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
Media Village www.media-village.co.uk
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Contents Welcome 4
Members’ News
Features 8
5th Annual FMPA Conference & Awards 2018
15
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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feature
NORDIC HAMSTRING EXERCISE – HOW CAN WE MAKE IT WORK IN THE ELITE FOOTBALL ENVIRONMENT? FEATURE/ ADAM JOHNSON: FIRST TEAM PERFORMANCE PHYSIOTHERAPIST, BHAFC INTRODUCTION We all know that the hamstrings are the most commonly occurring injury in elite football, with each twenty-five man squad suffering from an average of seven injuries per season (1). We also know that the problem is only getting worse with a 4% annual increase in training-related hamstring injuries (2) being reported over a thirteen year period. So why if we are seeing so many of these injuries and there is such a wealth of literature being published, are we seemingly struggling to prevent them from occurring? The answer to this question is obviously multi-faceted, but this article will look at the role that the Nordic Hamstring Exercise could play, and how it could be implemented within an elite football environment.
Photo Credit – Paul Hazlewood
THE NORDIC HAMSTRING EXERCISE The Nordic Hamstring Exercise has received a lot of attention within the literature over recent years with the invention and availability of the Nordbord in elite sporting practice. This device has led to much more interest in the screening and development of eccentric force production in the hamstrings. There is a general consensus that the exercise is effective in reducing hamstring injuries with a recent systematic review suggesting a potential 51% reduction in hamstring injuries following implementation of a NHE
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program(3). Despite this apparent drastic impact on reduction of hamstring injuries there is a lack of compliance from elite football clubs, with only 11% of clubs deemed fully compliant(4). This lack of implementation of the Nordic Hamstring Exercise protocol suggests that the desired number of repetitions may not be appropriate within an elite football setting. This is understandable as the heavily utilised protocol is usually performed within a group
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of subjects participating in a recreational sports setting, with one game a week and no other strength training included within their weekly program. In an elite football setting where there is a desire to develop other physical attributes whilst still ensuring that players are in optimal physical condition for the heavy fixture schedules, then prescription of 100 weekly repetitions of the NHE is unfeasible. Therefore below I will look to discuss some possible strategies for practical implementation of the exercise.
football medicine & performance HOW MUCH IS ENOUGH? If we feel that 100 repetitions each week is not a suitable figure for our day-to-day practice, then how low can we go in terms of prescription whilst still achieving our desired physiological outcomes of increased eccentric force production and increased fascicle length? Well a recent paper (5) has looked to address this question, and it appears to suggest that low loading protocols were just as effective as higher loading. The study suggests that as little as 8 repetitions a week was as effective in development of hamstring eccentric force and fascicle lengthening as the previously discussed high load program. This is really important for us as clinicians as such a small number of repetitions should be able to be performed in our players weekly programs without interfering with performance. It is worth noting however that both groups did complete a two week standardised program comprising of 48 repetitions at the beginning of the study.
These findings maybe highlight that increased exposure does not necessarily mean increased chance of success (5). Instead there is an argument that ensuring the exercise remains supramaximal through individualised prescription is more important. Presland et al. (5) ensured that any player who was able to complete three repetitions down to the final 15 degrees of range were then provided with an additional external weight for future performance. This ability to perform throughout full range of movement was assessed weekly throughout the study.
This leads us on nicely to discussing when we should perform the exercise both in relation to the season, and secondly at which point in the week. If we are to accept that the work of Presland et al. (5) gives us an evidence base from which to prescribe 8 repetitions a week, then we must also acknowledge the importance of the initial two weeks of moderate loading. It may therefore be appropriate to try and prescribe this moderate loading phase to our players in the final two weeks of the off-season program. This would negate the argument of muscle soreness hampering performance that we so often hear, and also place our players in a much decreased risk of hamstring injury come the intense preseason training schedule. We could then work with a low volume program alongside the already hectic preseason work.
Table One: Taken From Presland et al. (2018).
Low volume intervention
High volume intervention Week
Frequency
Sets
Reps
Total Reps
Frequency
Sets
Reps
Total Reps
1
2
4
6
48
2
4
6
48
2
2
4
6
48
2
4
6
48
3
2
4
8
64
1
2
4
8
4
2
4
10
80
1
2
4
8
5
2
5
10
100
1
2
4
8
6
2
5
10
100
1
2
4
8
Sum
WHEN TO IMPLEMENT?
So we have decided upon our loading levels that we are comfortable with in the squad and may even have decided to start this program prior to preseason commencing, however when can we finish the program? Well the research would suggest that we shouldn’t cease Nordic Hamstring loading, with as little as 14 days shown as sufficient time to completely reverse the positive benefits gained from six weeks of eccentric hamstring loading (5).
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to, or following squad training. Their findings that pre-exercise performance induces greater changes in fascicle length, with post-training performance resulting in greater changes to muscle thickness suggests that we may be best trying to vary players exposure. However if we
If this decision has been made to include the ‘Nordic’ within our injury prevention program then we must also be aware of when is the optimal time in the day to implement the program. Lovell et al. (6) recently assisted in answering this question by studying the different physiological outcomes that can be expected if the exercise is performed prior
Standardised training period Varied volume training period
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then take into account previous work by the same group (7) showing a decrease in eccentric hamstring strength, particularly in outer range then we may consider that NHE performance prior to training is too great a risk.
Photo Credit – Paul Hazlewood
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football medicine & performance
feature
Pictured: West Ham United’s Andy Carroll lies injured before leaving the field
EVIDENCE BASED PRACTICAL SUGGESTIONS The Nordic Hamstring Exercise has received a lot of attention, with some research and discussions suggesting that the exercise is either not effective, or not applicable to the elite football environment. Hopefully this article will result in some discussion and highlight that although maybe not appropriate for all club environments/philosophies, there is more clinically applicable research coming out to support and guide its use in elite football. Below is a summary of potential ideas for successful incorporation of the exercise; Prescribe moderate load (48 weekly repetitions) protocol in the final two weeks of the off season program to allow for a low load program to be implemented in the preseason period. Prescribe the exercise following training sessions to decrease fatigue-induced injury risk Ensure that the exercise remains supramaximal through addition of an external weight once three repetitions can successfully be achieved through full range of movement.
Be consistent with prescription of the exercise, with reversal of adaptations seen in as little as 14 days detraining. Consistency will also improve the ratings of soreness felt by the players following performance.
To finish off this article I would like to highlight that this is just one piece in the hamstring prevention puzzle. However if correctly executed then the research would suggest it is an important piece of this ever growing puzzle.
(1) Ekstrand, J., Hagglund, M. & Walden, M. (2011). Injury incidence and injury patterns in professional football: the UEFA injury study. British Journal of Sports Medicine, 45, 553-558. (2) Ekstrand, J., Walden, M. & Hagglund, M. (2016). Hamstring injuries have increased by 4% annually in men’s professional football, since 2001: a 13-year longitudinal analysis of the UEFA Elite Club injury study. British Journal of Sports Medicine, 50, 731-737.
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(3) Al Attar, W.S.A., Soomru, N., Sinclair, P.J., Pappas, E. & Sanders, R.H. (2017). Effect of Injury Prevention Programs that Include the Nordic Hamstring Exercise on Hamstring Injury Rates in Soccer Players: A Systematic Review and Meta-Analysis. Sports Medicine, 47, 907-916. (4) Bahr, R., Thorborg, K. & Ekstrand, J. (2015). Evidence-based hamstring injury prevention is not adopted by the majority of Champions League or Norwegian Premier League football teams: the Nordic Hamstring survey. British Journal of Sports Medicine, 49, 1466-1471. (5) Presland, J.D., Timmins, R.G., Bourne, M.N., Williams, M.D. & Opar, D.A. (2018). The Effect of Nordic Hamstring Exercise training volume on Biceps Femoris Long Head Architectural Adaptations. Scandinavian Journal of Medicine & Science in Sports. In Press. (6) Lovell, R., Knox, M., Weston, M., Siegler, J.C., Brennan, S. & Marshall, P.W.M. (2018). Hamstring injury prevention in soccer: Before or after training? Scandinavian Journal of Medicine & Science in Sport, 28, 658-666. (7) Lovell, R., Siegler, J.C., Knox, M., Brennan, S. & Marshall, P.W. (2016). Acute neuromuscular and performance response to Nordic hamstring exercises completed before or after football training. Journal of Sports Science, 34, 2286-2294.
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