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
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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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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
football medicine & performance
feature
LISFRANC INJURIES IN WATERSPORTS FEATURE/ NICK SAVVA, CONSULTANT ORTHOPAEDIC FOOT AND ANKLE SURGEON The most common problems encountered when on the water are sunburn, dehydration, cuts and bruises. Virtually every possible musculoskeletal injury has been reported during kite and windsurfing but I am going to focus on the lesser known, and potentially serious, Lisfranc injury. These are being recognised with increasing frequency in sports where the foot is attached to a board with a foot strap across the mid-foot. Lisfranc was a surgeon from the Napoleonic era who first observed this injury of the foot in horse riders. A rider dismounted in battle can be dragged by a foot caught in a stirrup causing a fracture dislocation through the tarso-metatarsal articulation. The Lisfranc joint is between the tarsal and the metatarsal bones is a very important structure for maintaining foot shape and function. The shape of these bones forms a Roman arch with the second metatarsal as a keystone recessed into the cuneiforms. The alignment of the metatarsals with the cuneiforms and cuboid is very regular and relatively easy to assess on plain radiographs. Road traffic accidents and falls from a height are the most common cause of high energy
fracture dislocations these days. These are relatively easy to diagnose and commonly associated with polytrauma. The majority require surgery to restore anatomy. More subtle sprains can occur to the ligamentous complex of this joint during sport if the foot is overloaded during a rotatory movement. It is easy to imagine how this might occur landing awkwardly from a jump on a wind or kite surfing board. We are getting better at spotting these injuries so they are now more frequently treated. Instability of the Lisfranc joint may eventually result in degenerative arthritis and so identification and treatment are very important. A detailed history and examination are the most important at identifying potential injuries. Presentation often includes bruising on the sole of the foot. The patient complains of a painful mid foot and sensations of instability. In severe cases the longitudinal and transverse arches collapse on weight bearing. It is useful to compare sides but beware the bilateral injury!. Weight bearing X-rays usually reveal malalignment between the metatarsals and cuneiforms. It is sometimes useful to image the normal side for comparison.
Occasionally stressing the foot in theatre is the only way to identify subluxing joints or an avulsion fracture of the Lisfranc ligament. CT and MRI scans can be very useful to identify more subtle injuries and sprains. Grade 1 injuries are essentially sprains, with no deformity. The ligaments are intact but there is bruising on the base of the foot which is painful to stand on. Grade 2 injuries involve up to 5mm of diastasis between 1st and 2nd rays due to a partial or complete rupture of the Lisfranc ligament. Grade 3 is when the diastasis is greater than 5mm and loss of the foot arches develops. The treatment of grade 1 injuries is rest in a stiff boot for a few weeks. An orthotic arch support will probably aid a return to sport between 6 weeks and three months. Treating Grade 2 and 3 injuries is more controversial. Percutaneous screws can be used to reduce the displacement. This however does have the disadvantage that relatively uninjured points are breached by a screw which may result in degenerative changes in the long term. An alternative strategy is to hold the joints reduced with plates. This has the advantage that the joints are not damaged by screws but it does require open surgery. Regardless these constructs are extremely stiff and are usually removed after a few months routinely. Currently flexible fixation such as the tight rope is being assess for its efficacy at holding these injuries reduced. There is the theoretical advantage that a secondary removal operation is not necessary but the jury is still out. Primary fusion of the Lisfranc articulation is considered for severe injuries where the joints are very badly damaged. Delay in treatment worsens the prognosis of all grades of injury. The most important issue is to raise our index of suspicion for these injuries.
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info@fmpa.co.uk
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