medicine & performance The official magazine of the Football Medicine & Performance Association
Issue 29 Summer 2019
Feature
Position Specific & Positional Play Training in Elite Football: Context Matters In this issue FMPA Conference Award Winners 2019 Maximising player availability whilst respecting the fundamental ethics of healthcare in sport Pre-Season – When Foundations Are Laid
Legal • Education • Recruitment • Wellbeing
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CONTENTS WELCOME
7
FEATURES
9 The “Football Creditors Rule” What Does it Mean for You? Marin Price FMPA Lawyer
Updates
25 A Balancing Act: Maximising Player Availability Whilst Respecting the Fundamental Ethics of Healthcare in Sport Dr Rob Tatham
10 Can Modern Football Match Demands be Translated Into Novel Training and Testing Modes? Paul S Bradley, Michele Di Mascio, Magni Mohr, Dan Fransson, Carl Wells, Alexandre Moreira, Julen Castellano, Antonio Gomez Diaz & Jack D Ade 15 The Importance of a Uniform Club Philosophy for Enhancing Athlete Health and Performance Adam Brett & Will Abbott - Brighton & Hove Albion FC
20 FMPA Conference Award Winners 2019
ABOUT
29 How to Thrive With a Little Help From Your Friends 31 Position Specific & Positional Play Training in Elite Football: Context Matters Paul S Bradley, Andres Martin-Garcia, Jack D Ade, Antonio Gomez Diaz 36 Pre-season – When Foundations Are Laid UEFA 40 FMPA Register
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 FMPA_Official Officialfmpa fmpa_official LinkedIn: Football Medicine & Performance Association FMPA_Register
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Chief Executive Officer Eamonn Salmon eamonn.salmon@fmpa.co.uk
Design Oporto Sports www.oportosports.com
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Photography PA Images, FMPA, Getty Images, FIFA via Getty Images, Jussi Eskola
Administration Assistant Amie Hodgson amie.hodgson@fmpa.co.uk Project Manager Angela Walton angela.walton@fmpa.co.uk
Contributors Paul S. Bradley, Michele Di Mascio, Magni Mohr, Dan Fransson, Carl Wells, Alexandre Moreira, Julen Castellano, Antonio Gomez, Jack D. Ade, Gary Souter, Professor Laura Serrant OBE, Dr Robin Lewis, UEFA Direct, Dr Rob Tatham, Andres MartinGarcia, Antonio Gomez Diaz
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COVER IMAGE Derby County v West Bromwich Albion - Sky Bet Championship Pride Park Stadium. Derby County’s Martyn Waghorn leaves the pitch after incurring an injury. Darren Staples / 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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football medicine & performance
A BALANCING ACT: MAXIMISING PLAYER AVAILABILITY WHILST RESPECTING THE FUNDAMENTAL ETHICS OF HEALTHCARE IN SPORT FEATURE / DR ROB TATHAM, SPORTS PHYSICIAN Ethical and medico-legal considerations regarding healthcare provision in sport A sports clinician’s role may be summarised as “assisting athletes to achieve optimal performance, enhancing resilience to injury, and maximising availability for training and competition”. To achieve this a multidisciplinary approach is required to address the many challenges that an athlete may face (Figure 1).
Enhancing athleticism Illness prevention & acute management
Acute injury management & rehabilitation
Optimal performance, resilience & availability Chronic injury managment
Psychology
Nutrition
Figure 1. The key facets of sports medicine
The provision of healthcare in sport is a unique employment environment. A clinician’s overarching duty is to the welfare of the athletes that they are employed to care for. Their employer (usually the football club) similarly has a vested interest in the long-term welfare of their ‘assets’. Occasionally however, a clinician may feel pressured to declare an athlete available for selection for short-term football-related gains despite the risk of exacerbating a condition. The decision-making dilemmas of sports medicine are further confounded by the medical uncertainties of diagnosis and rehabilitation progression (Figure 2).
‘targets’ are also quoted within football medicine. ‘Player availability’ and ‘return to training time’ are two common examples. However, such indicators do not necessarily give a direct insight into the preventative strategies in place (reduction in injury, illness and secondary complications). Preventative medicine is arguably the most important work that sports clinicians do, but possibly one of the most difficult to measure. Medical KPI’s may only tell part of the story and should always be placed in context. When faced with difficult decisions it may be helpful to refer back to the fundamental ethical principles of healthcare provision. In 2015 Baroness Tanni Grey-Thompson conducted an independent review for the government regarding the Duty of Care sport has towards its participants. The result of this review (Grey-Thompson, 2017) identifies the fundamental obligations that sporting organisations and care providers should deliver (and may be judged against). In particular; i) whatever the level of facilities and resources, taking steps to ensure the safety of people playing, supporting, officiating and watching sport is fundamental, ii) sports have a duty to respect the advice and guidance of medical experts, and put safety and athlete welfare above all other concerns. Determining availability to train & play is an opportunity to identify those individuals who may be at increased risk of harm if they are allowed
to be exposed to the occupational hazards presented by football and football training. Unfortunately the incidence of medical negligence cases within sport is increasing, with the majority being filed against clubs on the basis of failure of Duty of Care for a player (SEMPRIS, 2019). As is the case for healthcare providers in sport, a Club’s Duty of Care for players overrides everything else. So, whilst our employers (the Club) expect (quite reasonably) that a well-functioning Medicine & Science Department should maximise availability for athletes to train and play, this should never be at the expense of the player’s welfare. It is worth noting that such medical negligence claims are usually passed on from The Club to the Head of Medical Services to answer. Individuals appointed to the role of Head of Medical Services (and who therefore carry ultimate accountability) need to ensure they have adequate indemnity to cover them in the event of such claims. Indemnity providers may not cover certain professions to take up a role as Head of Medical Services, and this type of cover is not usually provided by the Club’s umbrella medical indemnity policy.
Club asset (long term)
Figure 2. The dual-role dilemma of working in sports medicine
Medical uncertainty
Clinician
Coach asset (short term)
Patient welfare
‘Key performance indicators’ (KPI’s) are used ubiquitously across industry as markers of productivity and effectiveness. Such
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feature
Figure 3. Common infections encountered amongst athletes (Scharhag and Meyer, 2014).
Upper respiratory tract infection (common cold)
Acute pharyngitis
Acute tonsillitis
Acute sinusitis
Infectious mononucleosis (glandular fever)
Influenza
Acute gastroenteritis (viral or bacterial)
Injury & illness affecting the ability to train The majority of training days are ‘lost’ due to: i) acute injury ii) illness (usually infection) iii) exacerbation of a pre-existing pathology iv) aberrant neuromuscular activation. The following section discusses pertinent aspects regarding the latter three in relation to fitness to train. •
Illness
Common infections encountered are illustrated in Figure 3. It is important to distinguish those illnesses that may place an athlete at risk of increased harm if they exercise. In general terms athletes should NOT train in the presence of: • Systemic symptoms (eg. arthralgia, myalgia) • Elevated resting heart rate • Evidence of dehydration • Fever • Suspicion of glandular fever As a general rule of thumb do not train if there are infectious symptoms below the neck (Metz, 2003; Eichner, 1993; Primos, 1996). Training during an infectious illness in the presence of these red flag symptom(s) may (2007; Eichner, 1993; Primos, 1996) : 1. Exacerbate symptoms and prolong illness duration 2. Increase the risk of heat-related illness and dehydration 3. Reduce muscle strength & endurance 4. Increase fatigue & reduce exercise tolerance 5. Increase the risk of acute viral myocarditis
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Glandular fever is of particular significance in athletes because of the risk of splenomegaly and the increased risk of acute splenic rupture. All suspected cases of glandular fever should be excluded from training pending further investigation. Key points regarding glandular fever are illustrated in Figure 4 below.
•
90% Ebstein Barr Virus (EBV)
•
<10% Cytomegalovirus (CMV)
•
4-8 weeks incubation period
•
Classic triad: i) fever + ii) sore throat + iii) lymphadenopathy
•
May have signifcant malaise
•
Up to 60% have splenomegaly (sensitivty of palpation only approx 20%)
Acute bronchitis
Athletes with glandular fever should be excluded from training during this period of increased risk (Figure 5). •
Exacerbation of pre-existing pathology (eg. tendinopathy, chondral lesion)
It is easy to forget about the pre-existing conditions that athletes may have if they are fully ‘fit’ and training. One example is that of a knee chondral lesion. This may be quiescent when the cumulative training load is tolerable, but beyond a certain threshold the knee reacts and forms an effusion. Note that the effusion is a symptom of the underlying pathology but is itself also a risk factor for further injury due to its effect on quadriceps muscle inhibition, proprioception, co-ordination and biomechanics (Arthrogenic Muscle Inhibition) (Rice and McNair, 2010). Key points 99 Aggravation of pre-existing pathology may produce symptoms that negatively affect the kinetic chain. This in itself may be a risk factor for further injury.
•
Adults more likely to have hepatomegaly +/- jaundice
•
Risk of splenic rupture 0.5% - highest risk in first 21 days
99 Establish a system to identify background pathology within a squad and monitor for key symptoms.
•
Assume splenomegaly is present (use ultrasound to confirm)
99 Ensure appropriate maintenance work is not neglected (eg. tendinopathy).
Figure 4. Key points regarding glandular fever (Dommerby et al., 1986; Kinderknecht, 2002; Macknight, 2002)
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99 Early coach communication may help facilitate a system of load-management to a level that is tolerable.
football medicine & performance
Minimum 3 week sport exclusion for acute infectious mononucleosis
Inflammatory markers and LFT’s normalised
Resolution of symptoms
Departmental functioning is critical to safely optimising player availability Addressing all potential issues that may lead to player unavailability requires a truly multidisciplinary approach (Figure 6). No one practitioner has all the answers, but collectively a systematic and structured approach can be created. Provide a clear structure of line management, expectations and accountability. Fundamentally, regardless of the demands made for player availability, clinicians should always strive to adhere to the ethical principle “primum non nocere” (first, do no harm).
Resolution of splenomegaly (ultrasound ideally)
Adequate preparation time Optimise fitness & athleticism
1 week graduated return to train period
Figure 5. Suggested return to train criteria following an episode of glandular fever (Kinderknecht, 2002; Macknight, 2002) .
•
Maximise recovery (including sleep)
Player reporting systems Availability
Aberrant neuromuscular activation
This is not necessarily a pathology in itself but is a failure of the neural and muscular systems to effectively communicate and may result in suboptimal muscular recruitment. This can occur at a spinal level (eg. disc pathology) or at a peripheral level. One such peripheral example is tibialis posterior dysfunction in the lower leg. The muscle ‘switches off’ and fails to resist pronation of the foot following heel strike (Ling and Lui, 2017) . Consequently, the mid-foot remains unlocked leading to aberrant biomechanics and load distribution. Unsurprisingly this is a risk factor for subsequent injury.
Player education & buy-in
Department integration
Early wound management
99 Test the muscle throughout its full range and into fatigue. 99 Identify athletes who may be at risk (eg. tibialis posterior is very common following ankle injury). 99 Establish individual activation programmes for athletes (self-led) to ensure readiness for training.
Nutrition
Figure 6. Factors in optimising player availability.
Key points 99 Aberrant neuromuscular activation can be picked up through simple movement screening (eg. single leg squat) or isolated muscle testing (eg. tibialis posterior – assessing resisted inversion of the foot).
Case managment of chronic pathology
Macknight JM. (2002) Infectious mononucleosis: ensuring a safe return to sport. Phys Sportsmed 30: 27-41. Metz JP. (2003) Upper respiratory tract infections: who plays, who sits? Curr Sports Med Rep 2: 84-90. Primos WA, Jr. (1996) Sports and exercise during acute illness: recommending the right course for patients. Phys Sportsmed 24: 44-52.
(2007) Exercise and febrile illnesses. Paediatr Child Health 12: 885-892. Dommerby H, Stangerup SE, Stangerup M, et al. (1986) Hepatosplenomegaly in infectious mononucleosis, assessed by ultrasonic scanning. J Laryngol Otol 100: 573-579. Eichner ER. (1993) Infection, Immunity, and Exercise. Phys Sportsmed 21: 125-135.
Rice DA and McNair PJ. (2010) Quadriceps arthrogenic muscle inhibition: neural mechanisms and treatment perspectives. Semin Arthritis Rheum 40: 250-266.
Grey-Thompson B. (2017) Duty of Care in Sport. Available at: https://www.gov.uk/government/ publications/duty-of-care-in-sport-review.
Scharhag J and Meyer T. (2014) Return to play after acute infectious disease in football players. J Sports Sci 32: 1237-1242.
Kinderknecht JJ. (2002) Infectious mononucleosis and the spleen. Curr Sports Med Rep 1: 116-120.
SEMPRIS. (2019) Personal communication regarding the rise of medical negligence cases within sport.
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Ling SK and Lui TH. (2017) Posterior Tibial Tendon Dysfunction: An Overview. Open Orthop J 11: 714-723.
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