• Reducing the Occurrence of Injuries

    John Orchard is a sports physician and sports injury researcher based in Sydney, Australia. He is a Conjoint Senior Lecturer at the University of New South Wales and a Senior Fellow at the University of Melbourne. Dr Orchard is Medical Director for the Sydney Roosters Rugby League Football Club. He is Injury Survey Co-ordinator for Cricket Australia and the Australian Football League, and is a board member of the New South Wales Sporting Injuries Committee.

    Dr Orchard is also an editorial Board Member for The British Journal of Sports Medicine and is Clinical Assistant Editor of The Journal of Science and Medicine in Sport. Dr Orchard disseminates his work and keeps the public informed on topical sports injury subjects at www.injuryupdate.com.au – Australia’s premier sports injury website.

    Dr Orchard accompanied the Australian cricket team on the 2007 tour of India and we caught up with him to get an insight into the medical issues of touring the sub continent.

    In the past the Australian cricket team haven’t always had a doctor accompanying them on tour. What do you think persuaded Cricket Australia to take a sports physician with them for the 2007 tour of India?

    “Finances are a consideration for cricket administrators obviously given that tours are on the longish side and doctors aren’t cheap. The tour party also had a masseur and exercise physiologist and with coaches and managers we were getting close to a 1:1 ratio between staff and players. I once discussed this issue with Daniel Vettori (when he was in Sydney seeing me because NZ didn’t have a travelling team doctor). I mentioned that the cricket administrators probably didn’t want to pay a high salary for a doctor who might do a few hours of very important work each week but then spend the rest of the week either watching cricket or in a hotel room waiting for something to happen. His reply was gold – “how would this make the doctor (on tour) any different to the players?””

    Was the profile of injuries you treated during the tour typical of elite level cricket? What sort of conditions were you presented with?

    “I did plenty of medical consults although I still wasn’t as busy as the team physiotherapist, Alex Kountouris. For that particular tour, most of the injuries were in the minor category and we didn’t need to send anyone home. A lot of the profile is random as you would realise. Alex had just come from the Twenty/20 World Cup in South Africa, where the Aussie team hadn’t take a doctor. From an injury viewpoint they unfortunately had a shocker, with 3 or 4 players doing bad hamstring injuries. Alex therefore spent a fair time on the phone from South Africa to Trefor James, the Cricket Australia medical director, trying to work out which of the hamstrung players to send home. In India, from a medical viewpoint, we had quite a few players come down with gastro and I’m certain that I made myself very useful in treating these cases. The guys who needed IV fluids and IV antibiotics got better very quickly, which turned what could have been major illnesses into minor ones. This sort of treatment of course couldn’t have been done by the physiotherapist.

    “A final point worth mentioning, is that I did many consults for members of the media, umpires, hotel and administrative staff and even a few for members of the Indian cricket team. Once word got around that a sports physician was with the Australian team I was pretty popular, given the alternative options. “

    Is the injury profile different between one day international matches, Twenty20 matches and Test matches?

    “When we had Test and one day cricket only, I used to think the injuries were pretty similar, but Twenty/20 has gone to the other extreme of Test matches. I now am confident we are going to be able to demonstrate a different injury profile between the different types of cricket. In particular, injuries of an ‘overuse’ nature (which are the bane of fast bowlers) are much more likely to be caused by bowling in Test and other first class matches, because of the higher match workloads. What we are just starting to appreciate is that the overuse injury doesn’t necessarily happen at the time of the overuse – perhaps you may break down a few weeks later and it could even be whilst playing a different form of the game. The apparently high rates of bowling injuries in Australian one day internationals that we have seen in the past may be artefact from the fact that players have usually just come off a long Test series. When you have a long stretch of one day internationals without Tests such as in a World Cup, the bowling injury rate comes down substantially. Although we have just started seeing dedicated Twenty/20 competitions, I am confident that there will be fewer bowling injuries than we have seen in the longer forms of cricket. Given that most commentators consider that Twenty/20 is a batsman’s game, it will be pleasing if we see the bowlers get lower injury rates as a result. There may be a slight reverse effect for the batsmen and fielders in that the intensity of play is so high that average running speed is higher. I suppose it is like the difference in injury profile between sprinters and distance runners.

    “The other factor is that the players all are heading towards having a 12 month season of cricket being available for them to play, which will create its own problems. The Indian Premier League shows that human nature on both sides (the administrators and most of the players) means that if you can make more money playing more cricket, then the extra games will happen.”

    Did you have a network of consultants and imaging facilities in India and did you have to use them much during the tour?

    “Although I’ve given India some stick for having poor quality sports medicine, it is worth mentioning that the availability of cheap medications and cheap MRI scanning leaves countries like Australia and the UK behind. You can get a good 1.5 Tesla MRI scan very easily and usually for under 100 pounds. In fact if you wanted to haggle, you could probably get the scanner people pay you for the privilege of having an elite player allow them to scan his body! Of course, the radiologist reading the scan might be a specialist in breast cancer images rather than musculoskeletal radiology, so it is good if you are a sports physician and can interpret the MRIs yourself! At least the machine quality and availability is good. The value for money on the drug side is ridiculous. I bought quite a lot of medications over with me but we did run out of antibiotics. At one hotel I got the concierge to order me another pack of antibiotics and he charged my room what was then converted back to about 30 cents in Aussie dollars. I must have appeared to raise my eyebrows at the price and he sheepishly apologised – “sorry Sir, the hotel has to put on quite a substantial markup for the service of going out to the pharmacy”. I then went out to find out that most packs of medications were about 10 cents in the local pharmacy and that prescriptions were ‘optional’. Obviously when buying medications in India you have to consider the lesser degree of regulation of the drug industry, but the amazing price differential made me think that Western drug companies must love using safety as an excuse to lessen competition and to gouge the market (that’s gouge not gauge!).

    “There appear to be a few good orthopaedic surgeons in India with sports medicine expertise, although at more than half the venues the doctors on duty were from completely unrelated specialties. I met Mandeep Dhillon in Chandigarh and Parag Munshi in Mumbai who both are high quality and Anant Joshi in Mumbai also has a very good name. Andrew Wallace, the English upper limb surgeon, also was visiting Mumbai at the time we were there. He is pretty close to the Indian team and probably has the keys to the entire country having successfully operated on Sachin Tendulkar.

    “I think the two competitions going on in India at the moment (Indian Premier League and Indian Cricket League) will lead to a much better network of medical specialists being developed. The ICL (Indian Cricket League, which is the rebel competition and which started before and in fact probably led to the formation of the IPL) was well advised to import most of their physiotherapists from countries like Australia, England and South Africa, to ensure a high quality of service. The IPL has followed suit and there are now good quality Western physios with most teams. The physios collectively will, in time, be able to uncover and discern which medicos are worth using. Unfortunately the default position in India has to be that you treat doctors with some suspicion. One of the most endearing personality traits of the Indians is that they are so obliging, but this extends to doctors offering to provide services in areas that they have no expertise in whatsoever, so you need to be careful! There will be plentiful opportunities for Western sports medicine doctors and physios to work in India over the next few years as their cricket infrastructure is obviously taking off and they will pay good money to attract quality international staff. A progressive company like Pure Sports Medicine, based in London, would probably also see a business opportunity in a city like Mumbai if they could work out how to get the professional staff over there. It is a different world to what we are used to in countries like England and Australia, but it is certainly not backwards across the board. The hotels, food, service, IT and marketing sectors are all very good in India. In some ways they are obviously becoming a world superpower and in the cricket landscape, it is hard to see how a country like New Zealand is going to have the financial resources to compete on the international scene. They may provide a lot of cricket manpower (players and even doctors and physios) but a lot of their work will gravitate to India.”

    The players are on their feet all day in temperatures above 30 degrees Celsius. How did you manage to avoid dehydration and muscle cramps?

    “These are certainly major concerns playing cricket in India and oral hydration is still the central pillar of avoiding dehydration and cramps. Most of the time the players can keep up, but when you throw gastroenteritis in the mix (which increases fluid loss and decreases digestion) then it can be enough to stop oral rehydration from being adequate. Interestingly, this means prevention of gastroenteritis is also an important part of prevention of dehydration. The Aussie cricket team uses a supplement called Travelan, which has some anti-E Coli properties derived from components of cow’s milk, and their un-controlled experience with this product is positive. As a nerdy doctor, I was prepared to follow my own advice to brush teeth using bottled water only, but I don’t know how many of the red-blooded Australian males in the team actually went to extreme measures like this. When players did get gastro to the point of being unable to keep bottled water down, I was quick to use Intra Venous therapy (including fluid and antibiotics). This was legal in 2007 although it will now require a full permission from anti doping authorities in 2008. This wouldn’t stop me from proceeding as it can totally be medically justified once a player is dehydrated and can’t keep fluids down.

    “On the cramps side we used Quinine in players who were susceptible. Apparently most of the Indian team takes Quinine routinely for matches. I have a lot of experience with Aussie Rules and rugby league players taking it in summer and it appears to be both effective (for preventing cramps) and safe in the athletic population. There are reports of arrhythmias (abnormal heart rythms) and thrombocytopenias (decreased number of platelets in the blood, which causes bleeding) with Quinine although these are mainly in old women taking it every night for night cramps. We need a study analysing efficacy and safety of Quinine in athletes and I have a sports physician registrar who recently submitted an excellent protocol for a randomised controlled trial in sportsmen. Just to prove the research world is going as mad as every other sector is, he got this knocked back by an ethics committee because one of the members of the jury was worried about side effects of Quinine. So rather than let us study the issue and work out what is scientifically best, the ethics committee has covered its own arse. We’ll just have to keep using (or not using if you are petrified about rare side effects) Quinine thinking that it works but not really being certain. One extra bonus (whilst in India) is that it is also an anti-malarial.”

    “One of my pet topics has been the introduction of the boundary rope into cricket. In the late 1990s when I had just started doing annual injury reports for Cricket Australia, we made the recommendation that the boundary rope (which was used to shorten the boundary at some of the biggest fields in Australia) be introduced for all matches for the safety of fieldsmen. We weren’t expecting much action, because David Janda in the USA had been advocating slide-away bases in baseball to reduce injuries for many years and Major League Baseball hadn’t taken heed (he is unsure whether it is sponsorship from the fixed-base companies or pig-headed tradition that is the stumbling block). Whether cricket is more open to new ideas than baseball (hard to believe, really!) or, more likely, that a marketing guru was also able to calculate that smaller fields would lead to more boundaries and hence a more interesting game, Cricket Australia and shortly afterwards the ICC brought in the compulsory boundary rope. However, we did have once instance in India where a wooden fence was very close to the boundary rope and one of our players was injured (not badly) sliding into this secondary fence. I managed to get into an argument with the match referee going into bat on this issue, but we had the rope moved in a bit for the following game where it was also a bit precarious.

    “One of my other pet issues that we considered at about the same time (the late 1990s) was that cricketers get into trouble playing any form of football as a warm-up or cross-training activity. This one has been harder to achieve change, as the players understandably get bored on tour and love a game of soccer or touch football as a breath of fresh air. Historically though, the vast majority of ACL reconstructions that Aussie cricketers have needed have been sustained playing football games at official training, so we have to work out a way to reduce this risk.

    “Something else that was surprising at some venues in particular in India (where training is chaotic) was that there are multiple nets at different sections of the ground. You could have a scenario where at opposite ends of the ground Andrew Symonds and Matthew Hayden might be doing batting practice and if you are in the centre of the ground it can seem like it is raining hard cricket balls from all directions. Eventually in a scenario like this someone is going to get a fractured skull being hit on the head from behind. Perhaps it has already happened but no one gets too concerned about one fractured skull in a country of one billion people. Again, it is difficult to offer a short-term solution because the guys need to practice and the facilities at some places are not top class. In the longer-term the BCCI needs to channel some of the millions from the IPL into upgrading facilities at their venues (although there are an unbelievable number of stadiums in India to consider).

    “I could go on forever about epidemiology. Now that we have data on match workloads in Test cricket being a problem, I think that they trialled the 12th man substitute rule in the wrong form of the game (ODIs instead of Test cricket). Eventually I think they will allow the 12th man to bowl when replacing an injured player in cricket. From the perspective of other team sports, it seems amazing that cricket doesn’t allow for injury substitution in the 21st Century, but internally in cricket they value some of the traditions of Test cricket (like this one) very highly. Just like in other sports, prevention is in its infancy which makes it an exciting time to be a researcher.”

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