Football Medic & Scientist by Football Medicine & Performance Association

football medic & scientist The official magazine of the Football Medical Association

Issue 22 Autumn 2017

In this issue: Carb Periodisation Dental Screening Dr. Jag Basra Interview Sports Psychology

Exclusive:

Fibrous Dysplasia Dr. Gawain Davies examines its impact on an academy player

FMA FOOTBALL MEDICAL ASSOCIATION

Legal • Education • Recruitment • Wellbeing

Contents

FMA FOOTBALL MEDICAL ASSOCIATION SPONSORED BY

Welcome 4

Members’ News

Features 6

FMA Legal Services

Football & Carb Periodisation Dr Tom Little & Mark Hearris

12 Promote Yourself on the FMA Register 14 Fibrous Dysplasia & Stress Fracture in an Academy Football Player Dr Gawain Davies 18 FMA Branding for Promote Medical 20 Routine Preseason Dental Screening Must be the Norm Lyndon Meehan

CHIEF EXECUTIVE OFFICER With the season now well underway there is a “sense” of stability within our industry. But we all know this is a temporary hiatus in what is a long arduous season and that football and stability are two words that do not generally go hand in hand. As a rule, this is a quieter time for us all even though incredibly there have already been a number of managers who have been released by Clubs and with it comes the potential for backroom staff to lose their positions as well. This being the case we advise all members to constantly keep an eye on the bigger picture within their discipline and in doing so, have in mind what they would do if the worst was to happen. We are never more needed than when a Club decides to dispense with a member’s services and we all know now that our Legal support is second to none. But the FMA was set up to support its members whether they are working in the game or not. Accordingly, everything we do as an association is relevant to our members even when they are no longer working in football. • •

24 The Proof is in the Training: Employing Sport & Exercise Psychologists Jennifer Hobson

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The Role of a Sports Scientist in the Early Stages of Long Term Rehab of an injured Player Scott Pearce

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Intra-Session & Inter-Session Reliability of Vertical Jump Height in Elite Youth Soccer Russell Hitchen & Dr Jamie Highton

35 Modern Surgical Management of Knee Arthritis Mr Sam K Yasen 39 FMA Interview Dr Jagdish Basra

Cover Image Manchester City and England Head of Sports Science - Sam Erith Nick Potts/PA Archive/PA Images Football Medical Association. All rights reserved. The views and opinions of contributors expressed in Football Medic & Scientist are their own and not necessarily of the FMA Members, FMA 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 FMA. For permissions contact admin@footballmedic.co.uk.

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Our recruitment platform is a valuable gateway for those hoping to get back into the game Post graduate course listings will act as a resource for members to access and further their educational credentials Courses and conferences hosted on our site help provide access to CPD and to keep practitioners in touch with colleagues attending these events Our magazine continues to keep members up to date with events in the Industry The FMA Register is now a vital advertising medium for those who move into private practice or wish to set up as Consultants within the game And the FMA Register provides an opportunity for members to keep their profile in the frame as Clubs increasingly use it to source potential employees or consultants

All in all, members continue to benefit from our support and services even beyond the game and are considered a valuable part of our community of practitioners from professional football. I also believe it is vital that we keep hold of experienced practitioners in some capacity and make use of their knowledge to help others in the game. As such we have a panel from across the disciplines which we regularly turn to for interviews, articles, or appearances and who are in turn therefore, active ambassadors for the FMA. But we can do much more, and in this regards we are planning to look at the role of mentorships to make best use of these practitioners in order to support newcomers to the game. Eamonn Salmon CEO Football Medical Association Football Medic & Scientist Gisburn Road, Barrowford, Lancashire BB9 8PT Telephone 0333 456 7897 Email info@footballmedic.co.uk Web www.footballmedic.co.uk Chief Executive Officer

Eamonn Salmon Eamonn@footballmedic.co.uk

Executive Administrator

Lindsay McGlynn 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, Francis Joseph, Football Medical Association

Contributors

Dr Tom Little, Mark Hearris, Dr Gawain Davies Lyndon Meehan, Jennifer Hobson, Scott Pearce Russell Hitchen, Dr Jamie Highton, Mr Sam K Yasen Dr Jagdish Basra

Publisher

Academy Print & Design www.academy-print.co.uk

members’ news

MEMBERS’ NEWS

Conference Date for your Diary

polled delegates at our last Conference and discussed with the FMA Committee, we have decided to make a very slight change which we believe will resonate with attendees.

We have always been conscious however that the event takes up a precious weekend after what is a long hard season and these weekends, as we all know, are a rare commodity. Having

This season, the FMA Conference and Awards will be held over Friday 18th and the morning of Saturday 19th May with a 12.30 finish. This will allow delegates to spend most of the weekend with their families and we hope this will be a welcome change to what is a fantastic, not to be missed, event.

he first weekend after the last league game – also FA Cup Final weekend – is traditionally the date for the FMA Conference and awards event, and this has proved popular with members and delegates demonstrated by a rise in numbers attending year on year.

Embracing all disciplines

he FMA has always engaged with health care providers to clubs and worked to bring them into the fold as valued members of the health care and performance support team. Accordingly, we are building networks of practitioners for Sports Psychologists, Nutritionists, Dentists, Opticians, Podiatrists and Surgeons/Physicians in order that they are recognised as a key part of our association and that their contribution at clubs can be appreciated and indeed maximised.

One of the ways we can help facilitate this is to give each discipline a platform to submit articles for the FMA Magazine, giving an opportunity for them to extol the virtues of their profession to the industry and educate everyone as to their skill set. In this edition we include includes contributions from Sports Psychology, Nutrition and Dentistry, and others are set to be featured in following publications. This is a great opportunity for all clubs to engage their staff by letting them know they too are a valued part of the FMA network.

Website Member Menu

e have made things a whole easier for our Members to navigate around the FMA website. You can now click on the brand new Members Menu where you will find everything you need in one place. From Legal, Recruitment and Education to your profile and all the member benefits and services that the FMA offer.

SOCCEREX

he FMA were designated partners for the World Soccerex convention held in Manchester recently.

This was the last time it would be held in Manchester and as usual the event did not disappoint in terms of attendees , trade exhibition and presentations. The FMA played its part by submitting a panel for a discussion on player resilience which was led by Manchester United Physio Neil Hough and Swindon Towns sports Scientist Chris Neville with Nick Worth as chair. This was a lively discussion with several questions fielded from the audience. Day two saw a high profile panel discussing doping control in football and FMA member Dr Mathew Brown from Manchester city gave his views on this ever topical subject. All in all this is a great way to link up with businesses and mix with the great and the good in football.

football medic & scientist

Vivomed

ivomed is the latest company to come on board as Business Club members.

A family owned and run sports medicine supply company, Vivomed has a licensed Pharmacy and 2 full time pharmacists, meaning they can supply all your medical teamâ&#x20AC;&#x2122;s requirements from physiotherapy consumables, pharmaceuticals to trauma equipment. Vivomed has a huge wealth of experience working with sports teams playing at the highest levels and is delighted to join the FMA as a Business Club member for this season.

University partnerships

he FMA is currently looking to partner with a variety of Universities who offer both undergraduate and post â&#x20AC;&#x201C;graduate programmes relevant to our members. Our aim is to host information about such programmes in order to help cement the FMA as a one stop shop for members when searching further educational opportunities. We are also hoping our FMA Online Forum will be linked to this platform to facilitate an

exchange of views and experience. The partnerships have begun with UCLAN as the first University to list their programmes and we are delighted to welcome them onboard. www.footballmedic.co.uk/universities We are now working to bring many more to the site to offer members a resource to help them in planning their educational development.

Branding under way

romote Medical is the first company to use the FMA logo alongside their product. Having gone through the process of evaluation with practitioners in the game, their medical bags will now display the FMA logo giving clear indication that these products are of real value to the industry. Other companies are currently undergoing the same evaluation process and we hope this will become a welcome benchmark to help members in accessing key products for their clubs. The FMA Branding Agreement is a tried and tested process that enables

companies to access the professional football market in a quick, simple and cost effective manner never before possible. If you would like to know more about this arrangement and working with the FMA please contact us at info@footballmedic.co.uk or call 0333 4567897.

Support for courses

art of the role of the FMA within education is to give members access to those courses, conferences and events that are relevant for CPD/further education. As such, we are continuing to support those Clubs who host an event, by marketing and promoting the programme via our website and database. If you are considering such an undertaking, please do contact us to discuss how we can help you help our members.

Foreign shores

MA committee member Alan Rankin was recently part of a medical team supporting the 5th Asian and martial arts games in Turkmenistan. Seconded to the Footsal arena he was surprised to find fellow Physiotherapist Richard Evans there who currently works in Ghana and who is also an FMA member! Our reach truly is International!

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football medic & scientist

FMA Legal services Being a part of the FMA and having this open door access to such high quality legal advice is reason enough for any football medic to join the FMA.

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Pictured: Arsenalâ&#x20AC;&#x2122;s Theo Walcott (right) and team-mates during a September training session at London Colney.

FOOTBALL AND CARB PERIODISATION FEATURE/Dr Tom Little & Mark Hearris Nutrition is a field that is awash with contradictory information. In particular, carbohydrates or carbs present a dichotomy of interests. For years carbs have been associated with improved exercise performance and athletes have intuitively consumed high carb diets to support performance.

owever, in recent years, there has been a resurgence of interest amongst social media users in the use of low carb and/or high fat (LCHF) diets as the optimal fuel for athletes. Additionally, the marketing prominence of protein and cultural support of low carb dieting has led to some athletes actively avoiding traditional carb choices. However, in contrast to both dietary extremes, it appears athletes should â&#x20AC;&#x2DC;meet somewhere in the middleâ&#x20AC;&#x2122; and switch between periods of high, moderate and low carb intake, whereby carb intake is periodised in accordance with the goal of the session, the individual athlete and the weekly training schedule (Anderson, 2017),

Carbs are seen as the prominent fuel for intermittent exercise as they are capable of producing energy at a faster rate than fat or protein. Although the oxidation of fat provides a higher energy yield than carbohydrate, its rate of energy production is certainly insufficient for high intensity actions that are frequently performed in intermittent sports like football. Indeed, key moments in football are typically made up of high intensity actions, such as sprints, shooting and jumping, with matches typically containing 150-250 such actions. In accordance, numerous studies have shown that starting a match with high muscle glycogen stores, via a high carb diet, is beneficial to football

performance as it allows players to cover greater distances and more of this distance to be covered at higher intensities (Saltin, 1973), whilst maintaining technical performance. Therefore, there appears to be an overwhelming case for footballers consuming a diet rich in carbs. Somewhat paradoxically, however, an emerging body of evidence suggests that restricting carbs at selected times surrounding training can augment the aerobic training effect (Bartlett, 2015) via increased mitochondrial production, resulting in a greater capacity to produce energy aerobically, utilise fat for energy production and spare precious muscle glycogen for high-intensity actions. As the

football medic & scientist aerobic system is the predominant energy source during match play, and muscle glycogen is essential for performance, it could be argued that it may be beneficial for a footballer to periodically consume low amounts of carbs surrounding training. Practically, low carb availability can be achieved using a variety of strategies: (1) chronic low carb intake, (2) an acute period of low carb intake (e.g. low carb intake in the evening, then train in the morning before breakfast or following a protein only breakfast), (3) two training sessions with minimal carb intake in-between. However, such severe restrictions of carbs are probably inadvisable to footballers during the in-season as they are required to compete so regularly and have to frequently perform high-intensity, and skill based actions in training. In addition, low carb availability is associated with compromised immune function, increased muscle breakdown, whilst chronic reductions in carbs decreases our capacity to use carbs as fuel (Cox et al, 2010). As such, severe low carb strategies may only be suitable during the off-season, with injured players performing low-to-moderate intensity exercise or with players who excessive body fat has been identified as a severely limiting factor to performance. Whilst severely restricting carbs may not be a viable option for footballers, reducing carbs at appropriate times may be beneficial for optimal health and body composition.

Figure 1. Benefits of high and low carb intakes for footballers High carb foods such as pasta, cereals, breads and high sugar foods tend to have a low ‘nutritional value’, whereas colourful vegetables and salad contain less carbs but have greater health benefits (in terms of vitamins, minerals and fibre). Furthermore, many traditional high carb foods, such as white bread, pasta and potatoes, also have a high glycaemic index, which indicates how quickly a food elevates blood glucose. A rapid rise in blood glucose causes a high insulin response, resulting in a rapid uptake of nutrients and, as such, high glycaemic foods are good for promoting carb storage

(A) Traditional British 2-match week

(B) European style 2-match week

(D) 3-match week with a Wednesday fixture

Figure 1. Relative match & training loads for weekly structures commonly used in football. MD refers to number of days since (+), and leading up (-) a match. Red = high carb, Yellow = moderate carb, Blue = low carb.

following exertive exercise. However, habitual intake of high glycaemic foods can cause body composition issues due to increased fat storage and a lack of satiety, and potential health issues such as insulin resistance and type II diabetes. Additionally, high carb foods, particularly those containing sugar, tend to contain a higher number of calories for a given quantity of food than less carb-dense foods, hence their regular consumption can be associated with weight gain unless energy expenditure is consistently high. Finally, varying carb intake may help promote ‘metabolic flexibility’ where the body is primed to use both carbs and fats optimally, as and when required. In light of the above, it appears that players should vary carb intake based upon match, and training demands. Increasing carb intake around matches and hard training will maximise performance, whilst reducing carbs when physical demands are lower, allows the promotion of foods that optimise health and lean body composition, which will further increase performance potential. Footballer’s energy demands and performance tasks tend to vary during the week based on match schedules and the manger’s training philosophies. Match performance is paramount, and matches normally represent the highest energy demands during the week. Therefore, carb intake should be high the day before, and on the day of a match. When there is no midweek fixture, teams tend to perform mid-week high load training session(s), with the aim of improving, or maintaining fitness levels. High load training days also need to be supported by high carb intakes to optimise performance and recovery, and minimise injury risk. Teams tend to use low to moderate training loads ~ 48hrs before a match, in order to reduce fatigue and maximise fuel stores, and 48hrs post-match to promote recovery and reduce injury risk. These low load periods (barring the day prior to a match) present an opportunity to reduce carb intake. Figure 1 illustrates relative loading for weekly structures commonly used in professional football. The red bars indicate days were carb

Situation

Carb guidelines

Comments

2-3 g.kg of athletes BM per day

• Low glycaemic index & high fibre vegetables

Daily needs for fuelling & recovery: Fat loss & injury rehab

Aim of the athlete is to reduce fat mass or regain fitness before returning to play

• Incorporate periods of fasted training Light training

Low intensity & skill based sessions

3-5 g.kg per day

• Low-moderate glycaemic index depending on preference

Moderate

High intensity / double sessions

5-6 g.kg per day

• High glycaemic (low fibre) index foods are advisable between double sessions

intakes need to be high to support match performance or hard training. Yellow bars suggest moderate intake of carbs, when training load is moderate, or training load is low but there is a short period between matches. The blue bars indicate days where training load is low, and therefore carb intake can be low. Table 2 illustrates recommended carb quantities for these different training and match scenarios, and Table 3 shows an example meal plan with varying carb intakes. Practical Implications •

Acute fuelling strategies: Carbohydrate loading

Preparation for match

6-8 g.kg per day

• High glycaemic (low fibre) index foods allows gut comfort and lower match day weight

Immediate refuelling

Optimise muscle glycogen resynthesis post-match

1-1.2 g.kg per hour for 3-4 hours

• CHO dense snacks and drinks are advisable – combine with protein if targets cannot be achieved

Table 2. Practical carb guidelines for the athlete

•

Footballers should align their carb intake with the energy, and performance demands of competition and training. Increasing carb intake around matches and hard training will maximise performance, whilst reducing carb intake around on days off, and low training loads, allows the promotion of foods that promote health, such as vegetables, and lean body composition, such as proteins. To provide a balanced input of carbs, whilst promoting health, footballers should eat mainly low glycaemic carbs, such as vegetables, salads, oats, beans, nuts and seeds. Around matches, players should allow some inclusion of higher glycaemic carbs to provide an easily digestible efficient energy source.

football medic & scientist

Pictured: Charlton Athletic players warm up before their game against Gillingham in September.

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During the off-season or if a player is injured, in may be advantageous to train during periods of low carb availability to induce greater aerobic adaptation and fat oxidation. However, training should only have moderate intensity and performance demands, and adequate protein (1.5-2g.kg day) should be ensured to prevent muscle wastage. Training in the morning before any carb intake probably represents the most viable methodology of low carb training for footballers, rather than prolonged carb restrictions. Players need education tools which align food to performance, health and

body composition goals. They then need practical cooking skills to reap the benefits of their more informed choices. References Anderson, L., Orme, P., Naughton, R. J., Close, G. L., Milsom, J., Rydings, D., O’Boyle, A., Di Michele, R., Louis, J., Hambley, C., Speakman, J. R., Morgans, R., Drust, B. & Morton, J. P. (2017). Energy intake and expenditure of professional soccer players of the English Premier League: Evidence of carbohydrate periodisation. International Journal of Sport Nutrition & Exercise Metabolism, 4, 1 – 25. Bartlett, J. D., Hawley, J. A. & Morton, J. P.

(2015). Carbohydrate availability and exercise training adaptation: Too much of a good thing? European Journal of Sport Science, 15, 3 – 12. Cox, G. R., Clark, S. A., Cox, A. J., Halson, S. L., Hargreaves, M., Hawley, J. A., Jeacocke, N., Snow, R. J., Yeo, W. K. & Burke, L. M. (2010). Daily training with high carbohydrate availability increases exogenous carbohydrate oxidation during endurance cycling. Journal of Applied Physiology, 109, 126 – 134. Saltin, B. (1973). Metabolic fundamentals in exercise. Medicine & Science in Sports, 5, 137 – 146.

Bios Dr Tom Little is a Performance Specialist with over 17 years experience in professional football. Tom developed Colour-Fit™, an app that simplifies choosing and preparing optimal meals for performance, health and body shape goals. For more info visit www.colour-fit.com or email tom.little@sky.com Mark Hearris is a PhD researcher within the sports nutrition & exercise metabolism research group at LJMU. Mark also provides nutrition consultancy support to Preston North End Football Club.

Table 3. Meal plan for a 2-match British training structure taken from Colour-Fit™. All the pictures link to Meal Cards, Prep Videos and nutritional breakdowns.

football medic & scientist

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PROMOTE YOURSELF ON THE FMA REGISTER T he FMA Register is a network of member practitioners who have experience in professional football within their discipline and has proven to be a huge success before it has even been officially launched!

The concept behind the project was simply to bridge the gap between the Professional game and grassroots football, placing our members in front of fans and grassroots players and bringing best practice care from an elite level in reach of those playing the amateur game or supporting their Club. A by-product of this project has been the emergence of the register as a resource for clubs and colleagues to source practitioners should they need their particular skill sets either on a consultancy level or on a temporary/permanent basis. This has proved invaluable for members who embark upon private practice after leaving a club, and as part of our support we encourage them to get listed on the register to actively keep their profile in focus. The Register continues to grow with almost 300 practitioners now listed and a campaign underway to bring health care providers to clubs into the fold will see further growth. Yet another by-product is the establishment of networks for these practitioners which is

giving them a platform within the FMA to develop and consolidate as an entity in the Professional game. In preparation to launch to grassroots football we have been working hard building our database of clubs and have received a great response from businesses including Teamer and Club website, who with a reach of over 1 million players on their database are pleased to support and promote our initiative “Giving Back to the Game”, which involves FMA Registered practitioners being encouraged to offer discounts to grassroots players.

As we are keen to support health care providers who are part of the medical and science framework at your Club, we are busy informing as many practitioners as we can about this unique opportunity. Your support with this has been greatly appreciated and remember you can contact Project Manager, Angela Walton, at any time with the names of your health care providers angela@footballmedic.co.uk 0743 236 0789. We have recently made a few changes to the Register to make it more user friendly allowing members quick access to update their details and for potential clients, colleagues and clubs to access those practitioners listed.

The listings are very clear to identify each individual practitioner, their profession and experience at current and previous football clubs. The Register offers a great opportunity for members already in private practice or those just starting out, to highlight their experience, services and professional profile to potential clients. We have a specific section on the listing to highlight your private practice which pulls through a location map. We also have a ‘Profile Focus’ section, which appears on the Latest News page, to additionally highlight practitioners and this is promoted on our social media platforms. If you would like to join your colleagues on the FMA Register and take advantage of the promotional offer “currently free for members to join the Register!”, sign into your profile www.footballmedic.co.uk/memberaccount and click ‘Join the FMA Register’ button. If you have any any questions, please do not hesitate to contact Angela Walton 0743 236 0789 or 0333 456 7897 angela@footballmedic.co.uk

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It’s Not Always “Impingement”

Fibrous Dysplasia and stress fracture

in an Academy Football Player FEATURE/DR Gawain Davies Summary This case outlines the diagnosis and management of Fibrous dysplasia and multiple stress fractures in an academy footballer. He had played from the age of 14 with groin pain and a presumptive “diagnosis“ of Hip impingement had been made to account for this. At age 16 he sustained a stress fracture of the tibia early in his first season as a full time scholar. Groin/Hip pain during his rehabilitation from this injury led us to obtain a plain x ray and he was diagnosed with Fibrous Dysplasia. This was treated with bone grafting and led to a successful return to play after 6 months. He subsequently sustained two femoral stress fractures. No obvious cause for his three stress fractures was found. He is now playing elite football at U-23 level.

Key Points 1. Fibrous dysplasia- Low awareness of this condition and high risk of fracture. 2. Stress fracture is the commonest overuse injury. 3. Multiple stress fractures are unusual. History Player joined this championship club, level 2 Academy following successful trial and release from a Premiership Academy. Initial Medical Assessment. June 2014 Afro- Caribbean descent, Born in U.K.Position: Striker Past Medical History. Nil of note. No Sickle disease /trait.

Past Injury History. Right groin pain for last 2 seasons. Pain was worse at end of matches, resolved in a few days. Pain resolved completely in close season. He received conflicting diagnosis/ advice from medical team at former academy. Suggested diagnosis included “impingement “, “flat feet”, and ”needs surgery to release TFL/ adductor “. Had received several courses of NSAID for pain. No Imaging. On Examination Height 180cm. Weight 75.8 kg. BMI 23.6 Right leg 1.2 cm shorter than left. Right central groin pain increased on internal rotation/ impingement testing. Nil else of note.

football medic & scientist Injury Timeline

Referred to tertiary metabolic bone centre and Orthopaedic department in Sheffield.

24/6/2014).

Metabolic bone opinion.

Admitted to not taking Calcium/ Vitamin D. Vitamin D level 26.7nmol/l

“High risk of pathological fracture – early fracture lines visible on X –ray.

Given Bolus dose 100,000 units and advice re compliance

Vitamin D low 26nmol/l. Supplementation commenced.

3. Injury

July 2014 Commenced pre –season training. 1. Injury 24/8/2014 Stress fracture Left Tibia Sudden onset pain in left calf while sprinting. O/E. Tender medial upper calf, antalgic gait. MRIscan. “Severe stress reaction and cortical fracture of proximal diaphysis of left tibia. Periosteal reaction and intense bone marrow oedema.” Diagnosis. Stress fracture, atypical site. Investigations. Bloods FBC, U and E, LFT, Vitamin D, Bone profile, PTH. Results. All normal except borderline low Vitamin D.

Bone Mineral Density within expected range for age. Treatment. Iv. Zolendronate for bone pain. He had acute phase reaction and flu like illness for 1 week. NM Scan / SPECT scan. “Low uptake in right femoral neck not typical of fibrous dysplasia. No other areas of FD identified. No features to suggest McCune-Allbright syndrome.

Advised stop activities. Tertiary referral required.

Rest, Non-weight bearing initially. Calcium and Vitamin D supplements. Gradual return to sport.

28/1/2015 Reviewed at Royal Orthopaedic Hospital Birmingham

2. Injury

On Examination. Patient asymptomatic. Normal gait. ( the patient had done no sport , restricted walking ).

Post session c/o Right hip/ groin pain. X-ray. Right Hip “Grossly abnormal appearance of femoral neck with large cystic area making up most of the neck of femur. ( image below). Differential Diagnosis. FIBROUS DYSPLASIA/? Bone tumour.

Attended training camp in Portugal. After jogging on sand c/o pain in Left thigh. 31/7/2016 MRIscan grade 4 stress reaction of distal femur – subacute (image below) X ray Trabecular stress fracture. Left femur mid/distal portion, medial side.

Seen by University Hospital Orthopaedics, Sheffield

Treatment.

11/11/2014. Fibrous dysplasia Right neck of Femur. Running at 60-70 % for 4 x 4 minutes as part of rehabilitation.

23/7/ 2015 Stress fracture Left femur

Confirmed likely diagnosis and high fracture risk. 17/2/2015 CT guided Bone Biopsy confirms Fibrous Dysplasia. Surgical options discussed. Tibia donor site bone graft not suitable as possible effect on running and sprinting. Donor graft sourced from Liverpool transfusion service. Operation said to have 75% success rate. Increased risk of cam type impingement and would need six months restricted activity post operation. 20/3/2015 Surgery. Curettage of bone cyst and allograft bone grafting using frozen tibia and demineralised bone matrix. Non-weight bearing for 2 weeks. 21/4/2015 OPD Review. Wound healed / Weight bearing / good ROM. Player returned home with rehabilitation programme and physiotherapy review. 11/5/2015 Metabolic bone review. Height 182.9cm (3cm growth since

Treatment Strict non-weight bearing and rest. Vitamin D level 50.1nmol/l (normal). Metabolic bone review arranged Rehabilitation Slow rehabilitation with rest then increased weight bearing using cross trainer/Alter G/ Pitch running.

result from fracture, deformity, functional impairment, and pain. The disease occurs along a broad clinical spectrum ranging from asymptomatic, incidental lesions to severe disabling disease affecting one bone (monostotic) or multiple bones (polyostotic).

Return to training 4. Injury 11/11/ 2015 Stress fracture Right femur

Fibrous dysplasia is a non- hereditary genetic condition. Presentation usually occurs before the age of 10 years. Treatment in fibrous dysplasia is mainly palliative, and is focused on managing fractures and preventing deformity. There are no medications capable of altering the disease course. Intravenous bisphosphonates may be helpful for treatment of bone pain, there is no clear evidence that they strengthen bone lesions or prevent fractures although a single case report suggests they may be helpful in fracture healing. (1).

Rehabilitation “going well”. Running 4 x 4 minutes at 70 % pace. c/o pain in R hip and R distal femur. MRI. Right Femur. Intense bone marrow oedema affecting R distal femoral shaft. Grade 3-bone stress reaction. X ray -Stress changes medial Right femur Treatment 8 weeks non-weight bearing X- ray.Right femur healing stress fracture. Metabolic Bone Review. Professor. Advice: High dose vitamin D and long-term vitamin D supplementation to achieve and maintain level of >75nmol/l. No other treatment likely to help. Slow Rehabilitation with return to training March 2016. Ensure compliance with Calcium and vitamin D supplements. Epilogue In March 2016 his contract was extended by 6months from July 2016. Played match at end of season 2015-16 – first appearance for club since July 2014 Season 2016-17.

Full participation in pre-season with U-23 team. Played all matches. Joined professional club first team squad January 2017. No problems reported with R hip or previous areas of stress fracture. 24/6/16 Vitamin D level checked 57.1 nmol/l – Normal but still below target. Discussion Fibrous dysplasia is a rare bone disorder where normal bone is replaced with disordered fibrous tissue. Complications

Surgical techniques such as bone grafting, curettage, and fixation are frequently ineffective and reserved for lesions causing pain, deformity or at high risk of fracture. Bone grafting has been used for similar cystic lesions in bone in adolescent basketball (2) and grafting plus compression hip screw fixation in a more sedentary population (3). Graft survival is only moderate with a 50% survival of graft at 14.5 years (4) Stress fractures occur when (usually unaccustomed) repetitive load on bone exceeds its ability to re-model (5). Known risk factors are previous stress fracture and female sex. Diet, Body Mass, low Calcium / Vitamin D intake and Growth have all been cited as risk factors in stress fracture but with little clear evidence (6). Interest in Vitamin D has suggested a possible

football medic & scientist

genetic vulnerability (7) and wholesale supplementation for athletes (8). No obvious cause was found for this player’s stress fractures except his low vitamin D level at time of the first fracture. Vitamin D levels were normal at time of second and third fractures. The fractures occurred at unusual sites and the loading involved in second and third fractures was minimal. Reflection What went well? Diagnosis made of Fibrous Dysplasia. Prompt specialist opinion. The player was at high risk of potentially catastrophic fracture of neck of femur.

Rest periods and return to play- in retrospect longer rehabilitation and more non-weight bearing elements might be indicated. The stress fractures suggest he was exercising at a greater level than his bones were able to withstand during this period. Learning points 1. Think of Fibrous Dysplasia. 2. Early imaging of hip pain in young athletes. 3. Seek expert intervention. 4. Support the athlete in long-term goals rather than quick return. 5. Consider Calcium and Vitamin D supplementation especially in September to April (Northern Hemisphere) in adolescent athletes. 6. Moderate exercise in times of growth. Thanks to:

Evidence based treatment from metabolic bone centre with realistic expectations of limited treatment. Player attitude and dedication was excellent in all aspects. Physiotherapy and club support. Contract extension granted by the club despite the fact he played almost no competitive football for two seasons. What could be improved? Early diagnosis made of cause of hip pain. No significant underlying cause of his stress fractures identified.

3. Nishida, Y.; Tsukushi, S.; Hosono, K.; Nakashima, H.; Yamada, Y.; Urakawa, H.; Ishiguro, N.; Surgical treatment for fibrous dysplasia of femoral neck with mild but prolonged symptoms: a case series. Journal of Orthopaedic Surgery and Research, 2015, Vol.10, pp.63.

The Player. Mr A. Fickling, Physiotherapist, SWFC. Mr D. Ramsdale, Academy Director, SWFC. References 1. Ohno, I.; Higuchi, C.; Zoledronate Therapy for the Pathological Humeral Fracture in Polyostotic Fibrous Dysplasia: A Case Report. Journal of clinical medicine research, November 2015, Vol. 7(11), pp.901-6. 2. O’Brien, M.; Donnell, A.; Miller, J.; Iven, V.; Pascale, M.; An Abnormal Bone Lesion of the Scapula in a Collegiate Basketball Player: A Case Report. Journal of Athletic Training (Allen Press), 2013, Vol.48 (6), p.859-864.

4. Leet, A.; Boyce, A. ; Ibrahim, K. ; Wientroub, S. ; Kushner, H. ; Collins, M. ; Bone-Grafting in Polyostotic Fibrous Dysplasia. Journal of Bone & Joint Surgery, American Volume, 2016, Vol.98 (3), p.211220. 5. Solomon L.; Warwick D.; Nayagam S.; (2005). Apley’s Concise System of Orthopaedics and Fractures. Third ed. London: Hodder. 6.Alexis A.; Wright, L.; Taylor J.; Ford, K.; Siska l.; Smolig J.; Risk factors associated with lower extremity stress fractures in runners: a systematic review with metaanalysis Br J Sports Med 2015; 49: 1517– 1523. 7.McClung, J.; Karl, J P.; Vitamin D and stress fracture: the contribution of vitamin D receptor gene polymorphisms. Nutrition Reviews, 2010, Vol. 68(6), pp.365-369. 8. McCabe M,; Smyth, M.; Richardson D.; Current Concept Review: Vitamin D and Stress Fractures. Foot and Ankle International 2012 by the American Orthopaedic Foot & Ankle Society. DR Gawain Davies January 2017-01-16 Correspondence to gawdavies@aol.com

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FMA branding for Promote medical P

romote Medical’s range of medical bags will now display the Football Medical Association logo giving clear indication that the products are of real value to the industry. Use of the FMA logo is only given after evaluation of the product by a panel of practitioners from within the professional game who give an honest assessment of service, costing, ease of use, needs of the industry, and whether they would recommend the product to colleagues. Roisin McClory, Commercial Director of the company said “We are delighted to receive and display the FMA brand on our product especially as we are the first to be given that authorisation and as such are unique within this sector. Practitioners

throughout the game will now know ahead of any enquiry that they are sourcing a product that has been recognised by their colleagues as being of real value and that they are not wasting valuable time trying to source the right product.” FMA CEO Eamonn Salmon added “The application of the FMA logo on a product says that a product is worth considering and that fellow practitioners working in the game have recognised its value. We know our members are inundated with company enquiries and struggle to assess or evaluate products on a regular basis. As we move forwards with this initiative it may be that we will have a range of products with the FMA branding thereby saving much of our member’s time by narrowing down the market to those products that are worth their time and consideration.”

“I

heard Promote Medical’s products were to be given FMA Branding so decided to take a look. Their medical bags were fantastic so we went ahead and bought two of them. Steve Allen, Head Physiotherapist, Bristol City FC

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ROUTINE PRESEASON DENTAL SCREENING MUST BE THE NORM FEATURE/Lyndon Meehan BDS, BSc. MJDF RCS (Eng), MSc Endo Professional footballers are not immune from dental diseases, despite apparent superior fitness, conditioning and general health.

ommon dental pathologies seen are tooth surface loss (through acidic erosion, tooth attrition and abrasion), dental caries (dental decay), and periodontal disease. It is therefore imperative players and clubs undertake routine preseason oral health assessments. This will strive to inform the sports medicine department, on the dental status of their players. At present this author feels this is a neglected area of sports medicine. Anecdotally dental health and attendance for treatment, tends be of low priority for players until symptoms arise. There may be a tendency to ‘snack’ during journeys and training, with overuse of sports drinks and gels, thereby relying on sugary items to replace spent energy. Poor oral hygiene results in gross tooth plaque deposits. This in conjunction with frequent sugar intake and during periods of dehydration through a reduced salivary flow, all enhance bacterial degradation of carbohydrates. This therefore provides an acidic source for tooth surface

demineralisation and dental caries lesions. If left untreated an early carious lesion may progress to an irreversible cavity that requires restorative intervention and will become symptomatic. If not dealt with, this may further progress to a dental abscess and facial swelling, which may ultimately require extraction of the tooth. CURRENT LITERATURE There is a growing pool of high quality evidence strengthening previous anecdotal evidence, that professional sportspersons have higher caries rates and treatment need than the equivalent aged person in the general population (2,3,6,9). Early studies by Ljungberg 1990 (5) within Swedish soccer and Gay Esconda’s 2011 (4) study on FC Barcelona players, illustrates higher rates of Decayed, Missing and Filled (DMF) scores and active carious lesions in comparison to students teeth of the same age. It is from this author’s own experiences in the infancy of treating professional

footballers, a multitude of complex dental issues were noted. Players attended emergency dental appointments the day before a game with acute irreversible pulpitic symptoms or intraoral /extra oral swellings, due to poor oral health. A “quick fix” to the problem was sought to be able to play, which was not always possible. Once the initial pain or swelling had subsided, subsequent appointments for follow on care were missed. Access to players was difficult and no baseline dental records or radiographs held on the majority of players. Therefore should one of the club medical staff phone for advice when travelling to away games, it was very difficult to triage the situation. Dental swellings and infections also impacted and delayed other planned general anaesthetic medical surgical procedures, due to concerns of airway risk management. This author therefore initially undertook a small pilot dental study with his club’s sports medicine department to assess the scale of the problem. This data was

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recognised and utilised by the Football Association of England. Dental health recommendations were distributed to all English football league clubs in 2014. A modified and updated version is planned for future. The following key results were noted and the study is unpublished: • •

•

The 22-25 year age group had the highest rates of decay with little thought for decay prevention. Footballers screened had a higher, Decayed, Missing, Filled (DMF) value at (9.09) than the UK average Adult Dental Health survey of 2009 (6.9). The 26-29 year old age group have had multiple complex dental interventions that could compromise tooth retention post career. 30% of professional clubs had ruled out players from matches, between 1-3 times a season due to dental infections.

FA INITIATIVE 2014 (thanks to Dr Jerry Hill FA medical committee) The FA Medical Committee encourages clubs to adopt the following: • • •

Club Dentist - Identify a local dentist for care including screening, education, and dental trauma management. Emergency Action Plan – develop and disseminate a plan for training and match day dental trauma management. Funding – develop clear pathways for funding care e.g. Health Partners, stand alone Dental Insurance.

of life were frequent and significantly associated to dental caries, ongoing oral symptoms / tooth sensitivity and wisdom tooth swellings or infections. • 45% of players were ‘bothered’ by their oral health • 20% reported problems with their mouths affected their daily quality of life: • 7% reported an impact on training or performance.

Conclusions drawn from the pilot study show: 1. Dental decay not uncommon and poorly addressed by players. 2. Pre-season and signing medicals may not screen for poor dental health. 3. Preventative care rare. 4. Emergency Dental Plans for trauma may or may not be present. 5. Lack of formal Club Dentist in many Clubs for screening or treatment. 6. Uncertainty regarding insurance cover for non-traumatic dental issues and the impact of poor dental health on performance. This authors pilot study results were expanded on and contributed in undertaking Needleman et al’s 2015 (8) study. This screening study was one of the largest single sports dental health studies conducted to date. It further corroborates the evidence base of high levels of poor oral health amongst professional footballers. The key findings were: • •

• • • •

Almost 4 out of 10 players had untreated dental caries. Dental caries or restorations increased with age: • 77.9% of 16–24-year olds • 92% of 25–34-year olds Dental erosion (tooth surface loss) was present in more than half of footballers. Inflammatory gingivitis was seen in over 80% of players and irreversible periodontitis in 5%. Sixteen per cent of players reported current problems or pain in their mouths. Self-reported impact on daily quality

Foster and Readman (3) allude to work by Shinkai et al (1993) Rohde et al (1996) and Gleeson et al (1999) identifying a relationship between physical stress, exertion and immunosuppression post training or competition in Olympic triathletes and in swimmers. D’Ercole et al (1) reports several studies linking this to an increased incidence of upper respiratory tract infections in sportspersons. Therefore previously asymptomatic and underlying chronic oral conditions can manifest with acute clinical symptoms during times of bodily immunosuppression. Common examples include pericoronitis associated to partially erupted wisdom teeth and chronic periapical dental lesions (dental abscesses). DENTAL SCREEN OBJECTIVES The objectives of a preseason dental health screen should be as follows: • • •

Detect underlying dental or medical conditions that may limit participation. Identify a history of previous and ongoing dental issues. Establish a baseline record of dental

• •

health. Development of an individual player dental portfolio, that can be reviewed and accompany a player between clubs. Establish a team database and identify higher risk player’s needing treatment.

Many clubs may or may not have a dedicated team dentist. It is essential that good lines of communication and a mutual role appreciation exist within and between all team members for a productive relationship. As Dental health professionals we sometimes can be solely focused on teeth. A slightly differing approach to dental care when treating players may need to be adopted. The timing of dental treatment or dental pathologies may restrict a player’s ability to train and play to their maximum potential. Any post treatment anesthesia, swelling or trismus as a result of a dental abscess, pericoronitis or toothache, will influence nutrition or perhaps other medical procedures planned under general anesthesia, as has been alluded to. TEAM DENTIST A team dentist can bring the following attributes to a sports medicine team. • • •

• •

Organize pre season screening, and coordinate club dental care. Contribute to player management meetings. Have an appropriate knowledge, experience, training, in immediate dental and oro-facial trauma management. Establish an emergency dental trauma management protocol for match days. Provide immediate emergency dental care in respect to the player’s

•

• •

availability. Consider prevention of dental trauma for those players that are at a higher predisposition to traumatic dental injuries. Provide adequate education on optimal oral hygiene advice to player’s, parent’s and club staff. Provision of continued professional development education on dental topics in relation to sport.

SCREENING PROCESS Routinely preseason screening may not take place in the dental surgery, but at a club’s training ground. The dental staff undertaking the screen, may therefore be outside their own normal clinical comfort zone and working within the limited facilities available. Prior planning preparation and readiness are the two main factors in organizing a dental preseason screening session to maximise productivity. A dental screening program should run parallel to a planned medical general screening day or days. This will also allow adequate time to carry out the necessary treatment pre season. Mandatory screening should be carried out at least once a season if not twice if time allows. This author has established and undertaken several training facility based screens as part of medical preseason screening rotation days across numerous clubs. If properly organized and set up, this can run very effectively for a quick basic visual dental assessment. Each player is seen on a 15-20 minute interval and subsequently categorised for treatment as a High, Medium, or Low need. The players are then recalled to the dental surgery and reported on for further investigation and treatment.

Data commonly noted is: • • • • • • •

Previous dental history Oral hygiene and dietary habits Caries (decay) rates Wisdom tooth status (3rd molars) Outstanding treatment needed and ongoing dental pathology Intraoral soft tissue examination. TMJ issues

Screening may bring certain issues to light that the clubs sports medicine department may have been totally unaware of. Commonly it has been found that players are trying to hide issues such as multiple decayed teeth /dental abscesses due to a dental phobia and avoidance of previous dental care. Another growing concern is the use of Snus tobacco (a moist powdered tobacco in pouches). Needleman et al (8) found that 5.4% of professional footballers screened were using Snus. In the armed services the following risk dental assessment categories have been used for many years. Richardson (13) outlined that military personnel were classified according to the following NATO categories: 1- Full dentally fit. 2- Dental treatment required but the condition is not expected to cause a problem in the next year. 3- Treatment is required and the condition is expected to cause problems within the next year. 4- Dental examination overdue. Richardson concludes that it is totally impossible to prevent dental morbidity, but that there is scope to reduce morbidity rates up to 25% by ensuring all personal are as

football medic & scientist

dentally fit as feasible by regular screening. Comparative screening methods can be drawn between screening of military personnel ready for deployment and sportspersons. Screening for oral cancer and early recognition of potential dysplastic oral soft tissues lesions has been common practice for many years. A variation of this and categorization method of sportspersons or a simple matrix on dental fitness, is something to be developed for sport in future. The invested hours to achieve a heightened level  of conditioning and readiness to play should in no way be compromised by preventable oral health problems in season. Therefore this author further echo’s calls for regular dental screening and dental education across all teams and club staff. Gay Esconda’s study is surprising that despite repeated dental screenings over several seasons, a large number of dental problems still became apparent in season. Considering this and it is from this author’s experiences, that the subsequent challenge post any dental screen is ensuring players follow up on dental treatment recommended during a busy preseason period. Appropriate oral hygiene advice and caries prevention education should be carried out in the infancy of a football career. This should run in harmony with diet and nutrition in order to instill good habits. The aim should be to minimise the need for complex restorative dental intervention at a young age and avoid multiple irreversible dental problems. Consideration or prevention of dental issues and striving for optimal oral health should have a vital role to play in the longterm health and well being of footballers during a career but also post career for tooth retention.

REFERENCES 1. Dercole S, Martinelli D, Tripodi D. The effect of swimming on oral health status: competitive versus non competitive athletes. Journal of Applied Oral Science. 2016; 24 (2): 107-113. 2. FDI Policy statement on Sports Dentistry. International Dental Journal. 2017; 67: 1819 3. Foster M, Readman P. Sports dentistry-what’s it all about? Dental Update. 2009; 36(3): 135-141. 4. Gay-Escoda C, Vieira-Duarte-Pereira DM, Ardèvol J et al. Study of the effect of oral health on physical condition of professional soccer players of the Football Club Barcelona. Med Oral Pathology Oral Cir Bucal. 2011; 16(3): e436-9. 5. Ljungberg G, Birkhed D. Dental caries in players belonging to a Swedish soccer team. Swedish Dent Journal. 1990; 14(6): 261-6.

9. Needleman I, Ashley P, Fine P, Haddad F, Loosemore M, De Medici A, Newton T, Donos N, Van Someran K, Moazzez R, Jaques R, Hunter G, Khan K, Shimmin M, Brewer J, Meehan L, Mills S, Porter S. Consensus Statement :Oral Health and elite sport performance. British Dental Journal. 2014; 217(10): 587-590 and British Journal of Sports Medicine.2015; 49(1): 3-6 10. Needleman I, Ashley P, Weiler R, McNally S. Oral health screening should be routine in professional football: a call to action for sports and exercise medicine (SEM) clinicians. British Journal of Sports Medicine. 2016; 50: 1289 11. Ranalli DN. Sports dentistry and dental traumatology. Dental Traumatology. 2002; 18; 231-236. 12. Richardson P. Dental Morbidity in United Kingdom Armed forces Iraq 2003. Military Medicine. 2005; 170 (6): 536- 541.

6. Meehan L. Sports Dentistry Part 1: Diet and Associated Pathologies. Journal of the British Society of Dental Hygiene and Therapy. 2013; 52(3): 27-33

13. Richardson P. Dental Risk Assessment for Military Personnel. Military Medicine. 2005; (170) 6: 542- 545.

7. Meehan L, Collard M. Sports Dentistry Part 2: Dental Trauma and Mouth guards. Journal of the British Society of Dental Hygiene and Therapy. 2013; 52(5): 15-22

14. Studen-Pavlovich D, Bonci L, Etzel KR. Dental implications of nutritional factors in young athletes. Dental Clinics of North America. 2000; 44(1): 161-78.

8. Needleman I, Ashley P, Meehan L, Petrie A, Weiler R, McNally S, Ayer C, Hanna R, Hunt I, Kell S, Ridgewell P, Taylor R. Poor oral health including active caries in 187 UK professional male football players: clinical dental examination performed by dentists. British Journal of Sports Medicine. 2016; 50(1): 41-4.

Lyndon Meehan Dentist to Cardiff City FC and Welsh Football Association Correspondence to Lynddent@yahoo.co.uk

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Pictured: Sport psychologist Rebecca Symes with Nathan Redmond during the team walkaround at the Kolporter Arena in Kielce, Poland

The Proof is in the Training Employing Sport and Exercise Psychologists FEATURE/Jennifer Hobson, Trainee Sport and Exercise Psychologist, MBPsS Would you rather: Use a chartered surveyor to survey your new house or a “building specialist” (or an individual with some other non-descript title)?

chartered/registered individuals would be preferred. Why? Because chartership and registration with official bodies indicates that an individual has the necessary skillset and qualifications to do their very important job both safely and effectively.

HCPC registration indicates that the psychologist works: • • •

Would you rather: Rely on a gas safe registered engineer to repair your boiler, or a risk fixing it yourself? Would you rather:

So why then, are there so many “mind gurus”, “mental performance coaches” and “mental training consultants” working with and within professional football clubs in a psychological capacity? When clubs could instead be employing HCPC registered sport and exercise psychologists.

• •

• Seek rehabilitation treatment for an injury from a health and care professions council (HCPC) chartered physiotherapist, or a “muscle regeneration specialist”? I hope in each of these scenarios, the

As illustrated in the image below, to gain HCPC registration, a sport and exercise psychologist invests a minimum of 8 years (but this is often much longer) in their education and training, endorsed by the British Psychological Society (BPS).

•

Safely, lawfully and professionally Effectively, since their work is evidencebased and underpinned by theory At a level that meets rigorous standards of proficiency With exemplary character and commitment Using up to date knowledge and skills in the area (thanks to the requirement for regular CPD for continued registration with the HCPC) Ethically, safeguarding their clients at all times Whilst holding personal liability and indemnity insurance

Trainee Sport and Exercise Psychologists are working towards their HCPC registration

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Pictured: Wales manager Chris Coleman (left) and performance psychologist Ian Mitchell (right) during a Euro 2016 training session.

through completing the British Psychological Societyâ&#x20AC;&#x2122;s Qualification in Sport and Exercise Psychology (supervised practice). These individuals will have a HCPC registered supervisor, and can be valuable to football clubs since they are carefully supervised to ensure they are working to professional standards. Anyone calling themselves a psychologist within a sport context, who is not in either of the final two stages of their training as shown in the image, is breaking the law and should be reported to the HCPC. To check whether an individual holds HCPC registration, you can conduct a quick and easy search here (select practitioner psychologist): http://www.hcpc-uk.org With the rise in mental health issues reported within sport, the growing acknowledgement of the importance of the mind when striving for peak performance, and the increasing presence of psychology roles in football clubs, it imperative that all football clubs do their due diligence when employing such sport and exercise psychologists. Failing to do so could be putting players, staff members and therefore performance, at risk. Donâ&#x20AC;&#x2122;t run the risk, check the register and employ a safe, HCPC registered practitioner psychologist.

football medic & scientist

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Pictured: Scott Pearce during his time as First Team Sports Scientist at Sunderland.

The role of a sports scientist in the early stages of long term rehabilitation of an injured player FEATURE/Scott Pearce INTRODUCTION Injuries are inevitable in football due to the increased demands placed upon players during training and competition with this is in mind a process of injury reduction over injury prevention seems more logical. Based on experience both backroom staff and players themselves have a collective responsibility to minimise the risk of injury. Injuries can range from minor injuries such as small strains, aches and pains to more long-term injuries that may require surgical intervention and extensive rehabilitation processes. Long term injuries can be devastating to a player both physically and psychologically. Football clubs have a full support team to underpin the rehabilitation process such as physio’s, doctors, surgeons, consultants, sports therapists, sports psychologist, strength & conditioning and sports scientists.

Sports scientist predominant role is the physical condition of the players thus the importance in the rehabilitation phase to return the player to competitive match play in optimal physical condition. The industry is saturated with return to play protocols and detailed prescription of what we should and shouldn’t be doing during these phases of injury, what I would like to discuss is my experiences of working within a medical department supporting the recovery process from long term injury and regaining optimal physical condition to return to competitive play, specifically during the early stages of rehab. EARLY PHASE During the diagnostic phase of injury and post-surgical intervention if required, the sports scientist role may be limited. This period typically involves large amounts of bed based treatments, leaving limited time

for sports science. Nonetheless from my experience the sports scientist will play an important role alongside the player and other supporting backroom staff. At the earliest point, I believe the sports scientist should provide the player with immediate emotional support via a conversation, message or social media. Players at this point go through a range of emotions such as anger, fear, isolation and so on. The first piece of advice I received when working at Sunderland AFC was from Kevin Ball (youth team coach) and he said, “players don’t care what you know but want to know that you care” a phrase I now pass on to aspiring sports scientist’s. The early phase provides opportunity to build a rapport and gain the trust of the player. The next phase is to sit, discuss and plan the rehab process with the club’s medical team. I was fortunate enough at Sunderland AFC to

Pictured: Kevin Ball - “players don’t care what you know but want to know that you care”

work with some fantastic physios and doctors which made this process seamless. I do appreciate that it can often be difficult to gain access to the injured player from the club’s physio’s/doctors. It is important to develop an understanding and relationship with your physio, it is crucial the player observes a unified approach from the medical team. Questions I would often ask of the physio’s/ doctors at this point would be - what can I do? How can we provide a physical programme around the injury? What are your expectations of the sports scientist? The relationship within the backroom team must be concurrent and remain that way throughout the players rehabilitation. It is important to note that players are different and have different concerns and demands from the sports scientist. Commonly from my experiences they have concerns over there body composition due to reduced activity levels. Assurances are important that muscle bulk will recover through appropriate S&C, Body fat levels will not elevate through appropriate training and nutritional strategies and prompting their responsibilities during rehabilitation, I often find myself referring to the phase we can take the horse to water… Some players at this point will set immediate targets and can often work around the club’s medical team seeking the answer they want again highlighting the importance of a

unified backroom staff. Players need to be aware that any agreed target is flexible and not rigid. Effective communication with the player is central to have a unified approach to rehabilitation. The phase provides opportunity to develop components of fitness that the player may be limited in. Typically, injuries are generally lower limb therefore providing opportunity to work the upper body. Maintaining aerobic fitness is also important during this stage and can be achieved. Bill Knowles (rehab specialist) is renowned for this and something I have witnessed myself. Working around an injured limb gives you a chance to come up with some innovative way to train aerobic fitness. I have witnessed and prescribed some novel ways of attaining this. Activities such as arm only swimming, one legged rowing, sit down boxing, seated ski ergometer have proven to be effective. Gain feedback from the player regarding his/her training preferences and make the activities fun. I was fortunate to have a swimming pool available at Sunderland and utilised this to maintain nonspecific aerobic fitness. If this is not available to you then seek out the local swimming pool, something we still did at Sunderland to change the player environment. Adjusting the players environment can have positive effects on preserving motivational levels during an intensive period of rehabilitation. Use of external gym facilities, training facilities and

even the beach are something that can be employed at this early stage. The sports scientist also has demanding squad responsibilities consequently prescriptive training which is physio led is a method to develop fitness for the injured player. Adjusting the players training schedule around the squad schedule is a way to gain direct access to the player, for example the injured player would have bed based treatments in the morning followed by fitness training in the afternoon delivered by the sports scientist. Effort levels from the backroom staff do not go unnoticed by the player and will increase player productivity during rehabilitation. TAKE HOME MESSAGES • Engage player early and show him/her emotional support • Work with your department, discuss ideas and work alongside the physio • Use this period to work on other aspects of fitness • Train around the injury • Be creative and innovative with training ideas • Engage the player and discuss ideas/ thoughts with him/her to gain feedback • Be prepared to work around the squad training schedule to gain full access to player

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Pictured: Chelsea’s Luke McCormick makes an aerial challenge during their UEFA Youth League match against Qarabag in September.

Intra-session and Intersession Reliability of Vertical Jump Height in Elite Youth Soccer Players FEATURE/Russell Hitchen, Dr Jamie Highton Abstract Purpose: The aim of this study was to assess the intra-session and inter-session reliability of countermovement jump (CMJ) and squat jump (SJ) with the Just Jump System. Methods: Ten elite youth soccer players completed 3 CMJ and 3 SJ on the Just Jump System and repeated the trial exactly one week later in conjunction with their full time training schedule. The intra-session and inter-session typical error (TE), smallest worthwhile change (SWC) and coefficient of variation (CV%) were calculated for each jump type. Results: Intra-session reliability of CMJ and SJ were TE 1.29 cm, SWC 0.25 cm, CV 2.40%, and TE 1.06 cm, SWC 0.22 cm, CV 2.06% respectively, showing that SJ was a slightly more reliable jump method with trial-to-trial jumps. In contrast, inter-session reliability of CMJ and SJ peak scores were TE 1.32 cm, SWC 0.25 cm, CV 2.39% and TE 1.33 cm, SWC 0.23 cm, CV 2.54% respectively showing that CMJ may be a slightly more reliable jump method with session-to-session

jump data. Conclusion: TE, CV% and SWC can detect true change in vertical jump height on the Just Jump System, if CMJ and SJ are used correctly with familiar jumping participants. Both CMJ and SJ are a reliable method of assessing vertical jump height on the Just Jump System. Introduction Vertical jump height is commonly assessed in athletic populations to calculate lower limb power, and can be used to discriminate between levels of physical ability (Markovic, Dizdar, Jukic & Cardinale., 2004). Performance in team sports, in particularly soccer require athletes to produce and reproduce force quickly; therefore methodologies used to quantify lower limb power need to be valid and reliable. Various methodologies can be employed to assess vertical jump height such as laboratory testing using a force platform or motion analysis systems. However, due to the expense of these systems, operational training and the

practicality of using them in the field setting, more simplistic and cost effective devices are being used within elite team sport clubs (Nuzzo, Anning & Scharfenberg., 2011). The Just Jump System (Just jump®, Probotics Inc, Huntsville, Alabama, USA) is relatively inexpensive, requires minimal operational training and provides immediate results without extensive data analysis. The Just Jump System determines jump height from measuring flight time, as microswitches within the mat sense when the participants’ feet lift off and land back onto the mat. The flight time measurement is then automatically entered into a standardised equation, which estimates jump height (jump height = [t²xg] ÷ 8, where g= acceleration rate due to gravity (9.81msˉ²) and t= flight time) (Nuzzo et al., 2011). The reliability of the Just Jump System has previously been investigated by Moir, Shastri and Connaboy (2008) whom assessed inter-session (session-to-session) reliability,

football medic & scientist

Pictured: Everton’s Callum Connolly heads the ball under pressure against Southampton during a Fourth Round FA Youth Cup tie in 2015.

comparing the mean and peak of 3 CMJ trials in each weekly session for 4 weeks. The peak score was found to be the most reliable measure when assessing inter-session reliability, as a learning effect and potentiation effect can cause substantial different flight times causing systematic bias. Additionally Moir et al. (2008) only used CMJ in their study and did not use any other vertical jumping techniques. Markovic et al. (2004) assessed seven different jumping techniques including sergeant jump, standing long jump, standing triple jump, Abalakow’s vertical jump ± arm swing, CMJ and SJ. CMJ and SJ were found to be the most reliable and valid tests for the estimation of lower limb explosive power with CV of 2.8% and 3.3% respectively, and had the greatest test-retest correlation coefficient of r = 0.89. Nuzzo et al. (2011) compared the reliability and validity of the Just Jump System against two other contact mats including the Vertec Jump (Vertec, Sports Imports, Hilliard, Ohio, USA) and the Myotest (Myotest Inc., Sion, Switzerland) using CMJ. The Myotest was found to give the most reliable results, with intra-session reliability of CV = 3.3% and intersession reliability of CV = 5.3%. However the validity of the Myotest was questionable, with the Just Jump System proving to be the most valid tool for quantifying the displacement of centre of mass and had intra-session reliability of CV = 4.2% and inter-session reliability of CV = 6.3%. As no study found has demonstrated the two most reliable vertical jump tests of CMJ and SJ on the Just Jump System, or compared the intra-session and inter-session reliability of these jumps; the purpose of this investigation was to assess the inter-session and intrasession reliability of CMJ and SJ with the Just Jump System.

Methods Participants Using a single group cross-over design, 10 elite full time youth soccer players (age 17 ± 1.8 years, height 1.81 ± 0.09 m and mass 74 ± 7.4 kg) volunteered to take part in the study from a League One professional soccer club. All participants were uninjured and fully training for the duration of the study. Each participant had a minimum of 9 months full time training experience and regularly performed jumping movements as part of their weekly training routine. All participants had undergone health screening checks and gave written informed consent after the testing procedures and potential risks were verbally explained to each participant. Testing Procedures Testing was completed the morning (9.00 am – 10.00 am) after a recovery day off, on match day +5 to reduce the influence of training and match fatigue on the participants’ jumping performances. Before testing every participant conducted 5 minutes submaximal cycling followed by 10 forward and 10 lateral hip movements over a 50 cm hurdle. Participants then completed 2 submaximal practice jumps of their choice followed by 2 minutes of passive rest. A similar warm-up protocol has previously been used by Young and Behm (2003), which showed a positive influence on jump performance. Participants then completed 3 maximal CMJ with 10 seconds rest in between each jump followed by 2 minutes rest, before completing 3 SJ again with 10 seconds rest in each jump. The order of CMJ followed by SJ was randomly alternated between participants to reduce systematic bias. All jump tests were completed on the Just Jump System with scores of predicted jump height being recorded. The

same warm up and test protocol were repeated exactly 7 days later in the morning (9.00 am – 10.00 am) following the same training week (match day +5) with data being collected on the same Just Jump System. CMJ began from an upright position, making a downward movement to a self-selected knee angle and simultaneously pushed off. SJ began in a squat position with a self-selected knee angle without any downward movement. All jumps were completed with hands placed on hips to prevent arm swing. A self-selected knee angle was used as Domire and Challis (2007) found no difference in vertical jump height when a set knee angle of 105° was compared to a self-selected knee angle. It was discussed that setting a squat angle may lead participants to loosing motor coordination as many participants do not practise jumping from a deep squat position. Statistical Analysis The intra-session mean of each trial for CMJ and SJ was calculated with standard deviation (SD). With the inter-session data, peak height scores were taken from the three trials of week 1 and from week 2 with the SD. Both intra-session and inter-session data were analysed with a repeated measures analysis of variance (ANOVA) to generate the mean square error (MSE) of each session using IBM SPSS statistics software (SPSS version 22, IBM SPSS INC, Chicago, Illinois, USA). The MSE was then used to calculate typical error (TE) (TE=√MSE) and CV% (CV%=(TE/MEAN)x100). Cormack, Newton, McGuigan and Doyle (2008) suggested that the SWC is also significant to athletes and coaches, as it represents the smallest change that is of benefit to athletic performance. The SWC was calculated with 0.2 x between-subject SD. A paired samples t-test was also used to

Pictured: West Ham United U21 Lewis Page and Hull City U21 Will Annan challenge for the ball during the U21 Premier League Cup Final 2016

calculate significant changes from week 1 peak jump height to week 2 to detect any significant changes with inter-session CMJ and SJ scores. P values were set at p = 0.05 to detect if a change was significant. Results Intra-session and inter-session reliability of CMJ and SJ is shown in Table 1 and Table 2 respectively. Table 1 reports mean ± SD, TE, SWC and CV% for intra-session data on CMJ and SJ. Table 2 reports peak height ± SD for each week session, TE, SWC and CV% for inter-session data. Intra-session reliability for CMJ showed that the mean scores in trial 3 were increased compared to trial 1 and 2. However this did not provide a significant change in the data (p = 0.341). The mean for SJ in trial 3 did not increase to the extent of CMJ in trial 3 with an increase of 0.33 cm (SJ trial 1 – 3) compared with 0.83 cm (CMJ trial 1 – 3). TE (1.06 cm), SWC (0.22 cm) and CV (2.06%) were all lower with SJ compared with CMJ with values of TE (1.29 cm), SWC (0.25 cm) and CV (2.40%). This lends to the suggestion that SJ may be more reliable with intra-session data than CMJ. Inter-session reliability of CMJ showed that the peak scores in week 1 compared to week 2 altered marginally (0.10 cm difference) with SJ altering less (0.04 cm difference). In contrast to intra-session reliability, TE (1.32 cm), SWC (0.25 cm) and CV (2.39%) were all lower with CMJ compared with SJ with values of TE (1.33 cm), SWC (0.23 cm) and CV (2.54%). These results show that CMJ may be more reliable than SJ when comparing inter-session data, however the difference is small. Paired samples t-test proved no significant changes in week 1 to week 2 for both CMJ and SJ with p values of p = 0.863 (CMJ) and p = 9.51 (SJ).

Intra-session

Mean Trial 1 ± SD

Mean Trial 2 ± SD

Mean Trial 3 ± SD

SWC

CV%

CMJ (cm)

53.84 ± 1.23

53.97 ± 1.19

54.67 ± 1.28

1.29

0.25

2.40%

SJ (cm)

51.28 ± 1.19

51.49 ± 1.09

51.61 ± 1.02

1.06

0.22

2.06%

Table 1. Intra-session reliability Inter-session

Peak Height Week 1 ± SD

Peak Height Week 2 ± SD

SWC

CV%

CMJ (cm)

55.25 ± 1.27

55.35 ± 1.22

1.32

0.25

2.39%

SJ (cm)

52.41 ± 1.09

52.37 ± 1.18

1.33

0.23

2.54%

Table 2. Inter-session reliability Discussion The results of both studies demonstrate that using the Just Jump System for calculating vertical jump height exhibit high reliability for both CMJ and SJ (CV<3%) which is far less than what Cormack et al. (2008) set their CV%, with a cut-off of <10% to declare if a variable was reliable. However no variable in the present study was capable of detecting the SWC with a TE˃SWC which concurs with Cormack et al. (2008) results. Hopkins (2000) suggests that larger participant numbers would alter withinsubject variation, which would in turn make the TE and CV% more accurate. The observed higher intra-session reliability of SJ compared with CMJ may be due to the less complexity of the jump pattern movement required for explosive lower limb power, with squat jump not requiring the downward countermovement force (Markovic et al., 2004). As SJ requires participants to hold a squat position before jumping, concentric extensor muscle mechanisms are more isolated in this type of action. CMJ requires athletes to complete a downward countermovement

before concentric extensor activity. This movement requires the lower limb extensor muscles to go through an eccentric - isometric - concentric phase before flight, which requires more motor unit control (Artega, Dorado, Chavarren & Calbet., 2000). The reliability of performing maximal vertical height has been discussed by Cormack et al. (2008), whom measured maximal CMJ height on a force platform. Cormack et al. (2008) reported that maximal height reflects a relatively gross performance measure which is limited by force, power and flight time; of which a force platform can detect these values. Therefore reliability of jump height is likely to be affected by the fact that displacement has not been measured directly, but inferred by mathematical assumption (Dugan, Doyle, Humphries, Hasson & Newton., 2004). Similar studies using various contact mat devices have reported CV of 2.8% (Markovic et al., 2004), 4.0% (Moir et al., 2008) and 4.2% (Nuzzo et al., 2011). These results show higher CV% to the current study, showing that calculated jump height from flight time using the Just

football medic & scientist

Pictured: Shakhtar Donetskâ&#x20AC;&#x2122;s Yakimets Volodymyr (left) and Manchester Cityâ&#x20AC;&#x2122;s Jacob Davenport battle for the ball.

Jump System can be a reliable means of measuring lower limb power. However, the successful use of contact mats is reliant on the participant maintaining a consistent movement pattern during jump trials. For example, if the participant tucks their legs in slightly whilst in flight phase, the calculated jump height will be increased despite the participantsâ&#x20AC;&#x2122; centre of mass not changing. Therefore take-off and landing positions can effect jump height scores on the Just Jump System, with familiar participants with repeatable jumping patterns, providing more reliable jump data than less experienced participants (Moir, Button, Glaister & Stone., 2004). In the present study, the high reliability of CMJ and SJ suggests that these jump methods remain stable across a single session and from session to session with elite youth soccer players. This is probably due to the familiarity of the participants regularly completing vertical height jump tests as part of their training program. Moir et al. (2008) found that by repeating the jump tests for 3 series, the participants would improve over the third series as the participant becomes more familiar with the movement required and would have potentiated their lower limb muscle sarcomeres creating systematic bias within the study. As participants in the present study were already familiar with CMJ and SJ methods, a learning effect could not have been detected. For muscle potentiation, the warm up protocol included in this study allowed for muscle sarcomeres to potentiate with sub maximal jumps as researched by Young and Behm (2003). Practical Implications For practitioners to use the Just Jump System, firstly the reliability of the contact mat and inter-subject variation should be established. The TE, SWC and CV% allow practitioners to

identify a true change in vertical jump height performance and can report these changes to both coaches and athletes in a format they can understand. In the present study intrasession SJ was marginally more reliable than CMJ jump data, however a larger sample size of 50 participants would be required to ascertain reasonable precision (Hopkins, 2000). The data obtained from vertical jump height can be used to assess athletic development, monitor neuromuscular fatigue and be used as a tool for identifying players for talent selection if used correctly with familiar jumping participants. The athlete training status should be taken into consideration to determine how much familiarization is necessary. Athletes whom are less familiar with maximal CMJ and SJ, and who are overall less trained should undergo the greatest amount of familiarization. Practitioners are reminded that contact mat systems are not interchangeable to compare scores, as the Just Jump System has been found to consistently over-predict vertical jump height (Nuzzo et al., 2011). Practitioners should consistently use the same contact mat system to develop reliability measures for their athletes. References Arteaga, R., Dorado, J., Chavarren, J. & Calbet, J. (2000). Reliability of jumping performance in active men and women under different stretch loading conditions. The Journal of Sports Medicine and Physical Fitness, 40, 26-34. Cormack, S., Newton, R., McGuigan, M. & Doyle, T. (2008). Reliability of measures obtaining during single and repeated countermovement jumps. International Journal of Sports Physiology and Performance, 3(2), 131-144. Domire, Z. & Challis, J. (2007). The influence

of squat depth on maximal vertical jump performance. Journal of Sport Sciences, 25(2), 193-200. Dugan, E., Doyle, T., Humphries, B., Hassan, C. & Newton, R. (2004). The optimal load for jump squats: a review of methods and calculations. Journal of Strength and Conditioning Research, 18(3), 668-674. Hopkins, W. (2000). Measures of reliability in sports medicine and science. Sports Medicine, 30, 1-15. Markovic, G., Dizdar, D., Jukic, I. & Cardinale, M. (2004). Reliability and factorial validity of squat and countermovement jump tests. Journal of Strength and Conditioning Research, 18(3), 551-555. Moir, G., Shastri, P. & Connaboy, C. (2008). Intersession reliability of vertical jump height in women and men. Journal of Strength and Conditioning Research, 22(6), 1779-1784. Moir, G., Button, C., Glaister, M. & Stone, M. (2004). Influence of familiarization on the reliability of vertical jump and acceleration sprinting performance in physically active men. Journal of Strength and Conditioning Research, 18(2), 276-280. Nuzzo, J., Anning, J. & Scharfenberg, J. (2011). The reliability of three devices used for measuring vertical jump height. Journal of Strength and Conditioning Research, 25(9), 2580-2590. Young, B. & Behm, G. (2003). Effects of running, static stretching and practice jumps on explosive force production and jumping performance. Journal of Sports Medicine and Physical Fitness, 43, 21-27.

football medic & scientist

feature

Pictured: Manchester United’s Marcos Rojo lays on the floor holding his knee during a match against Anderlecht in May

Modern Surgical Management of Knee Arthritis FEATURE/Mr Sam K Yasen MBBS, BSc (Hons), MSc (Eng), MRCS, FRCS Tr & Orth, PGCE, Dip SEM Introduction Arthritis of the knee represents an increasing prevalent problem and is being seen more frequently in young and active individuals. The term ‘arthritis’ can cause confusion as it is non-descript and refers to a broad spectrum of joint pathology with varying underlying aetiology. In the surgical context, it typically implies loss, wear or injury to the articular chondral surfaces resulting in mechanical irregularity of the joint causing pain and reduced function. Although osteoarthritis represents the most common pathological process, not infrequently this is contributed to by prior sporting injuries causing meniscal tears, direct chondral damage, or knee instability. The focus of this article is on the surgical management of such mechanical forms of arthritis. Traditional Surgical Management The knee is functionally divided into the medial, lateral and patellofemoral compartments. Distinction should be drawn between symptomatic

unicompartmental disease and generalised tricompartmental arthritis, as modern surgical treatment options differ substantially. Non operative therapies should always be considered as a first line and optimised prior to resorting to surgical intervention. In persistently symptomatic patients, traditional surgical management of the arthritic knee has broadly either involved various arthroscopic procedures (with limited evidence base and unclear benefit), or resorting to arthroplasty when arthritis is more advanced. The incidence of total knee replacement (TKR) in the UK is increasing, but there remains a 20% postoperative dissatisfaction rate even in appropriately selected patients, and the procedure does not restore normal knee function. The current market leading TKR in the UK was introduced in 1984 and despite engineering advances there is no evidence that more modern implants reduce patient dissatisfaction or improve outcomes compared to this. More selective resurfacing arthroplasty of the

knee is possible, however, by means of unicompartmental replacement (UKR) when symptomatic arthritis is located in only one compartment of the knee. General consensus amongst knee surgeons suggests that at least one fifth of patients presenting with knee arthritis may be suitable for more limited resurfacing procedures, and in specialist centres UKR can constitute over 50% of the work volume. Nevertheless, the proportion of UKRs in the UK has not changed significantly in the past decade, remaining at less than 10% of all knee arthroplasty. A number of factors contribute to a reluctance to adopt a greater volume of UKR. These include a higher overall revision rate compared to TKR, and the apparent absence of evidence supporting improved outcomes of UKR versus TKR. The issue with the latter is that standardised scoring indices and patient reported outcome measures fail to adequately reflect patients’ improved activity profile and function post-UKR, and therefore underreport the benefit of UKR. However, even the best unicompartmental arthroplasty involves excision of the joint and replacement with artificial bearing surfaces which, by definition, are not self-renewing and subject to wear, loosening and failure over time. Impact loading and high end activity, although potentially possible, is therefore not recommended following arthroplasty as this may adversely affect implant longevity. Outcomes after revision of UKRs are generally poorer than from primary TKR. As a consequence, return to sport after arthroplasty is the exception rather than the rule, and the sensibility of such activity must be questioned. Contemporary Surgical Management The knee represents the most biomechanically complex joint in the body – a point which underlies the relatively poorer outcomes of knee arthroplasty compared to procedures such as hip replacement. These shortcomings with arthroplasty have encouraged surgeons to continue to explore alternative operative options, and there is an emerging trend moving away from joint-violating procedures and towards approaches focusing on preserving the native joint as far as possible. Such modern philosophies have been termed ‘knee preservation surgery’ or ‘joint conservation’. The knee, as with any joint, can be thought to function within a natural homeostatic envelope. If the joint is pushed beyond its physiological limits, either as a consequence of injury or degenerative processes, focal overloading can occur resulting in pain. Pain may be disproportionate to apparent radiographic changes (on plain x-ray), but symptomatic overload can typically be demonstrated on functional imaging such as a Technetium bone scans or SPECT scans. While articular cartilage has long been thought to have a limited natural capacity to regenerate

once damaged, there is emerging evidence that appropriate surgical intervention may result in reparative processes which prevent further decline of the joint. In the presence of persisting symptoms with radiographic support for the diagnosis, the surgeon may consider earlier intervention to return the knee to its natural envelope of function, and avoid the necessity for salvage arthroplasty. The treatment algorithm for the modern knee surgeon thus significantly differs from more established practices. At its core is an appreciation that focal overloading affecting a single compartment can be treated by appropriate offloading and/or biological reconstruction of the joint. The workhorse of this approach is to consider the coronal plane alignment of the knee. Symptomatic medial arthritis may be addressed by utilising a coronal plane osteotomy which creates valgus, shifting the weight bearing axis from the medial side to the healthy lateral compartment (see figure 2). Lateral arthritis may conversely be treated using a varising osteotomy. Osteotomy around the knee is itself not a new concept, having been utilised for centuries. The procedure has been associated with a multitude of complications, and many surgeons view it as historical and redundant. The reality is that osteotomy has progressed tremendously, especially over the past 15 years, with improvements in operative planning, surgical accuracy,

fixation stability and rehabilitation. The unpredictable results of previous generations, in the days when postoperative management entailed up to 3 months in plaster with limited or no weight bearing are gone. They have been replaced with reliable and reproducible results that can be achieved with shorter inpatient stays than arthroplasty and early weight bearing being permitted. Osteotomy has thus become a gamechanger in the young arthritic knee, and is often the only surgical intervention required to return an individual to an active lifestyle. Although viewed by some as an alternative to UKR, its true indications and application differ, and this can often bridge the treatment gap between ‘doing nothing’ and ‘waiting for arthroplasty’. Once alignment has been optimised, further reconstruction of the joint may be considered in a step wise manner. This is by no means always appropriate. Knee instability should be restored with appropriate ligament reconstruction as persisting joint laxity can contribute to secondary chondral damage. Next meniscal deficiency should be addressed. The importance of the menisci should not be underestimated, and consequently meniscal tears should be repaired where possible rather than debrided (as is the standard practice for many). Current indications for meniscal transplant surgery are for patients with unicompartmental pain in a well aligned, stable, postmenisectomised knee. Meniscal

Figure 1. Bone scan of right knee showing medial compartment ‘hot spot’ (left), with resolution following a valgising high tibial osteotomy (right). replacement is not currently indicated as a prophylactic procedure. Finally the surgeon should consider chondral lesions. Techniques in this area are varied and are generally not associated with excellent outcomes. Much of the previous literature on the topic, however, is confounded by a failure to appreciate the impact of knee alignment and instability when evaluating these therapeutic modalities. The modern knee surgeon should therefore assess the joint as a whole and advise on treatment according to this algorithmic approach. As Maslow previously identified ‘if the only tool you have is a hammer, it is tempting to treat everything as if it were a nail’. For many surgeons, arthroplasty remains akin to this blunt instrument, where patients are either bad enough to warrant surgery, or must wait to earn their operation. The contemporary movement away from this essentially binary philosophy is slowly gathering momentum. The young arthritic knee is thus best assessed by a surgeon proficient with the spectrum of operative options available, pursuing a joint preservation approach when possible. Conclusions

Figure 2. Active 46 year old man with bilateral medial compartmental osteoarthritis causing pain and functional limitation. Preoperative long leg alignment radiograph (left) shows a varus axis with a weight bearing line passing through the overloaded medial joint. Postoperative radiograph (right) following bilateral simultaneous valgising high tibial osteotomies shows the axis now passes just lateral to the midline. The patient was discharged, weight bearing as tolerated the day after surgery and is back to manual labour at 3 months.

In the management of mechanical forms of knee arthritis, the traditional approach of commencing with non-operative intervention is not to be replaced by new or ‘reinvented’ operations. Appropriate attention and optimisation of conservative treatment modalities must be adhered to. If these strategies are exhausted, however, there is now a broader spectrum and better understanding of surgical strategies that aim to conserve the native joint where possible, and restore it to its natural homeostatic envelope. Realignment osteotomy, ligament reconstruction and intra-articular soft tissue procedures can be utilised to rebuild the damaged joint. Arthroplasty should remain to be viewed as a last line of defence, and deferred where possible, especially in the younger and more active individual.

football medic & scientist

interview

Pictured: Dr. Jagdish Basra

FMA INTERVIEW WITH DR JAGDISH BASRA At the FMA Conference in May, Dr of Psychiatry, Jagdish Basra delivered a presentation on Growth Mindset and Building Resilience in modern day athletes. Here we look further into the realms of “Sports” Psychiatry with an in depth interview of the charismatic clinician.

INTERVIEW/ Dr. Jagdish Basra Tell me a bit about your background and how you became involved in Sport? I’ve always loved sport especially athletics, football, hockey and skiing. I have moved around a lot in my life so I have had exposure to lots of different experiences and sports. It’s a bit of a long winded story. My parents are Indian but I was born in Canada, in a small northern town of a couple of thousand at the most, where it would snow 4 feet plus in the winters. We use get ‘bear training’ in this town because you would often encounter one on the way to school. Skiing, skating and all winter sports were a big part of my life. When we moved to Vancouver city I discovered basketball and again developed a love for this. I loved Sport as a fan but science was my true calling. I did my undergraduate

degree in Microbiology and psychology. I loved science because I like facts but I have always been interested in the way people think. I moved to Leicester in England and qualified as a doctor. My nomadic life continued as I relocated to Belfast. It was here I started working as a psychiatry doctor which led to my involvement in Sport. I wanted to challenge myself and I was searching for opportunities when the Irish Football Association approached me to speak about all things mental health as part of the UEFA Pro Licence and UEFA A Badge programs. This is where my professional involvement began with football and so began the start of a very exciting part of my life. I now live in Scotland where football is a religion. People love it to the ends of the earth

here so it’s a great fit. You mentioned the UEFA Pro license, what is your role there? My role has been to organise and carry out workshops on mental skills, mental resilience and mental health. I’m able to utilise my psychiatry and psychology background and it is exactly the kind of challenge I was looking for. What began as an hour workshop for the Pro Licence has now it’s expanded to 2 days out of the week as the candidates are very much aware of the importance of maintaining their own mental health, and how much a person’s mindset can influence the game. It has now expanded to doing sessions for the A Badge. Football is a fast-moving and intellectual game.

Pictured: Sessions on gambling, depression and suicide are included as part of the course.

Those that realise this know the importance of how much a person’s mindset has an influence on results whether you are a player or a coach. The IFA is one of the most forward thinking football organisations in the world despite being small. Nigel Best, the head of coaching education at the IFA, is always looking to bring in innovation, and introducing new ways of thinking and best practice methods to their course content. UEFA recognises this proactive attitude and are hosting their annual conference in NI. You offer a different take to what traditional footballers might be used to, how do former players react to your course input? Initially when they meet me and see the course content there are definitely sceptics. Some of the topics aren’t the easiest to talk about as mental health isn’t seen as the manliest of topics. Sessions on gambling, depression and suicide are not something people like to discuss particularly in a competitive, predominately male environment such as football. The A Badge and Pro Licence guys are very clued in. Once I started doing the work and really getting them to engage in it, they bought in too and now can’t get

enough. The new age coaches and footballers are different. They know how football is a results driven world and are always looking to gain extra skills to give them that edge. If that means going out of their comfort zone they do. They want to be the best coach/manager possible and are willing to go to great lengths to do it. I’ve had some of the top players, guys who have won world cups and champions leagues medals, on the course and they are guys who love the game but are always looking for ways to improve themselves and push themselves to become better coaches/managers. It’s fascinating to see as they come up with some pretty challenging questions sometimes and even I get stumped! What has the feedback been to your course? The feedback has been fantastic. So many have told me how helpful it’s been and also what they want to learn about in the future. I also like to know what people don’t find helpful as it’s a way for me to improve and challenge myself. One of the greatest rewards for doing this is when you get a private email from a candidate saying how much the sessions have positively influenced their life. I’m

grateful that I have that opportunity to have that positive effect on people. It’s one of the most satisfying parts of the job. You are involved in a new Sports Tech start up, Profile 90 - tell us more about that? Yes Profile 90! It’s my passion and focus at the moment. It’s a sports tech platform that looks at talent identification. It’s a Smart scouting system that brings scientific insight to traditional scouting. I love science and facts, but also love to get into the minds of people and this platform fuses both. I never thought I’d be able to combine both passions into the field of sport, but we have. We wanted to bring data analytics, evidence based research and football experience together when it comes to talent ID and we have done just that. I’ve always been a doctor and to be a business woman as well was one of my goals. Having a start-up tech business, and doing it in sport is the ultimate dream. I’ve started out with no business background but being a doctor you have so many versatile skills. Communication skills, leadership, work ethic, being under pressure and being able to handle long

football medic & scientist

Pictured: “The IFA is one of the most forward thinking football organisations in the world despite being small.”

nights has been superbly helpful. I would encourage anyone who is looking for a challenge to never underestimate the skills they have.

ability to perform in a highly pressurised environment.

You mention psychometric testing for players - how beneficial is this to their development?

One thing that always amazes me in football is the business logic. Talent identification is key to bringing clubs value. It attracts fans, aids ticket sales, and grows advertising revenue. The players identified are the heart of the club. So why do we not put more value into our recruitment teams and make it more scientific driven with business intelligence. Scouts are extremely key people in a club and often are undervalued. To know a player is the most important thing for a club before signing. You want to know as much as you can before signing them to your club. Right now current systems of talent ID just really look at an individual’s tactical, technical and physical attributes, and someone gives an opinion on their psychological condition from the sidelines of a game, visual observation and hear say. There is no value in guessing and Chinese whispers. Even with current systems they are information storage systems. They don’t give you anything extra. They don’t

Psychometric testing is another tool to give you extra insight into the mind of an individual. Profile 90’s goal is to give a 360 view of a player based on the FA’s 4 cornerstones of physical, tactical/ technical, psychological and social. It gives you a baseline of what kind of psychology you are dealing with in an individual and where they may need some more focussed work. At the end of the day it can never tell you everything in the mind of a person. If I had that test available I’d be very, very rich! Humans are interesting and unpredictable at times so nothing is ever 100%. Studies in varying sports have shown that the mind-set is the most important determinant of athletic success. It makes sense because no matter how talented you are tactically or technically, if your head isn’t in the right place you can’t endure the endless hours of practice, the stress of competition and have the

How important is it for clubs to understand this side of a player?

give you extra insight into a player, a psychological/social behaviour profile of any sort. Profile 90 gives you actionable insights from the data that is collected from the club. We know psychometric testing is used in other industries, why has Sport being slow to adopt this consistently? It’s really interesting how sport works because some organisations are more open to it and some aren’t. The banking industry, tech industry all use psychometric testing of some nature to gain insight to anyone that is seeking employment in their organisation. We live in a world where we want to be more certain of what we are getting before we take someone on. It makes sense because what business wants to lose money and making the wrong recruitment decision can have large financial consequences. That comes with data and the psychological side can be best seen in an objective way via psychometrics. The key is to use it as another tool for gaining insight into an individual. What advice would you offer footballers who are struggling with Mental Health? I would say please go speak to your GP.

Pictured: Hibernian manager Neil Lennon watches on during their recent SPL clash with Celtic

You won’t regret it. A chat with your GP is confidential and ultimately you make a choice of what happens to you. It’s always good to get all the information and be armed with it. Anyone I have come across in the Pro Licence and A Badge who were struggling, who I have guided and supported to go their GP hasn’t regretted it. I most often hear “I wish I did it long before because I suffered pointlessly”. I’ve never had one person say they regretted doing so. Mental health impacts 1/4 people and many people struggle with some difficulty or another at some point in their life. We need to try reduce the stigma surrounding it particularly in sport as it can lead to suicide. We have lost a lot of professional athletes in sport and its important organisations work collectively to help reduce stigma and make access to services to help easier. In your opinion, how has scouting evolved over the last 20 years? Scouting has evolved in many ways but in many ways it’s much the same. Certain parts of scouting can never really change and that’s the intuition and gut feel of a scout, their experience. It’s changed in the sense that clubs all want that next big thing and are willing to pay unbelievable sums for players so the pressure increases on scouts to bring those players in. Scouting is an art form. We see our role

as helping these scouts do their job easier and give them the facts to back up that gut feeling. How would you describe the modern scout and the process they go through? The modern scout is looking for the talented player, looking for that individual who has the ability to potentially make it to the big leagues. Scouts are the most valuable part of the team and not always given the accolade they deserve. A club’s value is based on the talent they acquire. The scout is the one that brings the talent, and from Profile 90’s perspective they are the key link in the chain. The scout today is still passionate about the game and has a true love for it but they also are looking to simplify their life. They are looking to add structure and science to their art. They are looking to always learn new ways to help improve their ability to identify talent. One of the key things the “new age scout” is having on the scouting process is that they are much more open to using technology. They don’t want to have to sit in the rain and write a report on soggy paper, before travelling home to type it up. They want to be able to submit their scouting experience in real time so they can leave a game on a Friday night and go home to relax or go socialise with friends. They want the information they give the club to matter and hold value. They want to be valued by their clubs for the hard work and graft they do. That’s where Profile 90 comes

in. We give them the tools to do their job more effectively. What traits should clubs look for in their scouts? Scouts know exactly what’s important in a great player. They watch enough games and watch enough players. But they know that the key to what really determines a player’s likelihood of succeeding is their psychological attributes and I agree completely. Why? Because you can have all the talent in the world, but if you don’t have the right frame of mind you can’t endure the stress and levels of competition, the endless hours of practice, training and continue to perform 100%. Research evidence backs up that view and it isn’t wrong. Dr Jagdish Basra is a Doctor of Psychiatry who advises, sets up and leads workshops on mental wellbeing, mental resilience and personal development to improve productivity and efficiency. Dr Basra is a guest lecturer for various businesses/ organisations including the Pro Licence Course/ UEFA A Badge at the IFA. She is the CEO of “Profile 90” which is a start-up tech company that looks at talent identification. Dr Basra has a BSc (Hons) in Microbiology, Immunology & Psychology and is a Member of the Royal College of Psychiatrists