efficacy of thing protectors in preventing thigh haematomas

5fficacy of Thigh Protectors in Preventing Thigh Haematomas

Bruce Mitchell

Olympic Park Sports Medicine Centre & Reservoir Sports Medicine Centre, Melbourne, Australia.

Mitchell, B. (2000). Efficacy of thigh protectors in preventing thigh haematomas. Journal of Science and Medicine in Sport 3 (1): 30-34.

Thigh haematomas are cx~cremely common in Australian Rules Football (ARF). This is in contrast to contact sports overseas, the likely reason is the increased use of thigh protectors as part of team uniforms in contact sports such as American foothal]. Thigh haematomas can have a significant impact on an athlete's performance, ranging from short term performance impairment, muscle deconditioning and compartment syndromes, to long term problems, such as career threatening myositis ossfficans and possibly muscle tears. To assess the efficacy of thigh protectors made for Australian Football, a prospective study was undertaken involving two teams in the elite junior (U 18) VSFL competition in SE Australia. One team wore thigh protectors over the course of the season while the other team acted as controls and did not wear thigh protectors. The control group suffered nine thigh haematomas, while the protected group had none {p<0.01). The possible de-conditioning effect of the haematomas was evidenced by two of the control group suffering torn quadrieeps within four weeks of the haematoma. The protectors were generally well tolerated by all but one player, except in hot conditions, when they were uncomfortable.

|n{rocluction A thigh h a e m a t o m a (TH) is a con tus ion of the anter ior thigh muscles , usually the vast-us lateralis, c aused by b lun t t rauma. In Aus t ra l ian Rules Football (ARF) these tend to occur due to contact wi th an opponent ' s knee in packs or marking contests . TH's represent the second most c o m m o n injury in AFL (incidence of 38.4 per 10,000 player hours), the fourth m o s t common in Rugby League (Incidence of 102 per 10,000 player hours) and the eighth mos t c o m m o n in Rugby Union (incidence of 11 per 10,000 player hours) (Seward et al., 1993). TH's all cause per formance impairment, ranging f rom impaired range of motion and restriction while runn ing occasional ly requiring removal from game; to more ser ious injuries, s u c h as thigh compar tment synd rome (Colosimo et al, 1992; Martinez et al., 1993; Novak et al., 1992) myosi t is ossificans (Kaeding et al., 1995), a career threatening condi t ion (Kaeding et al., 1995; Orchard et al., 1995; R y a n et al., 1991; Wood et al., 1 9 9 3 ) a n d possibly quadriceps rupture .

In this increasingly professional environment , where the importance of a t ta ining and mainta in ing a h igh level of condit ioning is pa ramoun t , an injury wh ich leads to loss of training t ime can have severe consequences . Other contact spor ts have m a d e provision for th igh protectors in their uniforms (i.e. Ice hockey and American football.)

30

Efficacy of Thigh Protectors in Preventing Thigh Haematomas

To assess the efficacy of thigh protectors in protecting against TH, a prospective s tudy was under taken in the Victorian State Football League (VSFL) U18 Competition.

Method The VSFL U18 Competition is an elite junior Austral ian Football competition within South-Eastern Australia. Two teams were recruited for the study, Team One, who acted as the unprotected control group, and Team Two, who were supplied with thigh protectors. Informed consent was sought from the players and t eam offÉcials. Ninety-five percent of the players were compliant with thigh protector use over the season, ranging from 80 to 100% on any part icular day. There were no specific characteristics or injury history of those players tha t chose not to use the thigh protectors. Those who did not consent were not i ssued thigh protectors and not included in the data. Only the 18 home and away season games were included in the study and only injuries which occurred in these games were included. Teams in the VSFL U18 competition have 22 players. Games are played over four quarters with a total game t ime of approximately 112 minutes. The two t eams in the s tudy were of even ability as evidenced by them playing against each other in the Grand Final.

A TH was diagnosed by a history of direct t rauma and the subsequent presence of pain, swelling, bruising, without any clinical evidence of a muscle rupture. Provision was made, where there was clinical doubt as to whether this was a muscle rupture, for an ul trasound scan to be performed. This was not necessary during this study. A TH was only included in the s tudy ff it required a player to leave the field of play for the remainder of the game or required more t h a n routine (i.e. ice) post-match therapy.

The thigh protectors (Fig. 1) (Dynasport) consisted of shorts (82% nylon 18% lycra) with eight inm sorbothane inserts coveling the thigh and outer hip. The sizes u sed ranged from medium (maximal dimensions 370rain x 238mm) to extra large (maximal dimensions 445111111 x 277mm).

Figure 1: Dynasport thigh protector.

31


Results A total of nine thigh haematomas were recorded over 396 (22 x 18) player games or 739.2 (396 x 112 minutes) player hours by Team 1 (unprotected), all in separate games, giving an injury incidence of 122 per 10,000 player hours. The competition average for TH in 1994 was 72.0 (Orchard et al., 1995). These injuries resulted in a mean of 2.1 missed training nights. Two of these players had thigh strains within a month of their thigh haematomas . Team 2 (protected) had no thigh haematomas over 378 player games and no thigh strains for the season.

The results were analysed using a one tailed Students t test at the p= 0.05 level of significance. The difference in injury rates between Teams 1 and 2 was significant at p <0.01.

DiSCUSSiOn The problem of TH is common to all codes of football. In elite AFL competition the TH incidence was 38.0 per 10,000 player hours (Orchard et al., 1995). This in comparison to a competition average of 72.0 in the VSFL in 1994. When the effect of the s tudy group is allowed for, the average for the competition increases to 80 per 10,000 player hours. Thus our control group was 50% above the competition average. This is mainly explained by the more inclusive criteria of the two study teams compared to the rest of the competition, which only included missed games. All of these injuries affect performance, even if the player continues to play. The 1992 incidence per 10,000 player hours in AFL was 38, Rugby League 102 and Rugby Union 11 (Aspelin et al., 1992). The AFL incidence in the year of this s tudy was 51.5 per 10,000 player hours (Kaeding et al., 1995).

TH almost invariably result in some missed training in the week subsequent to the injury resulting in some degree of deconditioning of both the muscle and the athlete. One possible outcome of this is an increase in muscle injury. In this study, two out of the nine Team 1 footballers with TH's suffered quadriceps strains within a month of their TH's. This has not previously been reported as a consequence of TH. No other quadriceps strains where recorded for Team One over the course of the season. Team Two had no quadriceps strains for the season and the competition quadriceps strain prevalence was 1.8 (percentage of total time missed) compared with the AFL level of 4.4 (Orchard et al., 1995).

A more serious complication of the thigh haema toma is myositis ossificans. This is a form of heterotopic ossification tha t occurs within a consolidated haema toma in muscle tissue. The main risk factors for this are a severe initial injury, reinjury during recovery from a preexisting haematoma and inappropriate t reatment inducing further haemorrhage (Kaeding et al., 1995). Returning from this injury not uncommonly takes an athlete over six months and at five year follow-up, 3% still complained of symptoms (Kaeding et al., 1995; Kaeding et al., 1995). No player from within the protected or unprotected group developed myositis ossificans.

Another serious complication of TH is compar tment syndrome of the thigh. This is a l imb-threatening emergency and m u s t always be borne in mind when examining a severe TH (Martinez et al., 1993; Novak et al., 1992). This is relatively rare and was not seen in this study.

All bu t one player over the season found the protectors to be comfortable, except on one day when the temperature was over 24 degrees C; on this day all

32


players felt tha t the protectors made them overly hot. Thigh protectors cover 18°5 of the body's surface area and as such will (ACSM, 1984). interfere with heat exchange. They should NOT be used where there is a danger of hyperthermia as defined by the ACSM's position paper on preventing thermal injuries in sport. There was no skin irritation caused by the thigh protectors. Overall the protectors had a high level of acceptance, evidenced by 70% of players continuing to use them after the completion of the study.

22 of the players involved in this s tudy were drafted to the AFL at the conclusion of the study period. Some generalisation of results to AFL level is therefore possible.

This study has shown that the use of thigh protectors prevents TH. It is therefore appropriate to advise footballers, especially professionals, to consider their use. The only contraindication to their use is where there is risk of heat injury. Some players are more prone to TH thm~ others, especially key position players and ruckmen. These players should be strongly advised to use thigh protectors. Use of thigh protectors becomes increasingly important in those recove~ng from a complicated TH or quadriceps strain, those who have suffered several TH's in a season and anyone who has suffered myositis ossificans or a compartment syndrome at any stage. The culture of the game is against protective equipment, with mouthguards still not 100% accepted, however par t of our job as Sports Medicine professionals is to overcome these barriers through education and counseling, to achieve a safe environment for sport.

Conc~us~or~ This study demonstrates the efficacy of thigh protectors in preventing thigh haematomas with minimal side effects, except in the heat in Australian Rules Football. It also suggests the possibility of a de-conditionh~g effect of thigh haematomas and its possible relationship to any subsequent thigh muscle strain. The use of thigh protectors is recommended for Australian Rules Footballers. More research needs to be done on which positions are at highest risk of thigh haematomas and the best design of the protectors.

Acl~nowledgrnents The Author would like to thank Smith & Nephew for supplying the thigh protectors and Mr. Tony Holding for data collection.

References American College of Sports Medicine. (1984, December). Prevention of thermal injuries during

distance running - Position Stand. Meal J Anst, p.876. Aspelin, P., Ekberg, O., Thorsson, O, Wilhelmsson, M., & Westlin, N. (1992). Ultrasound

examination of soft tissue of the lower limb in athletes. Am J Sports Med 20{5): 601-603. Colosimo, A., & Ireland, M. (1992). Thigh compartment syndrome in a football athlete: a case

report and review of the literature. Med Sci Sports Exert 24(9]: 958-963. Kaeding, C., Sanko, W., & Fische, R. (1995). Myositis Ossificans, minimising downtime. Phys

Sportsmed 23[2): 77-82. Kaeding, C., Sanko, W., & Fischer, R. (1995). Quadriceps strains and contusions, decisions that

promote rapid recovery. Phys Sportsmed 23(1): 59-64. Martinez, S., Steingard, M., & Steingard, P. (1993). Thigh compartment syndrome. A limb-

threatening emergency. Phys Sportsmed 21(3): 103-104. Novak, P., Bach, B., & Schwartz, J. (1992). Diagnosing acute thigh compartment syndrome: A

case report. Phys Sportsmed 20(11]: 100-103. Orchard, J., Wood, T., & Seward, H. (1995, March). AFL & VSFL Injuries 1994 Report, AFL

Medical Officers Association.

33


Ryan, J . , Wheeler, J., & Hopkinson, W. (1991). Quadriceps contusions: West Point update. Am J Sports Med 19(3): 299-304.

Seward, H., & Orchard, J. (1993, September). Hazard H, Collinson D. Football injuries in Australia at the elite level. Mcd J A u s t 159(5): 298-301.

Sims, D., & Markey, J. (1990). Bubble packing: an alternative technique for padding severe thigh contusions. Athletic Training 25(2): 163-165.

Walton, M., Roestenburg, M., Hallwright, S., & Suthertand, J. (1986). Effects of ice packs on tissue temperature at various depths before and after quadriceps haematoma: Studies using sheep. J Orthop Sportstherapy 8(6): 294-300

Wood, T., & Seward, H. (1993). AFL Injury Survey. Zylks, D. (1989). Prevention of anterior thigh contusions in contact sports. Athletic Training

24(1): 45.

34

efficacy of thing protectors in preventing thigh haematomas

Documents