football medicine & performance The official magazine of the Football Medicine & Performance Association
Issue 25 Summer 2018
Exclusive:
How can we make it work in the elite football environment?
In this issue: 2018 FMPA Conference Review Long-Term Injury & Mental Health
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Football Medical Association, 6A Cromwell Terrace, Gisburn Road, Barrowford, Lancashire, BB9 8PT T: 0333 456 7897 E: info@footballmedic.co.uk W: www.footballmedic.co.uk
Chief Executive Officer
Eamonn Salmon Eamonn@footballmedic.co.uk
Executive Administrator Lindsay Butler Lindsay@footballmedic.co.uk Project Manager
Angela Walton Angela@footballmedic.co.uk
Design
Oporto Sports - www.oportosports.com
Marketing/Advertising
Charles Whitney - 0845 004 1040
Photography
PA Images, Liverpool Football Club, Football Medical Association
Contributors
Jack D Ade, Jill Alexander, Andy Barker, Paul S Bradley, Georgie Bruinvels, Mark Evans, Andy Laws, Scott Pearce, Mayur Ranchordas, Damian Roden, Andrew Wiseman
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Contents Welcome 4
Members’ News
Features 8
5th Annual FMPA Conference & Awards 2018
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Hand Injuries in Goalkeepers Sam Haines, Raj Bhatia
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Great Toe Plantar Plate Injury Mr loan Tudur Jones
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Why long-term injury to players is a mental health problem Dr Misia Gervis
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Nordic hamstring exercise - how can we make it work in the elite football environment Adam Johnson
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Musculoskeletal ultrasound: a summary of its uses, limitations and training opportunities Stuart Wildman The 5th Asian Indoor and Martial Arts Games: Ashgabat, Turkmenistan (2017). FMPA members’ experiences of working as part of the event medical team Richard Evans, Kevin Petersen, Alan Rankin
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Keeping your finger on the pulse! Jim Moxon
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Lisfrang injuries in watersports Nick Savva
CHIEF EXECUTIVE OFFICER As we start the new campaign there is real sense of irony in that we are already collating figures for the number of members who have departed from Clubs in this 2018/19 season. We gather these figures from the 1st June, and even as players and staff report back for training, we still see staff being released while the initials on their kit are still drying. While we might all suspect there will be a lull in this regard, as the training programme gets underway, and that should indeed be the case, but this is football, and you never know. You will notice that when talking about our members leaving clubs we refrain from using the word “sacked”. This is because in general the word infers that someone has done something wrong or has failed in their job and, while this might be appropriate for some industries to use this term, it rarely fits with the departure of our members from the game. As the table in our article on page 4 suggests, the vast majority of our members (60%), exit a club when a new manager is appointed, as this is a time when they are likely to bring their own personnel with them. Notably, the number of backroom staff following their managers, particularly international ones is on the rise, as illustrated by Arsenal and other leading clubs in recent weeks. While the introduction of overseas personnel can be an illuminating feature within the backroom team, we need to also recognise the disruption this can cause to the existing set up. Upheaval is never in the best interests of a Club or player and indeed players themselves value the stability of the medicine and performance teams when a new manager is appointed and there is uncertainty around the club and even their careers. Clearly there is discussion to be had surrounding this situation but ultimately it is up to the clubs to value and protect their medicine and performance teams while still allowing a manager to bring in his own personnel, who might then act as a conduit between the incumbent and the established.
Eamonn Salmon CEO Football Medicine & Performance Association Football Medicine & Performance Association 6A Cromwell Terrace, Gisburn Road, Barrowford, Lancashire, BB9 8PT T: 0333 456 7897 E: info@fmpa.co.uk W: www.fmpa.co.uk
Chief Executive Officer
COVER IMAGE
Liverpool’s Mohamed Salah reacts after picking up an injury during the UEFA Champions League Final at the NSK Olimpiyskiy Stadium, Kiev. Nick Potts/PA Wire/PA Images Football Medicine & Performance Association. All rights reserved. The views and opinions of contributors expressed in Football Medicine & Performance are their own and not necessarily of the FMPA Members, FMPA employees or of the association. No part of this publication may be reproduced or transmitted in any form or by any means, or stored in a retrieval system without prior permission except as permitted under the Copyright Designs Patents Act 1988. Application for permission for use of copyright material shall be made to FMPA. For permissions contact admin@fmpa.co.uk.
Eamonn Salmon Eamonn.salmon@fmpa.co.uk
Executive Administrator Lindsay Butler Lindsay.butler@fmpa.co.uk Project Manager
Angela Walton Angela.walton@fmpa.co.uk
Design
Oporto Sports - www.oportosports.com
Marketing/Advertising
Charles Whitney - 0845 004 1040
Photography
PA Images, Liverpool Football Club, FMPA, Ashgabat 2017 / LAUREL Photo services, Paul Hazlewood
Contributors
Sam Haines, Raj Bhatia, Mr Loan Tudur Jones, Misia Gervis, Adam Johnson, Stuart Wildman, Richard Evans, Kevin Petersen, Alan Rankin, Jim Moxon, Nick Savva
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THERAPIES. HAND IN HAND. www.bsnmedical.co.uk
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feature
HAND INJURIES IN GOALKEEPERS FEATURE/ SAM HAINES AND RAJ BHATIA INTRODUCTION Sam Haines Core Trainee Orthopaedics Bristol Hand & Wrist Clinic Spire Bristol Hospital BS6 6UT Mr Raj Bhatia BSc(Hons), MBChB, FRCS, FRCS(Tr & Orth), MD Consultant Hand & Orthopaedic Surgeon Bristol Hand & Wrist Clinic Spire Bristol Hospital BS6 6UT www.bristolhandsurgery.co.uk
Football is one of the most popular world sports, with FIFA estimating there to be around 270 million active players(1). Injuries therefore are extremely commonplace, with evidence to show injury incidence is around 8 injuries/1000 hours(2). Owing to the feet being the most utilized body part in the sport, lower extremity injuries are common and count for around 80% of total injuries within football(2). As a result, most of the literature focuses on preventative measures in such injuries(3). There is very little published data on hand injuries in football. However, considering upper extremity injuries as a general entity it is known that goalkeepers are five times more likely than outfield players to
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suffer from one(4). This is particularly significant due to goalkeepers requiring longer lay-off times from upper limb injuries as functional hand use is necessary as opposed to outfield players. Hand injuries can also be overlooked due to the fact they can initially be passed off as mildly debilitating. However, failure of recognition of such injuries can have potential disastrous functional sequelae; especially for elite level goalkeepers. This review article focuses on hand injuries goalkeepers are likely to suffer from and makes a case for an injury database in order to guide possible future prophylactic measures and evidence based treatment options.
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feature FRACTURES/DISLOCATIONS Fractures of the metacarpals and phalanges have been shown to be one of the most common in sport in general5. Usage of the hands by goalkeepers in actions such as ‘shot stopping’ gives a clear mechanism by which goalkeepers are prone to fractures and dislocations involving the hand. Phalangeal and metacarpal fractures are common and can cause goalkeepers to be on the sidelines for a median time of 26 and 55 days respectively(4). Fractures of the metacarpals/phalanges can be managed conservatively if stable/undisplaced but otherwise operative fixation with Kirschner wires or open reduction internal fixation should be performed. (Figures 1,2,3 SHOWING PHALANX #, METACARPAL # AND POST OP ORIF)
Figure 2. Fracture of ring finger proximal phalanx
mal-reduction has been shown to lead to post-traumatic arthritis(8). Goalkeepers are also predisposed to dislocations, in particular dorsal dislocations of the phalanges owing to a hyperextension mechanism from impact to the palmar surface to the hand. These would usually be managed by pitch side reduction and buddy strapping of the finger (FIGURE 4,5 DISLOCATED FINGER, BUDDY STRAPPED FINGER), however if unstable or irreducible then surgery is required. Recurrent dislocations are rare but have been documented in goalkeepers, causing need for surgical repair(9).
Figure 4. Dorsal dislocation of little finger proximal interphalangeal joint
Figure 1. Fractured neck of little finger metacarpal
Scaphoid fractures are notoriously difficult in their management due to the high rates of non-union from the retrograde blood supply to the bone. There are cases in the literature of not only acute fractures but also stress fractures, which can lead to elongated immobilisation periods of 12 weeks(6). If an acute scaphoid fracture is present in the elite sport population we would advocate surgical fixation with a percutaneous approach which has been shown to reduce time to union and an earlier return to work(7). Base of thumb metacarpal fractures, which can be simple or comminuted, often result in a deformity which cannot be controlled with a splint and often lead to operative fixation. There is no good evidence to show if conservative vs surgical management of these fractures results in faster union times or earlier return to function however
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Figure 5. Buddy strapping
Figure 3. Above fracture treated with open reduction internal fixation
TENDON/LIGAMENTOUS INJURIES Goalkeepers are also susceptible to soft tissue injuries of the hand. Saving/ punching the ball alongside collisions with other players or the goalposts are clear aetiologies of such injuries. Among these are tendon ruptures(10), for which we would recommend surgical fixation followed by a period of rehabilitation. Mallet-finger injuries (avulsion of the extensor mechanism at the distal
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interphalangeal joint with or without a bony fragment) can occur; sometimes simultaneously in multiple digits(11) and can be treated with either a mallet splint or if closed reduction cannot reduce the deformity, operative stabilisation. (FIGURE 6,7 BONY MALLET AND MALLET SPLINT) Sprains (collateral ligament injuries) respond well to immobilisation and early motion for most digits. However, ligament injuries of the thumb metacarpophalangeal joint, often known as skiers thumb, can occur with forceful abduction of the thumb, resulting in a tear in the ulnar collateral ligament of the thumb. In such cases we would most often advocate surgical fixation owing to faster return to competition(12).
football medicine & performance
Figure 6. Bony mallet injury
Figure 7. Mallet splint to treat mallet injuries
CONCLUSION We have discussed a non-exhaustive list of potential injuries a goalkeeper may suffer from and our preferred methods of treatment. However, the evidence for treatment is often not highly powered due to several references being single case reports and otherwise poor studies. Cricket is another sport where functional use of the hand is of utmost importance and the England and Wales Cricket Board (ECB) alongside the county clubs have an extensive database of injuries. We have previously looked at this database, studied the injury patterns and published recommended actions as a result(13). As previously stated, hand injuries in goalkeepers can be significant and may result in lengthy lay-offs. With the current capital in professional football, these lay-offs could have large financial implications. Owing to this we would welcome a detailed injury database, such as that seen in professional cricket, in which research could be done to establish best treatment protocols for goalkeepers in order to optimise outcomes and guide physician advice for future injuries.
Raj regularly treats professional sportsmen and sportswomen in his Bristol Clinic. His research interests include the prevention and treatment of hand and wrist injuries in professional sport. He is widely published in his field.
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FIFA, 2007: 270 million people active in football http://www.fifa.com/ media/news/y=2007/m=5/news=fifabig-count-2006-270-million-peopleactive-football-529882.html Ekstrand J, Hägglund M, Walden M (2011) Injury incidence and injury patterns in professional football—the UEFA injury study. Br J Sports Med 45:553–558 Ekstrand J, Gillquist J (1983) Soccer injuries and their mechanisms: a prospective study. Med Sci Sports Exerc 15:267–270 Ekstrand J, Hägglund M, Törnqvist H, et al. Upper extremity injuries in male elite football players. Knee Surgery, Sport Traumatol Arthrosc. 2013;21(7):1626-1632. doi:10.1007/ s00167-012-2164-6. Court-Brown CM, Wood AM, Aitken S. The epidemiology of acute sportsrelated fractures in adults. Injury. 2008;39(12):1365-1372. doi:10.1016/j. injury.2008.02.004. Saglam F, Gulabi D, Baysal Ö, Bekler HI, Tasdemir Z, Elmali N. Chronic wrist pain in a goalkeeper; Bilateral scaphoid stress fracture: A case report. Int J Surg Case Rep. 2015;7:2022. doi:10.1016/j.ijscr.2014.12.025.
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Bond CD, Shin AY, McBride MT, Dao KD. Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg. 2001;83A:483– 488. Edwards G, Giddins G. Management of Bennett’s fractures: a review of treatment outcomes. J Hand Surg Eur Vol. doi: 10.1177/1753193416642691 Saremi H, Karbalaeikhani A. Recurrent dislocation of the proximal interphalangeal joint of the finger: A rare issue in hand surgery. Arch Bone Jt Surg. 2017;5(2):121-124. doi:10.22038/abjs.2016.7182. Perugia D, Ciurluini M, Ferretti A. Spontaneous rupture of the extensor pollicis longus tendon in a young goalkeeper: A case report. Scand J Med Sci Sport. 2009;19(2):257-259. doi:10.1111/ j.1600-0838.2008.00779.x. Degreef I, De Smet L. Multiple simultaneous mallet fingers in goalkeeper. Hand Surg. 2009;14(2-3):143-144. doi:10.1142/S0218810409004396. McKeag L. Skier’s thumb: a literature review. Aust J Physiother. 1995;41(1):29-33. doi:10.1016/S0004-9514(14)60420-7. Ahearn N, Bhatia R, Griffin S. Hand and wrist injuries in professional county cricket. Hand Surg. doi: 10.1142/ S0218810415500124
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Leukoplast Like Skin
BRINGING QUALITY PRODUCT AND THERAPY SOLUTIONS TO SPORT AND SCIENCE PROFESSIONALS
BSN MEDICAL PROUDLY SPONSORS THIS YEARS FMA CONFERENCE
For more information visit: www.bsnmedical.co.uk Call: 01482 670146 or email: commercialsales@bsnmedical.com
THERAPIES. HAND IN HAND. www.bsnmedical.co.uk
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