PhD Candidate in Applied Physiology at University of Sydney

https://theconversation.edu.au/essendon-faces-a-doping-investigation-but-what-are-peptides-12042

By now you’ll have heard the Australian Sports Anti-Doping Authority (ASADA) is investigating Essendon Football Club. At this stage, there has been speculation about the injection of “peptides” by players in training, without any confirmation that this was the case.

So assuming the speculation has some foundation, what are peptides?

In the literal sense, a peptide is just a very small protein. As might be expected, there are hundreds upon hundreds of known peptides, as many as there can be amino acids combined in short chains. Peptides have a wide range of potential activities, including:

• hormones (insulin and glucagon are both peptide hormones)
• neurotransmitters (such as the endogenous opioid)

There may be no cause for alarm in the case of Essendon, as there are several sports-legitimate and unregulated uses for peptides, per se. Leucine peptides or the hydrolysed protein mixture PeptoPro, for instance, are simply the high-performance cousins of whey protein supplements– essentially, they are “pre-digested” protein fragments designed to aid recovery from vigorous activity.

These substances are no more controversial than ordinary protein supplements. Such peptides can be bought over the counter and require no secrecy.

Certainly, such peptides are never injected.

Worst-case scenario

The ugly and entirely more likely option is that the peptide being speculated about is one from the family of growth-hormone-releasing peptides, of which there are several available: pralmorelin, hexarelin, tesamorelin, or sermorelin, and more.

These various growth hormone-releasing peptides, or secretagogues, stimulate the production of growth hormone by the pituitary gland. This is reminiscent of Lance Armstrong’s drug of choice, erythopoetin (EPO), which stimulates the body to produce red blood cells.

A spike in endogenous growth hormone (which may also be injected directly) is used to aid recovery and muscular growth – and, while not as effective as anabolic steroids for the growth and maintenance of muscle mass, growth hormone has significantly fewer side effects. Significantly, it’s also more difficult to detect.

Suffice to say, these growth hormone-releasing peptides sit squarely in the WADA banned substances list. Much recent research has gone into identifying their patterns of usage, and how the individual drugs might be identified in blood tests.

Where to now?

The current investigation may have broad repercussions. Representatives of the Geelong and Gold Coast football clubs, and rugby league club Manly, have said they employed some of the people who worked for Essendon’s fitness program.

Given ASADA is involved in this case, there is unlikely to be much clemency if any club is found guilty.

Athletes operate under what is known as the “strict liability” clause, which means an athlete is directly responsible at all times for substances that are found in them, regardless of how they got there – and guilty until proven innocent.

The fact Essendon players supposedly signed a consent form or waiver will be of little relevance either way. But it’s unclear what the position is, as so far we are dealing with a report that a program of drug use existed, and not hard evidence of use.

We can assume more information will come to light and, given the high profile accorded to doping cases recently, we certainly haven’t heard the last of this story.

People have been busted for possession and use of growth-hormone releasing peptides before … and that list may be about to get a whole lot longer.

Essendon have come forth in a press conference regarding a possible breach of Australian Sports Anti-Doping Authority regulations.

The belief is that players were asked to sign waivers regarding the club’s fitness program and everything it entailed.

The former Essendon head of fitness, Stephen Dank, left the Bombers in late 2012 following controversy regarding the fitness program. Essendon players experienced a high number of soft-tissue injuries in the 2012 season, which was noted by senior officials including coach James Hird.

The implications are potentially horrifying for Essendon supporters. WADA guidelines are strict, and all performance-enhancing drugs are punished under these guidelines. Any individual player caught under PED regulations will almost certainly be subject to a 2-year ban, similar to the ban handed to former Tour de France winner Alberto Contador. Assuming the entire Essendon playing list from 2012 was involved, you’re looking at the Bombers having approximately a half-dozen players eligible for the 2013 season.

This goes further. Joe Daniher, the prized father-son pick in last year’s draft, could be implicated. If he was involved in an Essendon-run fitness scheme, which is not unheard of for father-son picks, then he could have been involved in a similar PED program as well, and would possibly fall under WADA guidelines as such.

There’s also Jobe Watson’s Brownlow Medal to consider. In the event that Watson is stripped based on events in the 2012 season, Trent Cotchin and Sam Mitchell would thus be awarded the Brownlow jointly. Nevertheless, it is very much a bittersweet affair; past Tour de France winners who were awarded the victory due to the “winner” being stripped due to drugs have said that it is simply not the same; the cheat received all the plaudits and the parades at the time.

The AFL would have to punish all involved. While the former fitness “guru” is no longer with Essendon, if it was found that the coaching staff had knowledge and gave approval to the fitness staff regarding this, you’re looking at a minimum of similar bans for the likes of James Hird and Mark Thompson, if not longer.

Finally, depending on what is found, there are implications that send shockwaves through the AFL. The likes of Angus Monfries and Sam Lonergan, no longer with the EFC but now with other AFL clubs, would also likely be banned if they had any involvement. Questions could be raised about Geelong’s 2007 and 2009 premierships if Mark Thompson is implicated. The legacy of one of the greatest to play the game in James Hird would be tarnished forever.

Discuss on BigFooty.com:

• AFL to investigate Essendon for controversial fitness program.
• Guess the next footy scandal!
• Bombers fans – keep your heads up

The AFL’s approach to illicit drugs was championed as a world leader of drugs-in-sport policy when it was implemented in 2005. It was fair, humane and had been effective in reducing match day and out-of-season positive test numbers, through better player education and frequency of testing.

In recent months however, some cracks have started to appear.

AFL CEO Andrew Demetriou has flagged that the 2012 data will show an increase in positive tests from the six detections made in 2011. And there are evidently wider concerns within some AFL clubs and sections of the media about levels of drug use among players, and the capacity of the current AFL policy to address this issue into the future.

This prompted the AFL player welfare and drug summit held this week in Melbourne, where a number of key stakeholders and drug health experts gathered to take stock of the current AFL illicit drug policy (IDP), and consider options for change.

Judging from the rhetoric and reaction surrounding Wednesday’s AFL summit, the AFL IDP is about to change, and not necessarily for the better.

If the clubs get their way, they will be more involved in player drug testing and managing the outcomes of positive results. Depending on the model implemented, this could represent an impossible conflict of interest – club business pressures versus their responsibilities to player welfare and community, and inequities in club budgets available for drug-testing are just two factors that could create a real potential for abuse of the AFL drug policy.

The other likely changes to the AFL IDP include a tightening of the rules and ramifications around player self-reporting of drug use, and the expansion of off-season hair drug tests to inform the further target-testing of suspect players.

But the most concerning thing to emerge from AFL drug summit is the strong public message being given by many involved: that all instances of illicit drug use require correction or rehabilitation through mental health counselling and medical treatment.

One well-known psychologist at the AFL summit argued for the use of personality tests on players to measure their “addiction potential”, so they could be flagged as likely to have future problems.

Some clubs want earlier notifications if their players test positive, again because they want to help one way or the other. Tellingly, the Collingwood president’s take on it was that “Players with mental health issues need help and support. Those who are smart-arses need to be belted.”

And, former Hawthorn president, Jeff Kennett argued that clubs should be alerted earlier so they could support the player back to a “condition of good behaviour”.

It became clear this week that many in the AFL, and at least some experts, see drug use as a pathology needing a cure.

Such a stance makes sense from a community message perspective. When individual players inevitably test positive it allows the AFL and the clubs to say two things that the community wants to hear:

1. Player X made the wrong decision, is remorseful, and is receiving the counselling and medical treatment that is necessary to correct his problem.
2. The AFL drug policy is working.

However, the problem with the “drug use = pathology” message is that its simply not true. Not all instances of drug use reflect an underlying mental health or medical problem that requires counselling and treatment. We know from the available data that most people who use drugs never encounter major health harms from doing so, and never require treatment or rehabilitation.

But perhaps the biggest issue with the pathologising message gathering pace in the AFL setting is how the players currently using drugs, and perhaps those around them looking on, might interpret it.

As confronting as this will be for some, the experience of most AFL players using drugs has most likely been positive. They would find drugs exciting, pleasurable, fun, and may have also experienced perhaps unexpected enhancements to their performance in various areas (sexual, cognitive, physical, emotional and so on). That is why they do it.

We have to ask ourselves then, what real value is there in publicly framing drug use as a pathology needing medical treatment and cure, while the private experience couldn’t be more different in most cases?

The danger here is that such conflicting messages about drugs serve to teach the players and the community watching them that if you get caught doing something disapproved of like using drugs, you had better confess to having a mental health or medical problem that needs correcting, submit willingly to that rehabilitation you need, and all will be fixed.

Again, for the most part that’s not true, and it’s rarely that simple.

We should by all means put in place the best evidence-based policy structures and treatment options to assist those individual AFL players who do experience health and other problems caused by or related to drug use. A health and welfare focus like the AFL IDP is more effective than a punitive criminalising approach to illicit drug use.

But, we must also reflect on the credibility of the messages that accompany these health and welfare focused drug policies, in sport and in other domains of life.

The broader issue here is that we have a tendency to panic about drugs in our midst. Parents panic about their children using drugs. Teachers panic about drug use by students. AFL clubs panic about their star players using drugs and the damage to their brand and success.

We panic because we remember the terrible cases of lives ruined and lost through drug dependence. Such cases do exist.

We should also remember that drugs and other psychoactive substances have always served important spiritual, therapeutic, economic and cultural functions in our societies. We should remember that some of the most accomplished and celebrated people in history were drug users – authors, painters, poets, musicians, presidents and prime ministers, sportspeople, soldiers and generals and so on.

We must accept that drugs, illicit and otherwise, will continue to shape our society in the future too.

There is no doubt that the AFL executive, the AFL Players Association, and other community leaders have a responsibility to send appropriate messages about drug use and its potential consequences.

The most credible message we can give here is that we have an AFL illicit drugs policy that can privately provide the appropriate health and welfare assistance to players if and when it is needed.

Saying that all people who use illicit drugs require rehabilitation through mental health counselling and medical treatment is not true, and it is not helpful.

Panicking is no basis for effective drug policy.

Brent Macaffer's shin can clearly be seen rotating inwards after a knock to the outside of the knee.

ACL injuries occur in a variety of different ways, but the principles remain the same. The ACL attaches to the inside of the tibia (shin), but to the outside of the femur (thigh).

This means that any force that moves the shin in and the thigh out will place the ACL under stress. Additionally, the ACL sits further forward on the shin and moves backwards up to the thigh. So any force that moves the shin forwards and the thigh backwards will place the ACL under stress.

If you add these scenarios together, you get the ACL’s “perfect storm”: the thigh rotating outwards and the shin rotating inwards. If this happens, the ACL is as good as gone.

ACLs often tear when a force is applied to the outside of a knee, with the foot planted on the ground. This force causes the rotation described above.

Additionally, this force places an enormous amount of stress on the medial collateral ligament (MCL), which runs along the inside of the knee.

On top of all this, the now loosened knee joint often squeezes the cartilage that sits inside the knee joint (meniscus), causing an additional meniscus tear.

When an ACL, MCL and meniscus are all teared in one single injury, this is called the unhappy triad (for obvious reasons). A recent example of this mechanism is the Brent Macaffer injury.

The basic mechanism of an ACL tear.

The ACL can also tear without any contact, when a player pivots and turns on a foot that is firmly planted on the ground. This motion can cause the same twisting as described above, without the need for a bump to the leg.

This mechanism is more likely to occur when the knee is bent, but even then it is fairly rare. A recent example is Mark Lecras’ injury at pre-season training.

After a player goes down with a suspected ACL tear, there are several ways that the club doctor or physiotherapist can tell whether the ACL is actually torn.

The most popular and easiest test to perform is called the anterior drawer test. If you remember from the last article, the ACL is not particularly important for stabilising the knee, however careful examination will show a small amount of instability after the ACL tears.

The ACL helps to stop the shin from moving forward relative to the thigh (remember, this role is vital in converting the pull of the hamstrings into rotation at the knee). If the ACL is torn, you should be able to move the shin forward relative to the thigh. This is a positive anterior drawer test.

Next up in the ACL series we’ll look into ACL surgery and recovery.

Some have come in-game, others before the first ball-up has even been contested.

By my count, we have seen 3 ACL tears and 2 isolated MCL tears this pre-season. If you add to this Max Gawn’s ACL rupture in December, that makes 4 ACL tears since Geelong held the cup aloft in October.

That’s an alarming number.

AFL data reveals that for every club in the competition, there are 0.7 ACL ruptures each season. With the addition of GWS, that means we might reasonably expect 13 ACL tears in season 2012. Does that mean that we’re “4 down, 9 to go”? It seems likely.

Between 2001 and 2010, with 16 teams in the competition, there were between 8 and 14 ACL injuries every year. That represents quite a consistent rate and one that has shown no evidence of improving.

While the debates about playing surfaces, bench rotations, interchange size and the controversial LARS surgery have raged, there have been no significant inroads into the rate and recovery of ACL injuries in AFL football.

A ruptured ACL can happen to anyone, from professional athlete to professional journalist. Many people have had experience with this injury, and many more have held strong opinions.

But what is the anterior cruciate ligament? What makes it so important? How does it rupture? How is it diagnosed? How is it fixed? In the next few weeks, we’re going to bring you the definitive guide to the ACL.

Part 1: What is the ACL and why does it break?

The anterior cruciate ligament (ACL) is a surprisingly unnecessary ligament for everyday life. The knee joint is quite an unstable joint and needs all the stabilisation it can get, but very little of this comes from the ACL.

The quadriceps muscles in the front of the thigh are the most important muscles for keeping the knee stable. As some of you may have experienced, after rupturing an ACL these muscles tend to tighten to keep the knee stable.

The ACL seems to be doing very little, until you start running.

The ACL has several functions, the main one being to make the knee joint flex. When the muscles that flex the knee contract, they pull on the thigh bone (femur) and calf bone (tibia).

Without the ACL, this would mean that the thigh would move backwards on the calf. The ACL holds these bones in place and converts this motion into a rolling motion — instead of falling backwards, the knee bends.

Remove the ACL and the knee simply doesn’t bend properly. The quadriceps can stabilise the knee as much as they want, it still won’t work the way it should and bending will always feels unstable.

Without an ACL: the femur falls back when trying to bend the knee

With an ACL (red): the femur rotates on the tibia when bending

The ACL stops backwards movement of the thigh, while its counterpart, the posterior cruciate ligament (PCL) stops backwards movement of the calf. But why don’t we see so many PCL injuries? Two reasons come to mind: one, the PCL is stronger, and two, the mechanism of ACL injury is much more common.

So, the ACL is important, not because the knee is unstable and you cannot walk without it, but because the knee joint just doesn’t work the way it’s meant to. This failure for the knee joint to pivot the way it should is not 100% vital for everyday life, but becomes exceedingly apparent when trying to play sport.

Why it is injured comes down to the mechanism, which we will explore in the next instalment.

The first game of football for 2012 was a forgettable one for all involved. In a generally scrappy affair, North Melbourne came away with a narrow victory at the expense of an injury headache.

Leigh Adams and Reece Conca clashed heads, with Adams needing to be subbed off with a concussion scare and Conca needing attention to a gash on his face. Neither will see any time on the pine for injuries, but Conca may have a date with the match review panel.

The most concerning incident of the night came courtesy of a heavy blow to the side of Nathan Grima’s knee. The knock resulted in a tear to Grima’s medial collateral ligament (MCL), which will cause him to miss 4-6 weeks of footy.

A heavy blow to the side of the knee can cause everything from bruising to an ACL tear. If the knee is bent and the foot planted firmly on the ground, it will absorb that force by twisting, which places strain on the ACL.

If the leg is straight and not so firmly planted on the ground, it can take the force through the MCL without twisting. Grima’s leg lifted and there didn’t appear to be any rotation, hence MCL was most likely. Being the optimist that I am, I originally suggested that bruising was most likely, hoping that North Melbourne fans would start following me on twitter. No such luck for Grima or my twitter feed.

GWS, Western Bulldogs and Collingwood

Collingwood bore the brunt of the injuries in the second three-way encounter of 2012. Premiership player Brent Macaffer suffered an ACL rupture. Macaffer was hit hard from the side in a scrappy contest. The replay clearly shows Macaffer’s leg twisting, placing pressure on the ACL. These sorts of traumatic ACL ruptures, in contrast to the non-contact injury incurred by Mark Lecras, often produce not merely damage to the ACL, but also to the MCL and the medial meniscus. This makes for a more complicated surgical and rehabilitation process, and greatly increases his chance of chronic knee pain in the future.

Essendon, West Coast and Fremantle

Match-up three provided precisely what any footy fan would hope for: no significant injuries. There were some heads rattled (Matt de Boer and Jack Darling) and lots of big physical contests, but everyone managed to keep their knees out of harms way.

Injuries

Brent Macaffer (Collingwood) – ACL (season)
Nathan Grima (North Melbourne) – MCL (4-6 weeks)

The incident occurred yesterday during training, not long after LeCras was announced in the side to take on cross-town rivals Fremantle this Sunday. The Eagles will now be faced with the option of a traditional ACL repair or the artificial LARS surgery. The LARS surgery could see LeCras return as early as round 8, but research is yet to shed light on the long-term benefits and risks of the LARS procedure.

More to follow.

Hawthorn: Jarryd Roughhead – Jarryd Roughead had a difficult 2011. An achilles tendon rupture in round 12 meant that Roughead had to watch his side edge close to, but ultimately fall short of finals success. To compound matters, 2 months after having an operation to fix his achilles, Roughead developed an infection in the repaired tendon. Complications following operative repair of the achilles tendon are actually not that uncommon and risk of infection is considerably higher than, for example, ACL repair (although, the consequences of an infection in an ACL repair are much more disastrous). Despite this, Roughead and Hawthorn will be satisfied that they have elected for the right option with surgery, where the rate of achilles rerupture is in the vicinity of 2.5%, compared with over 10% in those who don’t receive surgery and allow it to heal on its own. As an opposition fan, I enjoy seeing Roughead wield his massive frame with an unusual amount of grace and poise, and hopefully we all don’t have to wait long in 2012 to see him line up in the Hawthorn colours.

The navicular bone in the foot.

Melbourne: Jack Grimes – James Hird, Shane Woewodin, Tom Williams, Matthew Egan, Hayden Ballantyne and Jack Grimes. What these players have in common is that they have all fractured a small bone near the centre of the foot, the navicular bone. Hird went on to captain a premiership side and capture the imaginations of a generation of football fans – and on the other end of the spectrum, Matthew Egan’s career was sadly cruelled by an injury to this little bone. The navicular bone is a sort of in-between bone, helping to bridge the ankle to the foot: it has to deal with a lot of forces pushing it in lots of directions. Symptoms of navicular fractures are not very alarming, often just a bit of pain in a vague area. Add to this that they are not common across all sports and that there is not much written about them, and you start to see why navicular fractures get picked up so late. Navicular fractures can be treated with a moon boot if it isn’t too bad, or surgery may be required. One of the theories concerning the variability in recovery relates to the blood supply, which is generally poor, but also varies from individual to individual. Grimes had surgery on his navicular early in 2011 and looks set to return early in 2012 after a reportedly solid pre-season. Melbourne fans will be keen to see him running through the banner in round 1, with fingers crossed that his navicular won’t give him any troubles. Only time will tell and with this little bone, it hasn’t been enough time to say for certain.

Port Adelaide: Brent Renouf – With injuries to Matthew Lobbe and Brent Renouf, Port’s already lean ruck stocks look positively anorexic. Both Lobbe and Renouf are set to return early, if not round 1, but if there are two rules to go by with injuries they are to never be too certain and to be even less certain with ruckmen. Renouf has been afflicted with the same problem as Jonathon Patton, patella tendinopathy. Port appear to be taking the more conservative approach with Renouf and avoiding that Swedish knee surgery. Generally speaking, patella tendinopathy has a limited course and resolves with time, rest and subsequent strengthening, but when it becomes chronic it is a debilitating condition for a professional athlete to endure. Renouf will be looking to have a big impact at his new club in 2012 and Port will be keen for their experienced recruit to shoulder much of the rucking duties. They will both be hoping that injury does not limit this.

North Melbourne: Daniel Wells – North are a tough team to write about on the injury front, and their fans should be grateful for this. It’s been known for a long time that North have been building a promising and talented midfield and ruck group. The problem they’ve had is with getting all that talent fit and in form all at the same time. At last they have had an almost dream pre-season and we may see the true potential of this squad. But there’s a catch. As I have written about elsewhere, North’s talented midfield group will be without Daniel Wells as he finishes his 6 months on the blood-thinning medication Warfarin. Wells will not be ready to go as soon as he ceases the medication. After he stops the medication, his blood clotting will be tracked and once it reaches a safe level he will be allowed to start contact training. It’s going to take some time for him to train up to match conditions. I will be waiting until around round 5 before I get too excited about watching North’s midfield group at full flight.

Richmond: Jack Riewoldt – Richmond are the team you want to support right now, at least in terms of injuries. The biggest problem they’ve had is booking all of Jack Riewoldt’s surgeries. He has had hip, finger and ankle surgery. The ankle surgery was for a damaged left ankle that appeared to have restricted him in 2011. The hip surgery was essentially to remove loose cartilage and clean up the joint to minimize hip pain – an increasingly popular surgery in AFL post-seasons. All this has meant a restricted, but encouraging pre-season for Riewoldt. Where his ailments appeared to restrict him at times in season 2011, after a pre-season focused on getting his body ready for another long season, I’ll be watching for a dominant Jack Riewoldt as the Tigers make their claim for a finals birth in 2012.

St Kilda: Lenny Hayes – At last we come to an ACL. Lenny Hayes, the engine room of the St Kilda midfield, summarised St Kilda’s disappointing 2011 season with a single torn ACL. Hayes and St Kilda opted for the traditional repair and not the LARS, probably with his post-football life in mind (long-term outcomes for LARS are more of an unknown). His recovery appears to be tracking nicely and if positives can be gleaned, they probably centre on the relatively older age of Hayes. He will likely suffer no chronic consequences of an ACL injury during his playing years, which is a plus for St Kilda fans keen on seeing Hayes run out his career in top form. From all reports coming out of St Kilda, Hayes has recovered well and is vying for round 1 selection.

Sydney Swans: Nick Malceski – Poor Malceski had a horror run in season 2011. It all started with a pre-season ACL tear, for which he had his second LARS surgery to the same knee (right) and his third ACL repair in total. After a swift return in round 9 all was looking good, until recurrent groin pain restricted his output in the second half of 2011. After a full pre-season, Malceski will be looking to put in a strong showing for a young Sydney side that looks fast and attacking. The youthful brigade up forward and through the middle appears to be developing well, with Sydney’s traditionally strong defense the notable key to creating a formidable end-to-end side. Malceski will need to test both his groin and his knee this season to create invaluable run out of defense. Should he have an injury in season 2012, Sydney fans should rest assured that Malceski’s history of recovery is almost suggestive of mythical healing powers, even by LARS standards.

Right leg: typical forces in an ACL tear

West Coast: Mark LeCras – I was going to dedicate this section to the renaissance man of 2011, Andrew Embley, who experienced a subluxation (partial dislocation) of his shoulder two weeks back. I will leave the shoulder subluxation spiel for another time and instead turn my attention to the big injury scare of the moment: Mark LeCras. LeCras, a perennial favourite of Eagles fans and opposition fans alike, came to grief yesterday during training. Vision of the incidence shows LeCras collapsing to ground after pivoting to his left off his right knee, which was in a relatively extended position. Unfortunately for Eagles fans, this is almost the classic description of a non-contact ACL tear. On the flip-side, this is almost the classic description of a lot of other knee injuries, all of which are less serious than an ACL tear. Weighing this up and given the mechanism of injury and the way he was walking afterwards, I would err on the side of an ACL. The Football World awaits the definitive results of LeCras’ scans with eager interest. Alternatives to an ACL injury include meniscus and medial collateral ligament tears. Depending on the grading, these injuries could mean anything from a round 1 return to 8 weeks on the sidelines. Of course, 9 months with an ACL is what we all fear – and I’m 75% sure that is what it is.

Western Bulldogs: Adam Cooney – I would have loved to write about Brian Lake’s battle with injury, but every time I sat down to write about Lake I was plagued by two problems: the number of different injuries Lake has been battling and how many of these injuries remain a mystery. Instead I have decided to shed some light on Adam Cooney’s battle with chronic knee pain, which restricted the Brownlow medallist to just 13 games. Cooney suffered a heavy blow to his knee, fracturing his patella in the 2008 qualifying final against Hawthorn. High-energy impacts on the patella tend to cause horizontal fractures that can easily separate, requiring surgery to hold the two fragments together. There are many ways to fix a patella fracture, unfortunately none of them greatly reduce the risk of developing chondromalacia patella, a painful condition in which the patella scratches against the cartilage it sits on. The only solution is regular surgery to smooth the patella surface or to remove the patella (not an option for any sportsperson). For Adam Cooney, this is a career-long issue, all he can do is learn how to manage it the best he can, which includes slimming down and optimising his recovery.

Adelaide: Ben Rutten – Adelaide appear to have escaped with a relatively injury-free pre-season. The biggest question mark entering the NAB Cup is over the fitness of Ben Rutten, who had surgery on his foot earlier this month. Rutten has had an up-and-down battle with plantar fasciitis throughout the summer. Plantar fasciitis is thought to be caused by tiny tears in the plantar fascia, a sheet of tissue that supports the sole of the foot. When the plantar fascia is stretched (in walking and flexing the toes upwards), the tears are stretched, causing pain. If the condition is not relieved by rest, detaching the plantar fascia from the heal bone can be done to stop it from being stretched. This procedure is not without complications and I will certainly be keeping a close eye on how he runs out games in season 2012.

Brisbane: Daniel Merrett – Merrett developed a stress fracture in his spine halfway through last season and has been on the sidelines since. If the Lions are to climb the ladder in season 2012, a much improved defensive performance is necessary. In the 11 games Merrett played last year the Lions conceded an average of 89 points per game, compared to 115 per game after he was sidelined, underlining his importance to the young side. Stress fractures of the spine are not a common injury in AFL, so much of our knowledge comes from cricket, where on average upwards of 4 first-class fast bowlers are diagnosed with stress fractures of the spine every year in Australia. Recent studies suggest that, in fast bowlers, certain actions that place more side-to-side stress on the lower back increase the risk of these injuries. Unlike conventional fractures caused by random events, stress fractures are often related to physical risk factors and so it is important not just to heal the fracture, but to eliminate the risk of recurrence through physiotherapy and retraining of certain movements and posture. Signs are looking good for Merrett and after a long preseason with the Lions sports science team, Lions fans should be optimistic that he can anchor their defense in 2012.

Carlton: Chris Judd – Is any footy list complete without Chris Judd? Judd’s shoulder troubles are well documented and this pre-season has been nothing out of the ordinary for Judd. After developing shoulder pain through the early stages of the pre-season, Judd had scans which prompted his surgeon to perform a “tweak” to the shoulder rather than a reconstruction. What I can gather from the scant reports is that Judd had some degree of impingement to the rotator cuff muscles, which was released. Rotator cuff impingement usually occurs as the tendons of the rotator cuff muscles pass under the acromion process (the “A” part of the famous “AC joint”). This causes pain and restricted movement. Once a release is performed, symptoms subside fairly quickly and complications are minimal. This is all good news for Carlton fans, who will be hoping that Judd can lead their star-studded midfield all the way to October.

hip adduction

Collingwood: Alan Didak – Regardless of whether you think he’s past his prime or not, we all have to begrudgingly admit that a fully fit and inform Alan Didak would’ve been pretty handy in Collinwood’s attempt at a premiership defence in 2011. Likewise, if he can recapture his best form and fitness in 2012, Didak will be important in Collingwood’s tilt at a 2^nd premiership in three years. Those are some big “ifs”. Didak tore an adductor two weeks out from the Nab Cup and will be managed fairly conservatively. At this stage of his career, Didak will want to do everything in his power to prevent that injury from becoming chronic, which would do seriously hinder his chances of recapturing top form. The fact that there are numerous adductor muscles (if you’re in the lucky 33%, you even have one extra) means that there is no appreciable loss of function at the hip for most adductor tears. However, the action of hip adduction is used so frequently and the pain so intense, that any problem with the hip adductors is tough to ignore. Collingwood will keep Didak in cottonwool through the NAB Cup and will probably give him plenty of time to train up to full fitness before he has his first start a few rounds into the season.

As your hands glisten from the chlorhexidine solution that you used to remove the Staphylococcus bacteria from the patient in bed 4, you may just walk past Chris Judd. You might even shake his hand. You will, of course, then return to your ampoule of antiseptic, for even Brownlow Medallists have germs and even AFL footballers get sick.

Daniel Wells was one of those fit young people who passed between the chemical-washed walls of a Melbourne private hospital at the end of a long and weary AFL season. In fact, I tell a lie, Wells had his surgery before the end of the season – it was reported on the Kangaroos website in late August that Wells would have his shoulder surgery and sit out the rest of the season, which he did. According to the Kangaroos, they wanted Wells to have his surgery performed and rehabilitation completed in time for their pre-season training camp in sunny Utah, which he did. Where’s the story? A footballer had surgery, underwent post-operative rehabilitation and did all this in time to prepare for the next season. There is nothing exciting or “special” here. But there is never anything “special” about what happened to Wells – he got sick, he became a patient.

Every surgery has its risks. Some of those risks play out on the operating table, others manifest themselves playing Angry Birds in the hospital bed, and some take even longer. At some point between shoulder surgery and putting his feet up on the couch at home, Daniel Wells became unwell. He went in for routine surgery (an unsettling term for any medical professional to use) and developed a complication. Clots that most likely developed in his legs had travelled through his veins and to his lungs, causing him chest pain and difficulty breathing (now is the time to panic).

Blood is a phenomenal thing. It carries cells that can fight off infection and electrolytes that keep nerves firing, it filters out the waste and carries all the nutrients. Despite all this, what we think about most when we consider the role of blood is really quite a bland and simple thing: it delivers oxygen. But this is the most immediate of blood’s roles, the one that keeps you alive, not from day to day or year to year, but from second to second. It does more than this, oxygen doesn’t simply keep you from dying, it keeps you running, jumping, kicking and winning games of footy. If I may opine, for a footballer, blood is the key to all their success. A footballer’s blood and, more poignantly, its ability to deliver high volumes of oxygen at a very fast rate, distinguishes them from the mere mortals. When Daniel Wells’ blood started to clot, it was a serious matter for his football future. But then, it is a serious matter for anyone’s future.

Pulmonary Embolism is the term we use to refer to blood clots in the lungs or, when it all seems like a mouthful (it always seems like a mouthful), we simply call it a PE. The fact that blood clots occur in the lungs is not simply a matter of chance, it’s almost a matter of destiny. PE’s do not originate in the lungs themselves, but most often start in the legs. For over 100 years doctors have been quizzing medical students on the three key factors (known as Virchow’s Triad) that lead to blood clots, and for over 100 years the students have been answering that question correctly (you don’t need to be a fast learner in this game). In a nutshell, blood has to have some chemical tendency to form clots, it has to be moving slowly and there has to be some level of damage to the walls of the veins (on the micro-scale). Blood clots form in the legs because, all the way down there, blood doesn’t move very fast. When these blood clots form, they can dislodge and travel up to the heart, where they are pumped into the lungs.

If blood is the engine that powers the Titanic, then the lungs are the workers shovelling the coal for 6 cents an hour. The lungs serve a single purpose: to get oxygen into blood. Blood enters the lungs without oxygen and exits the lungs full of the stuff. Blood clots enter the lungs and that’s where they stay.

Without swift action, and sometimes even with it, a blood clot in the lungs is a deadly thing. Small clots might not be noticeable, until you start to run. Something’s not right, there’s not enough oxygen in your blood and you start to puff after only a few metres. Bigger clots might give you chest pains, you might start gasping for air – you haven’t even gotten up off the couch. The biggest clots require swifter action. These clots are stopping blood from getting to your heart – it’s the same effect as having a heart attack, but even worse. Your blood pressure drops through your boots, your heart is beating but it has no blood to pump. Right now, you need to be in a hospital, and even if you are, ‘luck’ is the treatment of choice.

Evidence shows that when a person has blood clots, even in the absence of an identifiable cause, they are at increased risk of developing more clots. To alleviate that risk, the standard treatment of PE’s includes not simply treating the clots, but using medication that makes it harder for new clots to form. Then, once all seems well and the nightmare is over, they’re left on that medication for up to six months.

In a recent interview with The Age, Wells spoke of his experience. “I didn’t feel like I was going to die at the time, but everyone was saying I could have” he said. The risk with a PE is not so much that it will turn from something more benign to life-threatening. It may be that the clots on Wells’ lungs were never going to threaten his life. The concern is that it could happen again, and that the next time it could be much more devastating.

For Daniel Wells, this has meant a protracted stint away from contact training. You see, a drug that makes it harder for blood to clot will make it easy for the opposite to occur: bleeding. In fact, sometimes this drug isn’t used, when the risk of bleeding is greater than the risk of clotting. Politics is often described as the balance of competing interest. Medicine is the balance of competing risks. For Wells and his doctors, the risk of having another PE is something they’re not willing to leave to chance.

In medicine, like in football, teams must work together towards a shared goal. The doctor in emergency collects the patient and rebounds from a difficult spot, she passes it on to the doctor on the ward who takes on a few hospital administrators (the opposition) to get the patient a bed. This doctor now passes it on to the radiologist, who sizes up the situation and then delivers it to the surgeon. The surgeon lines up the problem and then with full-forward-like precision, viola! It’s not always as smooth as that, but with a bit of coaching and a solid game plan, it can work pretty darn well. This, of course, is where the similarities end. The most glaring difference between medicine and football is significant: to get from emergency to theatre and out, medical professionals must make every effort to avoid and alleviate risk; for a team to move the ball from the backline to the forwardline and then through for a goal, footballers must take risks.

As the pre-season starts and the first bruising tackle is laid, cast your thoughts to Daniel Wells sitting on the sidelines. He’s not injured, he’s not sick. Maybe this is even the fittest he’s ever been. He’s just another patient avoiding a risk, rather than a footballer taking one.