THE CLUB DOCTOR
How much more of an emphasis are AFL clubs giving to their medical staff now compared to when you were at the Swans back in the mid 1990s?
Most clubs now would have a senior doctor with one or two assistants and a senior physio and one or two assistants. Back when I was there we had two physios, one of whom is still there (Matt Cameron). The year before, in '93, there were three surgeons doing the job and they were all very part-time, so they didn't come to training and didn't really have much input other than turning up on match day and seeing the major injuries. Their role at the club in terms of trying to prevent injuries was just about zero.
So it's all changed a lot. Now, there wouldn't be a club in the AFL that thinks doctors and physios have a minor role and that they don't have a big influence on how the football department ultimately gets success on the field.
Is there pressure on the medicos to get it right each week when making a judgment on whether a player is fit to play?
There certainly is. When I was at the Swans in the mid '90s, there was certainly pressure internally. The Swans obviously wanted decisions to be made as correctly as possible but I don't think there was the pressure externally.
If we had a player break down who had taken an injury into a game in those days, there weren't repercussions in the media and there wasn't an external analysis.
I think AFL doctors now are under tremendous pressure with the amount of external analysis, but I think that you have to accept the good with the bad – the status of the AFL team doctor is now a lot higher than it was 15 years ago.
Is a club doctor considered a glamorous job, at least in the medical profession?
Working in the AFL, along with the Olympics, might be the pinnacle of what you might be doing in sports medicine in Australia nowadays. It's certainly well-paid now but you're under a lot of scrutiny and the expectations come with that. Teams will not want to be seen to have injuries destroy their season, so there's a lot of pressure if there are too many injuries at a club, which can fall back on the doctor and the physio and the fitness advisors. So perhaps job security might be less with the increase in responsibility.
We've seen people asking questions at Richmond about whether Matthew Richardson should have played against Sydney.
That's the thing. Working in the NRL we don't have the same scrutiny. When risks don't come off you do tend to feel under more pressure perhaps as an AFL doctor than in any other environment in sports medicine in Australia.
In rugby league we tend to fly a little bit under the radar as team doctors. We don't tend to have the same media analysis of injuries and there's no equivalent of a [Dr] Peter Larkins or a [Dr] Peter Brukner in rugby league or any other sport in Australia.
The AFL media commentary probably leads the world in terms of analysis and dissection of medical and injury issues.
As a former AFL club doctor, how do you think the current crop of medicos feel having the media – and in some cases their peers – comment on whether a player might have come back too soon?
If they're the ones in the gun they might not find it comfortable but I think if you asked all of them 'would you like club doctoring to go back to where it was 10 years ago?' I don't think that any of them would say yes. I think that the fact that they're all better paid, more respected at their own clubs and all have a higher profile, I think that they'd understand that the good outweighs the bad.
It's a new era but I think it's one where the genie's out of the bottle now. I think that the trend that the AFL has set worldwide is one that will eventually become commonplace in all of the major sports across the world.
Having travelled a bit to the US and Europe, I can say that there's more dissection of the performance of AFL club doctors than in any competition in the world. Doctors in the Premier League in England do not face the same level of external scrutiny that AFL doctors do. Obviously if Cristiano Ronaldo tore a hamstring then far more people would read about it than for Matthew Richardson, but there would much less of a perception that the Manchester United medical staff were under the pump. It's amazing to think that's the case but that's the reality.
TRENDS
The 2008 AFL Injury Report is being released on May 20. You've been doing this now since the early 90's. What trends have you seen?
There have been some changes over time but there's still a remarkable similarity between the injury profile in terms of number of games missed with the various injury types. We do have a lower recurrence rate of injuries and that might be partly due to advances in terms of making decisions more correctly. It might also be down to a bit of extra conservatism that has come with that increased public awareness of the medical staff’s role. One other trend is that when the AFL was publicly releasing injury surveillance reports in the 90s, it was probably seen as a curiosity. Now many other sports probably look quite enviously at what a great long-standing track record the AFL has with respect to injury research.
In last year's report hamstrings and groins were identified as an area of concern. Are they still a problem?
They're [hamstrings] still the big injury because they're very common and probably the toughest to manage. With hamstrings and groins, it’s hard to pin down how many weeks a player needs to be out for and what his rate of recurrence is going to be. Both the frequency and unpredictability of these injuries make them difficult for the medical team.
The game's become quicker in recent years. Can we draw a line with this and the rate of hamstring and groin injuries?
It's a very important question and it's one that there's no simple answer to. If there was a simple answer I think the football department at the AFL has shown that it does have the courage to make hard decisions. If we could come up unequivocally with a statement to say that 'hamstring or groin injuries are related to 'x', then I think the AFL would actually be prepared to make changes to try to bring them down.
The injuries themselves probably somewhat relate to the amount of running. There's no doubt that AFL players run more in a game than any other football code in the world by a considerable margin.
There's been some concern about the rate of injuries among young players coming in to the AFL system, especially with things like osteitis pubis. Is this an area of concern for the AFL?
There is a research project I think in progress now, looking at groin pain in younger players. The good news is younger players definitely suffer fewer injuries in total than older players in the AFL. The injury rates go up as players get older.
Groin injuries are relatively high in younger players because younger players have relatively low rates of a lot of other injuries. So, for example, they have far fewer hamstrings, so groins probably make up a bigger percentage of their injuries and missed games for younger people.
RULE CHANGES
The decrease in head and neck injuries, as well as the centre-circle rule designed to reduce the number of knee injuries to ruckmen, have come about through rule changes. How much of a role do doctors have in those changes?
Doctors definitely get consulted and there definitely is a very good relationship between the team doctors and the AFL Medical Officers' Association and the AFL's football department. While they have their arguments like any people that have to work together, I think that consultation and sharing of ideas is terrific between these groups.
The AFL Medical Officers had a huge role to play in the change to the centre circle ruck rule with respect to posterior cruciate injuries and they've also been consulted on a very regular basis about head-high contact. That's been a hallmark of the AFL administration; they are interested in what doctors have got to say.
So if the AFL Medical Officers went to the League and said “You need to add more guys to the bench to cut down hamstring and groin injuries”, the AFL would definitely consider it?
If the evidence was unequivocal I've got no doubt that the football department at the AFL would listen. The problem at the moment is that there are two schools of thought and we don't know which one is correct.
If you increase the interchange from four to six, there are some who think that would reduce injuries because that means less average game time per player and the load would be spread around more. But there are some who think you might actually increase injuries because players would be less-fatigued and therefore running at a faster pace. So it's this fatigue versus speed trade-off.
Are we ever going to know an answer to that debate? We've trialed it in the NAB Cup.
The answer may be that at some stage, if a change is made, the great thing about having good injury surveillance is you can then follow up the results of any changes. I think that while the advice is conflicting, the AFL will tend to go with status quo and not bring changes into the regular competition.
COLLISION INJURIES
Have you noticed any change in the number of collision injuries?
Collision injuries, in general, have tended to go down and the injuries that are more running-type injuries have tended to stay at a similar level, or even slightly rise in the last few years. So we've moved to a profile that's more fatigue-based than impact-based.
For the image of the game, is a strained hamstring a better look than blokes running into each other all the time?
I think the AFL certainly has that opinion and it's a sensible viewpoint to have. I think the AFL would be more accepting of a player missing a game with a hamstring than a player missing a game with concussion. If faced with the choice I think they'd rather limit the collision injuries.
KNEE RECONSTRUCTIONS
What about the big ones – ACLs?
They're another big injury category and it's interesting that, while we'll be reporting in 2008 in the next week or so, 2009 is shaping up to be a low year for ACLs. We've had a few years that have been moderately high with respect to knee reconstructions and this year I think we only had two in the pre-season. We're probably going to have a low year all up for ACLs because they're more likely in the pre-season.
That sounds surprising, given I can think of Rhys Palmer, David Hille, Josh Hunt off the top of my head.
If you run through the injury lists for each club there's probably only six or seven for the season so far, and at this stage of the year in the last two or three years we've had maybe 10 or 11 by this stage. So we're running a little bit lower. We don't really know why some years are like that, although there's a little bit of a trend with rainfall and wetter years tend to lead to lower amounts of injuries. The drought and harder grounds perhaps might have been why we've had a few higher years the last few years. There's been slightly better rainfall so far this year, although in Melbourne it's only been minimally better than in previous years. But it might have had an impact, which is interesting.
What are your thoughts on the synthetic graft surgery that Nick Malceski employed to repair his knee? Most guys that have suffered an ACL rupture since tend to be going the traditional method.
The Malceski operation, I think, is unlikely to become something that everyone uses. I think that there's an acknowledgement that it's still very early days with that. It's possibly going to be one that is useful for a certain type of ACL injury in a certain type of player.
BATTLE OF THE CODES
You've been involved in both the AFL and NRL for the best part of two decades. With all that experience, can you tell us who's tougher – AFL or NRL players?
Well, they're both tougher than soccer players! I'll stay neutral but they're certainly two of the toughest sports in the world. AFL injuries are more related to running and NRL injuries are more related to contact. So you've got to ask is it harder to run close to a half-marathon every week and cop a few bumps on top of that, or run maybe 60 per cent of that distance and maybe make up to 40 tackles in a game? The amount of contact rugby league players have is a lot greater.
What about other football codes?
Chris Bradshaw, who's the club doctor at Geelong now and who worked in the English Premier League with Fulham, said what a big adjustment it was going between the two codes. He said in soccer there were some games where he'd walk in the dressing room at the end of the game and every player was up, they'd had a shower, were dressed and had all gone -- that was half an hour after the game!
In the AFL or in the NRL, half an hour after the game you'll have six or eight guys with bags of ice on them still sitting in the same spot. Where I guess soccer might make up for it I suppose is they have a very long season, with some of the players maybe having to play over 50 games.
What's been the toughest thing you've seen a player do?
I was the doctor at the Swans when Daryn Cresswell popped his own kneecap back into place and then played the week after. That's about as tough as it gets I think in terms of football experiences. To see a guy pop his own kneecap into place and then as he's sitting on the bench in the second half of the game with his knee already swollen and with the icepack on he looks around and says "I'm gonna play next week with this; I'm not missing a week" and he gets out does it, that's a great example of mental toughness.
What's the typical prognosis for an injury like that?
I think most players would miss 4-6 after a genuine kneecap dislocation where it's out for a few seconds and it has to be pulled back into place. I think you look at 4-6 as your average prognosis there but Cresswell was one of those players who just had an attitude of 'I don't miss games with injury'.
He was a player that maybe even looked down on other players who missed a lot of time with injury. And he just thought that he could continue to play with injury and he wouldn't miss and it wouldn't matter what the doctor said the average person was like.
