Tricks of the trade to keep bloodied AFL footballers in play

Blood flows from the midfielder's face. He's guided off-field into the change-rooms where his stained guernsey is removed.

There's no signs of concussion and the phone is ringing.

The coach wants a status report. He wants his star player back on the field as soon as possible.

AFL doctors clean the cheek laceration with antiseptic and inspect it. The player's face is injected with a local anaesthetic mixed with adrenalin to restrict blood vessels.

Bang bang bang — surgical staples are applied and the wound is covered with a zinc oxide and adrenalin paste.

The player is sent back into battle and just two minutes have passed since he was floored in a contest before 60,000 spectators.

"It's just like a pit stop," AFL Doctors Association president Andrew Potter explained.

"But sometimes it's not so easy."

Club doctors with long-term risks in mind

Dr Potter retired from the AFL in October last year after 20 years with the Adelaide Crows — 10 years as senior doctor. Prior to that he spent 10 years with the Norwood Football Club (SANFL) and seven years with the Millicent Football Club.

During that time he also spent 20 years with the Australian women's hockey team.

"Rather than watching the ball, you have to watch where the ball's been, to see who's left lying on the ground," Dr Potter said.

He has seen everything from a ruptured testicle to a fractured skull, but it is the minor injuries that need to be dealt with under pressure that also keep AFL doctors on their toes.

"A footballer's return to play always depends on, are we going to make this injury worse?" Dr Potter said.

"They have to have good function. They have to be able to contribute to the team, but most importantly, from the player's point of view, are we going to make the injury worse and keep them out for two or three weeks by sending them back on?"

Head lacerations and concussion

"The problem with any laceration is you get bleeding and in all sport you have the blood rule," Dr Potter said.

"The players have to come off the field and they have to remove any sign of blood, not only from around the wound, but also on the uniform."

He said a lot of clubs would bandage their players up and send them back on but it was not a practice embraced by the Crows.

"It can't be good for player function if you're running around with this bandage all over you."

He preferred surgical staples, which would be removed after the game and proper stitches put in place.

"But with any head laceration, it is really associated with a head knock, and that then brings us into the concussion gear," Dr Potter said.

Players had to be assessed for concussion before they could be brought back on, with tell-tale signs including a loss of consciousness and the "rag doll" look.

"When they fall, if they lose head control, they just seem to flop," Dr Potter said.

"They can look dazed, stunned, and not know where they are. They can be slow to get up after they've fallen and they may also lose their way."

He said new guidelines on concussion checks would soon be released and would incorporate more reliance on video replays to assess the type of knock a player received.

Broken noses

Dr Potter said broken noses caused two main issues — pain, which obscured vision due to tears in the eyes, and "a lot of bleeding".

"What we tend to do is take the guys down into the room and, while it's still hot and relatively numb after the fracture, you can actually push it back in, just using your thumbs," he said.

"It sounds brutal and it goes crunch, but it actually does reduce the bleeding, the swelling and the pain.

"You may not get it perfect, but you'll get it good enough to allow them to function.

"But if it's really bad, you'd get surgery within the next week or 10 days, or wait to the end of the season or indeed to the end of their career.

"Because once you have to repair stuff inside there, if you break it again, your chances of getting a good repair next time are greatly reduced."

Dislocated fingers

Dr Potter said dislocated fingers were relatively common and usually involved the first joint of the fourth or fifth finger.

"We would reduce that [put it back into place] and would always check for fractures at the time," he said.

"If it doesn't clinically look like a fracture, we would strap it to the adjacent finger, using the longer one, so it protects it and they can still function pretty well on the field.

"The follow up from that would obviously be icing, and we'll always do an X-ray during the week."

Dr Potter said dislocated fingers were relatively common and usually involved the first joint of the fourth or fifth finger.

"We would reduce that [put it back into place] and would always check for fractures at the time," he said.

"If it doesn't clinically look like a fracture, we would strap it to the adjacent finger, using the longer one, so it protects it and they can still function pretty well on the field.

"The follow up from that would obviously be icing, and we'll always do an X-ray during the week."

Finger in the eye

Dr Potter said there were three different types of eye injury that most commonly occurred.

The first was a scratch across the cornea, which they assessed by dying the eye with fluorescein.

An antibiotic ointment would then be applied and a patch put over the eye.

The second was bleeding in the eye that could lead to glaucoma, or pressure on the eye, and loss of sight.

"The third thing that's really bad is they can get retinal detachment — they get a little bit of retina come off," Dr Potter said.

"So anyone who has persistent blurred vision, we wouldn't let them back on until they've been checked properly by an eye specialist."

Traumatic iritis, of inflammation of the coloured part of the eye, usually caused by a finger poke, also occurred, as well as blepharospasm — a spasm of the eyelid muscles.

"That [blepharospasm] frequently settles within a short period of 20 minutes to half an hour," Dr Potter said.

Corked thighs

Dr Potter said a corked thigh, or muscle contusion, was "probably the most common" minor injury that occurred on field during an Australian rules football game.

It might involve muscle bruising, but it could also include muscle bleeding.

"Sometimes they keep going, they'll run it out. Other times, if it's quite severe and they're having trouble, that's where the interchange bench has been quite useful for us," Dr Potter said.

If it was assessed that the player was finished for the day, the muscle would be compressed to reduce its bleeding and strapped with ice. But if they are to go back on, the muscle would be compressed and ice avoided because it cooled down and contracted the muscle.

Hamstring and muscle strain

Dr Potter said hamstring strains were the number one injury in AFL but their assessment could sometimes be "tricky".

He said players might come off and say their "hammy" feels a little tight, but they did not remember what might have caused it.

"Other times they would say they were 'chasing somebody or I stretched and I felt this sudden pain in the hammy'."

If it was assessed as muscle strain the player would not be allowed back on because it would only make it worse, which applied to quadriceps as well.

Dr Potter said hamstring tightness could also be related to a back injury.

"If there's any doubt and we think it's probably OK, we will test their function."

This might include getting players to run up and down in the change-rooms or putting them back on the field to be assessed carefully.

"When they come off from their next rotations and say it's not working very well, you say, 'you're better off pulling the pin on this one rather than making into a four-to-six-week injury'," Dr Potter said

Strangest injuries

Dr Potter said it was often the way an injury happened that made it "unusual".

"I had a player who lost a testicle in a contest. He had to have it surgically removed because we knew it was ruptured — an accidental knee," he said.

"We also had a guy who had a fractured skull from an accidental contest at training and he then had to give up footy.

"We've had really nasty scalp lacerations. We have a fractured cervical spine, a broken neck, we've had all sort of things.

"But every year we used to see an injury we haven't seen before, and you look up the literature and there's 20 reported in the world, so it's just fascinating the different stuff you'll see.

"Often it's difficult to know if those need surgery or not."

Pressure from AFL coaches

Dr Potter said there was always pressure to get a player back onto the field, some of it up front, some of it more subtle, but coaches on the whole were generally understanding when a player was genuinely injured.

"Most of them, once you've given them a detailed explanation, are quite OK," he said.

He said their role as doctors meant the players' wellbeing had priority and they could not be "club servants".

But he added he had never received pressure from a coach when a case involved potential concussion.

"In the heat of the moment the coaches get as wound up as anybody, but I've never had any coercing with regard to concussion," Dr Potter said.

Team environment second to none

What Dr Potter enjoyed most about his role as a football doctor was the team environment and the "comradery" between other doctors and physios.

"The doctors all know each other and talk to each other before and after the games, and assist each other if we have problems," he said.

"It's not like treating cancer or heart attacks. But in fact, what we're doing, is helping people to achieve their goals and do what they want to do.

"We're assisting people to achieve what they want to achieve."