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
2
Contents Welcome 4
Members’ News
Features 8
5th Annual FMPA Conference & Awards 2018
15
Hand Injuries in Goalkeepers Sam Haines, Raj Bhatia
18
Great Toe Plantar Plate Injury Mr loan Tudur Jones
22
Why long-term injury to players is a mental health problem Dr Misia Gervis
24
Nordic hamstring exercise - how can we make it work in the elite football environment Adam Johnson
28
32
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
37
Keeping your finger on the pulse! Jim Moxon
40
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
3
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
feature
MUSCULOSKELETAL ULTRASOUND: A SUMMARY OF ITS USES, LIMITATIONS AND TRAINING OPPORTUNITIES FEATURE/ STUART WILDMAN, BSC (HONS) MSC, PG CERT, PG DIP BACKGROUND The use of diagnostic musculoskeletal ultrasound is rapidly expanding, driven by increased awareness amongst medical and allied health professionals, improving technology and reducing ultrasound system costs. This article aims to provide you with a brief and hopefully informative
28
summary of some of its uses, limitations and an insight into training opportunities. Musculoskeletal ultrasound as an adjunct to a clinical assessment can have a powerful impact on patient care. Enhancing the clinical examination and
info@fmpa.co.uk
directing management, potentially reducing the need for further imaging and facilitating care through high patient satisfaction (Lumsden et al, 2017). However, inappropriate and suboptimal use can be a concern, and high quality training forms the foundation of its use.
football medicine & performance ORIENTATING TO AN ULTRASOUND IMAGE Musculoskeletal ultrasound is able to offer high resolution, dynamic imaging of superficial structures such as tendons, bursae, ligaments, nerves, muscle and musculotendinous units. It is also increasingly recognised as a useful tool for evaluating bony injuries such as fractures (Hoffman et al, 2014). Ultrasound is a grey scale image, with varying degrees of brightness. These various degrees of brightness are referred to as hyperechoic (brighter) or hypoechoic (darker) appearances. Tissues have different appearances due to the acoustic impedence mismatch between them, ultimately leading to differing levels of reflexivity and appearance. Figure 1 illustrates a number of the more common musculoskeletal structures. One of the greatest challenges facing those who are starting to use diagnostic ultrasound is orientating to the image. Those first few views of an ultrasound image can often make looking through thick fog a walk in the park. An important aspect to grasp initially is the different views that are often utilised in ultrasound: the long and short axis. Figure 2 below is intended to assist with the understanding of this, and a further sonographic representation is seen in Figure 3.
Figure 1. Normal ultrasound appearances of musculoskeletal tissues
Figure 2. Illustration to demonstrate the two different core views on ultrasound
USES AND LIMITATIONS OF MUSCULOSKELETAL ULTRASOUND Diagnostic ultrasound is seen to complement and be a valid alternative to other imaging modalities such as MRI (Nazarian, 2008). One such advantage is the ability to dynamically interrogate regions and correlate this to the provocation of symptoms. Dynamic evaluation of ankle impingement would be an example of this, and the ability to visualise the talus dynamically interacting with the distal tibia (Pesquer et al,2014). Coupling established clinical tests and modifying them with sonographic visualisation, is also developing further recognition, for example when stress testing the anterior inferior tibiofibular ligament and syndesmosis (Mei-Dan et al, 2009). The ability to compare structural
sonographic findings to an asymptomatic side can also be extremely informative. Ultrasound is however limited by a number of factors including an inability to see beyond bone and as a result it is not the choice of imaging modality for intraarticular injuries. It may also have a limited role with larger patients or when trying to visualise deeper structures as a consequence of the fundamental physics of ultrasound. The best resolution will be created with a higher frequency. To visualise deeper structures, a lower frequency is required but this will reduce resolution and image quality. A clinician will often find themselves constantly trying to optimize the frequency to get as high a resolution image as possible.
www.fmpa.co.uk
Figure 3. Ultrasound images demonstrating the short and long axis view of quadriceps and hamstring muscle groups
29
football medicine & performance
feature Ultrasound is highly user dependent, with subtle angulations in probe position generating very different images and consequently the conclusions taken. This is a concern and demonstrates the importance of high quality training. The assumptions that an ultrasound machine makes are that the speed of light is constant, the beam access is straight, the attenuation of all tissues it passes through is constant and the pulse travels only to the targets that are on the beam access and back to the transducer (Hoskins et al 2003). There are a number of reasons why deviations from these assumptions occur and the variations around these assumptions give rise to many of the known artefacts associated with ultrasound image creation (Hoskins et al 2003). One of the most commonly encountered artefacts is Anisotropy. Anisotropy is a sonographic artefact and described as an ‘angle dependent appearance of tissues’. Fibrillar tissues, changing from hyperechoic to hypoehoic with increased angle of beam from perpendicular (Jacobson 2007). An example would be the distal insertion of the Achilles tendon as it attaches to the calcaneus. Fibre orientation and incorrect probe angulation can lead to a darkening of tendon fibres that can be misinterpreted and incorrectly reported as seen in Figure 4. A further significant consideration when utilising musculoskeletal ultrasound is the ability to place the structural or imaging findings in the correct clinical context. There is plenty of research demonstrating the presence of asymptomatic pathology on spinal imaging (Boden et al (1990) and the impact that poor handling of this information can have on patient outcome and treatment. Ultrasound requires the same due diligence of use, and this can be seen for regions where ultrasound is used more readily requested such as imaging the rotator cuff. Finding full thickness defects, often as part of the normal ageing process, in asymptomatic shoulders is certainly not uncommon. An article by Girish (2011) found asymptomatic shoulder abnormalities in 96% of 40-80 year olds. The correlation of symptoms and structural change continues to have a disconnect at times, and is very patient specific and context specific. Again, highlighting the importance of the clinical integration.
EDUCATION AND TRAINING OPPORTUNITIES
Figure 4. Ultrasound and probe position images illustrating the artefact anisotropy
competency documents and guidelines including the Faculty of Sports and Exercise Medicine (FSEM). For many allied health professionals such as Physiotherapists and Podiatrists, the core training is often now a program accredited by the Consortium of Accredited Sonographic Education (CASE, http://www.case-uk.org/) at a Higher Education institution. This will often be in the format of a Post graduate certificate (PG Cert) qualification, 60 credit M-Level program. As part of this program there is a requirement to perform a log book of scans with and without supervision, highlighting the students ability to correctly identify pathological and normal cases. Seeking mentorship and support is often a barrier to individuals progressing with this type of program, and developing professional networks and contacts can significantly assist here.
Ultrasound training pathways are currently diverse and at times confusing. The development of musculoskeletal ultrasound skills is not for everyone and to develop competency involves a significant financial and time investment and a foundation of clinical experience. Weekend courses often provide an informative and useful way of experiencing what ultrasound is like to use before committing further.
I would also strongly encourage those thinking of exploring this area to look at the website of The Royal College of Radiologists and British Medical Ultrasound Society, both whom produce excellent publications to provide guidance on training, quality assurance and standards of ultrasound practice.
If you decide to develop skills further, many professions have established their own
Musculoskeletal ultrasound use is increasing, and alongside this there needs
CONCLUSION
www.fmpa.co.uk
to be high quality training and responsible use. If this occurs, it can be an excellent tool to have available in clinic. Girish et al (2011) Ultrasound of the shoulder: asymptomatic findings in men. American Journal of Roentgenology, 197(4):W713-9. Hoskins, P.R. Thrush, A. Martin, K. Whittingham, T.A., (2003) Diagnostic Ultrasound Physics and Equipment. Greenwich Medical Media Limited. London. ISBN 1841100420. Hoffman,DF et al (2014) Ultrasonography of fractures in sports medicine, British Journal of Sports Medicine, 49, 152-160. Jacobson, J,A, (2008) Musculoskeletal Ultrasound. Saunders. Elsevier Limited. ISBN 10-1-4160-3593-1 Lumsden et al (2017) Physiotherapists utilizing diagnostic ultrasound in shoulder clinics. How useful do patients find immediate feedback from the scan as part of the management of their problem?, Musculoskeletal care, Mei-Dan et al (2009) A Dynamic Ultrasound Examination for the Diagnosis of Ankle Syndesmotic Injury in Professional Athletes, American Journal of Sports Medicine, 1009-1017. Nazarian, L (2008) ‘The top 10 reasons musculoskeletal sonography is an important complementary or alternative technique to MRI’, American Journal of Roentgenology, 190, 1621-2626. Pesquer et al (20014) US in ankle impingement syndrome, Journal of ultrasound, Volume 17, Issue 2, 89-97.
31
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
180001073 - Leukoplast FMA Advert Update-v3.indd 1
16/04/2018 09:30