Six Nations Injury Review

Six nations Injury Review – Heading into the fourth round of games in the RBS 6 Nations Championship we’re going to take a closer look at some of the injuries sustained by the players in the lead up to the weekend’s crucial matches.

Irish Rugby VivomedIRELAND

Ireland’s injury worries ahead of the clash at the Millennium Stadium against Wales were Jonny Sexton’s hamstring injury, Jamie Heaslip’s three broken vertebrae, Sean O’Brien’s concussion and Jared Payne’s head injury, but the good news is that all four injuries have been resolved and Heaslip is back in the team for Saturday’s game.

While Sean O’Brien followed the Graduated Return to Play Protocols credit goes to the Irish medical team for getting the full squad fit for the Welsh clash. In praise of the medics Jamie Heaslip said when reflecting on rumours about his fitness:

“I don’t personally listen to outside sources, I listen to our trusted medical team and they gave me some very good guidance. We mapped out a really good, clear plan, in terms of ticking the boxes in recovery and I have ticked them along the way and now I’m good to go.”

Wales Rugby VivomedWALES

While all the Irish injuries seemed to have resolved, the Welsh also have good news in that Sam Warburton has recovered from a bruised knee and Dan Biggar is fit after a hip injury.


England Rugby VivomedENGLAND

In the England camp Luther Burrell has recovered from his calf strain, and full back Mike Brown has completed his Graduated Return to Play Protocols after his concussion, but England will be without Tom Croft. Henry Thomas and Brad Barritt who picked up an ankle sprain and will miss the Scotland and France games. Courtney Lawes also returns to the team after an ankle injury.


Scotland Rugby VivomedSCOTLAND

Sean Lamont and Alex Dunbar drop out of the Scottish team with knee injuries with Dunbar having ruptured his ACL in a training session, while Ross Forde will return to the front row after a back spasm.


Italy Rugby VivomedITALY

Good news for Italian fans as the hugely talented Sergio Parisse has been declared fit for the France game. Coach Jacques Brunel indicating he will be ready for the game said, “”Sergio was required to have precautionary rest by the club but it’s nothing to worry about” However Italian winger Leonardo Sarto may not make it. “Sarto will be evaluated tomorrow in the first high-intensity workout of the week,” Brunel added..

France Rugby VivomedFRANCE

The ubiquitous hamstring problem has forced Sofiane Guitoune to sit out the Italian match with Wesley Fofana, while Clermont prop Menini returns to the squad after a foot injury, but the Six Nations is over for Morgan Parra who suffered a Posterior Cruciate Ligament Injury in the game against Wales. A 10 week recovery has been suggested for this injury.


We are fortunate this week to have two guest authors: Erin Byrd from Rebound Physio who compares Posterior Cruciate Ligament Injuries (PCL)  with Anterior Cruciate Ligament Injuries(ACL),  and former Munster physio Anthony Coole who shares his experiences with regard to Hamstring Injuries:

Last week scrum half Morgan Parra of France 6 Nations journey ended after rupturing his posterior cruciate ligament in the first half of the game against Wales. He continued to play until the 53rd minute until being replaced. Parra suffered a similar injury to his left knee in 2013. In a statement from his rugby union team Clermont Auvergne, Parra is said to be undergoing conservative treatment for the PCL rupture.

Morgan-ParraPCL injuries are infrequent in rugby making up only 5% of all knee injuries. It is 1.5 times as big as it’s neighbour the anterior cruciate ligament. The most

Cruciate Ligament
Knee Joint showing Anterior and Posterior Cruciate Ligaments

common mechanism of injury during play is a fall on the flexed knee with the foot in plantarflexion. When the foot is dorsiflexed the force is instead through the patella and distal femur than the tibial tuberosity, and therefore the PCL is more protected. Other mechanisms of injury include hyperextension of the knee, which usually causes a concurrent posterolateral structure (PLS) injury, or a forced valgus/varus movement.
The natural history of the recovery from an isolated PCL injury occurs in 3 phases:
1. Functional adaptation and return to sport (3-18 months)
2. Functional tolerance (15-20 years)
3. Arthritic degeneration (most commonly medial tibiofemoral) becoming increasingly disabling after 25 years have passed

Many studies have been done on both surgical and conservative treatment of the PCL. Unlike an ACL tear where there is usually significant instability in the cruciate deficient knee, a PCL tear can be treated conservatively even in elite level athletes. It is universally accepted among healthcare professionals that conservative treatment of the stable PCL deficient knee is more advantageous to the elite athlete because of the quicker return to sport. Surgical intervention is usually only performed when there are concurrent ligamentous or meniscal tears, posterolateral structure damage (which can significantly increase instability) or the athlete already has severe damage to the articular cartilage of the medial femorotibial compartment.

With the altered biomechanics of the knee with PCL deficiency, loading to the already damaged cartilage can accelerate the degenerative changes within the knee. Cadaveric studies with cutting of the PCL have shown these altered biomechanics with increased contact pressure on the medial aspect of the knee, most significantly after 70° flexion. With the medial condyle being larger and flatter than the lateral it is more vulnerable at the time of injury as the posteriorly subluxed tibial plateau cannot protect the femoral condyle. Therefore the main concern after a PCL rupture is more degenerative chondral lesions than stability, which for an elite athlete means that for the near future they can continue to play and earn money, without immediate concern for further injury.

Conservative treatment
The current standard of care after injury is where ACL and PCL injuries differ significantly. The PCL is better perfused than the ACL and has better supporting structures. Unlike the ACL even high grade PCL injuries can heal to a firm end point. If Parra had sustained an isolated ACL injury he would have been scheduled for immediate surgical repair of the ligament due to the greater instability that ACL ruptures create versus PCL. PCL ruptures have been shown to, in the short term, respond very well to conservative treatment.

A study by Toritsuka in 2004 found that 14 out of the 16 PCL injured rugby players (88%) were able to return to their pre-injury level of play with conservative treatment that ranged from 1-7 months (mean of 3 months). The most noticeably affected skill upon return to play reported by the players was high speed running. Another study in 2012 by Benjamin-Laing of 46 athletes with isolated PCL injuries had a return to sport rate of 91%.

In cases of surgical repair, rehabilitation after PCL reconstruction differs quite a bit to ACL reconstruction. One of the biggest difference is that there is currently very few accelerated rehabilitation programs. Even these claimed ‘accelerated’ protocols restrict return to sport to the 6-9 month range. Restriction on positioning due to the greater effect of gravity on the PCL graft, limits the early phases of rehabilitation. Therefore, return to sport usually takes at least 8 months. This is why for an elite player, conservative treatment and bracing tends to be a more viable option especially mid-season. Also in a review of 21 papers on the results of surgical reconstruction of the PCL, return to pre-injury level of play was 50-82% compared with 88%-91% in conservative treatment.

It stands to reason then why Parra and his medical team have chosen not to undergo surgical reconstruction this time around. He will most likely undergo a short phase of immobilization followed by protective bracing correcting for any posterior tibial stress. Quad strengthening will begin day 1 as the quadriceps pull is directed anteriorly on the tibia and can help to prevent posterior tibial translation. The quad strengthening will move to closed chain dynamic strengthening as soon as tolerated. Proprioceptive retraining, hip and core strengthening will also be a focus to ensure good functional biomechanics of the knee during return to play, and minimizing the risk of re-injury.

Dr Erin Byrd, MCSP, DPT, SCS, CSCS
Rebound Physiotherapy is a new physiotherapy clinic in Belfast on the Castlereagh Road that specializes in sports medicine and musculoskeletal injuries, as well as concussion education and management. More uniquely all of our clinic profits go directly to support the local charity Brain Injury Matters which helps to rebuild the lives of those who have been affected by acquired Brain Injury. If you want more information call our team at Rebound Physio on 02890992444 or go to


Anthony Coole former Munster physiotherapist has taken a more in depth look at hamstring injuries in the light of Jonny Sexton’s scare ahead of the Welsh game:


Hamstring Injury? Don’t stop moving!!!

Sexton's hamstring injury
Sexton recovered from hamstring injury

Johnny Sexton was removed from the field of play after 54min against England with a minor Hamstring strain. He also suffered a twinge in the week leading up to the South Africa game in November 2014. What’s going on with our Johnny?

Hamstring Injuries are the most commonly experienced injuries by athletes – rates of 12-15% reported in many sports. And as a rule people do not seem to follow a detailed rehabilitation programme to completion which then leads to recurrence of the same injury. Recurrence rates of 34% in Australian Rules football and 12% in the Premiership soccer competition.

The cause of Hamstring Injuries is generally multi-factorial and it is the skill of the Physiotherapist to recognise and address all these factors which will result in a successful rehabilitation and reduce the risk of recurrence.

Hamstring Strains are generally divided in 2 types. Type I being the more common strains experienced during high-speed running and Type II occurring during movements which leading to excessive stretching of the hamstrings when in higher degrees of hip flexion and normally occur at slower speeds.

The Type I strains are usually found in the long head of Biceps-femoris and

Type II are usually located near the ischial tuberosity and involved the proximal tendon of the semimembranosous.


Type I sprinting type strains generally require a shorter period of rehabilitation than the Type II stretching type strains. They also seem to occur at the end of the swing phase of the stride cycle as the hamstrings are working eccentrically to decelerate the swinging lower leg in preparation for the foot strike. The person normally feels a sudden onset of pain that usually stops them taking part in their activity and they are generally able to locate the site of pain quite specifically.

Type II more commonly occur in activities like ballet, gymnastics and dancing at these require large range and/or ballistic type movements. These types of strains often take much longer to rehabilitate and passive stretching and heavy loading of the muscle seem to aggravate the injury and prolong the rehabilitation period.

So, we might be fairly certain in making the assumption that Johnny sustained a Type I hamstring strain. Now what should he be doing about it?
The usual regime of RICE has become PRICE. Protect the area from any further damage and then the RICE regime. We could see this being implemented immediately by the Irish Rugby Medical Team by the application of the GameReady device which provides compression and icing at the same time. Experience would dictate that compression is often underutilised and can make significant gains in terms of settling down that swelling and pain. While most professional teams now have access to this relatively expensive technology, amateur teams can use compression and ice with crushed ice or ice packs and compression bandages.There would also be a number of Medical therapies applied to accelerate healing. There is an increasing amount of interest in the use of growth factors after muscle and tendon injury. These include plasma-rich platelets (PRP) and autologous blood.


Rehabilitation from Hamstring Injuries:

With the lesser injuries, the earlier one can bring movement into the rehab the better. Even sitting on your bag of ice and actively straightening the knee and bending it as you ice allows the muscle move through its pain-free range and prevent any tightening of the injured area through scar tissue formation.
The time in days taken to walk pain-free at a normal pace has been shown to relate to the length of time it will take for a return to play. If it has taken more then1 day to walk pain-free then it is 4 times more likely to take more than 3 weeks to return to play. Warren et al did a study on elite Australian Rules footballers which showed that combining this with a history of hamstring injury in the last 12 months resulted in a 93% chance of taking longer than 3 weeks to return.

Again, in keeping with the philosophy of moving pain-free as soon as is safe, Verrall et al showed that the days to jog pain-free is the strongest predictor of time to return to play. If this occurs in 1-2 days then the return to play will generally be less than 2weeks. If 3-5 days then the return could be significantly longer than 2 weeks, and if longer than 5 days the return to play will be significantly longer than 4 weeks.

As Askling et al have shown, the more proximal the site of maximal tenderness, the more prolonged the time to return to play. And, although the stretching Type II injuries might initially present less symptomatic than the Type I injuries, they will most likely be associated with a prolonged return to play.

There is now a growing body of evidence to suggest low-grade isometric contraction of the affected muscle in a pain-free manner immediately following injury would appear advantageous. There would also be sense in the use of the same principal regarding eccentric lower leg drops in prone.

One the person is pain-free with walking, and sufficient force can be generated on resisted testing, then jogging can commence and progress along a well-planned progressive run/loading programme. This return to run programme could begin when the person is running at approximately 50% and should be based on a day on/day off basis.
As this progressive run programme starts there should be an integration of agility and sprint technique drills. The run programme should have a planned acceleration and deceleration phase to introduce functional loading to the hamstrings. There will also need to be a strength programme put together which will not only strengthen the hamstrings themselves but also the synergists and drills that work on neuro-muscular control. Examples of these will be bridging, single-limb dead-lifts, squats and lunges. The final stage of the run programme should be an introduction of some functional sport and position specific drills.
Return to sport or competition should only be allowed once:
• Absence of clinical signs
• Successful completion of a progressive running programme
• Successful completion of rehabilitation exercises
• Successful completion of at least 2 normal duration training sessions
We hope that Johnny Sexton fits into the Type I Injury and that he resumed jogging pain-free after 1-2 days. This would mean that he has progressed well through a progressive run programme and rehab and strengthening. He would hopefully have completed most of the team training sessions this week and practiced his place kicking, in which case he should be fit to start for us against the Welsh in Cardiff this Saturday.
The key to a speedy recovery is to not stop moving – as long as the clinical symptoms allow!!!
Good luck Ireland, Johnny Sexton and Paul O’Connell on his 100th Cap.

• Phase 1 is the acute stage and can last 3 to 4 days.
• Phase 2 is the sub acute stage lasting anything from 10 days to 2 weeks depending on severity.
• Phase 3 is the final stage returning back to full fitness.


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