The official magazine of the Football Medicine & Performance Association
football medicine & performance
Issue 31 Winter 2019/20
Feature
Karen Carney A Pioneer for the Womens’ Game In this issue Injuries in Football: It’s Time to Stop Chasing the Training Load Unicorn Cautious Return to Play Could Prevent Muscle Injuries FMPA Conference 2020 Neurodegenerative Disease Among Former Footballers
Legal Ţ Education Ţ Recruitment Ţ Wellbeing
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CONTENTS FEATURES
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Injury Mitigation in Team Sports. Part-2: The risk management approach Colin W. Fuller
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What to do and When to do it? The Tricky Question of Specialisation in Youth Football Laura Finnegan
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Injuries in Football: It’s Time to Stop Chasing the Training Load Unicorn Franco M. Impellizzeri, Aaron J. Coutts, Maurizio Fanchini, Alan McCall
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Training the Semi-Professional Footballer Daniel Bernardin, Dylan Mernagh
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Karen Carney A Pioneer for the Women’s Game Sean Carmody
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Wrist Injuries in Goalkeepers Raj Bhatia, Adam Esa, Sam Haines
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Neurodegenerative Disease Mortality Among Former Professional Soccer Players – Summary Emma Russell
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Job Insecurity: Reducing Its Negative Effect on Your Wellbeing Caroline Marlowe
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FMPA Register
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ABOUT
Cautious Return to Play Could Prevent Muscle Injuries in Professional Football Håkan Bengtsson, Jan Ekstrand, Markus Waldén, Martin Hägglund
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Generalised Joint Hypermobility – Why should it be screened for within a football setting? Adam Johnson
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FMPA Conference 2020
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Understanding and Developing Relationships in the Modern Football Hierarchy Dr Daniel Parnell, Professor Barry Drust
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 FMPARegister fmpa_register Chief Executive Officer Eamonn Salmon eamonn.salmon@fmpa.co.uk
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Photography PA Images, FMPA
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Contributors Colin W. Fuller, Franco M. Impellizzeri, Aaron J. Coutts, Maurizio Fanchini, Alan McCall, Håkan Bengtsson, Jan Ekstrand, Markus Waldén, Martin Hägglund, Adam Johnson, Dr Daniel Parnell, Professor Barry Drust, Laura Finnegan, Daniel Bernardin, Dylan Mernagh, Raj Bhatia, Adam Esa, Sam Haines, Emma Russell, Caroline Marlowe
Marketing/Advertising Charles Whitney 0845 004 1040
Print Media Village www.media-village.co.uk
Administration Assistant Amie Hodgson amie.hodgson@fmpa.co.uk
COVER IMAGE England’s Karen Carney during the FIFA Women’s World Cup Third Place Play-Off at the Stade de Nice, Nice. Richard Sellers/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
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WRIST INJURIES IN GOALKEEPERS FEATURE / RAJ BHATIA, ADAM ESA & SAM HAINES
Mr Raj Bhatia BSc(Hons), MBChB,FRCS, FRCS(Tr & Orth), MD Consultant Hand & Orthopaedic Surgeon
INTRODUCTION Approximately 25% of all sports-related injuries involve the hand or wrist [1]. These incidents are on the increase, not only due to the increasing physical demands athletes face but also due to the increased activity level noticed amongst the general population [2].
goalkeepers. As poorly treated or undiagnosed injuries can be catastrophic and career ending for them. We will focus on the commonest injuries and discuss our preferred treatment options, to reduce non-playing time and increase functional recovery.
Lower limb injuries predominate in Football players and therefore much of the published literature focuses on the lower limb, with data on the upper limb being sparse. However in goalkeepers hand and wrist injuries are the most common upper limb injuries, and goalkeepers are five times more likely than outfield players to sustain such an injury [3]. Goalkeepers require a high level of hand and wrist function in their role and injuries to these sites leads to a longer nonplaying period than outfield player.
BASIC ANATOMY The wrist is a complex joint that is made up of two carpal rows, the distal ends of the radius and ulna and the bases of the metacarpal bones. Stability is provided by the osseous anatomy and ligaments and these work in concert to provide movement in different planes. The ligaments can be divided into intrinsic and extrinsic. The most important intrinsic iigaments are the Scapholunate and lunotriquetral of which the Scapholunate is the most commonly injured.
This article follows on from our previous article discussing hand injuries in goalkeepers [4]. We now turn our attention to acute wrist injuries in players, more specifically
The triangular fibrocartilage disc (TFC) attaches to the base of the ulnar styloid and to the ulnar head of the distal radius. It forms part of the triangular
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feature fibrocartilage cartilage complex (TFCC). The TFCC supports the carpus, absorbing and transmitting axial force across the ulnar aspect of the wrist, as well as stabilizing the distal radio-ulnar joint (DRUJ). The TFC is particularly prone to injury. Falling on an outstretched hand following a collision or direct impact of the football against the hand and wrist can lead to fracture, joint injury, ligament injury or a combination of injuries. FRACTURES Distal radius fractures In a study assessing the epidemiology of sports related distal radius fractures, football accounted for 50% of the fractures [5]. Furthermore playing football on synthetic pitches increased the likelihood of a distal radius fracture by a factor of five. In another study investigating professional football players, wrist fractures were the seventh most commonly reported upper limb injury, representing 17% of all wrist injuries. These players lost an average of 42 days playing time, or about one third of the season [6]. Non-operative treatment can be considered in the non-displaced, extra-articular fracture or the stable, reduced fracture. However, the risk of re-displacement persists and this often means a prolonged period in cast and a delayed return to playing. In a professional football player we believe open reduction and internal fixation of the fracture using a volar locking plate (Fig 1a,b) should be considered as long as the risks of surgery are fully explained. Following surgery we commence physiotherapy two weeks later when the wound has healed. An outfield player can play after 2 weeks with a splint. For a goalkeeper we would wait six weeks before allowing impact on the wrist.
Fig 1a. Comminuted intrarticular distal radius fracture
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For all multi-fragmented, displaced fractures we would recommend immediate fixation with a locking plate. Ulnar Shaft Fracture Ulnar fractures are often called nightstick fractures as they classically result from warding off an overhead blow (nightstick being the colloquial name for a policeman’s baton in the USA). Goalkeepers can sustain these injuries when colliding with a post or colliding with an outfield player with the outer aspect of their forearm. These injuries are classically mid shaft and transverse and have a slightly increased rate of non-union. In the majority of cases, these fractures show no significant shortening or angulation. Unlike other forearm fractures, the proximal and distal radio-ulnar joint is intact. This injury can be managed in a ulnar gutter splint and or functional brace. For displaced, shortened or angulated nightstick fractures, open reduction and internal fixation with a plate is required [7].
important to remember that goalkeepers are particularly prone to scaphoid fracture when stopping a shot as this is the same as falling on an outstretched hand. On examination the player may or may not be tender in the anatomical snuff box, however axially loading the thumb could re-produce the pain. We recommend radiographic scaphoid views and if these do not show a fracture then an MRI scan should be obtained. All acute proximal pole fractures should be treated with percutaneous fixation because of high rates of non-union in this fracture pattern. Waist and distal pole fractures can be treated in cast for 8-12 weeks, however this can lead to increased wrist stiffness and longer time off playing. We would recommend operative fixation of all acute scaphoid fractures with a headless compression screw (Fig 2). This enables early physiotherapy and return to football.
Scaphoid fracture The scaphoid is the most commonly injured carpal bone, with the incidence of scaphoid fractures increasing among both elite and amateur footballers [8]. Scaphoid fractures can be notoriously difficult to diagnose clinically and on X Ray and are often missed. This can lead to non-union and subsequent arthritis, termed scaphoid non-union advanced collapse (SNAC). This occurs due to poor retrograde blood supply to the bone principally the proximal pole. When treating professional footballers one must maintain a high index of suspicion. Clinically the player may only complain of mild non-specific pain and may not remember a fall or collision. It is
Fig 2. Fixation scaphoid waist fracture with headless compression screw
Fig 1b. Fracture fixed with volar locking plate, enabling early motion
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football medicine & performance
SOFT TISSUE INJURIES Scapholunate ligament injury The scapholunate ligament sits between the scaphoid and the lunate bones in a horseshoe fashion tightly binding these bones together and is important in carpal stability. Injuries to this ligament usually occur after a fall, typically the wrist is extended ulnar deviated and supinated, although the player never remembers how they fell. An X Ray can show a gap between the scaphoid and lunate (Fig 3). However, the radiographs can be normal and a diagnosis of wrist sprain is usually made [9]. Treatment of acute, scapholunate ligament injuries have better outcomes than chronic injuries [10]. Therefore if a player complains of dorso-central wrist pain and the Xrays are normal, then one has to be highly suspicious of a scapholunate ligament injury. MRI can be utilized to help with diagnosis, but is not always accurate and may not define the extent of the injury. We find a wrist arthroscopy to be the best modality for evaluation of intrinsic wrist ligament injuries, and this remains the gold standard [11]. Arthroscopy allows the grade of the ligament injury to be defined and concomitant injuries such as triangular fibrocartilage injuries and joint cartilage damage to be assessed and debrided if necessary. Partial stable scapholunate ligament injuries as defined by arthroscopy can be
treated with physiotherapy and the player can play once the wounds have healed (5-7 days). He/She may require a splint for up to 4 weeks whilst playing. Unstable Scapholunate injuries require open repair and a goalkeeper can be out of action for up to 3 months. If a scapholunate ligament injury is missed the player will continue to complain of pain, weakness, clicking in the wrist and inability to take load on the wrist. Goalkeepers will have pain when shot stopping. If the situation is left undiagnosed this will lead to early arthritis in a predictive pattern termed scapholunate advanced collapse or SLAC wrist Lunotriquetral ligament injury Lunotriquetral ligament injury is not as common as scapholunate injury but similarly under-diagnosed. After acute injury the player will complain of pain and swelling in the dorsal and ulnar aspect of the wrist. Xrays can be normal in the acute phase. MRI may be helpful in diagnosis, but arthroscopy remains the gold standard for diagnosis and treatment. Arthroscopic assisted reduction and percutaneous pinning with Kirschner wire fixation is our preferred treatment choice in complete lunotriquetral ligament tears [12]. Triangular fibrocartilage tears (TFC) A TFC tear often occurs following a fall on a pronated extended wrist, which leads to
Fig 4. TFC tear at arthroscopy
impaction of the carpus on the ulnar and damage to the intervening TFC. The player experiences pain on the dorsal ulnar aspect of the wrist. The pain is exacerbated by wrist rotation and gripping, actions which are important in goalkeeping. Radiographs are normal and MRI is commonly used to confirm diagnosis. However MRI sensitivity and specificity for TFC tears can be as low as 80% [13]. TFC tears which are diagnosed on MRI scan should be treated initially with rest and immobilization as well as taking nonsteroidal medication. Should symptoms not settle within 4 weeks then we would recommend a steroid injection. In players with persistent ulnar sided wrist pain we would recommend wrist arthroscopy for evaluation and debridement or repair of the tear. Central tears of the TFC are not amenable for repair as the central portion of the disc is avascular (Fig 4). Only peripheral tears are amenable to repair as they are in the vascular zone, but are much less common. Triangular fibrocartilage complex injury (TFCC) Isolated TFC tears are not to be confused with injury of the TFCC. The TFCC is a complex structure composed of the TFC, as well as the dorsal and palmar radioulnar ligaments, the ulnar collateral ligament and the extensor carpi ulnaris sheath. A greater force is required to injure the TFCC and therefore TFCC injuries are not as common as isolated TFC tears. TFCC injuries can lead to DRUJ instability or dislocation.
Fig 3. Gap between scaphoid and lunate indicative of Scapholunate ligament injury
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An acutely subluxed or dislocated DRUJ needs to be reduced immediately and held in place with k wires for up to 6 weeks. Sometimes the DRUJ cannot be reduced closed because the extensor carpi ulnaris tendon can become interposed in the joint and then an open surgical approach is required.
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Chronic DRUJ instability is often due to damage to a number of components of the TFCC. The players can experience pain over the DRUJ, weakness in grip, snapping of the distal ulnar and loss of forearm rotation. Treatment usually takes the form of reconstruction of the dorsal and palmar radioulnar ligaments using a free tendon graft. Injuries to the TFCC and consequent instability of the DRUJ are debilitating injuries for goalkeepers leading to a prolonged time away from football. CONCLUSION Given the greater susceptibility of football players and especially goalkeepers to developing wrist injuries, we advise having a high index of suspicion for ligamentous injuries and occult fractures. The aim is accurate and timely diagnosis as acute repair of the injured ligament or fixation of bone is preferred, owing to improved recovery times, less pain and more predictable outcomes. The goal of any treatment is to stabilise the wrist and expedite return to preinjury functional level. As previously discussed in our article looking at hand injuries, a database of such injuries amongst this elite group of athletes would serve to guide future research and provide a more evidence based approach in management of amateur and professional football players.
Lead Author: Mr Raj Bhatia BSc(Hons), MBChB,FRCS, FRCS(Tr & Orth), MD Consultant Hand & Orthopaedic Surgeon Institute: Bristol Hand & Wrist Clinic Spire Bristol Hospital Bristol BS6 6UT Website: www.bristolhandsurgery.co.uk Email: raj.bhatia@icloud.com
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1. Amadio PC. Epidemiology of hand and wrist injuries in sport. Hand Clin 1990 (6); 379-381
8. Fowler J, Hughes. Scaphoid fractures. Clinics in Sports Medicine. 34(1); 37-50
2. Avery, D. M., Rodner, C. M., & Edgar, C. M. (2016). Sports-related wrist and hand injuries: a review. Journal of orthopaedic surgery and research, 11, 99
9. Paci, G. and Yao, J. (2015). Surgical Techniques for the Treatment of Carpal Ligament Injury in the Athlete. Clinics in Sports Medicine, 34(1), pp.11-35
3. Ekstrand J et al. Upper extremity injuries in male elite footballers. Knee Surg Traumatol Arthrosc. 2013, Jul 21(7); 1626-32
10. Rohman, E., Agel, J., Putnam, M. and Adams, J. (2014). Scapholunate Interosseous Ligament Injuries: A Retrospective Review of Treatment and Outcomes in 82 Wrists. The Journal of Hand Surgery, 39(10); 2020-2026
4. Haines and Bhatia. Hand Injuries in Goalkeepers. Football Medicine & Performance. 2018(25); 15-17 5. Lawson CM, Hadjucka C, McQueen MM. Sports fractures of the distal radius epidemiology and outcome. Injury 1995, Jan 26(1); 33-36 6. Court-Brown, C., Wood, A. and Aitken, S. (2008). The epidemiology of acute sportsrelated fractures in adults. Injury, 39(12), pp.1365-1372 7. Ali, Mohammed & I. Clark, D & Tambe, Amole. (2019). Nightstick Fractures, Outcomes of Operative and Non-Operative Treatment. Acta Medica (Hradec Kralove, Czech Republic). 62. 19-23
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11. Andersson, J., Andernord, D., Karlsson, J. and FridĂŠn, J. (2015). Efficacy of Magnetic Resonance Imaging and Clinical Tests in Diagnostics of Wrist Ligament Injuries: A Systematic Review. Arthroscopy: The Journal of Arthroscopic & Related Surgery 2014, 31(10);1-7 12. Osterman A, Seidman G. The role of Arthroscopy in the treatment of L-T injuries. Hand Clinic 1995, 11; 41-50 13. Blazar, Chan et al. The effect of observer experience on magnetic resonance imaging interpretation and localization of triangular fibrocartilage complex lesions.J. Hand Surg (Am) 2001.
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