Football Medic & Scientist Issue 14 - Autumn 2014 by Football Medicine & Performance Association

FOOTBALL MEDIC & SCIENTIST The official magazine of the Football Medical Association

WHO’s THE BOSS?

Who Directs the Medical Team?

PUTTING THE BOOT IN

The Role of Boots & Studs in Injury

WHERE ARE THEY NOW?

Former Aston Villa Physio Jim Walker

FMA FOOTBALL MEDICAL ASSOCIATION

Issue 14: Autumn 2015

SPONSORED BY

Contents

FMA FOOTBALL MEDICAL ASSOCIATION SPONSORED BY

Welcome 4 Members News 6 Injury Prevention: A Soccerex Report 7 Touchline Rants 7 On the Couch Liam McGarry

Editorials & Features 8 750th PFA Player Undergoes Perform Rehabilitation 10 Women in Football Shelley Alexander 12 Half a Century in Medicine & Football: A Personal Perspective Dr. David S Muckle 15 A Place in History 16 Who’s the Boss Mary O’Rourke QC 20 Member or Not? The FMA Changes Outcomes

25 Alternate Sport: Shoulder Injuries Mr Ali Navarni 28 Where are they Now? Jim Walker

There is no doubt that the world of football medicine and science has been dominated recently by events surrounding our colleagues at Chelsea. Understandably so. The entire episode has been played out on a world stage and is still ongoing. Much is written in this edition regarding this episode and there is still a lot to be discussed in order to resolve the issues that have been highlighted by this case, namely those of governance, autonomy, professionalism, integrity and the fundamental right of our members to conduct their practice without interference or misguided direction from others outside the medical and scientific framework. The fact that there may be regulation put in place to prevent further or similar occurrences shows the gravity of the situation. Readers will notice much more content in this edition as we gather articles from far and wide. There is a new section which will feature injuries in other sports - but ones which we encounter as well. It is always useful to see how our colleagues manage conditions and to pick up tips and advice from them where appropriate. The women’s football section features an article about the Women in Football Group and in future it is hoped this section will highlight aspects of the women’s game that will be of interest to the wider readership. Our 2016 Conference is beginning to take shape and please set the date in your diary for the 21st/22nd May. It’s easy to remember as it’s FA Cup final weekend and we will all be watching the match after the afternoon lectures. The past two events have been fantastic so do make sure you join us. Eamonn Salmon CEO Football Medical Association

Pictured: France’s Zinedine Zidane examines his thigh after taking a knock during a friendly match against Portugal in 2001.

HALF A CENTURY IN

MEDICINE & FOOTBALL

A PERSONAL PERSPECTIVE

PART 1

22 Boots, Studs & Injuries in Football Professor Andrea Ferretti

WELCOME/EAMONN SALMON

FEATURE/PROFESSOR DAVID S MUCKLE DSC.MB.BS.MD.MS.FRCS.FRCS (ED).DPROF (HON) A long and unexpected career in both medicine and sport began inauspiciously with an invitation to train with a small amateur club, Whitley Bay in 1967. Although the club was later to create a Wembley record for three successive cup wins in 2011, at that time this small club gave an insight into training methods and injury treatment which was a microcosm of football in general. In those days most soft tissue injuries were ‘run off’ by repeated lapping the periphery of the pitch followed by a warm bath to ease the pain (and, of course, increase the swelling!). If a meniscus injury was suspected the knee was opened by a generous 3 to 4 inch incision and the offending meniscus removed. The leading authority of the day in his textbook of the knee said that to leave even a small piece behind was a dereliction of care and risked causing osteoarthritis. (He and his supporters were to become fierce opponents in years to come). Cruciate tears were often misdiagnosed and even with treatment generally ended a career (e.g. Brian Clough while playing for Sunderland in 1964 – at the time I was a spectator). While most joint injuries were encased in a plaster of Paris for a period generally sufficient enough to stiffen the joint and cause hyaline degeneration. Fitness was lapping the pitch, hill and country runs, numerous shuttles, and post-army

gymnastic exercises; while the pre-match meal was a juicy steak with beans and chips on the side. Little scientific thought had been given to the demands of a football match, the biochemistry and pathology involved in injury, the attainment of fitness and the post-match care. Indeed players suffered almost half of their injuries in the preseason. This was how I found football 50 years ago. At Oxford, and having completed a three year biochemistry thesis into muscle physiology and pathology, I felt that many aspects of sports injuries were folk-law, empirically treated and unscientific. A new opportunity beckoned with an association with Oxford United, the University and the FA - who eventually gave me a role within UEFA and FIFA. One of the first things that struck me was that no one (and this was repeated in my early international FIFA conferences)

seemed to know how long a football match lasted, despite the game being played for a century. To me this was the most basic of all facts. Nor was any thought given to the stresses on the player’s body by how far each outfielder ran and in what sequences (i.e. forward, obliquely, backwards etc.) and how often they jumped. While the biochemistry and pathology of injury were relatively ignored, being not deemed of much value in orthopaedics compared to more pressing problems (e.g. fractures, dislocations, infections etc). Using a stop watch, multiple grid papers and other techniques including video I studied Oxford United games throughout several seasons. The hard facts began to emerge, namely at least 20 minutes were lost through stoppages (Iran v Scotland in the World Cup lasted 48 minutes) and players covered 6-7 miles or 10-11k (almost identical to today, by the way. How much easier it is now to analyse a match by computer assessment.

So the situation began to change. Softtissue injuries were graded according to severity and treated accordingly, only the most serious cases needing surgery. The ICE rule sprang out of my book in 1967 (although much-quoted but not entirely original) and the biochemical treatment with early graduated physiotherapy and antiinflammatories became the rule, with even more accurate diagnosis eventually being attained through ultrasound, CT and MRI scanning. The first major educational courses were designed by FIFA as part of a World Football Development Programme in the 1970s. These were excellent forums to discuss the various aspects of football in countries that were keen to develop all aspects of the game. Such courses were not without incident - in the Caribbean the projectionist on the stage decided that the projector plug could be dispensed with and replaced by three bare wires. These he wetted with his fingers before inserting them into the socket. A sudden flash and he was rendered briefly unconscious. So the lecture began in a practical mode of resuscitation. The Afghanistan course was interrupted by the Russian invasion of 1978 and bombs rained down on Kabul; our party of four was arrested and confined to a hotel for thirteen days under an armed guard before we were released. Those incidents aside, the original courses were a bench mark for multiple educational programmes to follow around the world and foresaw the rise of countries within football like Japan, the United States, Israel, and in Africa and many more. The coaching badges, courses and levels of attainment have become commonplace in all football associations. FIFA is often criticised (and, at times, rightly so) but this concept was one of many that has led to a dramatic improvement within the game. The role of the doctor within football has also evolved. In the 60s he (and always a ‘he’) shared a common interest with the Directors through golfing, Rotary associations etc and this ‘good fellowship’ was extended to the Saturday afternoon lounge. The ‘trainer’ was the ‘bucket-andsponge man’ and was the first port of call on the pitch. Some had a military background (Remedial therapists) while others had attended basic first-aid courses; however, it must be said that many did a fine job. In the 80s a basic examination in Sports

A PLACE IN HISTORY

Pictured: Tottenham Hotspur’s Mitchell Thomas receives treatment for an injury in a match against West Ham United. December, 1986.

Pictured: Trainer Cecil Peynton, right, with Tottenham defender Ron Henry in 1960

Medicine was formed by a section of us in the Edinburgh Royal College of Surgeons and later was taken on board by the other Colleges. Also during my time with the Council of Professions Supplementary to Medicine, attainment in Physiotherapy became a degree requirement. In 1980 Dr John O’Hara, the vice-president of the FA, called me one Sunday evening and proposed a Medical Committee, with himself as Chairman and myself as the deputy. John had been on the Selection Board for the appointment of the Honorary Surgeon to the FA and amazed me, after the interview, by saying that he had been my GP in a very remote village when I was two. He was a man of vision, having failed through an inopportune coronary to become the FA President. He recovered his health and in his usual dynamic way proceeded to press on with the National Rehabilitation Centre at Lilleshall, The School of Excellence and The Human Performance Centre. Candidates for the School of Excellence, being fourteen years of age were educated and also coached at Lilleshall by top coaches including Dave Sexton among others. Future internationals included Michael Owen, Jamie Redknapp, Andy Cole and Sol Campbell.

Pictured: Fifteen years after total meniscectomy in a professional footballer, the patello-femoral joint is fragmenting; here are the hyaline pieces after arthroscopic lavage. A total rethink on treating meniscal injuries was needed in the 70s.

But the most outstanding contributions by the FA Medical Committee took several diktats which are still adopted universally today. In 1982 while visiting orthopaedic friends in San Diego and the West Coast of the USA, I became aware of a viral disease spread through blood contamination, which as a surgeon was of immediate concern. I thought it could be a type of hepatitis, possibly C, because of the reported seriousness of the disease. It turned out to be the Aids virus. The Medical Committee had felt for some time that general hygiene measures were wonting in football, with bleeding wounds, soiled bandages, communal baths etc being the norm. So in 1984, I began a study into blood contamination both within Trauma Care and Sport, finally compiling the first Aids document. It was to be seized upon by the Press and ridiculed in some quarters. I questioned Maxwell at Oxford United as to why the Mirror came up with the fatuous headline ‘don’t drink from the cup lads (i.e. FA cup) and no kissing (sic) after scoring’. The Government somewhat distanced themselves from the FA; and the BBC and ITV News coverage was patchy. The Minister of Health and a Genitourinary Expert downplayed the seriousness of the disease. Then the Government quickly produced a weak document stating ‘don’t die of ignorance’ (Which prompted an 11 year-old patient, with a mild cough, to asked, in all seriousness, if she had caught ‘the ignorance’). That hullabaloo is thankfully all in the past, for other sports around the World quickly followed our lead. Now, strict hygiene measures are in place. One misconception about this document is that it is based on a video of a red-shirted Terry Butcher (England were in white) heading a ball splattered in blood from a facial wound, v Sweden in 1989. It was a graphic illustration but had nothing

FOOTBALL MEDIC & SCIENTIST | 13

IMAGES OF OLD

FOOTBALL MEDIC & SCIENTIST | 15

Pictured: Notts County trainer/Physiotherapist Jack Wheeler (l) tends to Kane (r) and Kevin Randall (c) in the medical room. September, 1975.

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Cover Image Chelsea’s Eden Hazard is helped off by Dr. Eva Carneiro (left) and Jon Fearn (right). Mike Egerton/PA Wire/PA Images Football Medical Association. All rights reserved. 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.

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FOOTBALL MEDIC & SCIENTIST | 3

MEMBERS’ NEWS Audits underway

he first FMA Audit centreing on Medicines management and infection control has been well received with well over 55% responding to the initial launch of the project in August. Acknowledgement and support for the project were received from the Premier League and the PFA.

The process of collating the results is such that we are able to continue to enter data received at any point so if you haven`t yet sent your reply in please do so. This has been followed up recently with the dissemination of a questionnaire to all Club Dr`s with regards to Minimum Medical Requirements.

Once again the information gathered will form the foundations of our aims to improve standards across professional football. If you are in need of a copy of either of our audit questionnaires please contact lindsay@footballmedic.co.uk

Coincidence?

ollowing submission of the “injury prevention” review that appears in this edition, it came to our attention that the “Secret Physio” had something to say on this issue as well. The secret Physio is a contributor to the secret footballer website for those who are wondering what on earth we are talking about. The positive about this writer is that he can say it how it is - although as we all know that is not necessarily a good thing. Anyway one of his/her latest comments regarding injury prevention says: Communication in these larger departments is key.

Not only does there need to be clear, regular communication between the medical staff relating to players’ health, to ensure strategies are being followed, but also clear communication to the manager to avoid mixed messages from different medical staff members. Conflicting opinions within a department as to how a player is managed can be dangerous. A common, agreed approach has to be adhered to by all, even if not all agree with it. Sounds uncannily like the words of our panellists as you will read in this edition. Have we uncovered the secret Physio or is it just that experienced minds think alike, in which case we should all take note.

Website DEVELOPED

he FMA website is to host new sections in the coming weeks.

One of the new features will be a section for the 3 groups within the FMA (Medicine/ Physical Therapies/Sports Science) in which items of interest can be posted by members. This could prove to be a valuable tool through which to keep members up to date on areas currently topical and will also act as a forum for discussion.

New FMA Conference Business Club member set for 2016

kin Matrix are now on board as Business Club Partners and the FMA is looking forward to working with them in the coming months. Many of you will be familiar with the company`s business director, former England International Tony Dorigo who along with his wife Heather are keen to resume old acquaintances and bring the companies range of Cryotherapy devices to your attention. Tony added “ We are very excited by the partnership with the FMA and both our Cryopod™ and Cryo-T Med will be of great interest to their members and of even greater value in terms of overall recovery and the treatment of injuries.”

he 2015/2016 season FMA conference has been set for the weekend of the 21st/22nd May and will again be held at the Radisson Blu Hotel, East Midlands. This will see a return to the FA cup final weekend which best suits plans for a networking event as well as an educational Conference. The theme this time will revolve around the “Hip & Groin” Full details will be announced in the coming weeks

New staff at FMA

e are delighted to announce the appointment of Jayne Maddison to our staff as Business Development

Manager.

Jayne has a business education background and as well as helping with the day to day administration, Jayne will also be liaising with our commercial partners and Business Club Members.

FA Concussion Board Guidelines update announced

fter some considerable work by the FA`s Expert panel on Concussion and Head injury in Football, the resulting Concussion guidelines are set to be published in the next week or so ( at time of going to press) The FMA were invited to give our view of the proposed document and were able to offer our resounding support for the guidelines. It is envisaged that the FMA website will host a link to the guidelines in due course and the request for our thoughts from the FA were much appreciated.

he FMA is delighted to announce that Tony Strudwick has agreed to sit on the FMA Board. Tony is one of the most respected and experienced practitioners in his discipline and has a wealth of knowledge to offer the FMA going forward. This follows the departure of Jason Palmer who has been a Board member for the past 5 years. We would like to place on record our sincere thanks and appreciation to Jason for his input and commitment to the FMA from the very beginning. Jason will continue to engage with the association as an active member and his knowledge and contributions will continue to be much appreciated by all.

Product appraisal System

ver the past few months we have been developing a project that will see a selection of clubs conduct market research on various products. It is anticipated that the project will raise awareness of our Brand and more significantly, help our members keep up to date with new products within the industry. More will be revealed in the next edition.

FOOTBALL MEDIC & SCIENTIST | 5

Pictured: Swansea City’s Andre Ayew is injured during their stunning 2-1 comeback victory at the Liberty Stadium in late August.

InjuryPrevention FEATURE/SOCCEREX Injury prevention. Music to the ears of Club owners, managers and players. But to medical and science personnel does the term sound a little onerous to say the least? Can we really “prevent” injuries – or is it just a useful term to make some of us look more significant and indeed important?

o some extent this question was addressed at the recent Global Soccerex Convention in Manchester. As a partner the FMA hosted a panel discussion at the event in theory to discuss “Preventing impact of injury to players and team“ Understandably the audience assumed this was about injury prevention and put the panellists on the spot with an opening question – what is the best way to prevent injuries” The panel was composed of Grant Downie, head of performance Manchester City academy, Paul Williamson Lead Physiotherapist at perform SGP, and Chris Barnes Consultant Sport Scientist. The question was duly answered by highlighting the most effective method of Injury prevention we know of. So Was it GPS, Analysis, Saliva tests, Bloods, Psychological profiling? The answer was no. Our panel determined that the most effective measure in preventing injuries was – teamwork As Grant Downie explained, a coherent and

close knit medical & Science unit will have the greatest impact on injury prevention since communication, dialogue and teamwork ensure the best outcomes for players undergoing match training and rehabilitation programmes. Conversely, a fragmented and disjointed unit will result in poor communication and will inevitably lead to mishaps and injuries. The panel went on to say that the reason for any disengagement and uncooperation in departments was fundamentally down to …egos. Not of the players or coaches, but of medical and science staff who may be competitive and precious over their roles within a club. Given that there is such a huge number of staff now employed in this arena (up to 20 at the same club)it is easy to see why the potential for this disengagement exists. It is also important that this “teamwork” ethos is extended to management, coaches and recruitment personnel so that everyone understands the “probability of risk” when signing players and understands also the extent to which a player can be loaded in training and matches.

Medical & sports science teams should make sure they support this process & not under mine the team management when these players are injured. Likewise, the management cannot then blame the medical & sports science staff when players are overloaded & pick up an injury!!! Strong words indeed but when you take a moment to consider what is being said here, the chances are that the panel were ‘bang on’ with their ideas. At the very least their thoughts – and this article – will stimulate debate, encourage heads of department to reflect on this regarding their own staff and likely encourage one or two to take a long hard look at themselves…… are they really team players? The medical & SS team must work on its identity & purpose within its club & this be visible to management & owners…. The notion that a unified medical and science department can in itself have such an impact on injury prevention is one that every Club should therefore consider. And ultimately it costs nothing!

Touchline Rants! e by Pitchside Pet JUST ‘BAD LUCK’ ?

ow that the season is in full swing and the sacking of managers is becoming a weekly occurrence, why is it that some seasons you just seem to have bad luck with injuries? Often departing or under-performing Managers bemoan their bad luck in the treatment room... Saying things like ‘I’ve never known anything like it...it’s like a war zone in there’ or ‘if I only had my start striker fit, we wouldn’t be in this position’. Is it just that someone at the Club has crossed paths with a black cat or walked under a ladder? And what about the ‘it all evens out in the end’ merchants? Don’t they just get on your nerves? When you are towards the tail end of the league and fighting to stay up, then it always seems as though every decision goes against you. Trust me – I know what it’s like. I’ve been

deep in several relegation battles myself. When you are bimbling along in mid-table or pushing at the top end, then everything seems better – even your luck! When your second or third major player has gone down with similar long term injuries it feels as though the world and all of its good fortune is against you. It’s that dread you have when you slowly walk to the Gaffers office to discuss the prognosis – and you know that although it’s not your fault, you feel as though you may get the blame for it anyway! So does it ‘all even up in the end’? I really don’t think so. Fate just brings along what it wants to some seasons. When it is all going well then your treatment room is a happy place, when things are going belly-up on the field, then its standing room only around the couches. Maybe it’s worth packing some lucky heather in your run-on bag...just in case!

ON THE COUCH... FEATURE/LIAM McGARRY 1. Profession? Senior Physiotherapist at Blackburn Rovers Football Club 2. Where and when did you train? I studied at the University of Salford for both my Bachelor of Science degrees, one in Physiotherapy and the other in Sports Rehabilitation. I originally qualified in 2004 and then gained my second undergraduate degree in 2010. I am now currently studying for my MSc qualification at the University of Bath in Sports Physiotherapy which I hope to complete next year. 3. How did you get into football? During my time at university I sent a letter to every league and conference football club requesting work experience within their medical department. I got a call back from Alan Jackson, who at the time was physiotherapist at Halifax Town Football Club. He agreed to let me help out there voluntarily for a couple of nights a week and then on match-days with the first team. 4. Previous Clubs: Hull City (2004-2012), Blackburn Rovers (2012-Present). I was fortunate enough to work at Hull City during the most successful period in the club’s

Our current manager at Blackburn, Gary Bowyer, is also great to work for. He trusts our judgments and is happy for us to get on with things. The player would have to be Nick Barmby, he was always fun and a good laugh to have in the medical room. He was forever taking the Mickey out of people or telling jokes!

history. By 2008, I had worked my way up the physiotherapy ladder during my 8 years at the club and became Head Physiotherapist in 2011. In 2012, I took up a position at Blackburn Rovers. Working with Dave Fevre on a daily basis and trying to learn from his experiences has seen me develop massively as a clinician over the past 3 years. He was the main reason I joined the medical department at the club. 5. Which manager/player/coach have you enjoyed working with? I really enjoyed it when Nigel Pearson was manager at Hull City. I liked that he treated everybody the same and his man management skills were also excellent.

6. Most memorable moment in Football? Winning at Wembley in the championship play-off final. The celebrations afterwards were special. From a personal point-of-view, seeing Cameron Stewart score 5 minutes into his first game back from ACL surgery at Derby County in Nick Barmby’s first game as Hull City manager was pretty memorable. Watching any player return to match-action unscathed following a long period of injury is always satisfying for any medical team. 7. Long term plans/Aims for your career? My aim for the short-term is to finish my MSc and keep developing as a Physiotherapist through relevant CPD courses. Although I am happy where I am at this moment in time, long-term the aim is to lead my own medical department within a football club again.

FOOTBALL MEDIC & SCIENTIST | 7

750th PFA player

undergoes Perform rehabilitation FEATURE/PERFORM Perform at St. George’s Park and the PFA recently celebrated the news that 750 professional players have now used their highly-successful Residential Rehabilitation Scheme.

he scheme, funded by the PFA, supports clubs by providing intensive rehabilitation at the world-class medical facilities at Perform St. George’s Park. The popular scheme has been used by players including Anton Ferdinand, Swansea City’s Neil Taylor and England Women’s World Cup star Karen Carney. Perform’s leading SEMs, physiotherapists and sports scientists work together in an interdisciplinary team to treat the patient at the highest level. PFA Deputy Chief Executive John Bramhall, pictured with Perform Elite Physiotherapist Steve Kemp and PFA ambassador Fabrice Muamba, said: “The Residential Rehab Scheme is available to both current and former players and represents another benefit of PFA membership, providing access to the world-class facilities at St. George’s Park. The specialised and tailored treatment helps members who are dealing with the uncertainty of injury, which can be one of the most challenging time in a player’s career. “The overwhelming positive feedback we receive from our members is testament to the work undertaken by the Perform team.” All players attending the scheme stay in the on-site Hilton hotel at St. George’s Park for four days, spending seven hours a day in the 25,000-square-foot Perform sports

medicine facility. They receive assessment, physiotherapy, hydrotherapy, massage, Pilates and strength and conditioning tailored to their recovery programme. There is an opportunity for players to stay for up to three weeks under the PFA scheme, then they go back to their clubs with a thorough assessment of their condition and recovery plan. The Perform interdisciplinary team works closely with the player’s club medical team to ensure the rehabilitation

helps them return to play as soon as possible. The PFA has so far funded over £500,000 in player recovery at Perform St. George’s Park and the intensive rehabilitation has also been used by medical staff, such as Gary Lewin, and the PGMOL referees. Perform Director Phil Horton believes the scheme can now stride for even greater results in injury recovery. “It’s vitally important that players make the best recovery they can from injuries. We have some of the best people in the industry working on player recovery. The scheme has also proved incredibly popular with the general public and giving people the best possible chance to recover from injuries that occur in everyday situations.” The Perform team works with the England football teams, professional sports squads and athletes from a range of sports on a daily basis as well as working with individual members of the public, schools and corporate organisations. As well as the PFA scheme, any club medic or employee, athlete or member of the public is able to access the accelerated recovery programme, SEM clinics, sports science assessment and conditioning services. These services can be self-funded or some elements can be funded by Health Partners (for players) or through private medical insurance. Perform, which is part of leading private hospital group Spire Healthcare, also operates cardiac screening and pathology services to football clubs and the England teams. This service is available at Perform, Spire hospitals and also on the road – regularly visiting football stadiums and training grounds. If you would like more information on any of these services or to understand what is covered on funded schemes, please contact Jake Keeling at Perform at St. George’s Park on 01283 576333 or email jake.keeling@spireperform.com Spotlight on the Perform facilities: • Hydrotherapy Suite with Hydroworx underwater treadmill, hot/cold plunge pool and pool with variable depth pool with fully movable floor. • Human Performance Lab with the latest innovations in sports science testing run under the leadership of Dr Carl Wells, with an Altitude Chamber, Wattbikes, Functional Movement Screening, Biomechanical Analysis and VO2 Max testing. • Strength and conditioning gym with four Olympic lifting platforms, extensive free weights and plate loaded areas, Technogym resistance and cardiovascular equipment and team spin bike area. • Rehabilitation gym with six therapy beds, large gym area including boxes, bungees, TRX, Bosu and bands used for functional rehabilitation and Pilates area. • 60-metre sprint lane for plyometric training with a focus on linear speed acceleration drills, maximal velocity training and technique drills often combined with hurdles, bungees, run rockets or parachutes.

Pictured: WiF board member Jacqui Oatley presents alongside pundit Martin Keown during Reading’s FA cup Semi Final Replay against Bradford City at the Madjeski in March of this year.

Women In Football FEATURE/Shelley Alexander

More than a thousand women work in a myriad number of roles in our national game and Women in Football (WiF) provide a platform to enhance the business performance and the welfare of these women through career workshops; networking opportunities and employment legal advice, explains WiF Board Member, Shelley Alexander...

ur partnership with football has been strong since our first networking event at West Ham eight years ago when FA Board member Heather Rabbatts, then Executive Deputy Chair at Millwall FC, took centre stage to inspire the audience with advice drawn from her own extensive business career. In the audience that day were senior women at Tottenham who hosted us next at White Hart Lane and invitations have followed from the likes of Manchester City; Arsenal; Wolves, Fulham and also from Wembley at the invitation of The FA. But it was at Stamford Bridge that we held our first business of football workshops which illustrated the depth of our commitment to all women in all circumstances in the industry - in one room a packed session for club employees on effective crisis management while just across the corridor, WiF board member Jacqui Oatley discussed business strategies

for working mothers with Justine Roberts, CEO, Mums.net. International Women’s Day in March of 2014 provided Women in Football with the opportunity to survey our network to discover what they thought were the opportunities and challenges for females working in our national game. Significantly, around 60% of the 600 odd women who responded worked for football clubs and governing bodies within the game. This anonymous survey spoke of committed, ambitious women dedicated to their professions whether that was as a Finance Manager; Club Doctor; a Stadium Safety Officer or a Referee. But there were also barriers to progress through outdated business practices and a culture that in some areas of the national game harks back to the 1950s - sadly, 66% said they had experienced sexism in their workplace. A sponsorship offer from Barclays then allowed Women in Football to develop

from an entirely voluntary organisation to being able to employ our first staff member Clare Fitzboydon, formerly at The Football Foundation. Work then began to address some of these outdated workplace attitudes highlighted in our survey and to begin to consult with the Football Association; the Football League and the Premier League among others. This is reflected in advising on the gender section of Football’s AntiDiscrimination Plan and also working with Premier League stadium Safety ) fficers to pilot a gender specific steward safety briefing document. Last season we also actively encouraged women to report on discrimination within the game and passed those complaints on to The FA. The progress on investigating these cases is then relayed back to WiF and is also enhanced by representation on the FA Inclusion Advisory Board. For example a major BBC News investigation by Natalie Pirks in March which went global, revealed

that female match officials and medical staff within English football are often subjected to disgraceful abuse in the course of carrying out their work in stadia that are home to some of the biggest clubs in the country. Investigations were pursued and some of the clubs involved have now implemented new procedures. Women in Football, also number female players within their ranks, and so were delighted to co-host a panel discussion with The FA at Wembley ahead of the historic occasion when England women played Germany in November last year. Our guest speakers, Darren Bailey, FA Director of Governance; Katrien Meire CEO of Charlton; Sangi Patel former physio at QPR and Crystal Palace and sports diversity consultant Michelle Moore contributed to a lively and informative debate. International Women’s Day in March this year also gave Women in Football the opportunity to highlight discrimination in the game using the hashtag #ShameontheGame - significantly supported by Laura Bates and the Everyday SexismCampaign. And, on a more positive note WiF requested football clubs to use a page of their programmes to celebrate women who have spent their professional lives in football using the hashtag #SheBelongs - wonderful stories of dedication were revealed as well as unknown women emerging who had been instrumental in setting up football clubs back in the 19th century and early 20th century. We continue that theme on our Women in Football website which also includes news of job opportunities within football. Our recent Women in Football events have reflected another strong theme from our 2014 survey - that of female leadership in football. So Mishcon De Reya hosted a Women on Boards evening where panel members including Julie Harrington, Managing Director of St George’s Park and soon to also hold that position at Wembley,

Pictured: Sian Massey runs the line at White Hart Lane as Tottenham draw 2-2 with Everton in their final game of the 2012/13 season.

discussed strategies for gaining senior positions and negotiating the politics of board membership. Earlier in the year Ernst & Young hosted our Women and Honours evening where the DCMS put on a workshop about how we nominate some of the stellar women in the national game. Looking ahead our WiF September (Thurs, 24th) event at Charlton FC will look specifically as those women who work pitchside. Women coaches are in the minority. Like former professional BAME players they struggle to get on UEFA B and A licence courses despite having the qualifications and experience. Female match officials are still only a small minority in the professional

game - how can WiF help to break down the barriers to further progress? And do we need to help develop further guidelines around women who work on the medical side of football? FA Cup winning Chelsea Ladies manager Emma Hayes, the only female in the top tier of the FA Women’s Super League, will be leading the conversation on the lack of female coaches across men and women’s football, while Annie Zaidi, Chair of the Black and Asian Coaches Association (BACA) will share her experiences as she pursues her UEFA B license and an ambition to work at the top of the men’s game. Claire Sullivan from the Chartered Society of Physiotherapy (CSP) will be on hand to discuss the role of the Union in ensuring equality for all among football’s backroom staff. Breakout workshops will explore how football authorities and clubs can better support women across all of these important roles. Then Easter Road is the venue for our first Women in Football event in Scotland in October (Thurs, 29th), featuring Britain’s coaching trailblazer Shelley Kerr, the first woman to manage a senior men’s team Stirling University FC - as well as Hearts’ Head physio Karen Gibson and Hibs’ CEO Leanne Dempster. Women in Football is the only specialist organisation working on gender and football, providing pro bono legal advice as well as help and support on workplace issues everything from how to move to the next step in your career to queries on maternity and employment rights. Please get in touch if you are a woman working in football: Email: info@womeninfootball.co.uk Website: womeninfootball.co.uk Tweet: @womeninfootball

Pictured: Chelsea’s England International striker, Eniola Aluko during a Women’s Super League match against Sunderland in October.

Published by kind permission of fcbusiness.

FOOTBALL MEDIC & SCIENTIST | 11

Pictured: France’s Zinedine Zidane examines his thigh after taking a knock during a friendly match against Portugal in 2001.

Medicine & Football

a personal perspective

Part 1

Half a Century in FEATURE/PROFESSOR DAVID S MUCKLE DSc.MB.BS.MD.MS.FRCS.FRCS (Ed).DProf (Hon)

A long and unexpected career in both medicine and sport began inauspiciously with an invitation to train with a small amateur club, Whitley Bay in 1967. Although the club was later to create a Wembley record for three successive cup wins in 2011, at that time this small club gave an insight into training methods and injury treatment which was a microcosm of football in general. In those days most soft tissue injuries were ‘run off’ by repeated lapping the periphery of the pitch followed by a warm bath to ease the pain (and, of course, increase the swelling!). If a meniscus injury was suspected the knee was opened by a generous 3 to 4 inch incision and the offending meniscus removed. The leading authority of the day in his textbook of the knee said that to leave even a small piece behind was a dereliction of care and risked causing osteoarthritis. (He and his supporters were to become fierce opponents in years to come). Cruciate tears were often misdiagnosed and even with treatment generally ended a career (e.g. Brian Clough while playing for Sunderland in 1964 – at the time I was a spectator). While most joint injuries were encased in a plaster of Paris for a period generally sufficient enough to stiffen the joint and cause hyaline degeneration. Fitness was lapping the pitch, hill and country runs, numerous shuttles, and post-army

Pictured: Trainer Cecil Peynton, right, with Tottenham defender Ron Henry in 1960

FOOTBALL MEDIC & SCIENTIST | 13

Pictured: Real Madrid’s Gareth Bale goes off with injury during a Champions League tie against Shakhtar Donetsk in September.

to do with the paper which had already been written. There were other significant changes. Crowd doctors followed the Taylor Report and were welcomed, the Referees Committee guided by Ken Ridden (also of UEFA), accepted the need to stop the game when a serious injury was suspected. The head injury protocol at the Radcliffe Infirmary and at Oxford United meant that all players, including visiting players, were routinely admitted overnight for observation once they were escorted from the pitch after a brief period of concussion. The Medical Committee decided to undertake a study of head trauma in football identifying a safe and cautious approach both during the game and after with regard to clinical assessment and scanning; while outlining a safe period for the resumption of training and playing. UEFA were to accept all of the above FA recommendations during my time on their Medical Committee, as did FIFA. So the 90s arrived with Sky Sports and the aftermath. Having been involved with two of the initial transfers of half a million pounds and a million respectively (which seemed beyond my comprehension) the money in football began to mushroom until today’s astronomical fees. Matt Busby once pointed out that Manchester United could not afford the transfer fee (£150) to take him from City to United (what would he think of Gareth Bale at £85 million and Cristiano Ronaldo at £80 million?). Times change but not the players; they have a fixed physiology and recovery capacity after injury. Thus, in a nutshell, the principles of treatment remain the same. Now, however,

there is the added financial pressure on Club Doctors and Specialists to implement quick and accurate diagnosis and treatment. Time is of the essence to most large professional clubs, but treatment should not involve cutting corners and encouraging a too hasty return to playing. In the wake of the expansive growth in wages and transfer fees Worldwide, the level of medical insurance cover has become one reason why several doctors/ surgeons, with whom I have spoken, are naturally disinclined to get involved. Many clubs send their players abroad where the ‘grass is greener’ in the forlorn hope that treatment is more ‘advanced’. I once asked the President of Rangers in 1996 why he was sending all his cruciate injuries to the USA and was told that they were better treated there. Pointing out that I had just returned from Chairing a Seminar at the New York Academy of Science on cruciate injuries (where their favoured surgeon had attended) he remained blank in his reply. There is no doubt that British doctors, surgeons, engineers and biochemists have generally been at the forefront of medical and surgical advances, as is the training in the prestigious British Royal Colleges. Managers are often belt-and-braces men who often enjoy an opinion which coincides with their own. Harold Shepherdson, who was an excellent trainer to the England Team and especially pivotal in the 1966 World Cup, told me that it was Bobby Robson’s illness in Hungary in 1960 that led to the appointment of a doctor with the International Team. However, when a player developed a shoulder dislocation in 1986 at the time of the World Cup, the manager and player opted for a

restraining harness which did not work. I felt that an arthroscopic fixation of the labrum and capsule would have been effective. It goes without saying that the relationship is between the doctor and patient (player) - the manager does not have to act as a middleman; after all he has no medical training. Comparisons of complex injuries by players are odious - my friend got better in 3 weeks etc. etc. and had this done etc .etc. The components of the knee, for example, are one synovium, two menisci, three joints, four ligaments and five degrees of severity; this gives a variable number akin to the lottery draw. Fortunately Nature unifies the healing process. Generally modern managers/coaches are quite happy with the doctor/player interaction and during my years have had some good and some outstanding managers to deal with, John Neal at Middlesbrough and Gerry Summers at Oxford were prime examples of allowing doctors to work unhindered. On the other hand, Bill Shankly rarely got involved fearing that an injury was infectious and thus banished injured players to the far end of the training ground. It is essential for the doctor to express his/her views on the medical protocols each season. It does mean speaking to all involved as personnel change from year to year. It is no good protesting in court that the coach, however special, dictated the treatment. The Judge will suddenly become animated and laugh out loud. So I will return to the 60s in the next article, how influencing the biochemistry of a softtissue injury came about, and especially one tablet that is now swallowed by 150 million daily, and the changes that have influenced international orthopaedic surgery.

Prof. David Sutherland Muckle has an international reputation in science and orthopaedic surgery. Honorary surgeon to The FA and England team, UEFA and FIFA for over 30 years, he has written books and articles since 1966 which include Sports Injuries (1971, reprinted to 1988 in 5 languages), Injuries in Sport – a surgical guide, Football Injuries, and Femoral Neck Fractures, all were international best sellers. Awards include the first recipient of the British Orthopaedic Association Research Society Gold Medal (1970), Euro’92 and Euro ’96 Final Medals – the first person to receive consecutive medals - and the Press Association Children of Courage (Child Surgery) (1986 &1993). He was awarded the higher doctorate in Science (2010) for his work at Oxford and Durham Universities on the discovery of the use of anti-inflammatory agents in trauma and the pathology involved. He is currently a visiting academic to the School of Science and Engineering at Teesside University; and has been a visiting professor to many universities world wide. In 2014 he was given an honorary doctorate as a life time achievement award by Teesside University.

A PLACE IN HISTORY

Pictured: Tottenham Hotspurâ&#x20AC;&#x2122;s Mitchell Thomas receives treatment for an injury in a match against West Ham United. December, 1986.

IMAGES OF OLD

FOOTBALL MEDIC & SCIENTIST | 15

Pictured: Notts County trainer/Physiotherapist Jack Wheeler (l) tends to Kane (r) and Kevin Randall (c) in the medical room. September, 1975.

Pictured: Chelsea’s Eden Hazard (centre) lies on the ground injured during the Barclays Premier League match at Stamford Bridge, London

Who’s the Boss? FEATURE/Mary O’Rourke QC Who directs the Medical Team? Who controls entry of that Medical Team onto the field of play? A leading sports medicine barrister gives her own personal interpretation of recent events.

t might be thought the answers to these 2 questions are obvious. A Club’s medical team can surely only be directed by a Medical Director (with the requisite medical knowledge and understanding of duties owed to the player/ patient) and above him the Chief Executive or Chairman, depending on the line management structure. Entry onto the field of play is wholly controlled by the Referee, acting under relevant FA and/or UEFA or FIFA Rules. Until late afternoon on Saturday 8th of August 2015, no-one around the World but especially in the UK would have questioned these 2 propositions. The issue had been addressed by me and others in previous editions of Football Medic and at the FMA conferences (Article in issue 6; Spring 2014 edition Who is my Patient?). The issue had also unequivocally been answered by the Court of Appeal in the case of West Brom vs El Safty in the summer of 2006 (during the Germany World Cup and when there was much talk of Wayne Rooney’s

metatarsal), as to where a medic owed his duty in footballer cases. The GMC and HCPC had also both provided guidance on duties of sports medics on issues such as patient records, medical confidentiality and treating players as patients. So why am I writing this now and why are the papers and TV also asking questions about the role of the medic and the role of the team manager in treating players on the pitch? You will no doubt be aware of the cases of Dr Eva Carneiro and Jon Fearn at Chelsea - where they went onto the pitch at the very end of Chelsea’s first game of the season in the Premier League at home to Swansea - when summonsed by the referee Michael Oliver and after he had spoken to the player Edin Hazard. As a consequence of meeting their now widely acknowledged duties to that player as their patient they were both – apparently “demoted” in that neither has since undertaken duties on the Chelsea bench during matches and indeed Dr Carneiro has since left the Club’s employment following the incident.

That this has happened despite the fact they could not have entered the field of play unless directed by the referee and in accordance with FA Rules is troubling. Moreover that this has happened when the game could not have continued and the referee would not under the relevant Rules have been able to continue it if they had not come unto the pitch makes everything that happened afterwards even more bizarre. Their cases over the last 8 weeks have attracted many printed and spoken words and Jose Mourinho has largely been criticised for what he said and what has happened, ie the apparent demotion, by fans, by the FMA, by pundits, by other medics in sport and even by the likes of Gary Lineker. So far, a few out of work managers (as pundits) have supported, though somewhat weakly, Mourinho’s postmatch comments. Belatedly the FA, first in the form of its Chief Executive Martin Glenn, and then Chairman Greg Dyke and Heather Rabatts, an Independent Non-Executive Director of the FA, have also stepped into

Pictured above: Germany’s Christoph Kramer celebrates winning the 2014 FIFA World Cup Final. Kramer suffered a head collision on 17 minutes and despite suspected concussion was allowed to play-on until the 31st minute. He is said to have not remembered the game and reportedly asked the referee twice ‘Is this the Final?’

the fray to say that Carneiro and Fearn did everything right and that Mourinho was in the wrong. Greg Dyke going so far as to say that Mourinho should apologise to Carneiro. In the midst of it all Chelsea as a Club and as an employer (in Carneiro’s case now former employer) has remained silent. Perhaps this has been for tactical reasons and in the hope that things will sort themselves out quietly behind the scenes in what they perceive as the best interests of the Club. From the medics’ perspective the silence must be very difficult to comprehend and could be argued to send a bad message to all of its employees, medical and sports scientist staff and indeed its supporters (and specifically its female supporters – see further below). On the other hand the Club has an interest in not making a bigger deal of an incident which one suspects it must wish had never happened and will quickly go away and be forgotten so that it can concentrate on the winning of matches. The silence by the Club might be said to send a bad message around the world as to the state of English football, given we are talking about one of the wealthiest and most powerful Clubs in Europe and the current Premier League Champions and past Champions of Europe. Even the FIFA Medical Committee, amidst all the other problems whirling around that organisation has stepped into the fray in support of the medics. They put the matter on the Agenda for their meeting of the 11th September and are now talking about devising a Code to work with, for medics and managers. So what is it all about and why might there be an argument for Chelsea and the LMA

speaking up, or quickly trying to sort the issues out for the future good of all in the game and the welfare of the players. Firstly, because it really cannot be disputed that the referee controls the field of play and entry onto it. The referee owes players a duty of care if they appear injured (or claim they are). Although as far as I am aware there has been no claim against a football referee in the UK there have been successful claims against rugby referees by injured players alleging breach of a duty to prevent injury or more serious injury through failure to control a scrum or failure to ensure the player is removed from the field of play when concussed or injured. Not being medically qualified, as far as I am aware Michael Oliver was fulfilling his duty in calling the medical team onto the field, once Edin Hazard indicated he wanted medical assistance, as he the referee was not qualified to determine the extent of any injury himself. Secondly, as a human being was Hazard entitled to enjoy medical autonomy and seek his own medical advice and assistance without his manager’s or Club’s permission. The answer to that in legal terms is resoundingly yes – and the Court of Appeal confirmed so in the El Safty case that a player is to be distinguished from a race horse (one of West Brom’s more innovative arguments during the legal argument in Court) and is not an asset but has full autonomy to decide on and consent to treatment. So given Hazard clearly told the referee he wanted assistance he clearly indicated he was considering himself as a patient at that point. So when the referee summoned Carneiro and Fearn to a patient, were they doing

anything wrong by responding to the referee and player/ patient by entering the field of play to assess? Unequivocally, the answer has to be NO. Indeed had they not responded the referee could have stopped the game until they did. They could arguably have also been disciplined by their Club for not discharging their contractual duties to treat the Club’s players and by their professional regulators, the GMC and HCPC, for not discharging their professional duties to their patient. More particularly I am not sure how you can discharge your duty to assess a patient from 50 plus yards away. In 30 years of defending healthcare professionals before Courts and Regulators/ Tribunals it’s a new one on me that you can visually assess from a distance someone lying rolling around on the ground with other things obstructing your view and in such a manner make a competent assessment. Most Healthcare Regulators would be unimpressed by an examination that did not include questioning the patient to take a history and laying on of hands to examine! I would say, based on my many years of experience defending medics that you would be exposing yourself as a healthcare professional to a serious risk of being sued, so to do and so to get it wrong. Remember also when the Claim form for millions of pounds comes from the player who is injured the target will be the medical team and not the Team Manager or First Team coach and it will be the medical professional who has to look to his/ her indemnity cover and future premiums. So did Jon and Eva get it right? Unequivocally YES. If the situation reoccurred, should they do the same again – unequivocally

FOOTBALL MEDIC & SCIENTIST | 17

Pictured: Bayern Munich Chief medical officer Hans-Wilhelm Muller-Wohlfahrt in 2013, He left the club in 2015, following criticism from Pepe Guardiola over a defeat to Porto the entire medical staff also resigned in solidarity.

YES. Should it arise elsewhere else what should you do (on the basis you the reader are a sports health professional) – answer - the same as they did Chelsea must appreciate (or have asked their lawyers to tell them) about the medics’ common law duties owed to players as patients, and also their professional duties owed to their Regulators to treat their patients? They must be aware of the case of West Brom vs El Safty – much commented on at the time in 2006 and since. They must know players can sue their Clubs and their healthcare professionals and given most of the medics in football are asked to maintain their own professional indemnity cover they must understand that they expect the medics to assume the liability in such matters and essentially delegate it to them as experts in the issues of injury etc. Given such awareness it is surely in the best interests of the game for all those involved to now come out and say publicly: (1) That they unequivocally support Dr Carneiro and Jon Fearn and wholly accept they did nothing wrong but rather put their duty to the player first (and which – as the FMA statement said - is a duty to be exercised without reference to extraneous issues such as the stage or state of the game) and in so doing, fulfilled their contractual duties to the Club to look after its players and also the Club’s duties to the FA etc., by complying with referee requests and instructions. (2) That they wish to dissociate themselves from the remarks made after the match and subsequently by the manager and that in making them, he perhaps did so in the heat of the moment and without thinking but does in

fact appreciate and understand that it is not his role to tell medics how to discharge their professional duties – given he is not qualified to do so and accepts the special expertise of a qualified medical team. (3) That there should have been no question of either Dr Carneiro or Jon Fearn being in any way punished or adversely affected within their employment for doing their jobs in accordance with professional responsibilities and FA/ FIFA rules and in the best interests of the Club’s major assets ie its players. There is of course a further potentially nasty aspect to the whole sorry tale and that is the potential sexist connotations of Mourinho’s comments - apparently directed at Carneiro (or certainly interpreted in that way by much the media - despite an FA disciplinary committee ruling otherwise). Certainly one inference that could be drawn from his comments is that Dr Carneiro was like a secretary (95% female) and lacked knowledge of the game and hence should not be on the bench if unable to follow the game. The implication of such remarks (certainly taken by many in the media and on the blog sites) is that women know nothing about football. As a female football supporter (rather than a lawyer) for almost 50 years and a season ticket holder at a major Premier League club for almost 25 I strongly resent the inference on behalf of women fascinated by and following football. I know that in my last 25 years of regular match attendances all round the country and all over the World, that increasingly there are large numbers of women attending matches, bringing in much needed revenue which pays the Managers and players top dollar wages.

Therefore, do Chelsea want to risk antagonising their loyal female supporters with the slur that women are ignorant on football and its Rules and that the Club will employ male medical staff rather than females with the requisite medical skills due to their knowledge of the game? I thought Gary Lineker’s tweet was spot on – he might apply for Dr Carneiro’s job, in fact sadly now vacant, given his football knowledge, as it wasn’t clear medical expertise was actually required! My hope when first asked to write this article was that by the time you read it Jon and Eva would both be back on the Chelsea bench. Also that the FIFA Medical Committee would have sent all Clubs a clear re-affirmation of the duties of the medics and that Team Managers really cannot interfere (or even try to interfere) in medical matters, given the special qualifications and expertise required for those jobs. They should stick to team selection and tactics where they undoubtedly have the greater knowledge. Sadly, that has not happened as FIFA has passed matters for consideration by a Committee as to the development of a Code with consideration given to the role of coaches and managers. More particularly Eva Carneiro has lost the job of her dreams, when she did nothing wrong and everything right. Jon Fearn has still not returned to the Chelsea bench and the message of it all to other medics in football must consequently be a worrying one. My advice to those of you on the front line is to make sure your Club recognises your legal and professional duties and in your contract makes clear that your line manager is not the team manager or coach, but is someone qualified to understand and direct on such fundamentally important issues!

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Member or not? FEATURE/How the FMA can influence outcomes

There is no question that recent events involving colleagues at Chelsea have proved to be a wake-up call for all of us.

hile we are always aware of the precarious nature that is football, these events have illustrated just how perilous indeed our positions can be, and with a recent spate of managerial sackings taking place, the potential for colleagues to lose their positions at those clubs, grows exponentially. Such events throw into focus just why the FMA is proving so important. Losing your post Being called into the “office” to be told your services are no longer required is a life changing, heart pounding moment. The reaction is bound to be one of anger, upset and resentment especially given that we all put so much time and effort into our roles and become part of the fabric of the Club. Leaving the “office” after just such a dismissal can feel like the loneliest place in the world and the need to turn for expert help becomes paramount. In similar circumstances, players turn to the PFA and managers to the LMA. Medical and science personnel know they too can turn to the FMA for the very same support, advice and guidance. Where an individual is relieved of their services the pathway for this support and guidance is well known. But what about situations where there is a dispute with the manager or player or someone else in the club? Disputes By nature, situations like this have to be handled on an individual basis and the pathways

for resolution or otherwise, are determined according to the circumstances of the dispute. In the majority of cases the initial aim has to be to keep the member in their job. Where a situation is allowed to escalate, negotiation is a must if a negative outcome is to be avoided. Discussing a problem confidentially with the FMA, can provide the necessary support and understanding needed for you to take a deep breath, analyse the whole picture and determine what is the best thing to do in difficult circumstances. Countless times following just such situations – and where we are able to keep the member in post - we have witnessed members eventually seeing the departure of the manager or player or member of staff concerned. Our member often then goes on to experience a totally different working environment and enjoy a fulfilling career at their Club It is ultimately all about rationalising, putting into perspective and understanding a given situation. The price of challenging a situation head on can often result in the loss of your dream job and having to endure the humbling experience of going from a high profile position to a role possibly outside professional sport or even unemployment. Such outcomes necessitate careful consideration and a clear line of thought in all instances. So, if we can keep a member in their post, what about the circumstances of the dispute itself. As a body, the FMA would seek to make a comprehensive assessment of the details of the dispute. If it was felt that in the best interests of the member no further action was needed, then, none would be taken. In some cases, there might be a need

however to assess the wider implications of a dispute and, in such instances, we would have to determine (i)whether dialogue with relevant administrations or representative bodies was appropriate and (ii)whether there would be a need to develop a pathway to prevent such situations arising again. Advisory It is also the role of the FMA to give clear guidance to its membership following any dispute that is played out in the public domain. It is important for a member to know exactly what his or her position is should a similar situation arise and that the FMA is here to advise them. In this regard, we invited Mary O’Rourke QC, a leading Sports Medicine Barrister, to give her interpretation of the events that unfolded at Chelsea and in her article “Who is the Boss?” Mary gives very clear guidance to our members of their position. It is vital to point out that the FMA`s legal framework is a very considered and structured entity. Our legal team is in our opinion the very best in our industry and has vast experience and knowledge of the working practices of Professional Football Clubs. Engaging with solicitors who are not familiar with the intricacies of Professional Football can be a time consuming and costly mistake. While members are clearly in charge of directing the course of any dispute, the FMA can clearly play a pivotal role in determining the eventual outcome following an incident. As we have witnessed, that outcome is likely to be very different for a member than for that of a non member.

BOOTS, STUDS &

INJURIES IN FOOTBALL FEATURE/ProfFessor Andrea Ferretti, member of the UEFA Medical Committee Football is the worldâ&#x20AC;&#x2122;s most popular sport. It is now estimated that more than 200 million people play some form of the game (i.e. including futsal and beach soccer) at one level or another.

ootball is generally considered to be a safe sport. However, the risk of injury (especially at professional level) is substantial. It has been estimated that the overall risk is about 1,000 times greater than that of a typical high-risk industrial occupation. Although the rules limit physical contact between players, this is an essential part of the game and can lead to some forms of trauma. However, the majority of the injuries that occur during matches and training are not contact related. These include sprained ankles and knees, strained muscles, torn tendons and overuse injuries (stress fractures, tendinopathies, soreness following muscle overload, cartilage degeneration, etc.). Some of the most common injuries concern the anterior cruciate ligament (ACL), typically involving a sudden overloading of the joint complex responsible for a specific action. According to literature, the majority of these injuries are not contact-related, occurring without a player being tackled or touched by another player. Recently, our expert group performed video analysis of a series of ACL tears occurring during competitive football matches, looking

at 58 cases that were captured on footage broadcast by major television companies. The most common injury mechanism for ACL tears in football players is deceleration with the body unbalanced posteriorly and the foot planted on the ground. In these circumstances, ligament loads exceed tolerable limits owing to inadequate control over the playerâ&#x20AC;&#x2122;s movement. In most cases, the injury seems to occur when the player tries to change direction. Although valgus external rotation stress is often reported as the most common injury mechanism, more detailed analysis of the mechanism reveals that, in the case of an ACL tear, a forceful and abrupt internal rotation stress is first applied to the joint while the knee is in a valgus position. This stress leads to a sudden tearing of the ACL (which occurs in about 40 milliseconds), before the knee eventually collapses in valgus external rotation. In fact, the injury mechanism described above, involving a combination of valgus and internal rotation stress, mimics the pivot shift test â&#x20AC;&#x201C; one of the most popular tests used in the diagnosis of rotatory instability of the knee, which is commonly associated with an ACL deficiency.

Thus, most non-contact-related lower limb injuries in football occur while running, turning, pivoting, landing following a jump or shooting. In all of these situations, one foot is planted on the ground while the body turns either clockwise or anti-clockwise. According to the website www.footballboots. co.uk, the first recorded pair of football boots were made for King Henry VIII of England in 1526. In the 19th century, when the game became increasingly popular (especially in England), the majority of players used work boots, which were very hard and heavy and not designed for running or kicking. They often had steel caps, resulting in injuries when opponents were tackled or accidentally kicked. Later on, metal tacks or studs were put on the bottom of those boots in order to obtain a better grip. In the early 1900s, the first official studded football boots were produced. They were made from black leather, they were heavy and thick, and they went right up to the ankle. The black studded boot became a kind of icon for football players. It was not until the 1950s that Adidas introduced boots with interchangeable screw-in studs. These studs were made of rubber or

plastic and meant that players could choose which studs to use with their boots depending on the weather and the condition of the pitch. More recently, thanks to new materials and manufacturing techniques, and as a result of the popularity of boots as a fashion and consumer item, boots have become even lighter, with new types of stud, more flexible soles and sometimes extravagant colours. At the same time, with various manufacturers paying professional players to wear boots, research into more appealing and more easily recognisable models is probably now considered more important than developing boots with even better biomechanical properties. The goal of today’s product development teams should be to adequately address questions of flexibility and stability within the confines of a lightweight boot, paying special attention to players’ safety. Combining these elements with a clean, functional playing surface will result in lasting grip, increased friction between boot and ball, greater ball control, increased power and swerve, and biomechanical stability. The various types of football boot that are available today can be classified as follows: Firm ground – for playing on firm or moderately forgiving pitches. Firm ground studs are perhaps the most common stud type. They generally range from 10mm to 14mm on the outsole plate. Blades and round studs are equally preferred in today’s market. Hard ground – for playing on hard, unforgiving pitches. These studs are generally short and positioned in fairly uniform patterns across the outsole plate. They are very effective at providing grip where pitches are difficult to penetrate. The studs tend to be shorter and softer than the firm ground variety. Soft ground – for playing on soft pitches Football boots for rain-soaked or soft pitches

occasionally require longer detachable studs. These studs vary in length (ranging from 12mm to 19mm), depending on the condition of the pitch. Many professional players now use a mixture of soft and firm ground studs for standard pitch conditions. Artificial turf – for playing on extremely hard or synthetic surfaces These finely studded boots are most helpful where the pitch is even and there is no – or only sparse – natural grass. Although it has been speculated that the traction properties of football boots on natural grass and artificial turf are responsible for acute and chronic injuries, little research has been published on the football. Knowledge of the effect that different types of boot and stud have on muscles, tendons and joint stress is of paramount importance for the prevention of major football injuries. German researchers at the University of Freiburg conducted an excellent study looking at the effect that bladed and round studs mounted in commercially available football boots had on knee joint kinematics. They compared boots with eight round studs in the forefoot and four studs in the heel area with boots with nine blades in the forefoot and four blades in the heel. Using video cameras, retroreflective surface markers and surface electrodes, they found no significant differences between the two types of football boot in terms of ground reaction forces,3D kinematics and electromyographic activity in the lower leg. Although major manufacturers continue to release new models, they seem to be focusing solely on aesthetics, rather than players’ safety and efficiency. Indeed, we seem to be a long way from striking the right balance between the grip needed for technical skills and the avoidance of non-contact injuries. In some cases, very light studs positioned in areas with maximum load result in unacceptable breakage rates.

Recently, an Italian company (Camparilab in Parma) specialising in the production of carbon fibre devices and accessories protecting footballers (shin guards, face and nose masks, etc.) developed flexible studs that could be mounted on all commercially available types of boot. These were designed with the aim of partially absorbing loads and stresses that were transferred from the ground to the boot and the player’s body. This new stud features a polymeric elastomer positioned between two aluminium sections. It aims to absorb the energy that is generated when the boot strikes the ground, which would otherwise be transferred to the foot, heel and ankle, before going up the leg to the knee. These studs were evaluated by a group of researchers (led by Carlo Mapelli) at the Polytechnic University of Milan using a specially modified testing machine. Boots equipped with flexible studs were tested and compared with commercially available boots with aluminium studs. The results of this preliminary series of tests indicate that the new flexible studs have the potential to absorb up to 25% of the load that conventional studs normally transmit to the sole and the rest of the body. Although the results obtained by the Italian researchers need to be confirmed by further studies evaluating flexible studs’ resistance to cyclic loading and torsional stresses, the preliminary results seem to be encouraging, and the researchers’ attempts to break new ground in the development of football boots could potentially contribute to the prevention of football injuries. In conclusion, we speculate that studs and boots could represent a key factor in both the performance and the safety of footballers. In addition to providing proper grip to keep the player well balanced in all circumstances requiring good traction, boots should be flexible enough to absorb excessive loads and stresses, which might otherwise result in a risk of major injuries to the player. It is very important that doctors and researchers encourage companies involved in the manufacture and sale of boots and studs to continue to address this issue with the aim of making the best sport in the world even safer. References: 1 De Carli A., Ciompi A., Lanzetti R., Lupariello D., Marzano F., and Ferretti A., ‘ACL injury mechanism in soccer. A video analysis’, presented at the 16th ESSKA Congress, Amsterdam, May 2014. 2 Drawer S., and Fuller C.W., ‘Evaluating the level of injury in English professional football using a risk based assessment process’, Br. J. Sports Med., 36, pp. 446-451, 2002. 3 Ekstrand J. et al., ‘Injury diagnosis and treatment’, UEFA Football Doctor Education Programme, Workshop 2, Nyon, 2013. 4 Gehring D., Rott F., Stapelfeldt B., and Gollhofer A., ‘Effect of soccer shoe cleats on knee joint loads’, Int. J. Sports Med., 28, pp. 1030-1034, 2007. 5 Hennig E.M., ‘The influence of soccer shoe design on player performance and injury’, Res. Sports Med., 19, pp. 186-201, 2011. 6 Koga H., Bahr R., Myklebust G., Engebretsen L., Grund T., and Krosshaug T., ‘Estimating anterior tibial translation from model-based image-matching of a noncontact anterior cruciate ligament injury in professional football: a case report’, Clin. J. Sport Med., 21, pp. 271-274, 2011. 7 Koga H., Nakamae A., Shima Y., Iwasa J., Myklebust G., Engebretsen L., Bahr R., and Krosshaug T., ‘Mechanisms for noncontact anterior cruciate ligament injuries: knee joint kinematics in 10 injury situations from female team handball and basketball’, Am. J. Sports Med., 38, pp. 2218-2225, 2010.8 Liebeskind H., ‘The biodynamics of soccer and soccer cleat design’, Pod. Man., pp. 189-194, March 2011.9 Mapelli C, Barella S, Gruttadauria A, Giovi S. ‘Progettazione e prove meccaniche su tacchetti compositi per il calcio e per il rugby.’ Tesi, Politecnico di Milano, 2012.

Published by kind permission of UEFA Medicine Matters.

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Pictured: Scotlandâ&#x20AC;&#x2122;s Michael Jamieson on his way to silver in the Menâ&#x20AC;&#x2122;s 200m Breaststroke Final at Tolcross International Swimming Centre during the 2014 Commonwealth Games in Glasgow.

ShoulderINJURIES FEATURE/MR. ALI NARVANI BSc, MB BS (Hons), MSc (Sports Med.)(Hons), FRCS (Orth & Trauma), MFSEM (UK) Alternate sport: We can learn a lot from the work of colleagues in other sports how do they see and deal with injuries that we encounter in our professional work?

p to 87% of competitive swimmers, according to recent papers, suffer from a disabling shoulder pain at some stage. In most cases, this is supraspinatus, tendinopathy and impingement. But there can also be bicep abnormalities, rotator cuff tears, labral tears, os acromiale, ACJ pain and arthritis. One condition can lead on to another, and even another, so it is very important to isolate and treat the primary condition. Physiotherapy is the most effective treatment. Surgery is the last resort. Only in rare cases will surgical arthroscopic subacromial decompression be necessary for impingements.

A competitive swimmer swims between 60,000 and 80,000m per week, which means approximately 80,000 rotations. That represents a huge stress on the shoulders which can result in repetitive micro-trauma. Damage to the tendons and cells can lead to tendinopathy and impingement. Comparing the numbers of hours swum to the frequency of supraspinatus tendinopathy indicates a strong correlation between the amount of training and the amount of injury. Freestyle, the stroke with most shoulder issues, has three distinct phases: hand entry; pull-through; hand exit and recovery. 70% of symptoms are felt in the first

half of the pull-through, as the athlete is generating a lot of force to pull the body over the water. The scapula is protracted, the humerus is adducted, extended and internally rotated. As the muscles fatigue, the swimmer feels pain. Also, if the muscles stabilizing the scapula are not working efficiently, the scapula will not move efficiently, causing secondary impingement. Faulty technique is often the cause. During the pull-through, the elbow should be much higher than the wrist. If the elbow is lower, the muscles are lengthened, are not at their optimal contraction length and fatigue earlier. Again, if there is a dropped

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Pictured: Arsenalâ&#x20AC;&#x2122;s Petr Cech throws the ball out of his area during a game against Chelsea during their recent Barclays Premier League match at Stamford Bridge

elbow in the recovery phase, this causes an upward force on the humerus which can result in secondary impingement. The head should be in the water during the pull-through. If the swimmer is looking forward instead, the muscles extending the neck will prevent the scapula from moving normally, which can lead to secondary impingement. The hand should enter the water somewhere between the shoulder and head with all the fingers entering together. If the thumb leads, this will rotate the forearm producing excessive force on the long head of the bicep where it attaches to the superior labrum, potentially causing damage. Swimmers and throwers often have a lax anterior capsule and so mild anterior hyperlaxity can lead to secondary impingement. Many competitive swimmers use paddles to increase their resistance. Paddles

mean additional forces on the structure of the shoulder, therefore increasing the likelihood of injury. Most swimmers have increased thoracic kyphosis and hyperlordosis of the lower back, so as a result of the reduced subacromical space, there can be secondary impingement and scapular dyskinesia. Surprisingly, errors in technique are very common in competitive swimmers, who also believe that pain is inevitable in elite sport, so do not address it. Prevention is key. This means recognising and correcting faulty technique, in addition to programmes of stretching, strengthening, endurance training, core muscle exercises and careful monitoring. When the shoulder is injured, training volume and intensity should be adjusted to enable recovery. Rest, reduced training, ice packs, technique correction, exercises for core and scapula stability and to tackle a tight posterior-inferior capsule will all help.

Physiotherapy will correct posture and will encourage general strengthening and balance work. It will address issues such as a tight anterior chest wall, a hypermobile thoracic spine, excessive joint mobility or a tight posterior-anterior capsule. This should greatly help patients who get pain only at the time of swimming. For those who get pain even when they are not swimming, in addition to the treatment above, they should have a longer period of rest from swimming, take non-steroidal anti-inflammatories and possibly have a single steroid injection. Only then, if the patient has been symptomatic for more than three months, should surgical decompression for a mechanical primary impingement, or repair to injuries such as labral tears, be considered. In conclusion, swimmersâ&#x20AC;&#x2122; shoulder pain is common and technical error is often the cause. Prevention is the best solution and treatment is mainly non-surgical.

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Pictured: Jim treating Gareth Barry during Aston Villa’s 1999/2000 FA Cup Semi-final match against Bolton Wanderers. Villa eventually win on penalties, with Barry scoring the penultimate spot kick for the Villans.

WHERE ARE THEY NOW? FEATURE/JIM WALKER - Written by Paul Jenkins Jim Walker is a man who has spent his whole working life in football, but one who has unusually tasted much success in the dual roles of player and a physio.

embley finals, European trips, championships won, an afternoon spent in his company is a wonderful trip down memory lane featuring famous football names who are close personal friends and former colleagues to the amiable Cheshire born Jim. Possibly best known for his 17 years at Aston Villa, he was part of the set up that provided a ‘golden era’ at Villa Park, which brought two runners up positions in the top division and two league cup wins, their first silverware since winning the European Cup, In terms of championships won, Jim can claim being part of two, though not as a physio. As a player, he became part of the incredible Clough and Taylor era at Derby County after being signed as a youngster from home town club Northwich Victoria in 1968. He went straight from the Northern Premier League to the Baseball Ground

Pictured: Jim on the touchline at Ewood Park in 2003.

after being spotted when scoring freely for the Vics. He played 26 times in County’s second division winning team in 1968-69, and despite limited appearances in the first division winning team, he scored a vital goal in the 1971-72 season at Crystal Palace that sent them top of the first division with seven games to go. In an era of glory for the Rams made famous by the book and film ‘The Damned United’, that goal earned Walker a place on the plane for the end-of-season trip to Spain, where they learned of their triumph via telegram whilst on the beach. “It was a wonderful time under Brian Clough, he was a real character and never forgot anything, from things players did to family members. “I nearly missed the Spain trip because early in the season I had told him I couldn’t perform a club function as my wife was coming out of hospital that night with our second child. “At the end of the season the list was

Pictured: (Above) Jim tends to Savo Milosevic as referee Uriah Rennie looks on, during a 1998 League Cup tie against Portsmouth.

published of who was going on the trip and my name wasn’t there. When I asked Mr Clough why that was, he said ‘You’ll be too busy looking after that lad of yours’. “Between them they relented but I didn’t get to wear the same club suit as the rest of the players, I had to wear my own (see picture of the league winning side). But what a trip it was and when we got the telex that we had won the league, it got even better.” Spells at Brighton (with Peter Taylor) and Peterborough followed before his playing career came to an end after five years at Chester City, where he made 172 appearances. Jim explained how his transition from a player came about at Chester. He said: “In those days there was one person acting as the trainer and the physio, certainly at clubs like Chester. “I had a wonderful time at Sealand Road as it was then and didn’t want to give up playing but towards the end it was obvious something had to give and I found out I had a partial rupture of the achilles tendon. “In my last game I tried to play on but could only last around 30 minutes and after that started acting as the physio, such as it was, with Alan Oakes who played over 700 games for Chester as player manager. He spent two years as a physio and trainer at Chester and when he left, two years in Kuwait coaching with former team mate, the legendary Dave Mackay. This helped him decide where his future was as he took both a preliminary coaching

course and a treatment of injuries course. “I enjoyed both,” he said, “but I don’t know what it was I was just attracted to the phsio side of things, perhaps it was having seen players have so many injuries during my career and suffered plenty myself, I wanted to help out on that side and the science of the treatment of injuries was being taken more seriously and coming on all time” Former team mate Bobby Saxton took him to Blackburn, during which time he continued to study. The call from Aston Villa came in 1986 and it marked the start of a 17-yearassociation with the famous Midlands outfit, starting under Graham Taylor. Walker really became part of the fabric at Villa Park, moving to nearby Walmley where a lot of the players and staff lived on the same estate. “I became like a dad almost to the players, whenever they had a problem if one of the kids fell over or they needed help in some way, they would call me, it was like a little community built around the club and the area where a lot of players and staff lived. “Very often people from the club would socialise and the new apprentices would stay here for a while to help them get settled in. “It was very much that type of club, I was happy to help out and get them used to the area and the club.” On the medical side, Jim was given the freedom to develop facilities and the his team, working regular 80 hour weeks to

ensure players were looked after. He said: ““Eighty hour weeks were the norm, including Sundays of course and I made it an unwritten rule to take June off where we went on holiday as a family and were totally out of communication during that time, I made that a rule. “It was hard work, you could never switch off, don’t forget this is when football was coming into the modern era if you like, ahead of the Premier League and players were getting more and more valuable as commodities. “But I treated them all the same, they are all footballers and just wanted to play and as frustrating as it was for them to be injured, my job was to be honest with them and tell them what needed to be done to get them back playing again.” During his time at Villa, Jim renewed his acquaintance with the Oakes family when the club signed Alan’s son Michael who went on to be sold to Wolves for £500,000 and enjoyed a successful career like his dad. And another connection with the club he is so associated with came when one of Jim’s daughters married defender Mark Delaney, who retired at 31 having made 193 appearances for Villa and 36 for Wales. Graham Taylor in his second spell in charge once said to Jim that if he himself left he couldn’t guarantee that the new manager would take him on, but he wasn’t worried. “It didn’t ever bother me that there might not be much security, I was too involved in the job at the time to think

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Pictured: (Above)Aston Villa’s Paul Merson is escorted off the pitch by Jim during their 1999/2000 FA Cup - Fifth Round match against Leeds United. Merson’s injury was sustained assisting Villa striker Benito Carbone’s winning goal,completing his hat-trick and sealing the victory 3-2.

about that and I was continuing my education to hopefully ensure I would have a future as a physio, whether at a football club or somewhere else.” In fact Jim worked under six incumbents of the Villa hot seat if you include an unsuccessful second spell that Graham Taylor had between 2002 and 2003. The full list of managers he worked with at Villa was Graham Taylor (twice), Josef Vengloz, Ron Atkinson, Brian Little and John Gregory. One of the most celebrated and famous was Big Ron and when he got the job it was two weeks before he spoke to Jim, leading him to think he might not be needed. When Ron did sit Jim down in his office, he said: ‘I don’t like physios and I don’t like Charles Hughes.’ Jim replied that he thought Charles Hughes was ok and Big Ron laughed, setting the working relationship straight. And what a working relationship it was, with Villa enjoying another successful period to follow on from Taylor’s tenure which had helped him get the England job. He reels off a list of players he treated and worked with that would make many Premier League manager’s mouth water now – Dwight Yorke, Paul Merson, Dalian Atkinson, Julian Joachim, Paul McGrath, Kent Nielsen, Mark Bosnich in his prime, it was a rich vein of talent that came out of Villa Park during Taylor and Atkinson’s era in particular.

Atkinson took Villa to their first silverware since winning the European Cup in 1982 when they triumphed 3-1 at Wembley over Manchester United in the league cup. Unknown to the fans or the media, two of the final winning team probably may not have been playing that day had it not been for the medics help as Jim explains. “The day before the final we were at Bisham Abbey doing some light training and Ron wanted the team to practice defending corners. “The ball came over for one of them and Mark Bosnich, in going for the ball, smashed Shaun Teale in the nose, breaking it and making him doubtful for the final. “Then at 2-o-clock in the morning in the hotel I get a knock on my bedroom door and it’s Paul McGrath who is complaining of pains in his neck and shoulder meaning he couldn’t sleep. “I managed to get him some medication and the next morning, when he hadn’t slept at all, we gave him some injections and both he and Teale played and starred in a great victory. “That wasn’t the end of it because Paul went on to play in the World Cup for Ireland with the same injury – a shoulder neuralgic amyotrophy – which is an uncommon condition which can cause paralysis on an intermittent basis.” Walker established an almost father-son relationship with McGrath, whose off field problems have been well documented, as

well as the fact he couldn’t train. “It didn’t work out at Walsall”, he said, “whether it was combining the coaching and physio role, whether it was that we didn’t get the results we needed, it just wasn’t a great time. He left Walsall when the club were relegated and Merson was sacked and returned to one of his former clubs Peterborough , as a physio before taking up a senior physio’s role at the Belfry Golf and Country Club near his West Midlands home. Not one for collecting medals and memorabilia, Jim has his memories and is most fond of his time as a player. He said: “As a player you always want to play as often and as long as possible and I was no exception. “I had a decent career as a player, perhaps I could have played more games but I enjoyed every minute of it. “And then to go on and have a career at the top level of the game in this country was more than a bonus and the skills I learned combined with the studying that was available led me to carry on after the football at the Belfry for a number of years before I retired.” “And I might not have reached the heights of some of the players I treated but I have the two championships in my locker and the memory of working and playing with some of the best.”