A traumatic leg injury can be a devastating experience to the amateur rugby player. When the incident occurs, the whole world instantly comes crashing to a halt. Tragically for many, this type of injury can be an unfortunate end to your competitive sporting career. From first-hand experience, I have written this article as part I of an IV part series exploring the injury process and what it takes to make a full return to rugby following a serious leg injury in particular.
- In this first installment, we will look at the Traumatic Phase of a leg injury sustained while playing rugby, the immediate medical intervention provided and what to expect in the hospital setting from Emergency Room to Operating Room.
- Part II will cover the Immobilization Phase, looking at both the mental and physical aspects of preliminary rehab.
- Part III will highlight the Mobilization Phase, breaking down how the amateur rugby player can regain muscle mass, joint flexibility, and mobility through stretching, exercise, and nutrition.
- The series will wrap up with the final article, which is the Re-Entry Phase. Identifying the psychological and physiological hurdles that must be overcome for a full and productive return to the rugby pitch.
According to The British Columbia Injury Research and Prevention Unit, 1 out of every four rugby players will face an injury during the season. (1)
One study, in particular, found that leg ligament tears and bone fractures account for 50% of all serious rugby injuries. (2) The science suggests that most injuries occur at the beginning of the season and that proper pre-season conditioning could help reduce these injuries significantly. This is an area where the amateur player will likely have to shoulder the responsibility for getting his or her body into proper playing condition. While many clubs offer a solid pre-season strength and conditioning program, you can't guarantee this is going to be available at your club every season. And when they are, they will generally only last around 4-6 weeks. That isn't enough time to get fit for rugby season and condition your body for 80-minute rugby games week in and week out.
In all actuality, the amateur player is best served to be training year round, as part of a periodized approach with an emphasis on strength training and flexibility during the off-season. There are some great annual rugby training regiments available online, including this 12-month strength and conditioning program from Rugby Renegade found in the resources section of our online store.
Coaches also have a significant role to play in preparing their players for the injury risk factors of rugby. Making sure players, especially those who are inexperienced, are well instructed in defensive skills and body positioning, proper tackling, bracing and falling techniques can greatly reduce the potential for a catastrophic leg injury. (3) Unfortunately, all the preparation and prevention measures in the world aren't going to mitigate the potential for serious injuries entirely. When you play rugby, you risk injury. While it's not useful to dwell on this, it is important that you and your family be aware of the risks and potential consequences of playing.
My Big Break
In April 2016 I was a passenger on this hell-bus.
Following a line break I received an offload and had only my opposing 15 to beat, 10 meters away from the try line, I made my cut. My opponent grabbed my jersey and whipped around into the side of my leg... fans from the midfield said they heard the snap too. As I collapsed in a heap to the ground, I reached down to find that the bottom half of my lower right leg was laid out with my foot precisely extended at a 90-degree angle. I am not sure if my brilliant collage of expletives was born out of the magnitude of the pain or the intense fear that everything in my life was about to change.
I had just earned the 15 jersey a few weeks earlier and took possession of the team's goal kicking duties at the same time. Things were looking up for this 34-year old who just took up rugby two years ago. I promise this endeavor wasn't a mid-life crisis thing; it was about building a better me. Rugby launched me on a radical self-improvement course of physical health, mental focus, and a rigorous work ethic. Every dimension of my life has gotten better. But laying on the ground just meters from the try line, I had to wonder whether this epic journey was over just as it was getting started.
Thankfully we were playing a home match that day and there was a paramedic on site. When she arrived at my side, her first corse of action was to cut my sock away to determine if my fracture was open or closed. Open being if the broken bone was sticking through my skin in a bloody mess or closed meaning the break was contained. With great relief, I had an apparently closed fracture, but the obvious deformity was pretty grotesque. Following protocol, the medic proceeded to rotate my lower leg back into alignment and hold tension, she then cut the laces and removed my boot to assess my distal (foot) pulse, which was strong and regular - again another win for my situation.
Had she been unable to find my pulse, it would be an indicator that blood flow was restricted to reaching my lower leg and that I would be at risk for compartment syndrome. A condition that develops when swelling or bleeding occurs within a muscular compartment cutting off blood flow to muscle tissue, capillaries, and nerves. Without a steady supply of oxygen and nutrients, nerve and muscle cells can be damaged. In acute compartment syndrome, unless the pressure is relieved quickly, permanent disability and tissue death may result, possibly resulting in the need for amputation. (4)
Once my leg was immobilized, most of the pain went away. The medic was able to splint my leg and for the next twenty minutes or so that I lay on the pitch waiting for the ambulance. I was able to speak with my wife and children, my coach and teammates. It was a surreal experience. Up to this point in my life, I had never broken a bone, had surgery or so much as even had stitches! Might as well knock out all three.
When the ambulance arrived, I was placed on a long spine board and loaded into the unit. The paramedics started an IV and offered me pain medication, which I declined because honestly, I was feeling very little pain at all. The transport to the emergency room was only about 15 minutes, and when we arrived I was paraded through ER to my designated trauma room; everyone wanted to get a look at the rugby player, it was as if the staff had never seen one before. Go, figure.
First order of business was to cut off the original splint so the ER Physician could get his hands on my leg and examine the break. An X-Ray was conducted in the room which was a very painful experience, but tolerable with IV pain medication. But when the Physician attempted to re-splint my leg, the pain increased by a huge degree. After several more attempts to manage with narcotic pain medication, I was put under with conscience sedation to complete the splinting procedure. When I awoke after about 15 minutes, the procedure was done and all that was left was to meet with the Orthopedic Surgeon after reviewing my films.
The Orthopedic Trauma Association reports that fractures to the tibia are the most common of all long bone fractures. (5) This particular skeletal break usually involves a high-impact blunt force or more common in sporting scenarios, low-impact torsion pressure. In my case, the Surgeon explained that the X-Rays revealed that I had a spiral-displaced fracture. Meaning, the break was caused by an impact coupled with twisting force so powerful that it broke apart both my Tibia and Fibula.
Further, he said this particular type of injury can cause an immense amount of interior damage to the muscle at the break site as the shattered bone shreds through the surrounding soft tissue. Time would only tell how much healing I had in front of me.
I remained in the Emergency Room for a total of 5 hours before being moved up to the medical/surgical floor. It was a great relief to hear that my Orthopedic Surgeon agreed to perform the surgery that same night, around 10 pm.
Once I got settled, he came in and explained that type of surgery he would perform was called Intramedullary Nailing, which is currently the most common form of surgical treatment for tibial fractures. It involves a preliminary procedure called Patellar Tendon-Splitting, where an incision is made over the knee and all of the tendons to the knee cap are severed to displace the patella to one side, exposing the anterior (top) of the tibia bone.
Once this initial procedure is complete, a guide pin is fed down the center of the tibia, past the break, to the posterior (end) of the bone. Then a drill-like tool called a rigid entry reamer is fed down the center of the tibia, clearing out the bone morrow and creating a bore for the nail. The nail itself is a titanium rod custom fit to fill the medullary (inter-skeletal) space. Once the rod is in place it is secured using an extended proximal jig to place three cross locking screws in place, two at the base and one at the top of the tibia, fusing the rod and bone as one unit (6). The tension created by this rigging is enough to also hold the fibula in alignment as well, so no intervention is necessary at that break site.
The medical team did a fantastic job controlling my pain and even after my surgery prep, I was able to traverse myself from the hospital bed onto the operating table with ease, where I was then given general anesthesia. The surgery lasted about 3 hours. Once back in the post-op recovery room I "unconsciously" woke up and I am told I kept pushing the end of the bed with my leg, causing myself such intense and unnecessary pain that I had to be given more medication to knock me out. I was transported back to my hospital room around 2 am. When I awoke, I observed that my incision and staple sites had been secured with 15 staples and my leg wrapped, elevated and iced to prevent swelling.
The long first day had finally come to an end. But my journey of rehab was just getting started. I can honestly say, at this point I had no idea what it was going to take for me to return to rugby, or if I would even have it in me. My family and my mates were rock solid. My wife in particular was by my side every minute, which was a great encouragement to me. As helpless as I surely was in the beginning, every one of my relationships would play an essential role in the days ahead of my recovery.
I look forward to sharing insights from the next phase of my experience and hope this series will be an encouragement to every rugby player who has ever faced the overwhelming task of making it from the Operating Room back to the pitch.
- Power, Fraser Common Rugby Injuries
- Gibbs N. Common rugby league injuries. Recommendations for treatment and preventative measures. Sports Med. 1994 Dec;18(6):438-50.
- Power, Fraser Common Rugby Injuries
- Compartment Syndrome, American Academy of Orthopedic Surgeons
- Tibia (Shinbone) Shaft Fractures, American Academy of Orthopedic Surgeons
- Max Morandi, MD; Trevor Banka, MD; Guilherme P. Gaiarsa, MD; S. Trent Guthrie, MD; Jad Khalil, MD; Joseph Hoegler, MD Intramedullary Nailing of Tibial Fractures: Review of Surgical Techniques and Description of a Percutaneous Lateral Suprapatellar Approach, Orthopedics, March 2010 - Volume 33 · Issue 3