NRL Casualty Ward: Storm's All Stars gun sidelined

THERE'S been absolute injury carnage with the NRL All Stars game and first round of NRL trials resulting in nine additional players entering the casualty ward with Round 1 just three weeks away.

In latest news:

* Melbourne gun Brandon Smith faces six weeks out after suffering a facial fracture playing for the New Zealand Maori

* Test players Wade Graham (ankle) and Dallin Watene-Zelezniak (back) have been cleared of serious injury.

* Bulldogs forward Chris Smith has been cleared of a full ACL rupture but will still miss plenty of time.

* Dragons forward Josh Kerr had just come into cheapie calculations following news he would take big minutes from James Graham, but he suffered a knee injury for the Indigenous All Stars.

* Warriors prop Jackson Frei was in line for a Round 1 bench spot following Bunty Afoa's ACL injury, but he suffered a knee injury of his own.

BLOW FOR STORM AS BRANDON SMITH SIDELINED

The Storm will be without Brandon Smith for the opening rounds of the NRL season.

On Tuesday, Melbourne revealed Smith suffered a facial fracture during his man-of-the-match performance for the New Zealand Maori.

He will be sidelined for four to six weeks.

ORIGIN STAR CLEARED OF ANKLE INJURY

Wade Graham left the NRL All Stars game late after a tackler fell awkwardly on his lower leg, causing an external rotation (outward twist) of his foot. However, he on Monday confirmed he only left the field as a precaution. He will likely play in the Sharks' final trial v Manly this weekend.

- David Riccio

DWZ SENT TO HOSPITAL, LATER CLEARED

Maori captain Dallin Watene-Zelezniak required a hospital visit for precautionary scans after suffering a back haematoma. The Bulldogs provided this update on Monday: "Dallin suffered back bruising while representing the Maori All Stars last Saturday night, however, there was no serious injury and he will travel to Port Macquarie with the Bulldogs squad and be assessed in regard to playing in Saturday's trial match against the Raiders."

TRIPLE ACL DRAMA

The most significant injury concerns involve the three most dreaded letters in the injury alphabet - ACL.

Thankfully, Bulldogs forward Chris Smith has been cleared of a full rupture. "Chris suffered a complete tear of the medial ligament in his knee and a partial tear of the anterior cruciate ligament," the Bulldogs said on Monday. "He will undergo surgery later this week. An assessment of his recovery period will be made after the surgery but he will miss a minimum of 12 weeks."

Cameron King will undergo scans in the coming days after suffering a suspected ACL tear.

Sharks hooker King took a run from dummy half, and after pivoting off his right foot collapsed to the ground almost immediately. This non-contact, change of direction injury mechanism is the most common way ACL ruptures occur (70-80 per cent of all ACL injuries are non-contact), and with King having suffered the same injury in 2014 he was clearly devastated as he left the field.

The manual testing medical staff can perform both on field and in the sheds is extremely accurate at assessing the integrity of the ACL.

Special tests are performed that put the knee under stress in certain directions whilst in specific positions, and the amount of instability present in the knee during these tests provides medical staff with valuable information regarding the nature and severity of the injury. Unfortunately when it comes to ACL injuries MRI scans often confirm what the medical staff already suspect, and with both players' initial assessments suggesting a rupture of the ACL this is extremely unfortunate.

If the worst case is confirmed, both players will likely undergo ACL reconstruction surgery, which comes with a 6-9 month recovery period in the NRL. There has been growing evidence, with some isolated cases in professional sports, that in the right circumstances athletes can opt against surgery and undergo rehab to successfully return to sport after suffering an ACL rupture. This is yet to be attempted by an NRL player but is something to look out for with several ACL ruptures already this year.

While not announced as a suspected ACL injury, there is significant concern Warriors forward Jackson Frei suffered a similar fate. In almost identical fashion to King, Frei collapsed immediately after an explosive change of direction during a hit-up.

He went to the ground in considerable pain, and it would not be surprising to hear Frei has undergone scans to assess for the presence of an ACL injury.

YOUNG TRIO COP KNEE INJURIES

Young Warrior Phillip Makatoa also suffered a knee injury. The knee ligament injuries continued with both Sione Mata'utia and Josh Kerr suffering suspected MCL injuries and ending the day in protective knee braces. As with the ACL, there are accurate tests the medical staff can complete to rule out any secondary injury to other structures in the knee, so if scans confirm the provisional diagnosis the general recovery times for the different grades of MCL sprain are:

Grade 1: 1-3 weeks

Grade 2: 3-6 weeks

Grade 3: 6-10 weeks

Both players will be hoping for a minor grading to give them a chance to be fit for Round 1. Kerr is of most immediate concern with reports of a potential high grade injury, whilst the presence of a knee brace for both players usually indicates at least a grade two sprain.

ROBERTS A CHANCE FOR ROUND 1

Tyrone Roberts failed to finish the All Stars game due to an achilles injury. Whilst an achilles rupture is a significant injury that requires surgery and 5+ months recovery, there was hope Roberts avoided this. He has a history of achilles issues over the past two seasons, and a minor aggravation is the best case scenario for the Titans' half. If confirmed this could still cost him a few weeks recovery, but would give him a chance to play in the opening round.

DREADED SYNDESMOSIS STRIKES

The week leading up to the trial games wasn't free of injury, with multiple NRL players requiring surgery that will cause regular season absences.

Dylan Edwards and Taniela Paseka both underwent surgery after suffering high grade syndesmosis injuries (high ankle sprains). Whilst advancements in the surgery and rehab from this injury has allowed recovery within SIX weeks over the past season, both players are expected to miss around eight weeks. The usual recovery time in the NRL is 8-10 weeks.

WARRIORS FORWARD SUFFERS ACL INJURY

Bunty Afoa's 2020 season is over after suffering an ACL rupture during training. The Warriors have confirmed the forward will undergo surgery in two weeks' time with the minimum six months recovery period effectively ruling him out for the season.

The two week delay until surgery is a common one in ACL reconstructions with the goal often to let the knee "calm down" first; settle the inflammation, improve the range of movement and get the muscles firing around the knee. This provides clear benefits for post-operative recovery.

LODGE'S SEASON NOT OVER YET

Matt Lodge sent a massive scare through the Broncos as reports came in mid-week that he too suffered an ACL injury at training. Whilst ACL injuries are most commonly complete tears/ruptures (up to 90 per cent of all ACL injuries), Lodge was fortunate to only suffer a partial tear. It was then revealed Lodge played with a partially torn ACL since 2015.

Unlike other knee ligament injuries a partial tear of the ACL does not guarantee surgery is not required. Rather than looking at the ACL itself and the severity of the tear, the knee joint as a whole is assessed to determine whether it is functional (stable) or not (unstable).

An ACL can be 60% torn, but the knee joint itself remains functionally stable (doesn't give way when changing direction etc). Conversely there can be a 20 per cent partial tear that results in constant episodes of giving way and instability. This instability can bring great risk for further injury to structures in the knee, which can have both short and long terms consequences for the athlete's health.

If knee stability is maintained surgery can often be avoided, and the initial prognosis for Lodge is he is able to do so. He will undergo an intensive rehab program to reduce swelling, improve range, build the strength back up and improve the dynamic stability in his knee joint. If this is successful return to play is often achieved within 2-3 months.

The initial signs for Lodge are definitely positive, successfully avoiding surgery for this injury in the past and recent review with an orthopaedic specialist identifying rehab as the best treatment option. However there is still a chance that surgery could be required. Recent evidence suggests that up to 40 per cent of partial ACL tears treated non-operatively progress to a complete rupture, with that number increasing to 75 per cent if the athlete plays pivoting contact sports.

Lodge has months of hard work ahead of him in the hope he can avoid the growing list of NRL players requiring ACL reconstruction surgery in 2020.

DRAGONS HOOKER HIT FOR SIX (AT LEAST)

The Dragons have copped a bitter blow ahead of the 2020 season with skipper Cameron McInnes ruled out for 6-12 weeks with an MCL tear.

McInnes suffered the knee injury during the NRL Nines and is expected to miss all of the club's trials and at least the first few matches of the regular season.

The injury could propel Issac Luke into contention for the starting spot at hooker, with Fijian international Joe Lovodua expected to come in on the bench.

In better news for the Dragons, fullback Matt Dufty is expected to miss just four weeks following surgery on a broken cheekbone, putting him in contention for Round 1, while Korbin Sims has been cleared of any fracture to the forearm but will still review with a specialist.

The two other players to fail to finish the Nines, Cody Ramsey (shoulder) and Tyrell Fuimaono (undisclosed), will be fit to start the season.

ROOKIES IN LINE TO FILL MANLY'S $2M HOLE

Manly will be forced to start the 2020 NRL season with more than $2 million of forward talent on the sidelines after another key front-rower underwent surgery on Monday.

The Daily Telegraph can reveal that boom young forward Taniela Paseka suffered a syndesmosis injury during the NRL Nines, which will sideline him for eight weeks.

Paseka, 22, was set to earn a starting spot in Manly's pack following injuries to Jake Trbojevic and Addin Fonua-Blake.

But the high ankle sprain, suffered during Manly's quarter-final loss to the Gold Coast in the NRL Nines in Perth last weekend, means the 197cm, 120kg giant will miss the first four rounds of the season.

It adds to a horror toll for the Sea Eagles.

There are suggestions Trbojevic will not be available until round three, while Fonua-Blake could be a week later after they both underwent off-season shoulder reconstructions.

COWBOYS CONFIRM McGUIRE MENISCUS INJURY

Scans have confirmed Cowboys forward Josh McGuire suffered a torn medial meniscus in his left knee in Saturday's NRL Nines quarter-final against South Sydney.

McGuire has undergone surgery and is expected to return for Round 2.

LOWE BLOW FOR RABBITOHS

Rabbitohs forward Ethan Lowe also suffered an MCL sprain at the Nines but he is expected to be fit for Round 1.

MOMIROVSKI SET FOR ROUND 1

The NRL's first potential player swap deal became more complex as Paul Momirovski suffered an ankle sprain in the Tigers opening game of the Nines.

The outside back was initially unable to bear weight through his left foot as he came from the field, with the way the injury occurred bringing concern for a high ankle sprain (syndesmosis injury).

Thankfully by late Friday night he was able to walk on that ankle. However after leaving the ground in a moon boot and on crutches the Tigers announced Momirovski was expected to miss 2-3 weeks. This won't affect his availability for the regular season but adds another element for the Storm to consider as they attempt to negotiate a swap deal for Harry Grant.

MORE INJURIES ...

Panthers back-up hooker Mitch Kenny should be back in full training by early March as he recovers from off-season elbow surgery, and will be available for selection in the early rounds of the NRL regular season.

Matt Moylan is still not back in full training after four hamstring injuries restricted him to 11 games last year. He's ready to go but the Sharks are taking a conservative approach with his rehab and formulating a "back-up plan" if Moylan can't go at any point this season.

Jack Gosiewski had off-season surgery on his lumbar spine which involved having a vertebrae shaved to relieve pressure on a disc. There are many different spinal surgeries with varied recoveries depending on surgery type, location and severity. There is no word from the Sea Eagles on an expected return date as yet.

Warriors winger David Fusitu'a missed the NRL Nines after suffering hamstring injury in pre-season training. While minor in nature this is an injury he has suffered multiple times in the past 12 months so will be one to keep an eye on as we get closer to Round 1.

Bulldogs skipper Josh Jackson missed the Nines as he continues his recovery after surgery on broken nose. While it's rare to require surgery for a broken nose it usually doesn't require an extended recovery. There is an increased risk for re-injury, but Jackson would expect to be fit to start the season.

JAMES SUFFERS ANOTHER DEVASTATING BLOW

After suffering a devastating ACL injury last month Ryan James has undergone an ACL reconstruction as well as a meniscus repair and a lateral tenodesis, which is a procedure that "tightens" the outer aspect of the knee to improve stability and help protect the ACL graft. Overall this is used to reduce the risk of re-rupture, particularly in higher level athletes.

James opted to use a quadriceps tendon graft in his ACL reconstruction surgery. The hamstring tendon graft has traditionally been more common, but the quads graft is growing in popularity. Some studies have shown reduced knee pain in the early stages of rehab post surgery, and comparable failure rates to hamstring grafts.

BATEMAN MAY MISS SEASON START

Paul Crawley reports that the Raiders have suffered a significant setback with fears star backrower John Bateman will miss the opening weeks of the 2020 NRL season.

Bateman is in doubt for Canberra's season opener on March 13 after undergoing shoulder surgery last week.

The Raiders have been tight-lipped on Bateman's likely return date, saying in a statement "at this stage, there is no set date for his return and it will be assessed closer to the commencement of the season".

While the best-case scenario is that Bateman could be ready for the opening round, it is feared he is more likely to miss several weeks.

- Paul Crawley

SHOULDER SURGERY DOMINATES OFF-SEASON

Even though two significant ACL injuries have dominated the NRL injury headlines in recent weeks, this has otherwise been the off-season of shoulder reconstructions.

If they are able to players will often opt to delay shoulder reconstruction surgery on a niggling shoulder injury until the off-season. This allows them to finish the season on the field, but requires diligent rehab for three to six months to recover completely from a surgery that reconstructs and stabilises the shoulder joint.

Players who underwent shoulder reconstructions include; Kieran Foran, Jake Trbojevic, Addin Fonua-Blake, Manase Fainu, Isaah Yeo, Kerrod Holland, Dale Copley, Shannon Boyd, Morgan Boyle, Karl Lawton, Wayde Egan, Waqa Blake, Cody Walker, Jed Cartwright and Jason Saab.

The majority of these players underwent surgery early in the off-season, and while it may take them a few games to gain that all important match fitness they would otherwise be expected to be fully recovered come Round One. However some did not have surgery until November and December, which will have implications on their ability to start the season.

KIERAN FORAN OUT LONG TERM

Kieran Foran won't return to the field until June after undergoing a shoulder reconstruction and rotator cuff repair. The Bulldogs half dislocated his shoulder playing for New Zealand and required two surgeries to repair the shoulder joint and the muscles surrounding it. While the initial expectation from the club was a 9-12 month recovery, Foran's early rehab progress has been excellent with his aim to return at around seven months post surgery. This is definitely achievable with a complication free rehab, as players in the NRL having returned in this time frame after similar multistage shoulder surgeries in the past.

FIFITA INJURY WOES CONTINUE

Fifita missed the All Stars game as he continues recovery from a knee "clean out" surgery and stem cell procedure just before Christmas. This surgery type is often used to trim/smooth damaged cartilage or remove scar tissue and loose bone fragments. With a usual maximum recovery time of 8-10 weeks, Fifita is still expected to be fit for Cronulla's trial games.

It is worth considering Fifita's recent history of injury in his left knee;

- he plays without a PCL in his knee after tearing it earlier in his career

- he had the same two procedures prior to the 2019 season; a clean out surgery and an injection of stem cells

- suffered an aggravation of his old knee injury late in the 2019 season

FULL CASUALTY WARD

BRISBANE BRONCOS

Matt Lodge (partial ACL tear, mid-season)

Corey Oates (leg infection, trials)

Kotoni Staggs (toe, trials)

Jordan Kahu (shoulder, early/mid-season)

Richie Kennar (shoulder, trials)

Sean O'Sullivan (knee, earliest round 13)

Keenan Palasia (knee, late season)

Izaia Perese (stood down)

CANTERBURY-BANKSTOWN BULLDOGS

Chris Smith (MCL and partial ACL, Indefinite)

Dallin Watene-Zelezniak (back, next trial)

Josh Jackson (fractured nose, trials)

Jeremy Marshall-King (shoulder, round one)

Marcelo Montoya (knee, round one)

Kieran Foran (shoulder, indefinite)

Raymond Faitala-Mariner (syndesmosis, early rounds)

Sauaso Sue (knee, round one)

Adam Elliott (ankle, trials week two)

NORTH QUEENSLAND COWBOYS

Josh McGuire (knee, round two)

Justin O'Neill (spleen, pre-season)

Mitch Dunn (shoulder, round one)

ST GEORGE-ILLAWARRA DRAGONS

Josh Kerr (knee, TBC)

Cameron McInnes (knee, round 3-9)

Matt Dufty (cheekbone, round 1-2)

Korbin Sims (arm, round one)

Cody Ramsey (shoulder, round one)

Tyrell Fuimaono (undisclosed, round one)

Tariq Sims (groin, pre-season)

Jack de Belin (stood down, indefinite)

PARRAMATTA EELS

Maika Sivo (hand, pre-season)

Waqa Blake (shoulder, round one)

NEWCASTLE KNIGHTS

Sione Mata'utia (knee, TBC)

Bradman Best (foot, trials)

Phoenix Crossland (pelvis, round one)

PENRITH PANTHERS

Dallin Watene-Zelezniak (back, round one)

Dylan Edwards (ankle, indefinite)

Kurt Capewell (quad, late trials)

James Fisher-Harris (pectoral, round one)

Isaah Yeo (shoulder, trials)

Mitch Kenny (elbow, round one)

Jed Cartwright (shoulder, trials)

Jack Hetherington (sternum, pre-season)

Caleb Aekins (foot, trials)

Spencer Leniu (hamstring, trials)

Dean Blore (shoulder, round six)

Soni Luke (pectoral, April)

Shaun Blore (ACL, April-May)

Brayden McGrady (ACL, April-May)

SOUTH SYDNEY RABBITOHS

Cody Walker (shoulder, trials)

Braidon Burns (hamstring, trials)

Liam Knight (foot, trials)

Ethan Lowe (knee, round one)

Mark Nicholls (shoulder, trials)

CANBERRA RAIDERS

George Williams (quad, round one)

John Bateman (shoulder, early rounds)

Curtis Scott (ankle, trials)

Hudson Young (suspension, round six)

Sebastian Kris (extended leave)

SYDNEY ROOSTERS

Boyd Cordner (workload, round one)

Ryan Hall (knee, round one)

Billy Smith (ACL, indefinite)

MANLY SEA EAGLES

Taniela Paseka (ankle, round four)

Tom Trbojevic (pectoral, trials)

Jake Trbojevic (shoulder, round three)

Addin Fonua-Blake (shoulder, round four)

Curtis Sironen (foot, trials)

Albert Hopoate (knee, round one)

Jack Gosiewski (back, TBC)

Manase Fainu (stood down/shoulder)

CRONULLA SHARKS

Wade Graham (ankle, next trial)

Cameron King (suspected ACL, TBC)

Andrew Fifita (knee, trials)

Matt Moylan (hamstring, indefinite)

Bronson Xerri (shoulder, round one)

MELBOURNE STORM

Brandon Smith (Facial fracture, early rounds)

Christian Welch (knee, early rounds)

GOLD COAST TITANS

Tyrone Roberts (achilles, TBC)

Moeaki Fotuaika (wrist/knee, round one)

Dale Copley (shoulder, round one)

Shannon Boyd (shoulder, round one)

Keegan Hipgrave (repeated concussions, indefinite)

Beau Fermor (knee, early/mid-season)

Ryan James (ACL, indefinite)

NEW ZEALAND WARRIORS

Jackson Frei (suspected ACL, TBC)

Phillip Makatoa (knee, TBC)

Bunty Afoa (ACL, indefinite)

Jazz Tevaga (ankle, round four-five)

Peta Hiku (shoulder, round one)

David Fusitua (hamstring, trials)

Wayde Egan (shoulder, trials)

Karl Lawton (shoulder, trials)

Nathaniel Roache (knee, mid-season)

Chanel Harris-Tavita (wrist, trials)

Sam Lisone (shoulder/chest, trials) ... set for Titans move

Gerard Beale (knee, early rounds)

WESTS TIGERS

Paul Momirovski (ankle, round one)

Jacob Liddle (knee, mid-2020 season)

Russell Packer (foot, indefinite)

Josh Aloiai (hand, pre-season)