football medicine & performance The official magazine of the Football Medicine & Performance Association
Issue 26 Autumn 2018
Exclusive: Are we squeezing the life out of adductor monitoring
In this issue: Cardiac Screening Life After Football
Legal
Contents Welcome 4
Members’ News
Features 5
The Barcelona Way Damian Hughes
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Research and Development What you should know about R&D
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Cardiac Screening Saves Footballers’ Lives – But We Can Do More David Oxborough
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Are we Squeezing the Life out of Adductor Monitoring Gary Silk
CHIEF EXECUTIVE OFFICER The launch of the FMPA Register is the culmination of much endeavour by the FMPA team and we are delighted with the response to date and the momentum that is starting to build. The Register was largely designed as an initiative to support members who leave the game often at a time of real need, giving them a platform to showcase their experience, helping them to maintain a presence in the game and supporting their private practice ventures. The needs of these members are clearly different to members in full time posts, hence why the register was set up as a separate entity and viewed as a potential bolt- on to membership, to be used as required. Continued support for colleagues, whether currently in the game or not, is what the FMPA is all about. Our membership is hugely diverse, covering more than a dozen disciplines, with a variety of specific needs. While this can be challenging at times, our profound belief is that ALL disciplines providing health care services to players and Clubs have an important role to play and individuals therein are an invaluable part of our membership. The change of title to FMPA underpins this belief. It is in working together that we have strength as an organisation and a significant voice in the professional game.
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What do sports medicine professionals working in football need to know about sport psychology? Dr Caroline Heaney
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The Supply of Medicines to Sports Teams Roni Lennon Bsc
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The FMPA Register
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Life After Football – Rob Swire
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A Commonly Misdiagnosed injury – Lisfranc Fracture Dislocation in a Professional Soccer Player Ashley Jones MSc Rodger Wylde BSc Richard Moss MSc
One of our main aims has always been to improve standards but there are many questions still to be addressed; areas such as governance, indemnity, safeguarding, fitness to practise and the increasing `brain drain` of skilled practitioners from the game, to name but a few. We should be very concerned that, in some areas, standards are actually falling Some of this is centred around cost saving measures at clubs who seem to think that as long as they have the minimum requirements in place, then everything is ok. Let me give one example for all to consider. If healthcare insurers determined long ago that their members (the public) can only be treated by practitioners who have a minimum of 5 years post graduate experience, why is it that `football` is happy for new graduates to treat professional players the day after graduation?
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The (Return to Play) Times, They are a Changin’ Markus Waldén Clare Ardern
While the foundations of the FMPA are firmly in place, all Medical and Performance practitioners working in professional football should recognise the role that the FMPA is playing and grasp the opportunity, not only to take the organisation forward, but to be an even louder voice in the game, raising standards to the world class level that you all deserve.
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
Eamonn Salmon Eamonn.salmon@fmpa.co.uk
Executive Administrator Lindsay Butler Lindsay.butler@fmpa.co.uk
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Swansea City’s Martin Olsson on the ground after picking up an injury. Richard Sellers/EMPICS Sport/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.
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David Oxborough, Gary Silk, Dr Caroline Heaney, Roni Lennon Bsc, Ashley Jones MSc, Rodger Wylde BSc, Richard Moss MSc, Markus Waldén, Clare Ardern, Damian Hughes.
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feature
A COMMONLY MISDIAGNOSED INJURY –
FEATURE/ ASHLEY JONES MSC, RODGER WYLDE BSC AND RICHARD MOSS MSC
Ashley Jones / @Ashjones1987 Ashley is a Senior Lecturer in Sports and Exercise Therapy and also a current PhD student at Leeds Beckett. He previously worked in professional football for seven years before transition into higher education. Ashley also sits on the board for the Society of Sports Therapists. Rodger Wylde Rodger is a chartered Physiotherapist with 30 years experience in professional football. He currently works part time in professional football and also in private practice. Richard Moss / @mossyrehab Richard is a Graduate Sports Rehabilitator and an Assistant Professor at the University of Nottingham. He also sits on the board of the British Association of Sports Rehabilitators and Trainers.
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Introduction Lower limb injuries are common within professional sport and particularly in soccer, making up 65% of reported injuries in the 2014 FIFA World Cup [1]. Within these soccer injuries the incidence of fractures within the foot is less than 1% [2], with the Lisfranc injury category even less commonly observed making up only 0.2% of reported injuries [3]. With such a low incidence of injury this can often lead to delays in diagnosis, with up to 20% of Lisfranc joint injuries being shown to be missed during initial clinical examinations [4]. One reason for this is the variation in how the injury is sustained from direct trauma in a plantar-flexed position to landing from a height with the plantar aspect of the foot making initial contact with the ground
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[5,6]. Injuries to tarso-metatarsal joints have shown to be particularly problematic, with delays in appropriate management possibly leading to localised arthritis, chronic pain and an inability to return to previous levels of activity [7]. This single case study, involving a professional soccer player, presents an example injury presentation and the subsequent clinical reasoning process that led to the diagnosis of the Lisfranc injury. Case Presentation Patient The subject was a 22-year-old male professional soccer player. The subject gave his consent for
football medicine & performance a single case report discussing his injury to be written up in order to highlight its mechanism, initial signs, symptoms and subsequent investigation to aid understanding of the incidence of the injury in soccer environments. The subject suffered a direct contact impact injury to the dorsal aspect of his right foot after striking the underside of a fellow player’s football boot. This occurred during the 30th minute of a competitive match. This is in-line with the direct force trauma mechanism in contrast to the indirect force application that is more commonly seen in activities such as dance. Intervention The subject presented on initial assessment with pain over the base of the first and second metatarsals on his right foot, which increased on palpation of the area and an inability to weightbear on the injured limb. Due to the intense pain described, the player was immediately removed from the field of play. On clinical assessment, within 5 minutes of injury occurrence, in the stadium medical facility by the club Physiotherapist the subject was asymptomatic when fully weight bearing and during functional activity, including single leg jumping and hopping. On palpation, the subject had intense pain over the base of the first and second Metatarsals and some swelling was observed once the boot had been removed. The Physiotherapist applied cryotherapy to the injury for 10 minutes whilst the subject was non-weight bearing on a plinth and followed this by applying a compression bandage. The subject was reassessed 20 minutes after the application of the compression bandage at which point there had been significant increases in the pain on palpation of the 2nd metatarsal head and the subject had developed pain during weight bearing. He was immobilized on crutches and given the relevant anti-inflammatory medication, whilst also being encouraged to apply ice every 2 hours for 10 minutes during the proceeding 24 hours. During the proceeding 12 hours, the pain increased, even when in a non-weight bearing, elevated position. The swelling had also increased; whilst the injury site had increased in temperature upon palpation. No previous significant injury within the foot and ankle region was present. The subject attended a private hospital, 18 hours after injury occurrence for radiological investigation. Dorsal-plantar non-weight bearing x-rays reported no fracture or significant bony injury. Due to the levels of swelling and pain the subject continued to report a Computed Tomography (CT) scan was completed 48 hours post injury, previously reported as a gold standard technique to confirm Lisfranc fracturedislocation injury [8]. The CT scan revealed an avulsion fracture from the medial cuneiform at the Lisfranc ligament attachment. The subject was scheduled for surgery six days from diagnosis where a procedure was completed to create fixation in the way of pins, to aid union of the injury site (Figure 1) [9].
The subject completed a post-operative rehabilitation protocol, initiated by the Consultant Orthopaedic Surgeon and conducted by the club Physiotherapist. Non-contact training commenced three months post-surgery and this altered to full contact training; an appropriate reported timeframe by Lorenz & Beauchamp [8]. The subject had no complications during rehabilitation and has since completed the full season, with no lasting effects upon review at 18 months post injury.
Figure 1.
Discussion While the Lisfranc fracture dislocation is relatively uncommon, making up only 0.2% of reported injuries [3], it represents a significant and potentially career-ending injury for some populations, with increased risks of secondary complications, such as thrombosis and necrosis [9]. The anatomical location associated with the injury presentation represents an area of mechanical weakness which when exposed to a both a direct and indirect mechanism is prone to damage. This case illustrates the subjective and objective ‘false positives’ that can occur when assessing for such an injury, particularly in athletes wearing rigid footwear and sustaining an injury during competition. The difficulty in diagnosis corresponds with previously published case reports, where initial injury was misdiagnosed [6,7]. The subject in this study appeared to have few symptoms when walking with his football boot on the injured foot, with this appearing to act as a splint. However, as soon as the boot was removed, the subject’s symptoms changed significantly. Haddix et al [8] suggest testing passive pronation of the foot, alongside palpation of the 1st and 2nd metatarsal heads may be a more reliable indicator of Lisfranc injury, due to the mechanics of the joint. Alongside this, it is also suggested to use a combination of MRI, CT and weight bearing radiography measurements to confirm Lisfranc injury. This corresponds with the presented case study, which showed misdiagnosis following a non-weight bearing x-ray. Therefore, therapists need to consider including
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this battery of outcome measures and imaging techniques in future assessments of patients with palmar or dorsal surface foot pain following a traumatic mechanism. In agreement with previous studies [9,8], this case report also highlights the importance of timely open internal fixation of Lisfranc fracture-dislocations in order to prevent long-term functional deficits. Alternative surgical intervention, in the form of ligament reconstruction, has been shown to have favourable results in relation to rehabilitation timeframes; with the patient in question returning to function 3 months post surgery [9]. This may be particularly useful in elite sport, where rehabilitation time is often considered when selecting the most appropriate procedure. Therefore, further large-scale studies could be considered to assess the different surgical options available for Lisfranc fracture-dislocations. Clinical Bottom Line This case study, although limited to a single incidence of injury, represents a potential subject presentation that clinicians should reflect upon when assessing and managing palmar or dorsal foot pain. This case also demonstrates that through the correct diagnosis and management of the injury an athlete can successfully return to their sport without significant impact upon their level of performance.
Junge A, Dvořák J. Football injuries during the 2014 FIFA World Cup. British journal of sports medicine. 2015 May 1;49(9):599-602. Valderrabano V, Barg A, Paul J, Pagenstert G, Wiewiorski M. Foot and ankle injuries in professional soccer players. Sport-Orthopädie-Sport-Traumatologie-Sports Orthopaedics and Traumatology. 2014 May 31;30(2):98105. Eleftheriou KI, Rosenfeld PF, Calder JD. Lisfranc injuries: an update. Knee Surgery, Sports Traumatology, Arthroscopy. 2013 Jun 1;21(6):1434-46. Trevino SG, Kodros S. Controversies in tarsometatarsal injuries. The Orthopedic clinics of North America. 1995 Apr;26(2):229-38. Benejam CE, Potaczek SG. Unusual presentation of Lisfranc fracture dislocation associated with highvelocity sledding injury: a case report and review of the literature. Journal of medical case reports. 2008 Aug 11;2(1):266. Pease J, Miller M, Gumboc R. An easily overlooked injury: Lisfranc fracture. Military medicine. 2009 Jun 1;174(6). Kadel NJ, Donaldson-Fletcher EA. Lisfranc FractureDislocation in a Male Ballet Dancer During Take-Off of a Jump A Case Report. Journal of Dance Medicine & Science. 2004 Jun 1;8(2):56-8. Haddix B, Ellis K, Saylor-Pavkovich E. Lisfranc fracturedislocation in a female soccer athlete. International journal of sports physical therapy. 2012 Apr;7(2):219. Mann RA, Prieskorn D, Sobel M. Mid-tarsal and tarsometatarsal arthrodesis for primary degenerative osteoarthrosis or osteoarthrosis after trauma. J Bone Joint Surg Am. 1996 Sep 1;78(9):1376-85. Lorenz DS, Beauchamp C. Functional progression and return to sport criteria for a high school football player following surgery for a Lisfranc injury. International journal of sports physical therapy. 2013 Apr;8(2):162.
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