Talking Hockey With The Top End’s Top Striker – Jamie Hullick


FN: Hi Jamie!
So you have just be dubbed the “Incredible Hullick” in the Darwin Newspaper’s and selected to play in the Australian Hockey League for the Northern Territory as one of the states key forwards. How many years have you been playing hockey and what does it mean to you to play for your state?

JH: Oh god, I’m never gonna hear the end of that headline. I’ve been playing hockey bang on 20 years this year, with state representative teams for the most part of my teens and twenties. Being a Darwin boy born and bred has instilled a fierce pride in alot of the boys that have grown up playing for the NT and I’m certainly no exception. I love hockey and I love the Northern Territory so the chance to represent both of those passions in one of the best hockey competitions in the world is just perfect.

FN; The last couple of years have been quite hectic for you, you returned to NT from Melbourne to attend University studying Medicine no less and still stay very active within the sporting community how did you manage to juggle study and sport so successfully?

JH: Juggling sport and study is never easy, I’ve had to battle with university administrations on a few occasions for my right to represent my state in sport but for the most part have come out on top. I think you need to pick your battles though, I unfortunately had to take the year off representative hockey last year due to my final barrier exams being just 2 weeks after the tournament. It was a short term pain for a long term gain though and this year I’m back into it and feeling as good if not better than years previously. Time management is key also, which I will admit is not my forte, and when all else fails you end up putting in the hard yards: late nights and long days.

FN: Despite its official stance of being a non-contact sport hockey can be a pretty rough sport, with many of the injuries associated with a direct blow from stick or ball. Have you had many injuries through your time as a hockey player? What were they and what kind of practitioners did you see to have this rehabilitated?

JH: Most of my hockey injuries have thankfully been fairly minor. A few broken fingers and your general bumps and bruises. The three more major things I’ve had to deal with are a shoulder reconstruction, a fairly unstable ankle and more recently 2 hamstring tears. The shoulder thankfully has been surgically fixed, a process that was made very straightforward by a GP referral to an orthopaedic surgeon. My ankle has (touch wood) been dealing well with the training loads so far and has mainly been managed by our team physiotherapist who is very involved in representative hockey at a number of levels. Hamstrings are an ongoing battle and again being managed by our team physio as well as my own research into rehab.

FN: Your shoulder injury seems to have been a big issue throughout your career so far. The ankles also see to have taken a battering have you found you have needed to rehab them at any stage or has the direct trauma not seemed to impact the strength and control needed to produce your fantastic speed and agility?

JH: As I mentioned earlier the ankles seem to be holding up fairly well at this stage. I’ve got no doubt the constant clicking noise coming from one of them is a bad sign and I’ll be a sucker for osteoarthritis in the years to come!

FN: In the upcoming series who do you see to be your strongest opponent and why?

JH: Queensland and New South Wales are the obvious threats as they are most years. The Queensland team is made up of many of the Kookaburra’s and New South Wales’ midfield would be up there with the best in the world. I don’t think anyone should write of Tasmania though as they are the defending champs and have more than shown what they can do on a number of occasions.

FN: What are your primary runners and shoes that you wear? What is it about them that you like and are they associated with a sponsorship deal?

JH: I’m an Asics man myself, they make good hockey shoes and cross trainers. In a hockey shoe I mainly look for something lightweight and flexible with enough grip to turn on a dime and enough durability to put up with the same torture I put my ankles through. In a cross trainer I’m looking for lightweight, comfortable and supportive as most of my cardio is done on a mixture of concrete and grass. I don’t currently have a sponsorship deal but if you know anyone I’ll be a poor uni student for at least the next 3 months!

FN: Run us through your training schedule, do you participate in much strength and conditioning work within the gym or are you specific to the skills needed on the pitch?

JH: At full tilt my training schedule is gym three times a week mainly focussing on power exercises (squats and deadlifts) with more general strength done after the important stuff is out the way. One cardio/agility/sprint session a week to try and keep some kilometers in the legs throughout the year. Finally 3-4 sessions on the turf per week depending on availability of varying intensity to work those hockey specific skills.

FN:What are the next big goals for yourself Jamie?

JH: I begin my career as a doctor (pending this year’s results) starting on the 5th of January so that will certainly occupy a large proportion of my time. It’s certainly in the works for some of my ongoing medical training to be in Melbourne but I am looking at establishing myself in the Top End medical community.

I will certainly remain an active member of the hockey community and do my best to continue to represent the territory at the top level in Australia. Physical fitness is something that I place great importance on and take great pride in, maintaining the current level that I have and building on that will certainly be on the agenda in the coming years.

Jackson McCosker
Director /Chief Editor

Falling Victim to Friction: Callous, Corns and Blisters


Your two kilometers into a five kilometer run in a new pair of shoes. Same brand and model as your last pair and have been your favorites for the last decade or so. But now your beginning to feel a hot spot, an area under your arch or toward your toes that is giving the signal that blister is about to form. Essentially, you only have a couple of options at this point; keep going and finish the last three kilometers and know when you get home you’ll be hobbling for the next couple of days. Two, turn back albeit to have to cover two kilometers anyway and probably end up hobbling for the next couple of days. Or three, laterally raise your arm and a thumb, hoping that the next nice person to pull over and offer you a lift is actually a legitimately nice person.
However, this scenario could have been avoided if you just took a little care and knew what to add, what to take away and what to wear when suffering from repeated callous, corns and blisters.

Blisters can be a nightmare; they can be painful, last for days and put you off physical activity for weeks. But there are a number of things which can be done to avoid developing blisters before they show up uninvited.
1. Make sure all new shoes, insoles or orthotic devices are worn in gradually, are fitted correctly in length and width as well as do not having any seams which will rub.

                 2. Adding products such as plasters (band-aids), gels and padding to protect the area which is suffering rubbing and the development of blisters can actually lead to increased blistering due to making the area of contact more prominent. These types of methods are best kept for once a blister has been lanced and released of exudates build up.

                 3. There are products which can be used to protect and toughen the skin against outside shear forces. The use of a Vaseline gel/wax can be used to deflect shear forces over the protective lubricant. Additionally, the use of a product such as Friar’s Balsam can be used over a number of weeks to increase the toughness of the often soft skin where a blister may be forming.

                 4. Talk to your local podiatrist and find out if the use of off-loading devices or orthotics can be used to reduce the amount of pressure occurring at the spot of issue and therefore limiting the chances for re-blistering.

Callus or hyperkeratosis as the podiatry community refer to it, is also developed under shearing pressures which cause the skin to thicken as a protect measure. Often an area which has blistered and re-blistered on multiple occasions will begin to develop a keratotic layer of skin, however, if only small amounts of this pressure is placed at the site of callus build up then it may take a couple of weeks or months for this to occur.
Corns develop from increased shearing forces which are pin-pointed to a particular spot. This usually occurs as callus builds up and spirals into the health underlying skin causing pain and discomfort, which is regularly described as stepping on a stone. These issues can be alleviated in a number of ways depending on how and where the corns and callus are developing.

       a) Stay away from over the counter products such as corn pads as they can cause more pain than you previously had. Corns need to be removed and this is best done by a podiatrist with a scalpel and sterilized tools.

       b) Off-loading devices and orthotics can be successful in reducing the speed or severity of the corns and calluses which are building up.

       c) Regular podiatrist visits can keep you out of pain and will provide you with the best information to reduce corn and callous development.

The debate of whether to add or subtract to footwear when a person is suffering from repeated epidermal stress continues, and where to place those additions/what kind of additions seems to be the where the main argument stems from. It has been concluded that the use of additions to footwear or the foot itself can increase the chances of blistering, however, strategically placed and tested additions, before a major competition may have its place in management of these issues.

Until next time, thanks for reading

Jackson McCosker
Director /Chief Editor

High Ankle Sprains: Syndesmosis Injury


Syndesmosis injury is not a term you will hear very often, sometimes it may be labeled as a “high ankle sprain”, other times it may be completely misdiagnosed as a Peroneus longus tear or shin splints. The syndesmosis is a part of the human body which sits very deep anatomically and is aptly forgotten about due it merely being considered as connective tissue which lies between the fibula and tibia.
In this article we will investigate the syndesmosis as a structure, common injuries or movement patterns associated with the injury and treatment options available.

Ankle joint injuries account for 10-30% of all single sport injuries within the athletic population. The syndesmosis of the lower leg is a made up of four ligaments which overlapping architecture provide significant joint stability. As our knowledge about anatomy and pathological stresses increase we begin to understand where an initial injury may have coincided with a secondary injury or perhaps caused one; that is why in recent years syndesmotic injury prevalence has moved from between 1-18% of ankle injuries to between 17 – 74 % of all ankle sprains in young athletes. A lateral ankle sprain is commonly described as the moment in which a foot undergoes both excessive plantarflexion and inversion further information about lateral ankle sprains can be seen here: https://footnotesblogging.com/2014/06/11/ankle-sprains-lateral-ligaments-instability-and-rehabilitation/

Syndesmosis develops as a result of traumatic forces which give rise to the disruption of the distal tibiofibular joint articulation ending in syndesmotic rupture. These forces are commonly a result of rotational torque penetrating the syndesmotic complex of the fibular or a moment of bending and rotation with an increase in the axial load. The syndesmosis is believed to have a much longer recovery period than that of a lateral ankle sprain, with estimates being anywhere from 2-30x as long dependent on the severity. Sman, et al found that syndesmotic injury recovery was four times longer than that of a lateral ankle sprain of equivalent grading.

The ankle joint undergoes significant stress and loading during both daily and competitive activity with the equal of six times body weight being place through the joint. Failure of the ankle joint complex at any time has the potential to create instability and increase pain locally. The ligaments of the ankle joint are responsible for the stabilization of the syndesmosis by reducing lateral displacement of the fibula which is important given the unstable nature of the foot as it moves through the triplanar movement pattern from plantarflexion through to dorsiflexion.

Clinical tests in the identification of syndesmosis injury can be found below;
1. Localized tenderness if palpation of the anterior inferior tibio-fibular ligament.
2. Pain with passive ankle joint dorsiflexion due to the widening of the mortise, eliciting pain in the region.
3. External rotational stress test using rotation of the talus.
4. Squeezing the middle of the lower leg with the intention of compressing the fibular toward the tibia and noting pain or discomfort.
5. Talar transition test
6. Degree of motion of the fibular in the sagittal place relative to the tibia and eliciting pain.

Further observations include whether the patient is able to weight bear, discoloration or bruising in the area of the syndesmosis and a positive anterior draw test with the knee at 90 degrees flexion and a display of laxity inferring both ATFL and CFL rupture. The presence of the latter two observations is 98% sensitive and 94% specific of 84% of acute lateral ligament ruptures.

It is believed that most syndesmotic injuries are caused by the external rotation of the lower leg resulting in the widening of the mortise and separating the tibia and fibular causing a strain of the syndesmosis and initial disruption to the anterior inferior tibiofibular ligament. However there is no way of duplicating this mechanism to develop evidence. Additionally no significant correlation has been seen between the mechanism of action and the severity of the injury itself. When preparing to begin intervention it is important to detail the time lapse between completion of injury and the evaluation as this can affect the treatment choices. A simple classification as follows will suffice;

Acute (< 3 weeks)
Sub-Acute (3 weeks to 3 months)
Chronic (> 3 Months)

True evaluation of the syndesmosis requires three radiographical views; AP, lateral and mortise of the ankle in a weight bearing position to provide the best possible report of suspected injury. Additionally, in the case of more subtle injury a CT or MRI may be more appropriate dependent on the individual. Syndesmosis injury can be classified into three categories which may require different approaches in the management protocols.

Classification Description Managment
I No evidence of instability with partial tear of AITFL NSAIDs, Cryotherapy, Immobilisation (for comfort purposes) Assisted rehabilitation
II No or slight evidence of instability with tear of AITFL and partial tear of IOL Use of offloading boot 6-8 weeks and seek surgical opinion.
Followed by assisted rehabilitation
III Definite instability with complete tear of the syndesmotic ligaments Surgical intervention required (see surgery explanation below)

Surgical intervention is commonly required for the grade 3 syndesmosis injury and at times for a grade 2 injury also. The most commonly used surgical intervention is fixation about 30-40mm above the tibiofibular joint, which has been proven to be more advantageous over fixation 20-30mm or the 40-45mm marks. Additionally, if a patient is suspected of a syndesmosis injury and required to undergo a arthroscopy of the ankle joint it is possible for a definitive diagnosis to be made with the use of a 3mm cinematic probe. Furthermore, it is suggested that the patient receive post-operative CT scans due to the correlation with malreduction in the mortise and functional outcomes.

After surgery and a significant reduction in pain any biomechanical issues can be addressed as deemed necessary and lower limb weaknesses improved with a rehabilitation program suitable for the individual patient. Once again an example of a lateral ankle sprain program can be found here: https://footnotesblogging.com/2014/06/11/ankle-sprains-lateral-ligaments-instability-and-rehabilitation/
As you can see a few simple assessments can be completed to rightfully identify a syndesmosis injury before imaging is even complete. Treatment options can be kept primarily conservative for the most part and return to sport is much faster if the actual injury is identified early as opposed to misdiagnosis or flippant assumption of it being an “ankle sprain”.

Until next time, thanks for reading.

Jackson McCosker
Director /Chief Editor

References

Bible, J., Sivasubramaniam, P., Jahangir, J., Evan, J., & Mir, H. (2014). High – Energery Transsyndesmotic Ankle Fracture Dislocation – The Logsplitter Injury. Journal of Orthopaedic Trauma, 200 – 204.

Kellet, J. (2011). The Clinical Features of Ankle Syndesmosis Injuries: A General Review. Clinical Journal of Sports Medicine, 524 – 529.

Sagi, H., Shah, A., & Sanders, R. (2012). The Functional COnsequences of Syndesmotic Joint Malreduction at a Minimum 2 Year Follow-Up. Journal of Orthopaedic Trauma, 439 – 443.

Simmon, D., & Brukner, P. (2010). Sports Ankle Injuries: Assessment and Managment. Australian Family Physician, 18 – 22.

Sman, A., Hiller, C., Rae, K., Linklater, J., Black, D., & Refshauge, K. (2014). Prognosis of Ankle Syndesmosis Injury. Clinical Sciences, 671 – 677.

Thormuer, J., Leonard, J., & Hutchinson, M. (2015). Syndesmotic Injuries in Athletes. An International Perspective on Topic in Sports Medicine and Sports Injury, 423 – 456.

van Reijen, M., Vriend, I., Zuidema, V., van Mechelen, W., & Verhagen, E. (2014). The Implementation Effectiveness of the Strengthen Your Ankle Smart Phone Application for the Prevention of Ankle Sprains: Design of a Randomized Controlled Trial. BMC musculoskeletal Disorders, 1 – 8.

Verim, O., Serhan, M., Altinel, L., & Tasgetiren, S. (2014). Biomechanical Evaluation of Syndesmotic Screw Position: A Finite- Element Analysis. Journal of Orthotpaedic Trauma, 210 – 215.

Wagner, M., Beumer, A., & Swierstra, B. (2011). Chronic Instability of the Anterior Tibiofibular Syndesmosis of the Ankle. Athroscopic Findings and Results of Anatomical Reconstruction. BMC Musculoskeletal Disorders, 1-7.