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
Legal
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
Media Village www.media-village.co.uk
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feature
GREAT TOE PLANTAR PLATE INJURY Plantar plate injuries of the great toe are thankfully not that commonly seen in football. They are much more common in rugby or American football. It is however important to be aware of how they happen, and how best to manage them. Missed injuries can be career threatening. As always an understanding of the anatomy simplifies the process. PLANTAR PLATE ANATOMY The plantar plate is of the great toe not well understood. The plantar plate is a fibrous sling that holds the medial and lateral sesamoid bones in place beneath the first metatarsophalangeal joint. It is made up of two ligaments, the metatartso-sesamoid ligament and the phalangeo-sesamoid ligament. This fibrous cradle is then further supported by intrinsic muscles that come in from the sides. The Adductor muscles are on the outer side (the side towards the lesser toe), and the Abductor muscles are on the medial side of the foot.As they contract they can adjust its position from side to side. The short flexor, the Hallucis
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Brevis muscle comes right underneath, moving it proximally or distally. The Flexor Hallucis Longus tendon fits in underneath all of this on its way to the distal phalanx.
PLANTAR PLATE FUNCTION The plantar plate has 2 main roles. Protecting and Stabilising the first metatarsi pharyngeal joint. As it envelops the metatarsal head it protects the articular cartilage . This is particularly importance in terminal stance (rising onto tip toe).
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The plantar plate also helps to stabilise the sesamoids.When the short flexor intrinsic muscles contract, they pull on the plantar plate which then plantar flex the proximal phalanx. This then allows Flexor Hallucis Longus to contract and generate power through the distal phalanx. The plantar plate, therefore, is a key stabiliser of the proximal phalanx. This as with it protective role is important during the terminal part of the gait cycle.This is when the proximal phalanx needs to be anchored on to the ground to allow for forward propulsion (via FHL).
football medicine & performance MECHANISMS OF INJURY OF THE PLANTAR PLATE The plantar plate is typically injured in hyperextension injuries of the big toe. There is classically one scenario. The end of the big toe is pinned to the ground and most importantly loaded. From this fixed point as the momentum of the player continues forward the toe is effectively forced into a extreme dorsiflexed position. The metatarsal head eventually is forced downwards and backwards thereby tearing the plantar plate or rupturing usually the medial sesamoid. An example of this mechanism would be a player whose foot is in a terminal stance position , i.e, about to push off. All the load is being driven through the terminal phalanx .The mtpj and foot is dorsiflexed. Suddenly another player might land on the back of our players ankle or foot . With our players forward momentum and the oppositions downward momentum all acting together the end result quite quickly is a plantar plate rupture. A similar injury might happen if somebody stands on the end our players toe as he is about to push off whilst running. It is important to realise that these are not common injuries. Most of the documented series of injuries are from American football players but we are seeing increasing numbers in rugby and to lesser extent in football. This might be due to changes in playing surfaces,(surfaces with more grip) or boots (more flexible soles ) both of which may allow hyperextension of the big toe much more than in the past.side to side. The short flexor, the Hallucis
CLINICAL EVALUATION Clinical evaluation of these injuries in the acute phase is very difficult and is dependent on the patient’s history and the appearance. Video footage can be very helpful. Physical examination is very difficult as the foot is often swollen and exquisitly painful. Once the initial swelling has reduced, a positive Lachman’s test is very suggestive of a plantar plate injury. A Lachman’s test on the toe involves translating the proximal phalanx dorsally and plantar ward on a fixed metatarsal . Normally there is little to no movement. Any extra movement compared to the other side is regarded as a positive result. Remember however that in the first few days after injury this is far to painful to do.
FURTHER EVALUATION If a plantar plate injury is suspected, the patient needs to be referred for further investigation, as the plantar plate is an essential part of the flexor mechanism of the great toe.
X-radiography X-radiography might reveal a fractured sesamoid. An X-radiograph taken while the patient is weight-bearing often reveals distraction between the two poles of the sesamoid as the short flexor contracts. A tear to the plantar plate itself will often cause retraction of the sesamoids: when the patient leans forward and puts his weight over the big toe, the short flexors contract and the sesamoids retract much more than on the other foot, as the plantar plate has detached from the proximal phalanx. Magnetic Resonance Imaging (MRI) MRI can reveal a shear fracture line within the sesamoid or a avulsion of the plate off the sesamoid. Finding a acute tear can be difficult. Sometimes a radiologist might inject the join to produce a arthrogram which will clearly show a tear. Ultrasound Ultrasound can also be very helpful in chronic cases, which can be more difficult to diagnose.
MANAGEMENT OF PLANTAR PLATE INJURY Acute Injury Management of acute plantar plate injury needs to be decided quickly. The decision is based on the whether the injury is stable or unstable. Acute stable plantar plate injury With a stable injury, for example a partial plantar plate tear, the patient can activate power within the proximal phalanx, and can plantar plate the proximal phalanx independently.This can be done because the short intrinsics that act on the plate and proximal phalanx are in continuity. MRI or ultrasound scan will help that diagnosis. In reality however often within the first few days this can be very painful. It can also be difficult to differentiate between FHL function and the FHB action ( intrinsic) . Ideally therefore any suspicion in a elite athlete warrants further review by somebody with experiencein such cases. Acute unstable plantar plate injury Unstable injuries potentially need surgical treatment. A player with an unstable injury is unable to plantar flex the proximal phalanx alone when you ask them to flex the big toe. The toe tends to ‘claw’ quite dramatically. This is an easy clinical sign and needs to be followed by ultrasound or MRI scan. These potentially need a surgical review. Chronic Injury Chronic plantar plate injuries can be more difficult to manage.
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Chronic stable injury There are several options for management of chronic stable injury: early movement work on the intrinsic muscles steroid therapy strapping of the toe use of a stiff-soled shoe or Aircast boot. Chronic unstable injury Chronic plantar plate injury are usualy seen when the patient thinks they have simply stubbed their toe and have ignored the injury. Chronic unstable plantar plate injuries need to be repaired, as these injuries involve a disruption to the flexor mechanism of the great toe. . Whether you operate or not depends on the patients level of function. There are only a few short case series of three or four players, usually from the USA, described in the literature. In professional athletes these are devastating injuries and the athlete can experience a lot of stiffness following fixation. There is often a degree of pain, particularly dorsal pain, and impingement-type pain on the big toe, which can be career-threatening at times. Fixation is usually through a plantar incision and the torn parts oF the tendon are sutured together. These are challenging cases and patients don’t always do well. Sometimes if the injury has lead to arthritis fusion may be needed.
CONCLUSION It is important to identify plantar plate injuries early. Try not to ignore them. If clearly a stable injury (sprain) then mobilise quickly .If you are not sure consider a early referral with appropriate imaging.
Mr Ioan Tudur Jones Consultant Foot and Ankle Surgeon, Fortius Clinic MB BCh FRCS (Eng) FRCS (Tr & Orth) Mr Tudur Jones has a particular interest in the treatment of lesser and greater toe deformities focusing on producing an attractive foot and, most importantly, one that works. He also has considerable experience in ankle replacement surgery. As a keen sportsman, having suffered plenty of injuries himself, Mr Tudur Jones is well aware of the limitations injury brings. His sports practice is therefore aimed at realistic and rapid return to form.
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football medicine & performance
feature
CASE A ruptured Right plantar apparatus through the medial sesamoid. Clinical and radiological findings. Surgical treatment and rehabilitation to play. History MM (27) was training on a 4G surface on the 6th of April. He was wearing astro boots.He was about to push off with his trailing right foot with the toes dorsiflexed when another player landed on the back of his leg. He immediately felt something tear and he was unable to carry on playing. He was put into an Aircast boot. Examination Revealed swelling and bruising around the great toe with marked tenderness over the medial sesamoid. He had good function within FHL. There was no function within the medial intrinsics and he was unable to plantar flex the proximal phalanx without also plantar flexing the distal phalanx via FHL. There was no loss of sensation. There was minor dorsal pain. There was a small effusion. Radiology An MRI scan performed on 10th April 2017 shows a complete disruption of the medial sesamoid with proximal migration. There was extensive oedema within the flexor hallucis brevis as it attaches on to the sesamoid. The inter-sesamoidal ligament was also ruptured. There was extensive areas of bone contusions within the metatarsal head and proximal phalanx. The simple weight bearing Xray showed retraction of the proximal pole of the sesamoid. Surgery Plantar Z incision .Tear found starting from the Metatarso-Sesamoid ligament medially, and extending laterally through the Medial sesamoid ( fractured ) into the Inter-Sesamoid-ligament. Proximal migration of the fractured (fragmented) proximal pole. Contusion within FHB.The proximal pole was excised as it was un-reconstructable . The FHB tendon was then attached via a drill hole to the distal fragment. Simple sutures to the remaining tear edges.Back slab. Rehabilitation Objective is to load the repair early but avoid stretching out or lengthening the plantar plate. Non weight bearing for 2 weeks, but encouraging active plantar flexion hourly, with dorsiflexion limited. At 2 weeks MM was convered to a boot and allowed FWB. Active DF encouraged.Passive PF and sesamoid mobilisation.Pool / Alter G from week 3. Return to play at 4 months.
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