LOWER LEG O VERU SE INJURIES IN HIGH SCHO O L FIRST TEAM SC H O O LG IR L H O CKEY PLAYERS Petrick M, Laubscher KF, Peters EM University o f Witwatersrand INTRODUCTION During the second half of 1989 the D ivi­ sion of Physical E d u cation of the W it­ w atersrand received com m unication from the G riq u a la n d -W e s t S ch o o ls H o ck e y Union (GW SH U), expressing their concern about the high incidence of "sh in splints" am ongst the hockey players during that season and requ esting an investigation into this matter. T h e A m e rica n M e d ica l A sso cia tio n defined "sh in sp lin ts" as a m usculoten­ dinous inflam m ation, in the absence of a stre s s fra c tu re o r is c h a e m ic d is o rd e r, m anifesting w ith "p ain and d iscom fort in the leg from repetitive running on a hard surface or forcible, excessive use of foot flex o rs"1. As low er leg pain can be caused by a spectrum of pathological conditions in the low er leg including stress fractures, c o m p a rtm e n t s y n d ro m e s and v a rio u s p re sen ta tio n s o f m u scu loten d in o u s in ­ flam m ation, the authors undertook a sur­ vey investigating the incidence o f hockey injuries w ith specific em phasis on these three form s of low er leg pain. In view of the contrasting environm en­ tal and training facto rs to w h ich high school players in the Southern Transvaal (ST) and Griqualand W est (GW) regions are exposed, it was decided to undertake a com parative study of the incidence and nature of low er leg injuries am ongst high school players in the hockey leagues in these two regions. The objective of this stud y w as tw o­ fold: firstly, to identify w hich of the lower leg overuse injury risk factors are most prevalent am ongst fem ale first team high school hockey players in the ST and GW r e g io n s a n d , s e c o n d ly , to e s t a b l is h w h eth er contrasting environm ental fac­ tors predispose players in the two regions to different injuries. METHOD Q uestionnaires w ere sent to the first team fem ale hockey players o f the top seven teams in the G W H igh School H oc­ key League (the experim ental group) and to the seven best hockey team s in the ST High School H ockey League (the control group) in 1990. The questionnaires elicited inform ation regarding history o f ortho­ paedic problem s, involvem ent in other sport, hockey training (eg. m ethods, pla­ ying surface, shoe w ear) and an injury profile. Players w ho reported having suffered from low er leg pain during the 1990 season w ere requested to provide further details w ith regard to footw ear pattern, shape of w et footprint, shoe types w orn w hen pla­ ying hockey and a description of the lower leg pain. In order to differentiate betw een the d iffe re n t lo w e r leg in ju rie s, those players w ho could localise a very tender spot and described focal pain on the shin bone w ere diagnosed as possessing a stress fracture1. Those that com plained of pins and needles and num bness and those that reported experiencing weakness of the leg w ere categorised into a group possibly p o s s e s s in g c o m p a r tm e n t s y n d r o m e , w hereas the rem ainder w ere, in keeping w ith the definition of the Am erican M edi­ cal Association, regarded as possessing shin splints. The use of the w ord "shin sp lints" in this paper is limited to the de­ finition provided by the Am erican M edical Association. Additional sports participated in by the first team hockey players w ere categorised into activities possessing a low or high risk for shin splints, depending on the m agni­ tude, frequency and duration of im pact loading w hich is characteristic o f each of the sports. The coaches o f each o f the teams also received a short questionnaire requesting d e ta ils re g a rd in g th eir co a ch in g tech ­ niques or protocols and w ere asked to keep an attendance register o f their players for both practices and matches. They w ere also asked to record any hockey injuries their players sustained during the 1990 hockey season. All questionnaires w ere com pleted during A ugust and Septem ber 1990. Statistical Analysis: For d iscrete v a ria b le s, g ro u p s w ere com pared using the chi-square test to ana­ lyse contingency tables w here the sam ple sizes and expected frequencies w ere ade­ quate. W here sam ple sizes and expected frequencies w ere too sm all, Fisher's exact test w as em ployed in the case of 2 x 2 tables. For continuous variables, groups w ere com pared using stud ent's t-test, tak­ ing into account w hether the variances of the groups w ere equal of not. W here ap­ propriate, the M an-W hitney test w as used. In all cases, the level of confidence was set at 0,05. RESULTS PLAYERS: Seventy five ST and 81 G W first team hockey players com pleted the p lay ers' q u estio n n aire. T heir m ean age w as 16 years. Seventy five players reported sus- 'ABSTRACT "n Questionnaires eliciting training histories and injury profiles were sent to the first team fem ale hockey players and coaches o f the top seven hockey schools in the G riqualand W est and Southern Transvaal high school leagues during the 1990 hockey season. During this season, 27,4% (n=43) of the players reported that they had experienced pain in the low er leg area. The findings o f this study sug­ gest that som e degree of pes planus may be a com m on problem and that the wearing o f hoc­ key boots m ay reduce the risk o f lower leg pain. A general lack of knowledge about low er leg overuse injuries and th e ir prevention was appar­ ent am ongst the players. The need fo r educa­ tion on these injuries and their prevention was identified and recom m endations fo r closer liai­ son between coaches and players w ere made. (Key Words: shin splints; hockey; high school girls) V_____________________________________/ ^OPSOMMING " Gedurende die 1990 Suid-A frikaanse hokkie- seisoen is vra e ly s te a a n g a a n d e oefe n g e s- kiedenis en beseringsprofiele aan die eerstes- pan hokkiespeelsters en afrigters van die sewe beste hokkiespanne in die hoerskole-hokkieliga van S uid-Transvaal en G riekwaland-W es ges- tuur. In bogenoem de seisoen het 27,4% (n=43) van die speelsters aangedui dat hulle pyn in die onderbeen ervaar het. Die bevindinge van hier- die navorsing dui daarop dat ’n m ate van pes planus ’n algemene probleem mag w ees en dat die dra van hokkieskoene die risiko van onder- beenpyn mag verm inder. Algemene onkunde aangaande oorgebruik-on- derbeen beserings en die voorkom s daarvan is by die speelsters gevind. Die behoefte aan op- laiding aangaande hierdie beserings en hulle voorkoming is gei'dentifiseer en voorstelle om beter kommunikasie tussen spelers en afrigters te bevorder, is gemaak.____________________ ^ ta in in g in ju r ie s d u r in g th e ir h o c k e y careers. O f the total sam ple (n=157), 43 (27,4% ) had experienced low er leg pain in the 1990 season, w hich excluded ankle in­ ju rie s and e xtrin sic in ju ries and direct trauma to the low er leg area. T h e d ia g n o s is and p re s e n ta tio n o f low er leg pain in these players is depicted in Figure 1 (page 57). In 34% (n=14) o f the players, shin splints w as diagnosed by a m edical p ractitioner. Fifty nine percent (n=26) of the players did n ot seek medical advice (Figure 1.1). A n terior low er leg w as by far the m ost com m on, w ith a total of 74% (n=32) of the players com plaining of pain in this anatom ical location (Figure 1.2). The percentage of players describing their low er leg pain as being on the shin bone, in the m uscles or in both areas is illustrated in Figure 1.3. Fifty six percent (n=24) of the players w ith low er leg pain reported "b u m p s" on Continued on page 57... R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) / ' COME TO AMERICA WE NEED QUALIFIED THERAPISTS I f you have a sincere interest in traveling to A m erica to practice Physiotherapy or O ccupat­ ional therapy, consider Maxwell/Healthcare In c for general options; • As an employee o f M axwell/Healthcare you will travel as a long term /short term locum therapist. * Be employed as a full time staff therapist by one of ou r client hospitals, rehab cent­ ers, sp ort medicine clinics. Maxwell/Healthcare Inc. has a proven history o f high professional standards. W e have the administrative s ta ff with strong healthcare backgrounds from Human R esource to H ealthcare Adm inistration - a desired quality when m atching the therapist to the preferred H ealthcare facility. M axwell/Healthcare is active in the Philip­ pines, A ustralia, New Zealand, Canada, E n g ­ land and Ireland. W e have the s ta ff and experi­ en ce to serve the needs o f the therapist as well as our client throughout the United States o f A m erica. IF YOU HAVE A SINCERE INTEREST AND WOULD I PRESIDENT AND V.P OF OPERATIONS OF MAXWEI MAXWELL/HEALTHCARE I N C O R P O R A T E D ' 8221 East 63rd Place, Tulsa, Oklahoma, U SA 74133 You will receive an excellen t salary and benefit package. In addition, all therapists w ill be con- tratually guaranteed: * Paid airfare to A m erica and place o f employ­ ment. * Paid housing, furniture and utilities for 60-90 days. * Travelling therapists receive paid housing and meal allowance for each assignm ent * Paid health / life insurance. * Paid professional liability coverage. * Paid immigration processing. * Paid state board review program s to prepare for national exams. Maxwell/Healthcare has representatives in the R epublic Of South A fric a to assist in all paper­ w ork and tim ely follow -through. A career in A m erica is not perfect - nothing is, but with the right start, it can be very rewarding. >IKE A PERSONAL INTERVIEW WITH THE X HEALTHCARE CONTACT: Palte & Associates Inc. Andrea Bernstein c/o P.O . B o x 3 7 0 0 2 Overport 4 0 6 7 R .S .A (0 3 1 ) 2 5 3 6 3 0 telephone ( 0 3 1 ) 2 9 7 0 7 2 fax R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) ..Continued from page 55 ANTERIOR ANO POSTERIOR 1.2 ANATOMICAL LOCATION OF REPORTED LOWER LEG PAIN Figure 1: Diagnosis and presentation of lower leg pain in schoolgirl hockey players the shin bone and 48% (n-20) could localise one very tender spot on the shin bone. Sw elling and tenseness o f the m uscles of the front of the low er leg w as experienced b y 59% (n=24) o f the sym p toma tic players, w hereas 40% (n-17) experienced a "p in s and need les" sensation or num bness asso­ ciated w ith the low er leg pain and 46% (n=19) had w eakness in the affected leg. % ( n = 3 6 ) Figure 2: Methods employed by hockey players to ease lower-leg pain W ith regard to the frequency and the duration of the low er leg pain, 88% (n=37) of the sym ptom atic players had experi­ enced the low er leg pain m ore than twice, 51% (n-21) reported that the pain lasted Phys. less than an hour, while 29% (n-12) experi­ enced the pain for a few hours or longer. The m ean duration of the pain w as ju st less than an hour. Thirty percent (n-11) w ere unsure about the cause of this pain. N ine­ teen percent (n-7) attributed the pain to "sh in sp lints" and 14% (n=5) suggested that the low er leg pain w as due to over­ exertion of the legs. Eleven percent (n=4) listed the type of surface played on as a m ajor etiological factor. W ith regard to the occurrence o f lower leg pain, 77% (n-33) of the sym ptom atic players reported that this pain w as associ­ ated w ith playing hockey. O f the total group of sym ptom atic players questioned, 36 (92%), how ever, reported pain while p la y in g h ock ey , w h ereas 30 (83% ) re­ ported that the pain persisted after the cessation of hockey play. Tw enty two players (58%) reported that ru n n in g m ad e the pain w o rse. Eleven (29%) described a w orsening o f pain with an increase in activity or over-exertion, w hereas two players (5%) m aintained that a quick change in direction w orsened the pain. The pain relief m odalities used by players are categorised in Figure 2. In ad­ dition, 33 (85%) o f the players continued w ith the activity w hen the pain started w hile five (13%) ceased the activity. The areas of the soles o f the hockey shoes most w orn w ere the m edial front parts o f the shoes (66% ; n=25 on both left and right), w hereas the lateral front parts o f the soles w ere w orn aw ay in 50% (n=19) on both left and right shoes. The m ost frequently oc­ curring shape o f a w et footprint for both the left and right foot identified first degree pes planus2 (Figure 3). W h e n c o m p a r in g th e ST an d G W players in our sam ple, no significant d if­ ference in the incidence o f low er leg pain w as found in the 1990 season (25,3% o f ST first team hockey players vs. 29,3% of the GW players had low er leg pain). O f the 157 players questioned, signifi­ cantly m ore players (p,05), w ho presented w ith lower leg pain (n=43), reported leg problem s (n=12) than those w ithout low er leg pain (n = l). Significantly m ore (p,05) players w ith low er leg pain also had knee p roblem s (25,6% ) than players w ithout low er leg pain (11%). O f the players with knee problem s, 47,8% also reported lower leg pain. No significant difference w as found in the num ber of sports participated in by players w ith and w ithout low er leg pain. Furtherm ore, no correlation w as found be­ tween participation in additional sports w ith low or high risk o f developing lower leg pain and the reported incidence of low er leg pain. In addition, no significant difference w as found in the incidence of low er leg pain betw een those w ho did not participate in other sports and those who did (p0,05). normal foot le ft: 3 2 % (n = 1 2 ) r ig h t : 32 % (n « 1 2 ) first degree second degree pes planus pes planus le ft: 4 2 % ( n s l 6 ) le f t : 2 6 % (n = 1 0 ) r ig h t : 4 0 % (n = 1 5 ) r ig h t : 2 8 % ( n = t t ) Figure 3: Various degress of pes planus A highly significant difference (p,01) w as found betw een the num ber o f players w ith low er leg pain w earing hockey boots (69,8% ) and the players w ithout low er leg pain w earing hockey boots (90,1% ). Signi­ ficantly (p,05) m ore players w ith low er leg p a in h a d h o c k e y i n ju r ie s (6 5 % ) th a n players w ithout low er leg pain (44% ). A significant difference (p,05) w as found in the num ber o f injuries per person, com par­ ing those w ith lo w er leg pain to those w ith ­ out. O f those that indicated no injuries, only 34,9% had low er leg pain. O f those indicating one injury, equal am ounts had low er leg pain (27,9% ) than did not have low er leg pain (29,8% ). O f the players that indicated two or m ore injuries, 37,2% had low er leg pain, w h ile 14% did n ot have low er leg pain. A significant difference w as found betw een the incid ence o f low er leg pain betw een those w ith no and one injuries and those w ith tw o to four injuries ( P , 0 1 ) . COACHES Tw elve coach es com pleted the q ues­ tionnaire. Eighty three percent (n=10) of the coaches had com pleted h ockey instruc­ tors courses and exam inations, w ith 55% (n-7) o f the coaches having had m ore than ten years of coaching experience and 83% (n-10) having played at provincial or inter­ national level. The coaches reported their players to have sustained a total o f 30 injuries in the 1990 season. The m ost com m on injury re­ ported by the coaches w as low er leg over­ use injury (n-13). T he m ost com m on injury reported by coaches in the ST w as "shin s p lin ts" or low er leg pain (62,8% o f the injured players), w hereas only 30,6% of the injured first team players of the G W w ere reported to have the above com plaint. DISCUSSION The concern about the high incidence of shin splints am ongst school girl hockey players in the G W area d uring the 1989 season, led us to expect a higher incidence continued on page 5 9... Mi,,.,.,, . a f i t R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) PHYSICAL AND OCCUPATIONAL THERAPISTS Hundreds of positions available immediately, in any state — Florida, Texas, New England. . . “M RI found us a wonderful job in a travel­ in g program. Our first assignment was in Las Vegas, N evada, then we were o f f t0 Rhode Island. We wanted to see the United States and get experience. Thanks to MRI, we are doing both. 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M a in S t., S u ite 2 0 2 , Fairfield , IA f o r p r e s e n t a t i o n d a t e s a n d t i m e s COKCC 11 C A C v ito ^OQ7 O f f i c e s in A u s t r a l i a , U . K . , H o l l a n d , P o l a n d , P h i l i p p i n e s , a n d U . S . A . ’ ’ ’ * * * ' ' R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) of low er leg overuse injuries am ongst the G W players w hen com pared to players in the ST. The difference w as how ever, not found to be sta tistically significant. D espite the high incidence o f "sh in sp lints" re­ ported am ongst high school players in G W d u rin g the 1989 seaso n , the in cid en ce d ro p p e d d u r in g th e 1 9 9 0 s e a s o n . A possible factor to w hich this could be at­ tributed is that greater aw areness of the risk factors o f low er leg injury am ong the hockey fraternity led to m ore precautions being taken. It is w ell docum ented that doing too much, too soon and too hard all play a role in the aetiology of these intrinsic low er leg inju ries1,3 as well as the frequent changes of direction and jarrin g on the low er leg w hich are com m on to the gam e o f hockey . Excessive strain on the tibia due to the pounding action o f prolonged running on a hard surface is know n to constitute a risk factor for stress fractures5'6'7. It is w hen the com pressive force associated with w eight bearing exceeds the structural strength of the bone that m icro-fractures o f bone re­ sult5,6. Com partm ent syndrom e may how ­ ever, arise follow ing extrinsic injury (a di­ rect blow to the shin) or due to intrinsic overuse inflam m ation in a tight com part­ m ent1. Sh in sp lin ts is m ost com m on ly caused b y excessive pronation o f the foot, w here tendinitis or periostitis develops from excessive rotational stress on the m uscles of the anterior tibial and deep pos­ terior co m p artm e n ts o f the low er leg, which control pronation8. It is in particular the pes planus foot w hich possesses hyper­ m obility in the subtalar jo in t and w hich is inclined to hyperpronate on landing and not supinate on take-off, that leads to shin splints ,8,6'3. H yperpronation may also be a result of inappropriate footw ear, too resi­ lie n t a p la y in g su rfa ce, im b alan ces in m uscle strength and flexibility and skeletal m alalignm ent. U neven terrain and hard lan d in g su rfa ces h av e b een associated w ith m usculotendinous inflam m ation in the anterior and deep posterior com part­ ments of the low er leg1' '6. M oore, em pha­ sises the fact that a com bination of insults on the m uscle-tendon unit may exceed the reparative capability of the m uscle-tendon unit, lead ing to ov eru se inju ries8. B io ­ m e ch a n ica l im b a la n ce s re su ltin g from skeletal m alalignm ent such as excessive fem oral anteversion, an increased Q-angle, external tibial torsion, valgus heels and tarsal coalition also predispose to intrinsic low er leg injury6. O ver-exertion w ithout p ro p er con d ition in g has also been d e­ scribed as playing a role in the aetiology of shin splints1,1 ,9 Backx11 et al states that the more one participates in sports, the higher the risk of injury but this w as not confirm ed by the findings o f this study. It w as, how ever, ...continued from page 57 found that the m ore injuries a player had su stained , the h igh er the likelihood of low er leg pain, due possibly to the fac t tha t, in com pensating for the injured part, ab­ n o rm a l b io m e c h a n ic a l fo rc e s m ay b e exerted on other anatom ical structures. In our study, the sym ptom atic players described a pattern of shoe wear that may indicate som e pronation of the feet. The w earing o f hockey boots also appears to reduce the risk o f lower leg overuse in­ ju ries, due to greater stability o f the floor. The studs on the soles increase the grip on the playing surface, thereby facilitating the quick changes in direction and stop-start actions necessary to hockey. The forces on the muscles of the lower leg are thus re­ duced during accelerating and decelera­ ting actions, thereby lessening the risk of shin splints. Hockey boots m ay also p ro­ vide som e shock absorption and reduce the pounding on the tibia. O f interest is the fact tha t all coaches in this study advocated the use of hockey boots. M ichael and H old er12 state that the so- leus inserts medially into the calcaneus and is therefore elongated w hen the heel pronates. A prolongation of the pronation time will therefore increase the eccentric loading of the soleus muscle, resulting in injury . Hockey players w ho pronate ex ­ cessively may therefore benefit from w ear­ ing orthotics14 or from w earing hockey boots. The low er leg pain associated with hoc­ key w as worsened by running, an increase in activity or over-exertion. R est helped to ease the pain in m ost cases. A ccording to M oore, shin splints pain is initially mild, develops during exercise and is eased by rest8. With continued exertion, pain p ro­ g ressively w orsens. The fact that m ost players with lower leg pain in our study did not cease the pain-provoking activity indicated a lack of aw areness of the im ­ portance o f preventing aggravation of an injury by either resting, reducing the in­ tensity of the pain-provoking activity or by correcting the etiological factors. G arrick et a!15 state that a history of prior orthopaedic problem s and the lack of in­ volvem ent in other fitness activities were more likely to cause aerobic dance injury than shoe brand or type of flooring. Our findings, how ever, clearly support the con­ tention that players w ith low er leg pain w ere more likely to have leg or knee prob­ lems than those w ithout low er leg pain. O f the players w ith knee problem s in this study, 47,8% also had lower leg pain. This may be indica tive o f a possible rela tionship betw een knee problem s and lower leg pain or, alternatively, the presence of a com m on factor, causing both knee and lower leg pain. It is well accepted that structural ab­ norm alities, w hen analysed biom echan- ically, can result in unbalanced forces on the soft tissue structures of the low er leg and m ay predispose to low er leg pain. Training errors play an im portant role in the ae tio lo g y of shin sp lin ts8. A s a w hole, the coach es w ere w ell qualified w ith extensive hockey coach ing experi­ ence. C oaching m ethods such as pre-sea­ son training o f shorter duration than the training in season and the em phasis on pre-season endurance training w ere ap­ plied. In addition, all coach es included a pre-season and in-season stretching p ro­ gram m e w hich w as executed b efore train­ ing and m atches, w hich is essential for the 16prevention o f injury . R epetitive concen­ tric m uscle contractions lead to muscle h ypertrophy and sh ortening 17. Therefore, as m uscles are stren g th en ed , they also need to be stretched regularly, in order to m aintain their length and flexibility17. The fact that players did not stretch after prac­ tices or m atches does give rise to concern, since this can lead to a h igh er risk o f over- • • 18 use injury . In a typical hockey practice, m ost time w as spent on stickw ork, follow ed by com ­ binations of sprinting and jo g gin g , and dribbling. It is, how ever, o f concern that players did not realise the im portance of b ecom ing fit for their sport b efore the sea­ son starts. U sing the actu al sp ort as a m eans of becom ing fit places the player at a high risk o f injury as a sudden demand w ill b e p la ced o n u n tra in e d m u scles. Lehm an1 states that there is a fine line betw een stress placed on the bod y produc­ ing the desired training effect and training that overstresses, cau sing injury. It is there­ fore advisable to start a grad ual fitness program m e before the h ockey season com ­ mences. In ord e r to p re v e n t inju ry, an ideal w arm up before a m atch should include jogging and stretching in addition to spe­ cific hockey techniques such as stickw ork. Jogging w ill increase the blood flow to the m uscles, and the w arm ed m uscle fibres can be stretched more effectively, thus p ro­ ducing a prolonged elongation effect. Spe­ cific hockey techniques also have a place in a w arm up as they will im prove the neuro­ muscular coord ination needed for the ac­ tivity to follow. The low num ber of players indicating the inclusion of stretching or jogging in their w arm up m ay be an indi­ cation that players w ere not aw are of the im portance of these elem ents in any w arm ­ up. The external environm ent a lso p la y s a role in the aetiology of shin splints ,6. Both team s played on grass surfaces m ost fre­ quently. The players from G W also play on soil m ore frequently than their ST counter­ parts. Poor shock absorption occurs when running on a hard surface and more of the im pact will b e exerted on the legs. Our findings did not how ever, show a signifi­ cant difference in the incidence o f lower leg continued on page 60... R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) injuries betw een the two regions in 1990. This m ay be due to m ore players in GW w earing hockey boots during the 1990 sea­ son. W hen com pared with the players, the coaches reported a m uch lower incidence of hockey injuries sustained in the 1990 season. O f the players, 43 (27%) alone indi­ cated a problem w ith low er leg pain in 1990,33 (22%) indicating that the low er leg pain w as associated w ith hockey. Accord­ ing to the co ach es, m ore ST than GW p la y e r s h ad lo w e r le g p a in o r "s h in sp lin ts" in the 1990 season. The coaches u n d erestim ated the n u m b er of players w ith low er leg pain and according to the inform ation gained from the players, no significant d ifference (p0,05) w as found in the incidence of low er leg pain betw een ST and GW in 1990. It thus appear to be a lack of aw areness by both the coach es and players of the in cid e n ce o f lo w e r leg o v e ru se in ju ry am ongst hockey players. CONCLUSION From the findings o f this study the fol­ low ing conclusions have been reached: • A com m on lack o f know ledge about overuse injuries, their cau se and their prevention w as evid ent am ongst the players. N ot all the players w ere able to recognise the on set of an overuse injury and players w ere unaw are o f the im ­ p ortance of m odifying their training and activity levels. The need for educa­ tion on overuse injuries m ust therefore be em phasised. • Players w ere not adequately aw are o f the im portance of * getting fit b efore the start o f the hoc­ key season, and * stretching after practices and m at­ ches as preventative measures. • The fact that the hockey coaches were not always aware of the injuries sus­ tained by their players as well as of their players exp erien cing low er leg pain gives rise to concern as this has im plica­ tions for the modifica tion of the training program m e and the consequent pro­ gression of the injury. Specific educa­ tion in sports injuries for coaches is needed and close liaison betw een the coach and player ought to be ad vo­ cated. The coach should not hesitate to recom m end the v isit to a d octor or physiotherapist should basic treatm ent measures not result in im provem ent of the injury. • Concerning rehabilitation after injury, most coaches realise the im portance o f p h y sio th e ra p y , b u t lack know led ge about the im portance o f strength train­ ing and proprioceptive exercises. ACKNOWLEDGEMENTS The authors are indebted to the follow ­ ing people for their assistance and would like to express their gratitude to Sandra Jordaan, Karen Rosen-A llan, H ester van Asw egen and Leigh Hale, the D epartm ent o f Biosta tistics of the CSIR, as well as all the participating coaches and players. Financial assistance for this project was p ro v id e d by the S n a a r V iljo e n g ran t, University of the W itw atersrand. REFERENCES 1. Briner W B. Shinsplints. A m erican Fam ily Physi­ cian 1988;37(2):155-159. 2. W ad sw orth H, C hanm ugam APP. Electro- p h y s ic a l a g e n ts in p h y sio th e ra p y . NSW : Science Press 1983:238. 3. N oakes TD , G ranger S. R unning Injuries. O x­ ford: O xford U niversity Press 1990:105-106. 4. V erow P. In juries in H ockey. The Practitioner 1989;233:612-616. IN MEMORIAM -W ILL IA M EDGAR GEORGE VAUGHAN (1920-1993) Born in Am m anford, W ales and trained at the Field and Morris S chool of Physiotherapy, Lon­ don. At the outbreak o f w ar Eddie volunteered as a physiotherapist in the RAF. He spent 6 years in the Middle East with the RAF achieving the rank of W arrant Officer 1st class the highest rank available to an allied medical professional who is not a doctor. At the end of hostilities he im m igrated to South Africa and worked at the Johannesburg General Hospital for some time before starting in private practice in Jeppe Street in 1949. He was the first physiotherapist to utilise spinal manipulation in practice and became a resounding success. Eddie was a great sportsm an, having played both cricket and rugby for the R AF and in later years cricket and golf fo r the W anderers Club. He was a founder m em ber of Nomad’s golf and was on the com m ittee of the National Football League. Professionally, he was C hairm an fo r many years of the Southern Transvaal branch of the SASP, was instrumental in founding the Private Practitioners Association of the Society and was its first Chairman. He was a driving force in organising the P P A to its present structure. With Pat Pilkington and Susie Oosthuizen he formed a formidable team which dealt with medical aid societies to set up tariff structures - much of which is still in use today. At the time of his death he was Honorary Life President of the PPA and attended the last Executive Committee meeting of the association in Bloemfontein. He had a very strong character and held definite views on the value of physiotherapy maintain­ ing that physiotherapists were grossly under­ paid for their skill and expertise. I am sure that all who knew him were sad to hear of his passing and will remember him with fond affection and respect for his enormous contribu­ tion to physiotherapy in South Africa. Our sym ­ pathies are extended to his wife, Jean and children, Gail and Anthony. 5. M atheson G O ct al. Stress fractures in athletes. T he A m e r ic a n J o u r n a l o f S p o r ts M e d ic in e 1987;15(l):46-57. 6. Paty JG. D iagnosis and treatm en t o f m u scu ­ loskeletal ru nning injuries. S em inars in A rth­ ritis an d R heum atism 1 9 8 8 ;18(l):48-60. 7. M e K eag DB, D olan C. O v eru se syn drom es of the low er extrem ity. Physiotherapy in Sport 1990;12(4):5-9. 8. M oore M. Sh insp lin ts - d iagnosis, m anage­ m e n t, p r e v e n t io n . P o stg ra d u a te M ed icin e 1988;83(1):199-210. 9. Reid DC. S ports Injury - A ssessm en t an d R eha­ bilitation. N ew York: C hu rchill Livingstone Inc. 1992:276. 10. Lehm an W L . O v eru se syn drom es in ru n­ n e r s . A m e r i c a n F a m i l y P h y s ic ia n 1984;29(1):157-161. 11. Backx FJG , Erich W M B et al. Sp orts injuries in sch ool-aged ch ild ren - A n ep idem iologic study. The A m erican Jou rn al o f Sports M edicine 1989;17(2):234-239. 12. M ichael R H and H o lder LE. T h e soleus sy n ­ drom e - A cau se o f m edial tibial stress (shin splints). The A m erican jo u rn a l o f Sports M e­ dicin e 1985;13(2):87-94. 13. V iitasalo J, K vist M. So m e b io m ech anical asp ects in the foot and ank le in athletes w ith and w ith ou t shin splints. T he A m erican jo u r ­ nal o f Sports M edicin e 1983;11(3):125-130. 14. Bates B, O stern ig L, M ason B. Foo t orthotic d evices to m od ify selected asp ects o f low er extrem ity bio m ech anics. A m erican jou rn al o f Sports M edicin e 1979;7(6):338-342. 15. G arrick JG , G illien DM, W hitesid e P. The ep id em iolog y o f aero bic d an ce injury. The A m e r i c a n j o u r n a l o f S p o r t s M e d i c in e 1 9 8 6 ;U ( l) :6 7 - 7 2 . 16. Peterson L, R enstrom P. Sport Injuries - Their prevention an d treatm ent. K enw y n: Ju ta and Co Ltd, 1986:16. 17. R oy S, Irv in R. Sports M ed icin e: P revention, E valuation, M an agem en t an d Evaluation. New Jersey : P rentice H all Inc., 1083:16-20. 18. N oakes T. Lore o f R unning. C ap e Tow n: O x­ ford U n iv ersity Press, 1990:381. WORLD CONFEDERATION FOR PHYSICAL THERAPY CONGRESS WASHINGTON, DC - JUNE 25 - 30 1995. The A m erican Physical T herapy A sso­ ciation is hosting the 1995 W CPT Congress to b e held Ju n e 2 5 -3 0 ,1 9 9 5 in W ashington, DC. A lthough it is still tw o years b efore the C ongress convenes, the O rganising Com ­ mittee is in the m idst o f p lanning a profes­ sionally stim ulating C ongress pre and post Congress courses and tours. We are planning to have various types o f presentations, so there w ill be som e­ thing o f educational interest for all m em ­ ber organisation participants. O f course, the social events will also be a highlight. For fu rther inform ation contact: Ruth W ood, PT, O rganising C h airm an, W CPT C o n g re ss R e g istrar, A m erican Physical Therapy A ssociation, 1111 N orth Fairfax Street, A lexand ria, Virginia 22314-1488, USA. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )