer’s instructions (some may be left in place for several days to a week). A moist clean environment promotes healing, improves tissue formation and protects the area from infection. If you reapply antiseptic, wash it off after five minutes and then redress the wound.
  • If signs of infection are evident then a course of antibiotics may be used as an additional treatment.

Healing

After the injury is sustained the damaged layers of the skin will first heel from deep to the superficial layers of the skin and from the outer edges to centre. As healing begins, the area of the abrasion may look pink and raw, but in time, the wound will form new skin that is pink and smooth.

Factors such as patient’s age, health, extent of injury, possibility of infection, and availability of first aid supplies help to determine the amount of time necessary for an abrasion to heal. Other factors that affect the rate of abrasion healing include:

  • Diet – the immune system and skin need healthy and proper nutrition
  • External temperature and weather conditions
  • Smoking
  • Drug use
  • Pre-existing medical conditions, such as vascular disease or diabetes.

Most abrasions and minor scratches heal in a few days. The formation of a scab is your body’s natural way for protecting the wound from dirt and germs, and a sign that new skin is growing beneath. Try not to pick at or scratch scabs, as the new skin underneath may not yet be fully developed.

Prevention of abrasions

Prevention of abrasions is possible by using Vaseline prior to  sessions/Game or protective pads, should the rules of the game allow it or covering any exposed skin with a layer of clothing. You can’t always predict when you will suffer an abrasion, but within rugby and the use of artificial surfaces it is certainly now becoming more common place.

Awareness of your Pitch/ground and other grounds artificial may aid you and the players to minimize the risk of moderate to severe abrasions. Due to the contact nature of the sport and the ever increasing exposure to artificial surfaces they are always going to be a factor in the game and during training. However, other precautionary steps include

  • Wearing long skins, legs and arms, or other layers of clothing as additional layers of protection for the skin
  • Wearing protective pads for knees, wrists, elbows, and hands during training.
  • Using lubricants such as Vaseline on exposed extremities with less flesh.
  • Keeping a well-stocked first-aid kit available can help provide immediate treatment for abrasions
  • Antibiotic ointment as mentioned above
  • Wound care management kit (irrigation kit with suitable dressings)

Points to consider

  • Keep a close watch on the injury
  • watch for signs of infection or complications.
  • If the abrasion does not seem to be healing, seek medical attention. You may also need an updated tetanus shot, particularly if you have not had a booster shot in the last five years.

Summary

With the increasing number of artificial pitches now in rugby, abrasion injuries are becoming more common place and need to be managed acutely and effectively to ensure the risk factors of infection and scarring are kept low. This blog serves as a guideline only in the management of acute abrasion injuries and should not supplement medical advice.

 

 

 

 

Paying it Forward.

Beating the odds

Ive been meaning to write this one for a while and having recently read @sianknott‘s recent blog on behalf of @sport_wales its inspired me to give a brief synopsis of how to use current and existing infrastructures of governing and professional bodies to progress through your career as a sport physio and with it being an olympic year what better time to share the info.

Rabbit in headlights

Where do I go from here???

Now when you first start out its a bit like a rabbit in the head lights – you don’t know where to go or what to do….. so my main aim for this blog is to give some advice and personal experience on where you can go as a newly graduated physio wanting to work in sport or for those looking for more exposure in multi sport events.  

I wouldn’t say I am the most experienced sports physiotherapist out there but if I didn’t have the help and support from some key figures in the sports physio world (you know who you are) I would never have worked with some of the teams I have or travelled to the farthest corners of the World. Therefore, I am merely just trying to return the favour by  “Paying it forward”.

CPD Pathway and Education-Going for gold.

Firstly, I have found and continually use the Association of Chartered Physiotherapists in Sport and Exercise Medicine (ACPSEM) as a great resource for  professional development and networking. The organisation has a clear and structured CPD and educational pathway. The process is straight forward and the “pathway provides a road map to help sports physiotherapists to plan, implement and reflect upon their learning”. 

The ACPSEM accreditation levels are internationally recognised by the International Federation of Sports Physiotherapists, the British Olympic Association and Sports National Governing Bodies. Evermore, employers are using the CPD levels as essential criteria on their job descriptions to ensure that they can be confident in the physiotherapists sporting experience. With more competition in the marketplace from other sports practitioners, the pathway can add value to your professional credibility. 

Secondly, The organisation clearly has some influence within the market place too, and regularly liaises with Health Professions Council and Chartered Society of Physiotherapy to inform them of any changes updates or woking practices on behalf of sports physiotherapists working in sport medicine. 

To volunteer or not????

As you enter into the sporting world it is very easy to get caught up in the volunteering process.  Now I for one feel strongly about this and speak from experience. All too often you hear of physios covering or volunteering for sports to gain experience but quite often end up working alone or exposed, and I’m not against volunteering but what I will say and question is what are you getting from it? 

Perhaps an example would help better here? – If you a covering a social sporting side to gain experience and you are the sole practitioner and responsible for trauma cover, question are you really going to benefit from it or are you just exposing yourself to a potentially vulnerable situation?

working alone pitchside

Exposure pitch side the need for Team support is essential

If however, you are involved within a team there is no reason why you cannot volunteer and access the previously mentioned ACPSEM pathway documentation and mentoring system to clearly define objectives and learning outcomes from within your role making the experience more worthwhile.

If you really seek a structured experience, with exposure within multi sport events then BUCS as an organisation is a  great place to start.  Throughout my career I been heavily involved and still am, reason being the cohort of physio and medics are so varied in their professional and sporting backgrounds that the information or learning you can gain is invaluable regardless of experience. Is it costly? simple answer no, all you have to do is give your time and be willing to work the hours and in environments your not used to.

BUCS volunteer

BUCS events, particularly the larger ones, provide an excellent opportunity for doctors and physiotherapists looking to enhance their sporting experience. BUCS currently operate two multi-sport events where are large number of doctors and physiotherapists come together to work and share knowledge and skills.  Involvement in the domestic programme can additionally lead to a variety of international opportunities. I can say that these have been some of the best working trips I have been on and made some real life-long friends. 

For domestic events, BUCS provides expenses and daily rates for ACPSEM qualified physiotherapists and doctors. Students and newly qualified individuals are also able to be involved in a shadowing capacity. Interested in volunteering click here

If after reading this blog your keen to progress further in the Sport and exercise medicine world then volunteer and get involved because who knows you may be attending the next World university Games, Commonwealth Games or  Olympics Games………………………

See you there 😉

tokyo

 

 

Topics to tackle

Lately rugby seems to be getting some very disappointing negativity and bad PR. First concussion and now banning school kids from tackling. What will these people think to ban or downgrade next????

Now don’t get me wrong, I don’t have issues regarding the safeguarding and welfare of players. When it comes to concussion and implementing a safe return to play I fully support the consensus but that’s another blog in itself.  Rugby is one of the largest participated sports in the world by both males and females from all ages.

World rugby reports that these numbers are continuing to grow with the introduction of their new program ‘Get into rugby’. When it comes to watching the sport I am like any other fan, I love to see the big tackle and great carry.

However, this recent letter written by doctors and health professionals calling for the UK Government to ban tackling in school rugby games is in my mind ridiculous – I will explain why later.  They as a group continue to make suggestions that the “high impact collision” may be contributable towards an increasing risk in injuries arguing that two thirds of injuries and concussions in youth rugby are down to “the collision area” and suggest schools play touch or non-contact rugby.

tackle mock

“This report comes at a time where sedentary lifestyle and inactivity is reported to be responsible for more deaths than obesity and that eliminating inactivity in Europe would cut mortality rates by nearly 8% (World rugby 2016).

I myself, with my physio hat on say tackling is an important skill and agree with recent comments made by coach Alun Wyn davies . A skill should be rehearsed and practiced for several hundred hours, time and time again so that the acquisition of that skill can be performed from a conscious to a subconscious state in the correct manner even when under fatigue. As this is when injuries are more likely to occur as evidenced by the annual WRU and RFU injury surveillance programs.

To banish this skill in the junior game I believe would be detrimental both to the sport and to the athlete in two ways. (1) It would further enhance the gulf between northern and southern hemisphere rugby (2). By delaying the age in which athletes are exposed to the tackle technique, could lead to further increased injuries. Teaching pedagogy would suggest that practicing skills at a younger age would neurologically embed that fundamental skill of the game, as children’s pre-frontal cortex is not yet fully developed which allows them to store and access this information more readily than a young adult.  Thus suggesting children would be more susceptibility to learning, understanding and performing the correct technique in comparison to older counterparts.

tackle

In my opinion I believe this skill set should remain in the game at a young age but more emphasis should be focus around delivery and correct coaching of the technique.