SOUTH A F R IC A N JO U R N A L OF SPORTS MEDICINE SPORTGENEESKUNDE JO U R N A L OF T H E S.A. SPORTS M E D ICIN E ASSOCIATION T Y D S K R IF VAN DIE S.A. SPORTGENEESKUNDE-VERENIGING N a tio n a l A dvisory B o ard E d ito r in C hief: ---------- V O L U M E 7________ N U M B ER 4 S E P T /O C T 1992 Clive Noble A ssociate E d ito rs: P ro f TD Noakes Dawie van Velden A dvisory B o ard : Traumatology: Etienne Hugo Physiotherapy: Joyce Morton Nutrition: Mieke Faber Biokinetics: Martin Schwellnuss Epidemiology: Derek Yach Radiology: Alan Scher Pharmacology: John Straughan Physical Education: Hannes Botha Internal Medicine: Francois Relief In te rn a tio n a l A dvisory B o ard Lyle J Micheli Associate Clinical Professor of Orthopaedic Surgery Boston, USA Chester R Kyle Research Director, Sports Equipment Research Associates California, USA P rof HC Wildor Hollmann Prasident des Deutschen Sportarztebundes Koln, West Germany Howard J Green Professor, Department of Kinesiology Ontario, Canada George A Brooks Professor, Department of Physical Education California, USA Neil F Gordon Director, Exercise Physiology Texas, USA Edmund R Burke Associate Professor, Biology Department, University of Colorado Colorado, USA Graham N Smith Physiologist Glasgow, Scotland CONTENTS R e p o rt fro m th e e d ito r Olympic Games - Barcelona 1992: Medical report and recom m endations.............................. 2 Soft tissue in ju ries Diagnosis and treatment o f long head o f biceps tendinitis in sportsmen - A Goldberg and CA S m i th ...................................................................... 6 Hockey Hockey injuries in high school first team schoolgirl players o f the Southern Transvaal and Griqualand West - M Petrick, KF Laubscher, EM Peters ....................................... 9 Phy sio th erap y Comrades Marathon 1992 - J M o r to n ............. 17 C rick et Cricket injuries o f the South African team at the World Cup and in the Caribbean: The physiotherapy perspective - Craig Smith ........ 20 JO U R N A L O F T H E SO UTH A FRICA N SPORTS M E D IC IN E ASSOCIA TION 2 6 9 W E S T A V E N U E H E N N O P S M E R E V E R W O E R D B U R G , 0 1 5 7 Photographs counesry o f the Image Bank T h e J o u rn a l o f the S A S p o rts M e d ic in e A s s o c ia lio n is p u b lis h e d b y M e d p h a r m P u b lic a tio n s , 3 rd F lo o r N o o d h u lp lig a C e n tre , 2 0 4 B H F V e rw o e r d D riv e , R a n d b u r g 2 1 9 4 . P O B o x 1 0 0 4 , C ra m e r- v i e w 2 0 6 0 . T e l: (0 1 1 ) 7 8 7 - 4 9 8 1 /9 . T h e v ie w s e x p re s s e d in th is p u b lic a tio n a re th o s e o f t h e a u th o rs a n d n o t n e c e s s a rily th o s e o f th e p u b lis h e rs . Primed by T he Natal Witness Priming and Publishing Company (Ply) Lid 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 2. ) REPORT FROM THE EDITOR OLYMPIC GAMES - BARCELONA 1992 MEDICAL REPORT AND RECOMMENDATIONS Clive N oble INTRODUCTION I was appointed to be Team Doctor by the President o f NOCSA, M r Sam Ramsamy on 24 June 1992, 26 days before departure to the Olympic Games. Recommendations The C h ie f Team D octor should be appointed a t the end o f the previous Olympic Games. It would be preferable f o r this doctor to have attended the previous Olympic Games as he would have a better understanding o f the structure and requirements o f the Olympic m edical team. The doctor should also become a member o f the International Olympic Medical Officers and attend their meetings. H e/She should aim f o r closer liaison with the African Group o f Olympic M edical Offi­ cers. H e/She should become a m ember o f the D oping Control Committee o f NOCSA and attend International meetings to increase knowledge. The C h ief Team D octor should help in the selection o f the rest o f the m edical team. I was the only doctor appointed and no physio­ therapist or masseurs were to accompany the team. The IO C is apparently going to prescribe m inim al standards on the size o f the medical team. In consultation with the Canadian M edical Team they advised that it was better to take physiotherapists who can do massage rather than pure masseurs. The President had arranged for the Australian physiotherapists to help with any injuries which may occur; they were adjacent to the S A team in the Olympic Village. I f the team is large enough, team doctors and physios should accompany the larger teams, e.g. soccer and athletics to their training and competition venues. A doctor/ physiotherapist should accompany any team which lives away fro m the Olympic Village. I f possible, a doctor should accompany the team f o r the more violent sports - boxing and wrestling. The reason for this small medical team was due to the fact that the late entrance o f the team to the Games had restricted the number o f persons involved in the Olympic Village and the Presi­ dent had, in my opinion, correctly decided to send more competitors than officials. The team consisted o f approximately 96 athletes and 24 officials. There were also 25 disadvan­ taged black sportsmen and officials who had FX accreditation and lived ± 100 km from Barce­ lona. They had the use o f the Olympic Village but could not sleep in the Village. There were approximately 25% black and coloured com­ petitors in the team. In order to increase the size and quality o f SPORTS MEDICINE - VOL. 7 NO. 4 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 2. ) REPORT FROM THE EDITOR the team, a massive restructuring programme o f sport in South Africa is needed. It is important to increase the num ber o f disadvantaged sportsmen in the team . To do this it is essential initially to work at the strengths o f these athletes. Therefore, sports such as athletics, soccer and boxing should be given priority. Adequate fa cilities are essential, e.g. Olympic tracks, gymnasiums and soccer fie ld s in all m ajor black areas. Coaches should be imported with the aim o f teaching our coaches but also helping to polish our distinguished athletes. More use o f sports science is essential. I was invited to participate in an investigative panel to assess the factors in Cheryl Roberts' stimulant drug taking case. Two major factors emerged: (a) the test was incorrectly done in that the question regarding the taking o f medication had not been asked and (b) the form was incor­ rectly planned. An Anti-Doping Committee should be re­ sponsible f o r educating both athletes and officials. It should also be responsible f o r a program m e o f random and routine testing to be carried out on all top athletes. The fo rm s and methods o f testing should be standardised and be brought up to inter­ national standards. P R E -G A M E A SSESSM E N T One week before departure, the team assembled at the Jan Smuts Sun Hotel. H ere they were tested for Banned Substances. Although the respective sports organisations were informed in M ay by means o f an IOC circular concerning banned substances, a number o f the Olympic competitors had taken banned substances. A ll athletes should be tested f o r drugs before departure as was done. They should be knowledgable as regards doping before­ hand. They were also forbidden from swimming in the sea because o f pollution and the danger o f gastro-intestinal infection. A f u l l investigation m ust be done into the site o f the next Olympics, i.e. Atlanta, as re­ gards temperature, humidity, altitude and any other fa cto rs that could affect the ath­ letes. This should be done as soon as possible so that training program m es can be m odified to improve performance, e.g. the marathon runners trained in the wrong conditions f o r Barcelona. A large p art o f their training should have been done in Barcelona or i f this was not possible running on a treadmill in correctly heated rooms with high humidity to improve acclimatisa­ tion. The athletes were apparently tested prior to this at the University o f Pretoria. These tests were for physical fitness. Sports Scientists should p la y a fundam ental role in preparing the team f o r Olympic competition. Careful monitoring o f the team is essential. Coaches should be taught m ore about the scientific assessment o f f i t ­ ness and should liaise closely with Sports Scientists. The team left on 20 July on a direct night flight from Johannesburg. The team travelled in Economy Class. D ay time flg ith s i f possible would be helpful to the athletes. An extra p erio d o f time should be made available f o r "jet la g ". For long flig h ts, e.g. Atlanta, 1 would recommend the use o f "sleeping p ills " f o r those who request them i f there is a night flight. The team arrived 5 'h days before the opening ceremony. A period o f acclimatisation and adaptation, as was done in Barcelona, is recommended. The team was advised that in Barcelona they O L Y M P IC A L V IL L A G E were not to drink tap water, even to clean their teeth with tap water, because o f the danger o f In the Olympic Village, there was an abundance infection. o f food'and water obtainable 24 hours a day. ------------ =---------------------------------------------------------------------- 3 SPORTGENEESKUNDE VOL. 7 NO. 4 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 2. ) REPORT FROM THE EDITOR Soft drinks were also readily available. Weight control, e.g. daily weighing is rec­ om m ended with suitable dietary restrictions in cases o f weight alteration. A thorough knowledge o f diet control and correct eating by a dietician is fu n d a ­ m ental to all coaches. This should be done through the individual unions but should be m onitored by NOCSA to assess that all sports associations comply. Until competitions began, training continued at venues in and around Barcelona. I f at all possible team and individual coaches should be given adequate accreditation in order to allow them to accompany the p a r­ ticipants to all venues and to the Olympic Village. These coaches should have (a) knowledge o f dietetics and (b) knowledge o f massage. One o f the teams rowing was not living in the Olympic Village and had no organised medical cover. Teams not living in the Village should have their own m edical team with them. Barcelona in July/A ugust has a high temperature and high humidity. A f u l l investigation must be done into the site o f the next Olympics, as discussed previ­ ously. MEDICAL A num ber o f athletes arrived at the Olympical Village with upper respiratory tract infections. Even on the plane, 3 competitors had to be treated for 'flu and two for nausea and vomit- ting. The basic medical requirements o f a team o f a sim ilar size should be a minimum o f 3 doctors: * a sports medicine specialist; • two general practitioners with sports medicine background; 4 ■ ■ -̂--------- SPORTS MEDICINE - VOL. 7 NO. 4 • three physiotherapists who would also do massage. Sixty two cases were treated in the 3 weeks I was with the team - 32 with injuries and 30 with illness. Seven cases were from the disad­ vantaged team and 6 cases were officials. Adequate medication to cover all m ajor and minor medical problems is necessary. Equip­ m ent to handle medical emergencies, e.g. heart attacks, should also be available. Only one case o f illness (L udw ig's Angina) from one o f the disadvantaged group required admission to hospital. The doctors m ust immediately assess the medical fa cilities available at the Olympic Village and sports venues. Nine cases were referred to the Australians for physiotherapy. Unfortunately massage was not available from the Australians as their masseurs were already overburdened with work. I therefore took over the role o f masseur and did 11 cases. The athletics teams brought in an American Chiro­ practor who did approximately 8 cases, most o f them from the Athletics team. The massage was not for medical treatment, but for the feeling o f general well-being that it gives. The swimming coach also gave massage to the swimmers. See recommendations f o r the basic medical requirements o f a team o f a sim ilar size, as discussed previously. MEDICAL COMMITTEES I attended: • The general meeting o f team doctors at the Olympic Village. This consisted o f an instruc­ tional talk covering all aspects o f medical treatment and drug testing at the Olympic Games. It is important that all m edical personnel attend all m edical meetings at the time o f the Olympic Games. This helps to keep abreast 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 2. ) REPORT FROM THE EDITOR o f the latest developments. • An instructional tour o f the Polyclinic in the Village as regards all its facilities. Polyclinic and drug testing tours are essential. • A tour o f the drug testing facility in Barcelona. • A meeting o f the International Olympic Medical Officers Association, under the Secre- tary-Generalship o f M ike Iraqui o f the United King­ dom. I was granted mem ber­ ship to this organisation whose aim is to increase knowledge o f Olympic Sports Medicine. Membership o f the IOMOA is important. • A meeting o f the African Olympic team doctors under the Chairmanship o f Prof. Constant Roux from the Ivory Coast. • A number o f meetings with the Australian and Canadian Medical Groups concerning the size and structure o f fu­ ture medical teams from South Africa. Closer liaison with the A f­ rican M edical Group is es­ sential in order to increase contact with our African colleagues. D r Clive Noble, MBBChB FCS (SA) Editor-in-Chief SUBSCRIPTION TO SPORTS MEDICINE Dear Doctor, The characteristic that distinguishes a professional from an educated person is the professional person's desire and responsibility to stay abreast o f the development o f his or her field o f expertise. The halflife o f our professional knowledge is about 3 years, and for this reason it is vitally important to continuously refresh and supplement our knowledge. Sports M edicine, the official mouthpiece o f the SA Sports Medicine Association, has over the years become a treasured source o f knowledge for the health care profes­ sional in the sports medicine arena. The journal features not only original research papers and articles by leading special­ ists in sports medicine, but also current news and relevant abstracts. 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J i___________________________________________________________________ i SPORTGENEESKUNDE VOL. 7 NO. 4 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 2. ) SOFT TISSUE INJURIES DIAGNOSIS AND TREATMENT OF LONG HEAD OF BICEPS TENDINITIS IN SPORTSMEN A Goldberg and C A Smith Key words: Soft tissue injury, long head o f biceps tendinitis, deep transverse frictio n s, rehabilitation programme. ABSTRACT Soft tissue injuries o f the shoulder jo in t in sportsmen are common. A condition that seems to be infrequently diagnosed by medical practitioners (yet well recognised by physiotherapists) is that o f long head o f biceps tendinitis. The signs knd symptoms for this extremely common condition are presented. Treatm ent is by deep transverse frictions (DTF) and response to treatm ent is uniform ly good. INTRODUCTION Soft tissue injuries o f the shoulder jo in t are common among both the sporting and non-sporting public. Such in­ juries in sportsmen are usually due to an overuse nature as in A Goldberg, BSc (Physiotherapy). Post graduate student, Department o f Anatomy and Cell Biology, UCT. CA Smith, BSc (Physiotherapy), BSc (Hons) Sports Science. UCT Sports Injuries Clinic. "throwers shoulder" o r "swim­ mers shoulder" but may also be due to sudden exertional force as in weight-lifting. The main soft tissue inju­ ries o f the shoulder affecting the sportsman are collectively grouped and generally known as the "rotator cuff impinge­ ment syndrome". This refers to a number o f clinical entities, the most common o f which is supraspinatus tendinitis, but also includes infraspinatus and subscapularis tendinitis. The well known "painful arc" sign is normally present (pain is experienced between 70 and 120 degrees when the arm is actively abducted') and the impingement sign may also be positive (passive flexion o f the arm to 90 degrees and then medial rotation o f the shoulder p ro d u c e s th e sy m p to m s). Continued impingement may lead to degeneration o f the rotator cuff tendons and pos­ sible rupture o f the cuff. H ow ever, injury to the shoulder is not only confined to the above structures but also commonly involves the long head o f biceps tendon. This structure is a common source o f shoulder pain in sportsmen, yet is often overlooked by clinicians. The reason for this is that the signs and symptoms associated with this lesion of­ ten match those o f rotator cuff injuries, and it has thus become fashionable to lump such inju­ ries under this diagnosis. This brief paper thus dis­ cusses the clinical condition o f long head o f biceps tendinitis with the intent o f bringing it to 6 --------------------------------------------------------------------------- SPORTS MEDICINE VOL. 7 NO. 4 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 2. ) SOFT TISSUE INJURIES the attention o f diagnostic cli­ nicians. ANATOMY The long head o f biceps tendon attaches superiorly to the su- praglenoid tubercle o f the scapula and lies within the cupsule o f the shoulder joint. It glides over the head o f the humerus and leaves the jo in t in the bicipital groove which is bordered by the greater and lesser tuberosities at the proxim al end o f the humerus. Above the humeral head, the c o r a c o - a c r o m ia l lig a m e n t forms an arch over the shoulder jo in t to joining the coracoid and acromion processes to each other. Underneath the acromion lies the sub-acromial bursa which lies over the supra- spinatus tendon and the intra- articular portion o f the long head o f biceps tendon. With abduction, elevation and exter­ nal rotation o f the arm , im ­ pingement o f these structures may occur. SIGNS AND SYMPTOMS Long head o f biceps tendinitis is known to occur in baseball pitchers, canoeists, swimmers, weight-lifters, javelin-throw - ers, golfers, volleyball and ten­ nis players and is thus recogni­ sed as the most common cause of anterior shoulder pain.2 Even so, this condition is seldom diagnosed by medical practi­ tioners when referring these patients for physiotherapy. The traditional diagnoses in­ clude impingement syndrome, painful arc syndrome and rota­ tor cu ff tendinitis which are uninform ative and non-specific regarding the injured structure. The reason for infrequent diagnoses o f this condition is unclear as it is well recognised by physiotherapists. The con­ dition may occur on its own or simultaneously with a supras- pinatus lesion, and thus pres­ ents with signs o f a painful arc and impingement syndrome. Biceps tendinitis may either present in the acute or chronic form. The acute patient nor­ mally complains o f pain in the shoulder caused by a specific action, such as baseball pitching o r spiking in volleyball, and may also have associated weakness when attempting to play. The patient with the chronic form may have the symptoms for some months, only seeking treatment when his pain becomes severe enough to limit his playing. The injury is often worse in the beginning o f the season becoming easier as the season progresses yet still remaining a chronic, nag­ ging ache whenever the patient plays. Several tests are available to the clinician to confirm the diagnosis. The most common ones are as follows: ^ Yergason’s test The affected arm is held with the elbow flexed at 90 degrees and against the chest. The patient is then told to rotate the arm out­ wards, bend the elbow and supinate the forearm while the exam iner resists these movements at the elbow and forearm. Downward traction must also be ap­ plied to the elbow. The exam iner palpates the bi­ ceps tendon in the bicipital groove in order to detect subluxation o f the tendon. Pain is reproduced by either subluxation o f the tendon o r due to the tendinitis injury itself. It must be stressed that Y ergason’s test is prim ar­ ily used to detect insta­ bility o f the tendon in the bicipital g ro o v e.1 J Impingement sign ^ The well documented im­ pingement sign may be present if either the supra- spinatus or biceps tendons are being pinched under the coraco-acrom ial arch during active flexion. Pain localised to the area o f the coraco-acrom ial arch is indicative o f impingement.1 In order to differentiate the tw o, the patient with biceps tendinitis will dem­ onstrate tenderness over the bicipital groove with palpation. 1 Resisted test Resisting elbow flexion may produce pain, but in order to clarify the affected structure, pain with resis­ ted supination o f the pronated forearm with the elbow flexed to 90 degrees would positively indicate biceps tendinitis. Crepitus may be felt if there is tenosynovitis o f the tendon in the groove. I f the above tests are negative, one should not rule out the diagnosis. In chronic cases, palpation may be the only posi­ tive sign which can be elicited. Tenderness should be sought along the length o f the tendon -------------------------------------------------------------------------------- — 7 SPORTSGENEESKUNDE VOL. 7 NO. 4 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 2. ) SOFT TISSUE INJURIES from the bicipital groove to the proxim al portion o f the muscle. The m id-part o f the tendon is usually at fault.3 T R E A T M E N T Treatm ent o f biceps tendinitis is by way o f D TF o f twenty minutes duration on alternative days3 or 5 to 10 minutes dura­ tion on consecutive days. The bicipital groove is easily pal­ pated with the arm in some degree o f external rotation.4 This is also the position recom- mbnded for perform ing D TF. The D TF act by breaking down the adhesions within the ten­ don and its sheath similarly as it does for muscle injuries.5 Other physiotherapeutic mo­ dalities which can be used in­ clude ultrasound and laser therapy. Steroid infiltration is not required as full recovery is to be expected if the correct site(s) is treated effectively with frictions. Usually three to four sessions suffice although chronic cases may require up to eight treatments until complete recovery is achieved. A rehabilitation program m e in v o lv in g stre tch in g and strengthening must also be in­ corporated once the acute phase is over. Stretching the tendon must be done before and after exercise with the arm in 90 degrees o f shoulder abduction and external rotation, with the forearm pronated and the el­ bow extended. The shoulder is then extended and slightly more o r less abduction can be applied to get the best stretch. The patient can also be taught to stretch the tendon by holding the arm out in this position but having the hand and wrist sup­ ported against a wall or door frame. The body is then used to apply further stretch to the ten­ don. The double handed method with the uninjured arm used to help stretch the tendon in extension behind the back is also useful. The patient must then be given resisted exercises to strengthen the muscle and tendon, especially in the posi­ tion which stresses the tendon most, i.e. full shoulder eleva­ tion for volleyball players and abduction, external rotation and extension for baseball pitchers. These activities need to be slowly retrained in order to completely rehabilitate the patient. C O N C L U S IO N Tendinitis o f the long head o f biceps is a common cause of shoulder pain yet is infrequently diagnosed by referring medical practitioners. The signs o f pathology are a positive Yer­ gason’s test while a positive impingement sign with tender­ ness localised over the bicipital groove provide extra confirm a­ tion o f the diagnosis. Treat­ ment is normally by way o f DTF applied to the affected area. Recovery is good in most, if not all cases. C A SE R E P O R T A young male, aged 23 years and a keen sportsman, repor­ ted for treatment for his right shoulder which he injured while playing baseball. A recurring injury which had troubled him at the beginning o f the previous two seasons, it hurt him most when he pitched the ball. When he presented for treatment, the pain had been present for two weeks and had progressed to the point where he could no longer pitch the ball without severe shoulder pain. He had recently begun a weights pro­ gram m e and felt that this could also have contributed towards the injury. On examination o f his shoulder, he had full range o f active and passive movements, the pain only being elicited at the end o f range o f lateral rota­ tion and elevation through abduction. He experienced dif­ fuse release pain in the shoul­ der when resisting abduction in the neutral position. All other resisted tests were pain free. Palpation o f the should did not produce a specific site o f pain although there was some ten­ derness in the region o f the long head o f biceps tendon. The differential diagnoses con­ sidered w ere sub-acrom ial bursitis and biceps tendinitis. H e was initially treated for the bursitis for two sessions with laser, ultrasound, inter­ ferential and m obilisation therapy, which had little last­ ing effect as he still had pain when pitching the ball. Reas­ sessing the shoulder, it was decided to treat the biceps ten­ don as this reproduced the pain most clearly with palpation and had since become painful when resisting elbow flexion. The treatm ent was thus changed to D TF o f the tendon in the bicipi­ tal groove with ultrasound and laser therapy. Following a fur­ ther two sessions he could p itc h p a in f r e e and w as summarily discharged from treatment. References on request. 8 ---------------------------------------------------------------------------- SPORTS MEDICINE VOL. 7 NO. 4 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 2. ) HOCKEY HOCKEY INJURIES IN HIGH SCHOOL FIRST TEAM SCHOOLGIRL PLAYERS OF THE SOUTHERN TRANSVAAL AND GRIQUALAND WEST M Petrick, KF Laubscher, EM Peters I Key words: Running head, hockey injury in high school first team players. ! Abstract ;. Questionnaires were sent to the first team players and coaches of the seven best hockey schools | in the Griqualand West and Southern Transvaal regions during the 1990 South African | Schools hockey season. Fifty percent of the players (n = 157) had sustained injuries as a re- | suit of hockey during their hockey careers. The most prevalent injuries were ankle injuries ; (27%), knee injuries (15%) and lower leg overuse injuries (8,5%). I f : Of all the injuries sustained during their hockey careers, in Southern Transvaal knee inju- i ries were the most common (19,6%), followed by ankle injuries (17,9%) and injuries to the face and head (8,9%). Ankle injuries were the most common in Griqualand West (33,3%), followed by overuse injuries of the lower leg (12%) and knee (10,7%) and thigh muscle (8%) injuries. Although the coaches were well-trained and took precautions attempting to prevent the ! development of overuse injuries in their players, a discrepancy existed between the injuries ; reported by the coaches and players. The coaches report a much lower incidence of injuries i amongst their players in the 1990 season than the players do. I M Petrick, BSc (Physiotherapy). Department o f Physiotherapy, University o f the Witwatersrand, Johannesburg. KF Laubscher, BSc (Physiother­ apy)- Division o f Physical Education, University o f the Witwatersrand, Johannesburg. EM Peters, MSc (Med). Division o f Physical Education, University o f the Witwatersrand, Johannesburg. INTRODUCTION In a study reported by Van Heerden (1 9 9 1)1 an injury rate o f 4,8% was found amongst prim ary school girl hockey players during a two week hockey competition. Four of the five recorded injuries oc­ curred due to high velocity impact, while one player sus­ tained a calf muscle tear. However, little is available on common hockey injuries am on­ gst adolescent and adult hockey players. In a preliminary study undertaken by Klemp and Jor- daan (1989)2 it was found that shin splints was highly preva­ lent among a select group of high school hockey players. This prompted the authors to undertake a broader survey of the incidence o f hockey inju­ ries am ongst female hockey players in South Africa. The objective o f this study therefore was to obtain a pre­ liminary profile o f injuries which are prevalent in first team female hockey players at high school hockey level in the Southern Transvaal and G ri­ qualand W est regions. ----------------------------------------------------------------------------------- 9 SPORTGENEESKUNDE VOL. 7 NO. 4 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 2. ) HOCKEY T able 1: Players' problems with feet, knees, back, legs and hips PR O BL E M A REA D ESC R IPT IO N IN CIDENC E n* % Feet Flat feet Painful feel, foot cram ps, plantar 11 7 fasciitis, callouses, blisters 13 9 Total 24 16 K nees Painful knee 13 9 W eak knee 3 2 O ther 5 3 Total 21 14 B ack L ow back pain 9 6 T orn back m uscles/back injury 3 2 O ther 6 4 Total 18 12 L eg s Shin splints/com partm ent syndrom e 5 3 W eak/injured ankles 3 2 T ight ham strings 16 10 M uscle soreness after playing 5 3 Total 29 18 H ip Painful/clicking hip 2 1 Total 2 1 * n = n u m b er o f players METHOD Questionnaires were sent to the first team hockey players o f the top seven schools o f both Gri- qualand W est and Southern Transvaal Schools’ Hockey League (n = 157). The ques­ tionnaires sought information on aspects such as a history o f orthopaedic problems, involve­ ment in other sports, hockey training (including training methods, playing surfaces, shoe wear) and a hockey injury pro­ file. The coaches o f each o f the teams (n = 12) also received a questionnaire requesting details regarding their coaching tech­ niques or programmes and were asked to keep an attendance register o f their players for both practices and matches. They were also asked to record any hockey injuries their players sustained during the 1990 hockey season. All question­ naires were completed during August and September 1990. Statistical analysis F o r discrete variables, groups were compared using the chi- square test to analyse contin­ gency tables where the samples sizes and expected frequencies were adequate. W here sample sizes and expected frequencies were too small, F ish er’s exact test was employed in the case o f 2 x 2 tables. For continuous variables, groups were compared using either Student’s t-test, taking into account whether the vari­ ances o f the groups were equal or not. W here appropriate, the M ann-W hitney test was used. In all cases, the level o f confi­ dence was set at 0,05. RESULTS Players Seventy five Southern Transvaal and 81 Griqualand W est first team hockey players completed the players’ questionnaire. The mean age was 16 ( + 1,06) years. These players were healthy, active individuals, most o f whom (93%) participated in other sports apart from hockey. Their level o f hockey partici­ pation was high, with 45% playing at a provincial level and 40% playing club hockey. The players had been mem­ bers o f the first school hockey team for a mean duration o f 1,8 ( ± 1,08) years. Details o f problems the pla­ yers experienced with their feet, knees, backs, legs and hips are given in Table 1. From this it is apparent that tight hamstrings, painful knees and feet were the most commonly found ailments. The players participated in a total o f 22 different types o f sport apart from hockey. O f the sum m er sports, swimming was the most popular (27%). Tennis was the next popular (16,6% ), followed by jogging (10,6% ), squash (10,6% ) and athletics (10,6% ). O f the win­ ter sports, jogging was the most popular (18% ), followed by tennis (15,5% ) and squash (12,9% ). The majority o f players 10 ------------------------------------------------------------------------------- SPORTS MEDICINE - VOL. 7 NO. 4 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 2. ) HOOKEY Table 2: Activities included in a hockey practice A ctivity % P la y e rs D u ra tio n (m inutes) Sprinting 82 5 Jogg ing 92 10 A com bination o f sprinting and jo g g in g 97 15 S tickw ork 97 20 D ribbling 96 15 S tretching 97 before training 10 after training 5 O th e r a ctiv ities m e n tio n e d by p la y e rs H ockey techniques 29 15 P ractice matches 27 15 G am e tactics 21 15 G oal shooting 15 10 Table 3: Club and indoor participation in the Southern Transvaal (n = 75) and Griqualand West (n = 82) % P la y in g c lu b hockey % P la y in g in d o o r hockey At school At a club ST SW ST GW ST GW 47,3 31,7 67,6 46,2 19,7 36 ST = Southern T ran sv aal GW = G riqualand W est (62%) played hockey more than three times a week and a typical practice session was considered to be longer than 60 minutes by 73% o f the sample while 82 % o f the players con­ sidered a typical match to be 30 minutes or less each way. Ac­ tivities included in a hockey practice and the mean time spent on each are listed in Table 2. All the respondents reported warming up before a hockey match and acknowledged the necessity of a warm up. The pre-season fitness level appeared not to matter greatly to the players, as 11 % reported never getting fit before a season, 56% sometimes getting fit and only 33% always getting fit before the hockey season started. The mean time spent w ar­ ming up before a match was 20 minutes. This included stretch­ ing (36,5 % o f players mention­ ing this), followed by hockey techniques involving stickwork (26,6% ). Jogging was men­ tioned by 23,6% o f the players, while 11,9% mentioned sprint­ ing o r a jog-sprint combination as part o f the warm-up. The shoes most frequently worn for playing hockey were hockey boots (85% ). Other shoes worn included "tackies" (6 %), j ogging shoes (12 %) and shoes with arch supports (11%). Seventy three percent o f the players wore the same shoes for practices and matches. Tw enty percent wore "tackies" for the practices and hockey boots for matches. Hockey was most frequently played on grass (97% ). O ther surfaces sometimes played on included synthetic surfaces and soil. Fifty percent o f the players had sustained injuries as a re­ sult o f hockey during their hockey careers. The total number o f injuries recorded was 130, 75 (58%) o f which oc­ curred in the 1990 hockey sea­ son. The most frequent injury was an ankle injury (27% ), fol­ lowed by 15 % o f knee injuries and 8,5% o f low er leg pain. Facial injuries were reported by 7,6% and quadriceps inju­ ries by 7% . O ther injuries mentioned included back inju­ ries (5% ), thumb and finger injuries (4% ), whilst shoulder and foot injuries each totalled 3%. When com paring Southern Transvaal and Griqualand West first team hockey players, it was evident that significantly m ore first team Southern Transvaal school hockey play­ ers played club hockey than G riq u a la n d W est p lay ers (p = 0,048) (Table 3). F ur­ ther, more Southern Transvaal than Griqualand W est players played indoor hockey at school (p = 0,008), whereas more Griqualand West players played indoor hockey at a club (p = 0,028). Both groups o f players started training before the start o f the season. The differences in time spent on activities during a hockey practice are given in Table 4. Before a hockey match, G ri­ qualand W est warm up for longer (25 min) than Southern Transvaal (20 min) (p = 0,027). No significant difference was found in the activities o f the Continued on pg 14 ----------------------------------------------------------------------------------- 11 SPORTGENEESKUNDE VOL. 7 NO. 4 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 2. ) [S3) R elifen 500 tablets 500 mg n ab u m eto n e. Reg no R / 3 . 1/265 W h e n y o u r p a t i e n t ’s in p a in , y o u r first r e s p o n s ib ility is t o t a k e a w a y t h a t pa in. Q u i c k l y . Effectively. B u t d o in g so could lead to unacceptable g a stro­ intestinal side effects a n d c o m b i n a t i o n th e r a p y . B u t n o w , ten ye a rs o f p rec is ely targ e te d m o le c u la r rese a rc h have p r o d u c e d a h i g h ly effective, n o n - a c i d ic a n t i - i n f l a m m a t o r y . Relifen. E a c h tab le t is m a d e o f 500 m g n a b u m e t o n e , a n o n - s t e r o i d a l a n t i - i n f l a m m a t o r y , p r o v e n in n u m e r o u s d o u b l e b lin d s tu d ie s to be as effective as o t h e r b e n c h m a r k N S A I D s . Yet its r o u t e o f a c tio n is t o ta lly different. Relifen is a n o n - a c i d ic p r o - d r u g . In the s t o m a c h , it is relatively inactive. I t is a b s o r b e d f r o m t h e d u o d e n u m , i n to t h e p o r ta l b l o o d s u p p ly . Fina lly, in t h e liver, it is m e t a b o li s e d in to a p o t e n t i n h i b i t o r o f p r o s t a g l a n d i n synthesis. R e f e r p a c k a g e i n s e r t f o r f u l l p r e s c r i b i n g i n f o r m a t i o n . F u r t h e r i n f o r m a t i o n is a v a i l a b l e f r o m o u r M e d i c a l D e p a r t m e n t . S m i t h K l i n e B e e c h a m P h a r m a c e u t i c a l s P O B o x 3 4 7 B c r g v l e i 2 0 ^ * 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 2. ) Relieving his pain is pretty sporting of you, old chap. But do you have to get him high on acid? i rT '' * T h e active m e t a b o li te p e n e tr a t e s t h e s y n o v ia l fluid to reach t h e in fla m e d site, giving effective relief °f s y m p t o m s . E x c r e t io n is b y t h e k id n e y s , so g a s tr o - ‘ntestinal d a m a g e t h r o u g h biliary re c irc u l a t i o n a n d reflux is unlikely. F o r effective relief f r o m pain and inflam m ation, with less c h a n c e o f g a s tr o - i n t e s t in a l d i s c o m f o r t , y o u now have an ideal c hoice. Relifen. ^clifen an d th e S B lo g o a re tra d e m a rk s . O G IL V Y & M A T H E R , R IG H T F O R D S E A R L E -T R IP P & M A K IN 5 4 9 8 1 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 2. ) HOCKEY Table 4: Differences in time spent on activities during a hockey practice A ctivity S o u th e r n T ra n s v a a l G riq u a la n d W est p -v alu e D ribbling 20 min. * 10 min. 0,000 Stretching (before training) m ean tim e = 5-10 min. distribution = 0 - > 1 5 min. mean tim e = 5-10 min. distribution = 0 - 1 5 mi n 0,013 Stretching (after training) < 5 min. > 5 min. 0,023 * m in. = m inutes Table 5: Differences in injury patterns between Southern Transvaal and Griqualand West I n ju r y S o u th e r n T ra n s v a a l G riq u a la n d W est Incidence Incidence n* % n* % K nee injuries 11 19,6 8 10,7 A nkle injuries 10 17,9 25 33,3 Injuries to face and head 5 8,9 5 6,7 T high m uscle injury 3 5,4 6 8 L o w er leg overuse 2 3 ,6 9 12 injuries O th er injuries ** 25 4 4,6 53 29,3 n = num ber o f players T h e category "other in ju ries” com prises 21 additional types o f injuries, each having been sustained by a sm all num ber o f players. players included in their warm up. A significant difference (p = 0,005) was found in the type o f shoes worn for hockey. Jogging shoes were worn by 4% o f the Southern Transvaal players, while 19% o f the G ri­ qualand West players wore them. Significantly more South­ ern Transvaal players (95%) wore hockey boots when com ­ pared to Griqualand West pla­ yers (75%) (p = 0,001). South­ ern Transvaal players appeared to have played hockey on synthetic surfaces m ore fre­ quently than Griqualand West players. Forty percent o f Southern Transvaal players and only 25 % o f Griqualand West played on synthetic surfaces (p = 0,044). The Griqualand W est play­ ers played more frequently on soil than Southern Transvaal. Only 13% o f the Southern Transvaal players played on soil, while 50% o f the Griqua­ land West players played on soil (p = 0,000). However, when players were asked to list all injuries ever sustained during previous hockey seasons, including 1990, no significant differences were found in the number o f injuries per injured player. There was a difference in the injury pat­ tern between Southern Trans­ vaal and Griqualand West (Table 5). Both groups o f hockey players recorded the highest amount o f injuries for the first 6 months o f that cur­ rent year (1990), followed by 1989 and the second half o f the year 1990 up to the date o f completion o f the questionnaire. No significant difference was found between Southern Trans­ vaal and Griqualand West in the incidence o f lower leg over­ use injuries in the 1990 hockey season (25,33% o f Southern Transvaal vs. 29,27% o f Gri­ qualand West players). Coaches Tw elve choaches, two o f which were male and equally repre­ senting the Southern Transvaal and Griqualand W est, com ­ pleted the questionnaire. Eighty three percent o f the coaches had completed hockey instruc­ to rs’ courses and examinations, with 55 % o f the coaches hav­ ing had more than 10 years o f coaching experience and 83% having played at provincial or international level. All coaches reported inclu­ ding pre-season training in the hockey training program m e o f their players. In all cases this pre-season programme included stickwork and stretching, while most (75% , n = 9) included combinations o f sprinting and jogging. The mean frequency o f re­ ported pre-season training was twice a week, increasing to twice or three times a week during the season. Pre-season prac­ tice sessions mostly lasted between 45-60 minutes while sessions increased to 60-90 minutes during the season. The main differences in the 14 ------------------------------------------------------------------------------- SPORTS MEDICINE - VOL. 7 NO. 4 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 2. ) HOCKEY program m es before and during the season were that endurance training was allocated 10-15 minutes pre-season while only given 10 minutes in season. Stickword received more at­ tention in the season (20 min­ utes per session) than in the pre-season period (15-20 min­ utes a session). All coaches emphasised a stretching pro­ gram m e and taught their play­ ers to stretch before training and matches. The coaches, how­ ever, maintained that most players did not stretch after training o r matches. The coaches expressed the opinion that it was necessary for the players to wear hockey boots and reported that both practices and matches were gen­ erally played on grass surfaces. According to the reports o f the coaches, 30 injuries were sustained as a result o f which a total o f 67 practices and 22 matches were missed during the 1990 hockey season. The most frequent injuries reported by the coaches in the 1990 sea­ son were lower leg overuse injuries (13 players = 43% ), followed by the knee (6 players = 20%) and ankle injuries (5 players = 17%). Two players had lower back problems while one -player each had a wrist, hip, nose or thumb in­ ju ry . Hockey practices were mostly missed due to knee in­ juries, followed by lower leg overuse injuries and ankle inju­ ries. M atches were mostly missed due to knee injuries and lower leg overuse injuries. Only 54% o f the coaches (n = 12) emphasised strapping after injury, while 64 % were in favour o f physiotherapy. Most did not emphasise strength training and proprioceptive ex­ ercises. Other post injury reha­ bilitation measures mentioned by the coaches were cool-down stretches after practices or matches, rest, and rubbing in some ointment. DISCUSSION The most significant finding o f this study was that half o f the players had sustained injuries as a result o f hockey ever since they had started playing the sport. This can be considered a high injury rate and the need for education on hockey inju­ ries is self-evident. A further important finding o f this study was that ankle, knee and lower leg overuse injuries were the most com ­ monly reported by the players (n = 157). This correlates with the most commonly found run­ ning injuries which are o f the ankle and knee.3'5 From the findings o f this study it would thus appear that education will have to be geared towards these injuries and their aetiology. Firstly, the high incidence o f ankle injuries can be attri­ buted to the sudden stop-start actions and changes o f direc­ tion needed in hockey which place strain on the ankle liga­ ments. According to Verow6 the use o f shoes with studs on artificial surfaces increases the instability o f the ankle and therefore the risk o f ankle inju­ ries. When wearing hockey boots while playing on grass, the foot may move inside the shoe for any twisting move­ ment since the shoe is anchored on the ground. More ankle injuries occurred amongst the Griqualand West players when compared to the Southern Transvaal players. This could be due to their harder playing surfaces and the greater length o f time the Gri­ qualand W est players spent on soil. In addition, the fact that the Griqualand West players did not wear hockey boots to the same extent as the Southern Transvaal players could have placed the Griqualand West players at a higher risk o f ankle injury. The hockey boot has greater mobility on soil than on an artificial surface or grass, leading to less strain on the ankle. This explains the differ­ ence in our findings, when compared to those o f V erow .6 Secondly, knee ligament injuries may result from a rotatory force on a flexed knee, which can occur due to quick changes o f direction or a knock on the flexed knee. Wearing studded shoes, more movement will occur at the knee during quick changes o f direction since the shoe cannot move on the playing surface. Sustained positions o f knee flexion such as required in hockey, pose much strain on the patello- femoral jo in t and may give rise to anterior knee pain. The greater incidence o f knee injuries am ongst Southern Transvaal players may thus be attributed to the fact that South­ ern Transvaal players wear hockey boots m ore frequently. Thirdly, although direct blows to the shin occur in hockey, doing too much, too soon and too hard all play a role in the incidence o f intrinsic or overuse injuries o f the lower leg7 among hockey players. The frequent changes o f direction and jarring on the lower leg also increase the risk o f overuse injuries. ----------------------------------------------------------------------------------- 15 SPORTGENEESKUNDE VOL. 7 NO. 4 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 2. ) HOCKEY When recording all injuries sustained during their hockey careers, more Griqualand West than Southern Transvaal players indicated lower leg overuse injuries. The hard ground in the Griqualand West region and the fact that the Griqualand West players play more often on soil than their Southern Transvaal counterparts, may have increased their risk o f low er leg overuse injuries. In addition to these major sets o f aetiological factors re­ sulting in injuries o f the ankle, knee and lower leg in hockey, Verow6associates injuries with playing position. He reports that injuries found in goal­ keepers included direct trauma from sticks and the ball, head injury, loss o f a testicle, rotator cuff strain (d.t. falling on the outstretched hand), olecranon and trochanteric bursitis from landing on these parts. On the other hand, outfield -p lay ers were reported having suffered lacerations around the head, muscle injuries and strains to the lower back and upper leg areas due to running or twisting in a stooped position. Further, he points out that synthetic surfaces give rise to more grazes and the use o f studs on these surfaces increases the instabil­ ity o f the ankle. As a whole, the coaches were well qualified and had extensive hockey coaching experience. Coaching methods such as pre­ season training o f shorter dura­ tion than the training in season and the emphasis on pre-season endurance training tend to re­ duce the risk o f overuse injury. However, it is o f concern that the coaches mentioned the fact that hockey players do not appreciate the importance o f post-m atch/practice stretch­ ing. The introduction o f greater emphasis on this aspect o f in­ ju ry prevention is thus advo­ cated in the training o f hockey players and their coaches. The unanimous opinion ex­ pressed by the coaches that players should wear special hockey shoes is o f interest. This observation is in keeping with the rationale that hockey boots facilitate the quick change o f direction and acceleration and deceleration which are com ­ mon in the game o f hockey and thereby reduce the stress on the lower leg muscles with con­ comitant reduction in muscle injuries o f the lower leg, par­ ticularly when, as reported, this is prim arily being played on grass. The coaches report a much lower incidence o f injuries amongst their players in the 1990 season than the players do (coaches report a total o f 30 and players a total o f 75 inju­ ries). It therefore appears that coaches are not always aware o f the inj uries sustained by their players and are therefore not in the position to make the necessary modifications to the training programmes o f these players. This may lead to a worsening o f existing injuries. In order to prevent injuries and to aid rapid recovery from injuries, it is essential that there should be good communication between players and coaches. Coaches need to be aware o f their players’ injuries in order to modify their training pro­ grammes or to be able to advise them to seek medical attention. CONCLUSION We thus conclude from this prelim inary survey o f high school hockey players that greater awareness and educa­ tion o f the hockey fraternity in terms o f factors predisposing to hockey injury is essential, if the high incidence o f injury re ­ ported in this study is to be reduced. As has occurred in so many o f the more frequently researched sports, awareness of the aetiology o f injury is a first step towards taking precautions to prevent the occurrence o f intrinsic or overuse injury. With regard to the discrep­ ancies which existed between the injuries reported by the coaches and players, this can be attributed to the fact that coaches are not always aware o f the injuries sustained by their players and therefore not in the position to make the necessary modification to the training program m es o f these players. This curcumstance increases the risk o f injury. Good com m uni­ cation and trust between play­ ers and coaches are essential and a deliberate attempt to achieve this, needs to be made. ACKNOWLEDGEMENTS The authors are indebted to the following persons for their assistance and would like to express their gratitude to Karen Rosen-Allan, Sandra Jordaan, the D epartm ent o f Biostatistics o f the CSIR, as well as all the participating coaches and play­ ers. Financial assistance for this project was provided by the Snaar Viljoen grant, U niver­ sity o f the W itwatersrand. References on request. 16 ------------------------------------------------------------------------------- SPORTS MEDICINE - VOL. 7 NO. 4 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 2. ) PHYSIOTHERAPY COMRADES MARATHON 1992 At the Comrades M arathon up- run this year, 9 Elastoplast sta­ tions were manned by 120 physiotherapists under the ban­ ner o f the Natal Sports Interest Group o f the South African Society o f Physiotherapy. These helpers consisted o f practising Natal physiotherapists, physio­ therapy students from the Uni­ versity o f Durban-W estville, final year physiotherapy stu­ dents from Wits University and two physiotherapists from Northern Transvaal. As usual we were sponsored by Smith and Nephew whose employees led by Dave Dunn, worked unstintingly to make the day a success. They supplied all the necessary medical parapher­ nalia to make the runners life easier and, as in the past, they donated literally miles o f strap­ ping. This year, approximately 45 helpers were on hand to record the injuries o f the runners treated at the stations. At my station, most o f these helpers were doctors. The data is now being analyzed. Again, as in the past, neither the physiotherapists nor Smith and Nephew received any ac­ knowledgement. W e were ignored by the media and even though we asked that the TV cameras focus on the physioth­ erapists at work, we were passed over. At a pre-Smith and Nephew lunch party, where I, on behalf o f all the physiotherapists, was thanked for the outstanding Joyce Morton w ork we do, a prominent "running" doctor was overheard telling a novice that at all costs, never stop at a physiotherapy station, but to just keep going and run through her problem! Working in the Red Cross Tent in Pietermaritzburg, I asked my patient, who had been ad­ mitted for other reasons, whether the bandage on his knee had been o f any help. He explained to me that he had been doing too much hill work and that he had developed an Iliotibial Band Friction Syn­ drome. Hoping that it would not be aggravated by the long run, he entered the race but by the time he reached Inchanga, he realized that he could not continue without help. He stopped at an Elasoplast station where he was strapped and given some advice. He told me that without the strapping, he would never have finished. The patient lying in the next stretcher, who was a doctor, proceeded to give my patient a lecture about the fact that an ITB is a friction syndrome and that the physiotherapist’s judge­ ment in strapping the knee, was completely incorrect. As the doctor’s own judgem ent was so bad that he had landed up in the tent with excruciating cramps, I thought it was not really the time to argue with him. Physiotherapists do know the pathology o f an ITB and other running problems. We deal with them every day of our working lives. But even in medicine there is a word called "empiricism" and if that strap­ ping helped that runner to achieve his goal, even though the "book" says it was wrong, must we deny him his moment o f glory? Every year we are inundated with thanks from runners who state categorically that they would never heave reached the finish without the help o f the physiotherapists. The physio­ therapists hear these thanks, but no one else does. The Natal Technicon Re­ search D epartm ent, who is handling our data, will be look­ ing for the runners who stopped at m ore than one station. Ques­ tionnaires will be sent to them asking them whether they did complete the race and whether subjectively, they felt that they were helped by the physiother­ apists. Does it matter that much if their answers are subjective? The Comrades M arathon is a fun race for thousands o f runners and even more specta­ tors. On the day, the physio­ therapists and their helpers give o f their time voluntarily. Smith and Nephew spend literally thousands o f rands on the event, as a fight to the physiothera­ py profession and to the run­ ners. Surely this is an ideal opportunity to show the public what the medical profession can do for them? Surely this is not the time for our medical colleagues to criticise us, espe­ cially without giving us the right to reply? ----------------------------------------------------------------------------------- 17 SPORTGENEESKUNDE VOL. 7 NO. 4 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 2. ) PROLINE SUPPORTS W ith th re e years design d e ­ v e lo p m e n t and sales behind th e m , th e e ng in e erin g and m a rk e tin g s t a f f a t Proline S u p p o rts k n o w th e y have a s u c c e s s fu l range of p ro d u c ts to c o v e r m o s t a p p lic a tio n s in the lim b s u p p o rt and d e fe n c e m a rk e t w ith so m e e x c itin g a d ­ d itio n s on th e w a y . T h e m a rk e t a t p re se n t is s p lit in to th r e e d is t in c t categories, the firs t is the basic use o f s u p p o rts as an e ffe c ­ tiv e m e a ns o f d e fe n c e a g a in s t in ju ry d urin g rig o ro u s s p o rtin g a c tiv itie s . U n fo rtu n a te ly th is represents the sm allest aspect o f th e m a rk e t because s p o rts m en and w o m e n alike o nly begin to th in k a b o u t p re v e n ­ tio n a fte r the dam age is done. S e c o n d is th e s itu a tio n w h e re people w e a r s u p p o rts to p ro te c t the in ju rie s th e y have re ce ive d during s p o rt. T h ird is th e v e ry u n fo r tu ­ nate p o s itio n w h e re s u p p o rts are w o rn long a fte r people have s to p p e d c o m p e tin g , b ut have to w e a r a s u p p o rt to enable th e m s e lv e s to lead a n o rm a l life . M o s t o f the se ca ses are v e ry sad e s p e c ia lly w h e n you co n s id e r th a t a lo t o f th e p ro b le m s co uld have been a vo id e d if som e fo rm o f protection had been envisaged. O f co u rse m o s t o f th e s u p ­ p o rts have o n ly re c e n tly been m ade a va ila ble due to the n e w hi-tech m aterials necessary fo r th e ir c o n s tru c tio n . The o b v io u s c o n c lu s io n is th a t p ro b le m s in th e se co n d and th ird s e c to r are s till lik e ly to e x is t u nless th e a d v a n ta g e s o f s u p p o rts are fu lly e xplaine d to and a c c e p te d by p a r tic i­ p an ts o f all s p o rts w h e re lim b in ju rie s are a p o s s ib ility . In v e ry m a n y sp ecialize d s p o rts th e use o f p ro te c to rs and b o d y a rm o u r is an e x ­ p e cte d and a c c e p te d p a rt o f Pinto hinged knee support th e p a rtic ip a n ts a tire . T h e re ­ fo re it is n o t u n a c c e p ta b le fo r lim b s u p p o rts o f all ty p e s to be used as an e ffe c tiv e m eans o f p ro te c tio n by c o m p e tito rs in a w id e v a rie ty o f s p o rts . So fa r o n ly s p o rtin g p ro blem s have been d e a lt w ith , b u t Proline S u p p o rts are e q u a lly s u ita b le fo r use by s u ffe re rs of m any co nd itio n s associated w ith lim b s and th e lo w e r b ack fro m dam ag e d te n d o n s and lig a m e n ts to som e a rth ritic a il­ m e n ts. Proline m ake s u p p o rts to s u it v e ry m a n y d iffe r e n t a p p li­ c a tio n s and a g re a t deal of c o n s id e ra tio n is a lw a y s d i­ re cte d to th e area o f user co m fort. Each model has been d esigned to do a p a rtic u la r job b u t also to be w o rn fo r long periods. The supports and their applications Wrist & Ankle These s u p p o rts reduce the w a rm -u p tim e th e re fo re m a k ­ ing th e te n d o n s m ore e la s tic and less like ly to s u ffe r d a m ­ age. T h e y also im p ro v e c irc u ­ la tio n b e lo w the s kin also around and into the ankle, w rist k n u c k le and fin g e r jo in ts th e re b y re d u cin g th e possib- lity o f c ra m p as w e ll as p ro v id ­ ing p o s itiv e s u p p o rt to o v e r­ s tre sse d or d am ag e d w ris ts and a n kle s. T h e y are ideal fo r speeding up joint recovery after p la s te r c a s ts h ave been re ­ m o ve d fo llo w in g te n d o n or bone dam ag e . Elbow E lb ow s u p p o rts do b a sica lly th e sam e th in g as ankle and w r is t, b u t w ith m ore e m p h a ­ sis on m u scle s u p p o rt and th e rm a l d e fe n c e fo r o v e r­ stressed tendons th a t give rise to p ro b le m s c o m m o n ly k n o w n as "te n n is e lb o w ” . Thigh & Calf The th ig h and c a lf are su p ­ ports providing d ire ct pressure fo r m u scle a s s is ta n c e and e x c e lle n t th e rm a l b e n e fits to speed up th e n a tu ra l repair o f to rn m u scle tissu e . Knee Knee s u p p o rts are th e m o s t _________ _______ J 18 ---------------------------------------------------------------------------- SPORTS MEDICINE VOL. 7 NO. 4 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 2. ) c o m p lic a te d , th e y are a v a il­ able in tw o d is tin c t v a ria tio n s : hinged and n o n -h in g e d . N o n -h in g e d are neoprene sle e ves w ith or w ith o u t s tra p s . B oth ty p e s o ffe r v e ry good m u s c u la r s u p ­ p o rt and s ta b ility . The s tra p p e d v a rie ty o ffe r in ­ s ta n tly va ria b le te n s io n to lo w e r thigh and upper calf. The sleeve m a te ria l on all knee supports provides the same benefits as described for calf and thigh supports. H inged knee types are very s o p h is tic a te d . T h e y p ro ­ vid e im m e n se p ro te c tio n and are a va ila ble in t w o d e sig n s, n a m e ly th e tw o stra p (" P in to ") or th e m ore ro b u s t fo u r stra p (" M u s ­ ta n g "). T he a s s is ta n c e p ro v i­ ded fro m a hinged su p p o rt is q u ite re m a rka b le . Be­ cause o f its m e ch a n ica l s tre n g th , it p ro vid e s th e knee jo in t w ith a big b oo st to its p o w e r to re s is t the u n n a tu ra l m o v e m e n t of h y p e r-e x te n s io n , tw is tin g Diamond Body Belt and la teral m o v e m e n t th e re b y a ffo rd in g e n o r­ m ous p ro te c tio n a g a in st firs t tim e in ju ry as w e ll as d e fe n d in g dam aged knee jo in ts fro m fu rth e r a g g ra ­ v a tio n . A p o in t w o rth n o tin g is th a t Proline hinges are user frie n d ly and in th e e v e n t o f e x tre m e pressure th e y b ecom e s a c rific ia l. T h e y are also hand fin ish e d fo r tifie d n ylo n (n o t steel) and are generally accepted fo r use in c o n ta c t s p o rts , b ecause o f th e ir p a te n t th re e piece s a fe ty design, a t th e d is c re tio n o f the v a rio u s g o v e rn in g bodies and re fe re e s , e tc . B ody belt The u niqu e s u p p o rt o ffe re d by th e P roline b o d y b e lt has be­ co m e fu lly re co g n ize d by s p o rts m e n and w o m e n and b a ck s u ffe re rs a like , m aking th is la te s t e d itio n to th e Pro­ line range a b e st seller in its fie ld . R etaining th e sam e fo r­ w a rd th in k in g and e m p lo yin g double th ic k n e s s neoprene, its th e use o f t w o re m o va b le c e n tra l pads th a t m a ke s th is b e lt tru ly a d ju s ta b le to su it the unique shape or p ro b le m s of th e p a rtic u la r w e a re r. The biggest com plim ent has c o m e fro m people w h o have s u ffe re d fo r m a n y years w ith b a ck pain and n o w fin d tr e ­ m e n d o u s re lie f w ith a Proline b elt. A ll Proline p ro d u c ts provide a va lu a b le degree o f im p a c t p ro te c tio n . M tc ro c e llu lo r C losed Cell C e n te ro l Lining fo r ro p id w o rm -u p p e rio d s o n d e x tro shock a b s o rb in g p ro te c tio n N y lo n O u te r Sleeve O p e n A re o ossists P otello S u p p o rt G e n u in e 'V e lc ro ' B ra cin g Straps Edges b o u n d f o r c o m fo rt 'Skin F rie n d ly ' n ylo n in n e r lin in g S culptured shope fo the re o r o f sleeve p re v e n ts c h o fin g Pivot Blades m o n u fo c tu re d fro m Hi-Stress fo r tifie d nylon P r o v id in g e x c e lle n t lo te ro l o n d o rs io n o l S ta b ility P otent " E o r l y Lock A n ti H yp e re x te n s io n Buffers B u ffe rlin k G u id e p lo te w ith Fo ld b o ck fe o tu re to p re v e n t H in g e b a r p ro tru s io n th ro u g h sleeve Hinged knee supports: New im proved design for greater com fort "Proline Supports" available from AJ Oates Engineering & Marketing Positive protection from positive thinking C o n ta ct Tel: ( 0 1 1 ) 6 1 6 - 6 4 1 7 Fax: (0 1 1 ) 6 1 6 -1 1 2 7 all hours -------------------------------------------------------------------------------------- 19 SPORTSGENEESKUNDE VOL. 7 NO. 4 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 2. ) CRICKET CRICKET INJURIES OF THE SOUTH AFRICAN TEAM AT THE WORLD CUP AND IN THE CARIBBEAN: THE PHYSIOTHERAPY PERSPECTIVE Craig Smith Keywords: Cricket, international tours, injuries, physiotherapy. ABSTRACT This paper discusses the injuries which were encountered during the two tours by the South African Cricket Team to the World Cup and the Caribbean Islands. The anatomical site most at risk was the lower limb and the structures most commonly injured were the bones/joints and the muscles. Fielding, batting and bowling all contributed towards injury. Further investigation into this subject should include intrinsic and extrinsic causes, the structures most at risk and injury side dominance. IN T R O D U C T IO N Recently, the literature has demonstrated a growing inter­ est in the subject o f cricket in­ juries, especially those associ­ ated with tours to and from this Craig Smith, BSc Physiotherapy, BSc (Med) (Hons) Sports Science. Physiotherapist, South African Team. Sports Injuries Clinic, University o f Cape Town. co u n try .1,2,3 It is this stimu­ lated interest and approach to the subject that will soon begin to reveal new evidence regar­ ding injuries encountered un­ der these circumstances. The fruits o f this w ork will become evident when the results are translated to the actual play and begin to show on the field in the form o f a decrease in the incidence o f injury. The purpose o f this paper is thus to report on the injuries which were encountered at the World Cup tournament and during the subsequent tour to the Caribbean where a series o f matches were played against the W est Indies team. T H E W O R L D C U P N in eteen squad m em bers made up the South African contingent, being comprised o f 14 team players, 2 players to gain experience and help with practices and a coach, physio­ therapist and team manager. The squad was away for two months and played a total o f 6 w arm -up games and 9 World Cup matches. Training ses­ sions were held on non-match 20 ------------------------------------------------------------------------------- SPORTS MEDICINE - VOL. 7 NO. 4 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 2. ) CMICKET days which incorporated a warm-up routine, batting and bowling in the nets and fielding practice. W arm -up stretching and technique practice was also done on match days. Injuries and treatment All 16 players received treat­ ment. There were a total o f 56 separate injuries with the most commonly affected area being the thigh. The most common cause o f injury was fielding with batting, bowling and gen- ral running also contributing. The muscular structures were affected most, followed by in­ jury to the bones/joints and the tendons. Ligamentous and cartilaginous structures were least affected. One player was treated for 6 injuries, four play­ ers for 5 injuries, three players for 4 injuries, two players for 3 injuries and six players for 2 injuries. Only one player was severely injured warranting his exclusion from team selection for a match. An account of some o f the commonly experi­ enced injuries and their treat­ ments are briefly discussed. Head and neck One player suffered with chronic cervical facet joint syndrome for which he received spinal mobilisation treatment and trigger point acupressure to relieve the associated muscle tension. Spine and trunk There were a total o f 7 injuries involving the thoracic and lumbar spines, although none serious. Two players suffered injury to their iliolum bar liga­ ments which responded well to spinal mobilisation treatment. One o f the bowlers complained o f chronic lumbar stiffness and pain. He had a history o f mild Scheurm ann’s disease with a slight scoliosis and marked quadratus lumborum spasm. A nother player developed "rib tip", a stress injury involv­ ing the teno-osseus attachment between the stomach muscle and the rib cage. A potentially serious and debilitating injury among fast bowlers, it did not hinder him too much and actually got better as the tour progressed with cross-friction, ultrasound and laser therapy. Finally, one player strained his external oblique abdominal muscle while batting. He was treated with cross-frictions and ultrasound and the area was strapped to assist him in the next match. Upper limb An all-rounder suffered with a chronic shoulder impingement syndrome which would flare up after he had done much bowling or throwing. This would then affect the rest of his shoulder complex leading to infraspinatus and trapezius muscle spasm requiring mo­ bilisation and massage treat­ ment. Four elbow injuries oc­ curred in the first week as a result o f the players having to adapt to the large Australian fields by throwing the ball far distances. These "sprained" elbows healed quickly after 2 to 3 days o f treatment. Three players injured the soft tissues overlying the meta­ carpophalangeal (MCP) joints. The wicket keeper brusied the second M CP joint o f his right hand by constantly having to catch the ball during practices and matches. Initial x-rays ruled out a fracture and a cortisone injection was given to relieve the pain and swelling and he continued playing with extra padding inside his gloves. The reserve keeper also injured his left hand in the same manner, yet his injury was not as severe. Another player bruised his fifth M CP joint o f his left hand from constant fielding o f the ball. Lastly, one player developed tendinitis o f his extensor pol- licis longus tendon in the right wrist. This responded well to cross-friction treatment, laser and ultrasound. O f the four finger injuries, the most serious was that o f the captain who was hit with the ball on his left thumb nail. The pain and swelling persisted for a couple o f days regardless of continual puncturing o f the nail to help it drain and only a week later when the nail came off, was he provided with some relief from the painful syndrome. Lower limb Four players bruised the front o f their thigh as a result of being hit with the ball through their protective padding. One player strained his quadriceps muscle while 4 others reported mild pain and stiffness in their hamstrings which were treated on a precautionary basis. A fifth player slgithly strained his right hamstring during one of the matches and came o ff the field temporarily for treatment and strapping support. H e was later treated with vigorous cross-frictions, ice and ultra­ sound and two days later played again without further worry. One player tore his left adduc­ tor longus muscle two weeks before the team left and re­ ceived extensive treatment to ----------------------------------------------------------------------------------- 21 SPORTGENEESKUNDE VOL. 7 NO. 4 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 2. ) CRICKET enable him to recover in time. D uring the tour his groin often became stiff and painful and required occasional massage and ultrasound treatment. H ow ­ ever, during the final game, he subsequently strained the right groin while fielding and could not continue playing. Another player had pain on the outside o f his left knee, diagnosed as a lateral meniscal cyst, which was aggravated when bowling. On examining his bowling action and infor­ ming him to place his front foot in a m ore straightened posi­ tion, his symptoms cleared up shortly. (However, it is thought that this change may have brought about a new injury to his ankle). Two others had in­ juries involving their iliotibial bands which did not completely clear up and required on-going maintenance treatment during the tour. Lastly, another deve­ loped popliteus tendinitis early on which responded well to treatment. Injuries to the lower leg in­ cluded two calf muscle strains, two achilles tendon strains, and mild shinsoreness (tibial stress syndrome) in one o f the fast bowlers. The serious calf muscle strain occurred while the player was batting and un­ fortunately he could not come o ff the field immediately. He was treated extensively there­ after, yet unfortunately had to miss the next match as his in­ ju ry had not healed sufficiently and the risk o f further injury with im portant matches loom ­ ing was too great. The wicket keeper developed a secondary achilles tendon strain as a result o f his sprained lateral ankle ligaments. M ore so, his injury was also aggravated by the prolonged crouched position he had to field in and he only just recovered before the first match began. The shinsoreness was managed with ice, ultrasound and shock absorbing inner soles. Two ankle sprains occurred in non-cricket related incidents, and recovered following ice, cross-frictions and ultrasound therapy. Lastly, an all-rounder injured his left tibialis pos­ terior tendon about half way through the tour. He became aware o f pain next to his left medial malleolus during foot- strike o f his bowling action. Initially it was thought that he had a posterior talar impinge­ ment injury (talar spur) and x-rays revealed the presence o f an enlarged os trigonum. He was given a cortisone injection into the area and rested. However, the symptoms only got worse when he played again and the pain spread to the achilles tendon. On returning home, inflammatory exudate in the region o f the tibialis pos­ terior tendon was evident with an MRI scan. THE CARIBBEAN TOUR The team o f 14 cricketers which toured the Caribbean Islands played three 1-day interna­ tionals and one 5-day test match against the West Indies team. The team followed the usual exercise procedures while on tour and three o f the players had minor injuries carried over from the previous World Cup tour. A total o f 15 injuries were reported with only 11 players requiring treatment. One player had 3 injuries, two players had 2 injuries while the other eight players each had 1 injury. The most commonly injured structures were the bones/joints followed by mus­ cular injuries. The causes o f injury were evently spread among batting (3), bowling (4) and fielding (5). Head and neck One player sustained a subluxed facet jo in t to his cervical spine during the 5-day test match when he ducked out o f the way o f a rising ball while batting. He had to continue batting for an hour before he could receive treatm ent in the form o f heat, a manipulation, ultrasound and a muscle relaxant. This enabled him to continue in less discom­ fort and he later responded well to further treatment with spinal mobilisations. Spine and trunk Two bowlers were treated for chronic lumbar pain and stiff­ ness. Another bow ler injured his right costochondral jo in t o f the fourth rib. He had collided with another player’s head while body-surfing and when he had to bowl two days later, he broke down in his third over complaining of severe chest pain with breathing and much diffi­ culty bowling. He immedi­ ately came o ff the field to apply ice to the chest and went for x-rays which excluded a cracked rib. His chest was largely swollen, yet following five days rest and treatment with ice, laser and ultrasound 4 times daily coupled with anti­ inflammatory medication, his injury healed to the point where he played the test match with supportive strapping, yet no recurrence o f the painful symp­ toms. 22 ■ — - — — SPORTS MEDICINE - VOL. 7 NO. 4 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 2. ) CRICKET Table 1: Anatomical injury profile World Cup West Indies Anatom ical site Head and neck 5% 13% 3 2 Upper limbs 27% 27% Shoulder 2 1 Elbow 4 — Wrist/hand 4 1 Fingers 4 2 Trunk and spine 18% 27% Chest/Abdomen 3 1 Spine 7 3 Lower limb 50% 33% Hip 1 — Thigh 13 2 Knee 5 2 Lower Leg 5 — Ankle 4 — Foot/Toes 1 Total 56 15 In ju re d S tructures Bones/Joints 16 9 Muscles 23 3 Tendons 11 1 Ligaments 4 — Cartilage 1 1 Soft tissue 1 1 Total 56 15 Upper limb One player suffered a haema- toma injury to his right wrist whereby on attempting to catch a batsman out he was struck on the volar surface causing a blood vessel to burst, with immediate swelling into the area. This had apparently occurred on a previous occasion and applying ice and a compression bandage to the wrist reduced the swel­ ling and he could continue play­ ing. Another player dislocated his distal interphalangeal joint o f his right middle finger but this was easily reduced and treatment ensured he could play the test match 2 days later. Lower limb One player strained his rectus femoris muscle which hampered him for the first half o f the tour as he could not rest it suffi­ ciently . Another bowler mildly strained his right groin towards the end o f the tour yet could continue playing. A third p re­ sented with symptoms o f a mild synovial plica syndrome in­ volving his right knee. He had a history o f previous injury to the knee which required a menisectomy a few years back. The knee responded well to mobilisations, ultrasound and laser therapy. The last two injuries were both as a result o f players being hit with the ball causing moderate periosteal and soft tissue bruising to the knee and dorsum o f the foot respectively. DISCUSSION The injuries associated with the South African cricket team ’s tour to the W orld Cup and West Indies have been presented. This paper adds to the already present and growing amount o f data reported in the literature on this subject. Tables 1 and 2 give an account o f the anatomi­ cal injury profiles and the phys­ iotherapy treatments given. The incidence o f injury as­ sociated with the W orld Cup tour was 3,5 per player while that o f the Caribbean 1 injury per player. These figures sup­ port M orton’s3 hypothesis that the injuries encountered on cricket tours may be propor­ tional to the length o f the tour. H er results demon stated an injury incidence o f ju st 1 per player for a squad o f 17 players with a total o f 22 injuries. Al­ though the number o f injuries seem to increase with the length o f the tour, a more true per­ spective o f the incidence may be found when the total number is compared to the number o f players injured. This then ad­ justs the Caribbean tour inci­ dence to 1,4 and the Natal tour to 1,7 per player. Applying the same adjustment to the tour o f India' also results in an inci- ----------------------------------------------------------------------------------- 23 SPORTGENEESKUNDE VOL. 7 NO. 4 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 2. ) CRICKET T able 2: Physiotherapy treatment modalities World Cup West Indies Players 16 14 Players treated 16 11 Treatments given 232 85 T re atm en t m odalities Electrical Interferential 16 3 Ultrasound 176 60 Lasesr 85 42 Total 111 105 Manual mobilisations Peripheral 20 23 Spinal 23 17 Massage Non-specific 17 6 Frictions 85 13 Acupressure 13 18 T otal 158 77 Ice 81 40 Strapping 29 10 Stretching exercises 15 Injections 4 Total 129 50 Total treatment modalities 564 232 T able 3: Causes of injury World Cup West Indies Batting 14 3 Bowling 11 4 Fielding 15 5 Running (not during cricket) 11 1 Other 5 2 Total 56 15 dence increase from 1 to 1,8 per player. The lower limb was found to be the commonest area injured on the two tours (50% and 33% ), followed by the upper limbs (27% and 27%), the trunk and spine (18% and 27% ) and then the head and neck (5% and 13%). On both tours, fiel­ ding accounted for most o f the injuries (20), followed by bat­ ting (17), bowling (15), non­ cricket relating running (12) and other causes (7). (See Table 3). In conclusion, it can be said that despite detailed prepara­ tion and precautionary meas­ ures, injuries will almost cer­ tainly result from the normal nature o f the game and circum ­ stances which cannot always be completely controlled. There­ fore, it is clear that a continued awareness and vested interest in this field can only be height­ ened by reporting this data, which will hopefully lead to further insight into the manage­ ment and treatm ent o f cricket injuries and a reduction in the incidence o f these injuries in the future. Areas which may warrant further investigation include the incidence o f injury related to intrinsic and extrinsic causes, identifying the high-risk struc­ tures associated with tours o f varying lengths and injury side dominance among batsmen and bowlers. Effective measures to lim it injury in the form o f spe­ cialised training programmes, regular stretching plus prom pt treatm ent will continue to bene­ fit not only touring cricket teams but other tours o f this nature and assist our cricketers in the international competitive arena. REFE R E N C E S 1. Smith CA. C ricket injuries w hile on to u r w ith the South A frican team in India. SA J o u rn a l o f S ports M edi­ cine, 1992; 7(1): 4-8. 2. Smith C A . Sports injuries encoun­ tered on a five w eek international cricket tour. SA J o u rn a l o f Sports M edicine, 1990; 6(1): 10-15. 3. M orton J. C ricket injuries o f the Northamptonshire county cricket team during a 15 day to u r o f N atal. S/1 Jo u rn a l o f Sports M edicine, 1992; 7(2): 18-20. 24 ------------------------------------------------------------------------------- SPORTS MEDICINE - VOL. 7 NO. 4R 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 2. )