Football Medic & Scientist - Winter 2016 by Football Medicine & Performance Association

FOOTBALL medic & scientist Issue 15 Winter 2015/16

The official magazine of the Football Medical Association

PEOPLE PERSON Les Parry on the Increasing Reliance upon New Technology

FMA Legal ~ Education ~ Recruitment ~ Wellbeing

FOOTBALL MEDICAL ASSOCIATION SPONSORED BY

Contents

FMA FOOTBALL MEDICAL ASSOCIATION SPONSORED BY

Welcome 4

Members News

Features 9

It’s All About People Les Parry

12 The Causes of Running Injuries Dr. Jonathan Rees 15 Return to Play: A Decision Based Approach Johnny Wilson and Beki Knight 17 ACL Injuries in Women’s Football Dr. Pippa Bennett 18 2016 FMA Conference 20 Making the Most of Commercial partnerships 21 Partnering the FMA 23 Half a Century in Medicine & Football: A Personal Perspective Dr. David S Muckle

CHIEF EXECUTIVE OFFICER First of all, a very happy New Year to all of our members and colleagues in professional football.

s we reflect back on the first part of the season there is no doubt that 2015 has highlighted, perhaps more than at any other time in the history of Football Medicine, the need for an independent representative body to support, guide and advise the medical and science community in professional football. The withdrawal of Indemnity for Physiotherapists, the fallout from events at Chelsea and the media attention that followed; the potential changes taking shape in respect of employee’s duty of care and the increasing scrutiny on educational standards of practitioners in football, all serve to remind us of the pressures and vulnerability of our positions in the game. At such a pivotal moment, it is increasingly clear that authorities and administrators now appreciate the fact that there is an established single collective organisation in place; the FMA. It is through our association that the collective desire to ensure a high standard of medical practice and player welfare can be facilitated and we are determined to fulfil our duties in this respect and on behalf of our members and the wider game. As the leagues now begin to take shape there are those with an eye on the upside of football as promotion or trophies appear on the horizon. And there are those who may be anticipating potential relegation battles and the inevitable merry-go-round of managerial and staff job losses that will inevitably follow. Whatever the rest of the season may bring and wherever fortunes may lie, the FMA is in place to support its members.

Knowing that support is in place is invaluable. Eamonn Salmon CEO Football Medical Association

29 Critical Concepts in Knee Joint Stability Dr. Nicholas Clark

Football Medic & Scientist Gisburn Road, Barrowford, Lancashire BB9 8PT Telephone 0333 456 7897 Email info@footballmedic.co.uk Web www.footballmedic.co.uk Chief Executive Officer

Eamonn Salmon

Business Development Manager

Jayne Maddison

Cover Image

Senior Administrator

Lindsay McGlynn

Les Parry in charge of Tranmere Rovers during their Johnstone’s Paint Trophy match against Chesterfield in November,2011.

Administrator

Nichola Holly

Francis Joseph

Contributors

Dr. David S. Muckle, Dr. Pippa Bennett, Dr. jonathan Rees, Johnny Wilson, Les Parry, Nick Clark, Maggie McNerney, CryoAction, Fortius, Spire Healthcare

Editorial

Oporto Sports - www.oportosports.com

Design

Soar Media - www.soarmedia.co.uk

Marketing/Advertising

Charles Whitney - 0845 004 1040

Published by

Buxton Press Limited

Photography

Football Medical Association, PA Images

Mike Egerton/EMPICS Sport 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.

FOOTBALL MEDIC & SCIENTIST | 3

MEMBERS’ NEWS FMA ANNOUNCE UNIQUE MEMBER BENEFIT DEAL WITH KEYFLEET CONTRACT HIRE & LEASING

e are delighted to announce that we have agreed a scheme with Lancashire based car and van leasing specialists KeyFleet that will see our members benefit from preferential deals, service and support for all their motoring needs.

2016 is set to be the most successful year for the UK leasing industry and we feel that our members can benefit from the fixed cost and inclusive nature of running a contract hire or rental vehicle and avoid the costs and hassle of owning and running a private or small business car.

Leasing gives you the chance to drive a new car every few years, with relatively low monthly payments and no worries about the car’s resale value. With both personal and business preferential leasing deals and advice available there really is no need for our members to go anywhere else.

So what’s on offer? 1. Dedicated FMA scheme manager at KeyFleet 2. Priority service and instant quotations 3. Unique offers for FMA not available to public with preferential rates 4. 50% reduction in lease arrangement fee

FORMER WOLVES CLUB DOCTOR PASSES AWAY

Contact Jake Yates or Luke Jarrold to discuss your requirements on 03303 13 11 11 or visit www.keyfleetdirect.co.uk to view all the latest deals and offers. View our latest FMA specials on page 32 of the magazine and via the FMA website.

FMA PARTNERS WITH

ormer Wolverhampton Wanderers club doctor, Bill Tweddell, recently died at the age of 84. Dr Tweddell, who operated as the club’s official doctor between 1982 -1994 combined his role with work at his local GP service in Kingswinford. Former Wolverhampton Wanderers board member, Roger Hipkiss, who worked with Dr Tweddell from 1982 to 1986, added: “Wherever you wanted him he’d be there, morning noon or night.

5. Complimentary PAYGO vehicle maintenance card via KeyFleet Service inc mobile servicing and mobile tyres (save on garage and dealer pricing) 6. Full breakdown cover on all vehicles 7. £10 voucher for KeyFleet Accessories shop for each order – www.keyfleet.uniquecorporate.co.uk

“He was fantastic person and a good friend to the players.” Jes Moxey, Wolverhampton Wanderers chief executive added “Dr Tweddell gave over a decade of loyal and dedicated service to the club. The condolences of everyone at Wolves go to Bill’s family and friends.

he FMA have partnered with the Undergraduate Sports & Exercise Medicine Society (USEMS) in order to explore a mutually beneficial arrangement. The group has recently published an ‘online’ magazine and are keen to exchange articles of interest with the FMA in order to raise their profile and increase awareness of the FMA to their members. As always the FMA are keen to support undergraduates who express a firm interest in football medicine as a career since they are invariably the practitioners of the future! We wish them every success in this venture and will continue to support the network in any way we can.

DAVE FEVRE SCOOPS TOP AWARD AT NORTH WEST FOOTBALL AWARDS 2015

onday 16th November 2015 saw the FMA represented at the North West Football Awards in Manchester. The Awards ceremony, now in it’s ninth year, was attended by 500 guests and hosted at the Point, Emirates Old Trafford by BBC TV and Radio presenter, Dan Walker. Once again FMA CEO Eamonn Salmon, was on the judging panel and was delighted to present the award to the winner with Fabrice Muamba in the category “Outstanding

Contribution to Football Medicine and Science 2015”

Nominees were; ~ Professor Barry Drust- Liverpool FC/ Liverpool John Moores University ~ Dave Fevre -Blackburn Rovers FC ~ Tony Strudwick -Manchester United FC

Eamonn Salmon said “Dave has worked for over

30 years in Professional Football and in doing so has dedicated almost his entire career to the game. Clinically, he is considered to be one of the top Physiotherapists in the country lecturing both nationally and internationally as well as sitting on the FMA Board where his experience and opinion are much valued. There is no question Dave is held in high regard by colleagues, players and managers throughout the game and is a worthy winner of this prestigious award”.

CRYOACTION JOIN AS FMA BUSINESS PARTNER

W MEMORIAL DINNER PROFESSOR STEWART HILLIS OBE 1943 – 2014

ampden Park was the venue for a memorial dinner held in memory of Professor Stewart Hillis. Tributes were paid to the former Rangers and Scotland Doctor and the event, attended by managers Alex Ferguson, Craig Brown and Walter Smith, raised significant sums for his nominated cause supporting adult congenital heart disease.. As consultant cardiologist at Glasgow University

from 1977, he developed the first BSc degree in sports medicine and MSc in sports and exercise medicine. It was not obvious then, but such specialist studies would eventually change the face of sport. Professor Hillis worked with the SFA 40 years and is best known for his role as national team Doctor officiating at no less that 228 games and making him probably the longest serving medic in International football.

e are delighted to welcome CryoAction as one of our business partners. Cryoaction is a provider of whole body cryotherapy equipment to the soccer elite. Cryoaction director Ian Saunders added “Chambers are in use by a number of leading clubs, enabling medical staff to keep players on the pitch and better equipped to manage the intensity of the modern game. CryoAction cryotherapy helps to accelerate recovery, enhancing performance and wellbeing for elite athletes. We are delighted to be partnering the FMA and see this as an exciting opportunity to engage with the Medical and Science community”

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PHYSIOLAB WELCOMED AS FMA BUSINESS PARTNER

he FMA are pleased to welcome on board Physiolab as a Business Partner. Many members will remember Physiolab as an exhibitor supporting our 2015 Conference and we are delighted to have this innovative company on board as a firm fixture for the remainder of this and the 2016/17 season. Physiolab deliver a wide range of repeatable, precision time controlled therapies which can include any combination of cryotherapy, thermotherapy, contrast therapy and clinical compression.

FMA TO SUPPORT MEN UTD’S FOOTBALL TO AMSTERDAM 2016

~ ~ ~ ~ ~

As well as the FMA, the ride is supported by The Football League and the LMA, plus well known names from the world of football. Last year VIP participants included Terry Butcher, Simon Grayson, Lawrie Sanchez, Paul Peschisolido, Barry Hunter, Matt Holland and Luther Blissett. Terry Butcher told reporters at the time it was harder than marking Maradona. But he found the camaraderie amazing and has reassured us that his quads have finally recovered enough for him to look forward to doing it all again in 2016.

ootball to Amsterdam is a bike ride organised by Prostate Cancer UK – to help beat a disease killing over 10,000 men every year. Last year was a sell out and already there are 200 riders on board. The aim this is year is for 500 riders and you could be one of them as part of the FMA Team.

All the details are at: www.prostatecanceruk.org/amsterdam

The Aims are: ~

It’s a two day challenge (3-5 June 2016), 145 miles, with London and Yorkshire starting points It’s a great networking opportunity for football clubs, staff and partners We will celebrate with the biggest party in football too with a great night out in Dam Square All food, transport and accommodation is covered as part of the trip We ask everyone to raise a minimum of £1,000 to help beat prostate cancer

If you are an FMA Member and want to take part in this fantastic ride then we want you in the FMA TEAM. Please contact Lindsay via email lindsay@footballmedic.co.uk or call 0333 4567897

To raise over £500,000 to invest in research to find a better way to diagnose, treat and prevent prostate cancer – in short, we want to beat it.

ADVERTISE IN THE

FOOTBALL MEDIC AND SCIENTIST... For more information And reach a targeted visit www.footballmedic.co.uk audience of medical and sports science Call 03334 567897 professionals Or email info@footballmedic.co.uk

PRE-SIGNING MEDICALS AT PERFORM ST. GEORGE’S PARK ADVERTORIAL/PERFORM It’s that time of year again; the madness of the January transfer window is upon us and medical teams across the country will be stretched far and wide assessing the condition of potential new signings.

nlike in the summer window, teams have to make quick decisions about potential signings and medical assessments need to be accurate and fast. When a player signs for a club, a medical is an integral part of the process, and with potentially large investments to be made by clubs, medical departments have a responsibility to provide as much information as possible on a player that may provide a risk analysis of that investment. Fortunately Perform and Spire Healthcare are available to support any pre-signing medical needs. The 39 Spire hospitals located across the UK are able to support clubs with cardiac screening, MRI scans and pathology assessments with just one phone call to the Perform St George’s Park team. If however you require a more detailed analysis of a players condition, Perform are able to offer some more extensive reports packages. All assessments can be carried out at short notice and have been designed to ensure they can be turned around in 24-48 hours to meet the requirements of transfer deadlines. All medicals are led by our Clinical Director Dr Charlotte Cowie, who works independently from any football club. A short overview of findings will be provided immediately after the medical and a comprehensive report submitted to the club within 48 hours. The medical will ensure confidentiality of the club and the player at all

times and can be carried out at St. George’s Park and all scans at any of the 39 Spire Hospitals across the UK. Located in the National Football Centre in St George’s Park, Burton on Trent, Perform’s stateof the-art facilities including BASES accredited Human Performance Lab, rehabilitation gym, strength & conditioning gym and hydrotherapy recovery suite, offer the perfect environment to get the most accurate picture of a player’s condition to allow your medical & management teams to make the best informed decision about investing in the player or not. Located in the heart of England we are ideally situated to work with any club across the country at short notice. As Perform Director, Phil Horton puts it: ‘At Perform we have all of the necessary

technologies and equipment under one roof to put players through the medicals they need to sign for their new clubs. As the deadlines draw closer sometimes timing can become limited so it is essential to have out expert staff on hand to make the process run smoothly.” From one initial phone call to Perform at St George’s Park the Perform team will manage the whole day from start to finish. This is to include the transfers to and from all hospitals, all investigations, lunch for players, club staff and agents and reporting. For more information please call us on 01283 576333 or email stgeorgespark@spireperform.com

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IT’S ALL ABOUT PEOPLE FEATURE/LES PARRY Shiny dumbbells engraved with the club’s name are eye-catching but are they any better than rusty old dumbbells pitted with grooves through 30 years of being knocked together?

ackrests with the club crest embroidered by Tibetan goat herders look the part and the chrome frames of row upon row of top-of-the-range spinner bikes catch the morning sunlight beautifully and bring a lump to your throat but, so what? Do these embellishments make the programme any better, any more effective? Lines of the world’s leading players queuing with sleeves rolled up to have blood taken, to spit on spatulas, to have sticky electrodes carefully placed at strategic anatomical positions, to try to aim a jet of urine into a tiny bottle with a hand shaking because they have only just got out of their Versace-dressed beds. Sitting, reaching, jumping, stretching, touching screens to answer the same questions that they have answered for the past 2 years, all in the name of Football Science improving performance. Marginal gains, the edge, the extra 1%, it’s what all professional football clubs throughout the world are after but do these space-age interventions give it to us? Can we be effective if we don’t have them? To gain this edge, ever more innovative methods of analysing performance, improving

levels of fitness, evaluating levels of readiness and physically and mentally preparing players are being introduced, but are they any better than what they replaced, people skill? The probable answer is that staff at every top club believe that they do provide an edge or they wouldn’t use them. However, the fact that no two clubs in the world delivery an identical monitoring, testing and preparatory battery suggests that there is no optimal concoction or blend of the hundreds of tests, investigations or monitoring tools on the market. There is no gold-standard, no magic-bullet. So, if you work in an environment which lacks these superfluities can you do your job as effectively, will the players still get stronger, quicker, more powerful? A 3 Tesla MRI system produces pictures which wouldn’t look out of place in a National Geographic article on the Himalayas, they are that clear. For most people, they may as well be pictures of Everest because they can’t read them, they mean nothing. Others can dabble and pick out the muscles, the odd tendon and ligament and even ‘woo and sigh’ as they point to bits that may indicate a bit

of unwanted fluid. To really appreciate the beauty of the scan and extract the maximum pertinent information an expert is required, a person. Football Science is no different to this. Terabytes of quality data can be produced but will be useless unless there are personnel to objectively and subjectively evaluate the data, put everything into perspective and extract the appropriate information. Without the right people, gathering the data in the first place is a waste of time. The ‘edge’ some clubs gain generally comes from the personnel who are examining this data, it’s all about people. There is no doubt that well-researched, reliable, valid and robust procedures provide quality information which assists in making informed decisions which, in turn, contribute to improvements in performance. Unfortunately, the amount of data that is currently being generated that is superfluous to what is needed is considerable. The cause of this data being useless is because its reliability is questionable, its validity is ambiguous or the variables of the data being collected simply don’t contribute to improving performance. However, quality, pertinent information is

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Pictured: Former Charlton manager Chris Powell shares a joke with Les and his assistant Kevin Summerfield on the touchline before their match at The Valley in 2011.

the bedrock of most things that happen in every aspect of football it is the growing dependence on technology that is in question. Is intuition a thing of the past? Is a manager who can look at his squad and tells the coach that the players need a fun day because they look a bit jaded condemned to history? In other words, are practitioners who don’t have all of the cutting edge technology able to provide quality information? With the exception of GPS, other well researched protocols and practices such as Total Wellbeing, recovery strategies and athletic development programmes are inexpensive and can be implemented without a massive drain on resources. A piece of paper can replace an iPad or wall-mounted touch screen for collecting wellbeing data, a tape measure and a chalk-mark CMJ can replace a digital goniometer and a force plate. Consistent and systematically delivered basic tests can provide coaching staff with good quality information. I might suggest, better information than its sloppily gathered high tech equivalent. People can work without technology but the same can’t be said for vice-versa, people are the vital cog in the workings of football science. We all work in an ever developing environment. If we all look back 3 years at what we were doing, some of us may have thought that we were close to providing an optimal service, the gold-standard. Subsequent developments suggest we weren’t anywhere near, we were technology limited, we weren’t people limited. The advert for ‘New formula brighter than white Daz’ doesn’t mention that the previous formula may have given us whites that may

not have been brighter than white! It’s all about the moment. Five Hz GPS was a great advance on HR data for assessing training load and we all produced multi-coloured graphs to show coaches. How many of us explained the massive limitations of GPS to the coaches? No, we left that bit out until we wanted to buy the ‘whiter than white’ 20Hz model! Technology is a great

Pictured: Les, in a physiotherapist role at Tranmere in 1998.

tool, but it’s a tool and shouldn’t be overrelied on. The gifts of intuition, perception, sensitivity, empathy, are characteristics which technology can’t bring to the table. Can a touch screen Total Well Being questionnaire look somebody in the eye and see that there is something not quite right? Can GPS perceive that a player’s touch is not quite what it normally is and that his body language is different? The answer to these questions is no but an aware, sensitive, switched on coach, medic or football scientist can. It’s all about people, having the right people. By employing the right people and then fusing them with robust cutting edge technology, we may well go on to find that elusive magic bullet! Les Parry is unique in professional football. Having spent 20 years as physio at Tranmere Rovers he went on to take over as manager from John Barnes and managed the club for over two and a half years. A PhD investigating the Football-Science topic of ‘The effects of detraining in professional footballers’ completed experience in all three of the major disciplines within professional football and influenced Brian McClair to invite him to join the academy at Manchester United. Les is now part of one of the most knowledgeable and respected Football Science Departments in the world and has recently been tasked with leading a major drive to advance the provision of Football Science and Athletic Development within the 9-16 age groups.

THE CAUSES OF RUNNING INJURIES A PHYSICIAN’S PERSPECTIVE FEATURE/DR JONATHAN REES - BSC MSC MB BS FRCP (UK) FFSEM (UK) MD CONSULTANT IN RHEUMATOLOGY, SPORTS AND EXERCISE MEDICINE An injury occurs when the tissues of the body are loaded beyond their resilience. There is a spectrum of injury causation from trauma – a large force – to ‘overuse’ injuries caused by much smaller but repetitive forces. Most running injuries fall into this latter category.

very running step results in a force being absorbed by the body. In health, with the correct technique, good conditioning and adequate rest between bouts of exercise, the body can cope with these repeated forces. Indeed, over a period of time, the body can improve its resilience and allow an increase in training. However if any part of a body is continually overloaded, injury will occur as inevitably as night follows day. Traditional medical doctrine for running injuries was rest, possibly with nonsteroidal anti-inflammatory medications,

and a cortisone injection. If these did not work then surgery would be considered. But for running injuries caused by repetitive overload and not major trauma, this approach is almost universally inappropriate, for it fails to address injury causation. Unfortunately even today this ‘traditional’ medical doctrine is believed by too many medical practitioners. The point is that running injuries have a cause and the cause is predominately tissue overload. The body may be thought of as a chain, and injury is most likely to occur at the weakest point of the chain. This encompasses all

the common running injuries including bone injures (stress syndromes and stress fractures), muscle injury, tendinopathies (eg Achilles and patellar), bursitis and even entrapment neuropathies. So if excessive force is at the root of running injuries what can we do to modify these forces and either treat, or ideally prevent, injuries? This requires an assessment of individuals’ ‘intrinsic’ and ‘extrinsic’ factors. Intrinsic factors are unique to that person; they include age, sex, previous injuries, physical conditioning and crucially

their individual biomechanics (anatomy or shape). It is the biomechanics that allow efficient (or inefficient) distribution of forces through the body. If forces are evenly distributed through the body and not concentrated in any particular area then the body will withstand these forces much better. Extrinsic factors are essentially what we do to our body; they include the amount and intensity of training, the surfaces on which we run and technique. It is the combination of an individuals intrinsic and extrinsic factors plus the amount of loading (running) that determines whether injury will or will not happen. Unfortunately traditional medical thinking remains so ingrained that many running injuries are simply not assessed in terms of the causes and a thorough analysis of the intrinsic and extrinsic risk factors. An example of this is chronic exertional compartment syndrome which, remarkably, is still considered by many sports medicine practitioners as a condition requiring surgical treatment rather than rehabilitation despite surgical results often being disappointing. The principles of force, force dissipation intrinsic and extrinsic factors are ignored. In chronic exertional compartment syndrome there is increasing pain in the lower leg, which increases progressively during running inevitably causing the athlete to stop running. Historically this was thought of as being caused by gradually increasing pressure within at least one of the four compartments within the lower leg. The theory of increasing compartment pressures has recently been challenged

(there is debate on what is actually causing the pain). However by applying the principles of rehabilitation, and of optimising collision forces within the lower leg, this condition can often be successfully treated without surgery. This will require an individualised approach for each patient. A programme will usually include running reeducation to avoid excessive heel strike, a more forefoot or midfoot landing, improved flexibility and strengthening of the muscles of the lower leg (including avoidance of over striding and a general conditioning programme). This brings us on to an area of great interest – ‘Barefoot Running’. Although this has been promoted as a ‘new’ style of running, it is certainly not new and indeed should really be regarded as ‘traditional’ running. The ‘new’ style of running is essentially the style that has been imposed by the modern running shoe. Most modern running shoes have a large well-cushioned heel, which promotes a heel strike (rear foot) pattern of landing rather than mid or forefoot landing. A ‘barefoot’ technique, which does not have to be performed barefoot, promotes a shorter stride length, greater cadence and results in lowered collision forces with the ground. These features of barefoot running are identical to many of the features that are so helpful in managing chronic exertional compartment syndrome. A word of warning however, barefoot running is a skill that has to be learned, transition must be gradual and it is not suitable for everyone, particularly those with a tendency to Achilles tendinopathy. In summary, running injuries have a cause, and this cause is invariably

repetitive force overload. A careful assessment of the factors causing force overload, namely the intrinsic and extrinsic factors, will inform the practitioner on the steps required to overcome or at least minimise the impact of the injury. This applies to all running injuries including chronic exertional compartment syndrome, which can often be treated successfully with rehabilitation. An understanding of the principles of barefoot running may aid the practitioner in the promotion of an efficient reduced impact running style. Copyright Dr Jonathan Rees 2015

Dr Jonathan Rees is a part of the Physician Team at The Fortius Clinic. The Physician Team at Fortius provides top class expertise in the fields of Rheumatology, Sport and Exercise Medicine, Metabolic Bone M-edicine and Pain Management. To find out more about The Fortius Clinic or to enquire about any of our services please visit www.fortiusclinic.com

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Pictured: Manchester United’s Owen Hargreaves (right) is substituted after suffering an injury only six minutes after starting his first game for Manchester United in two years.

RETURN TO PLAY A DECISION-BASED APPROACH FEATURE/JOHNNY WILSON - HEAD OF SPORTS MEDICINE, NOTTS COUNTY BEKI KNIGHT - FIRST TEAM PHYSIOTHERAPIST, NOTTS COUNTY Return to play decisions following injury lack standardisation, and are often a cause of heated debate between clinicians, players, managers and stakeholders.

he purpose of this article is to critically appraise our practice as frontline clinicians with regards to return to play (RTP) strategies in professional football. We will discuss the merits of a criterion based RTP model alongside a decision-based model that incorporates; evaluation of the injury, player characteristics and other decision modifiers such as; importance of player to team, timing in season, external pressure from coaching staff etc.

This article will also discuss injury recurrence rates in relation to RTP. For example, should we be striving for 0% recurrence rate in professional football and how realistic is this? Would it be more beneficial to have a higher recurrence rate, which over the course of a season might actually lead to an overall increase in player availability?

Criterion-based RTP Models

A criterion-based model assesses an array of biomedical variables such as; range of movement, strength, flexibility, neuromuscular control, power, agility, endurance and sport specific tasks. These criteria are then used to guide rehabilitation and justify a player’s readiness to RTP (Herrington et al. 2013). This model allows clinicians to progress/ regress rehabilitation if targets are being met or not. It removes the use of timebased goals, which often do not reflect the functional status of the player at that time. For example, following ACL reconstruction, players are generally not permitted to run until 12 weeks post operation to allow for appropriate graft maturation. However, players may not actually be suitable to run at this time point as they may not have met functional targets that would enable them to safely commence running. A criterion-

based model may give a more accurate assessment of the player’s readiness to run at 12 weeks rather than basing this decision solely on time. This “tick box” model is not without its limitations however, as it fails to account for player characteristics and decision modifiers related to professional football that may affect RTP decisionmaking. Decision-based RTP Models In addition to a criterion-based model, a decision-based approach incorporates nonbiomedical variables under the umbrella of a bio-psychosocial approach when deciding if a player is appropriate to RTP or not. This model takes into account variables such as the beliefs, culture, past experience, risk taking behaviour and other personality traits of the player. As well as this, it also accounts for other decision modifiers such as; timing in the season, the importance

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Pictured: Former West Ham United manager Avram Grant (left) consoles Kieron Dyer as he leaves the field following an injury early in the game against Blackpool in November 2010.

of the player to the squad, the manager’s views, external pressures from stakeholders etc. (Creighton et al, 2010). For example, it may be more beneficial to the club for a pivotal player to RTP sooner than another player of less importance to the team with a similar injury. How does a Decision-based Model affect RTP? Incorporating the decision-based model allows for transparency between the player, coaches, stakeholders and medical staff so that all relevant parties are involved in all aspects of the RTP decision-making process e.g. risk of injury recurrence associated with RTP, timing of RTP etc. This decisionmaking model means that the clinician does not have to take ultimate responsibility for deciding when a player is ready to RTP. It moves away from a blame culture and places responsibility with everyone involved. On the whole the player still has autonomy to decide when they feel ready to RTP (except in the case of suspected concussion and spinal injuries), however, the manager, stakeholders and clinicians can still delay the player’s decision to RTP if they are not willing to take the risk associated with injury recurrence following RTP at that time point. Does the RTP model affect injury recurrence rate? Due to the nature of football there is no guarantee that a player will not incur another injury regardless of which RTP model is chosen. To date, there is a distinct lack of research comparing RTP models in relation to recurrence rates. All RTP models

certainly have the ability to positively and negatively effect recurrence rates. No RTP model or protocol will provide absolute assurance that an injury will not recur, and returning any player back to play always comes with some level of risk. What level of injury recurrence is acceptable?

Depending on which research you read, injury recurrences range from 6% to 30% (Erkstrand et al., 2011) following RTP. The level of injury recurrence that a football club is willing to accept will be determined by a number of biomedical factors such as injury type, strength, ROM etc., and non-medical variables such as the importance of the player to the squad, stage of the season, position in the league etc. Consequently, the level of risk considered to be acceptable is a dynamic phenomenon, which has the ability to change to reflect the circumstances of the club at any given time point. It is a key role of the sports medicine team to minimise injury recurrence, however, striving to achieve a 0% recurrence rate might mean players spend more time in rehabilitation than on the training ground. In professional football we are always taking calculated risks, but having the ability to identify and evaluate risk for RTP will help us to provide the best possible advice to the player and club. For example if you have 10 hamstring injuries in a season and you return all of them one week ahead of schedule, that improves your player availability by 10 weeks or 10 matches. If one of those injuries recurs then it might cost an extra 3 weeks or 3 games, in any case you are still 7 games better off. Therefore as a

profession should we be willing to step out of the comfort zone, challenge our current practice, take more risk and work on the cusp of the danger zone? Accepting a higher risk of injury recurrence may be a small price to play for returning injuries as quickly as possible and ultimately maximising a player’s playing time and the team’s opportunity for success. Conclusion: Injury recurrence is common and due to its multifactorial nature little is known as to why some injuries recur and others do not. There is a paucity of original research on how to return athletes to play quickly and safely and to our knowledge there is no conclusive research that suggests that the type of RTP model used affects recurrence rates. Creighton et al. (2010) offers us an insight into the multifactorial model of RTP decision-making, in which, undoubtedly the non-biomedical factors play an instrumental role in this process. This clinical commentary is not suggesting that a decision-based model will reduce injury recurrence rates but it may provide for a more comprehensive risk analysis for RTP. In essence RTP decision-making is a risk versus reward procedure in which all parties should be fully involved regardless of the model being used. Whilst it is a key priority of the sports medicine team to implement strategies to minimise injury recurrence, maybe we should consider accepting higher recurrence rates by returning players back to play as quickly as possible in order to provide managers with greater player availability.

ACL INJURIES IN WOMENS FOOTBALL WOMEN IN FOOTBALL/ DR. PIPPA BENNETT CONSULTANT SPORT & EXERCISE PHYSICIAN

Football is becoming the leading sport for women worldwide with 26 million females registered with the Federation Internationale de Football Association (FIFA).

here have now been a number of prospective studies reporting injury incidence in women’s football across different levels of play. There have also been several studies conducted by FIFA and UEFA at international championships. (l) The majority of time loss injuries in both men’s and women’s elite football affect the lower limb (77-93%). Knee injuries constitute 19-25%, ankle 13-26%. Groin injuries are 5 times more common in men’s football than women’s and it has been reported that ACL injury is between 2-6 times more common in the female footballer. Anterior Cruciate Ligament (ACL) injuries are season ending injuries. With good surgical technique and intensive rehabilitation, players are returning to competitive play six to nine months after reconstructive surgery. In my experience return to performance may take 1 year. It is important to counsel athletes on this, in my opinion there are no short cuts to safe return to play. Unfortunately the long-term effects of osteoarthritis seem inevitable regardless of whether the athlete has reconstructive surgery or not (2). We also know from several studies that ACL injuries occur more frequently in female than male athletes. Arendt and Dick (3) showed that collegiate female soccer players had ACL injury rates 2 times that of their male counterparts. Other studies have put the rate at 2 to 5 times

the rate in men’s soccer (4). Female basketball may be even greater with differences between 2 and 8 times. One study of female professional basketball players reported the difference to be 10 times greater in females compared to their male counterparts (5). An estimated 80,000 ACL tears occur annually in the United States (6) Certainly in my tenure as Chief Medical Officer to the England Womens Football teams we dealt with too many ACL tears. I am pleased to say however that all the international players returned to play at the highest level and a number of them will be in the World Cup squad bound for Canada this summer. The Anterior Cruciate Ligament (ACL) is a three dimensional fan shaped structure. It is attached to the anterior intercondylar area of the tibia just posterior to the attachment of the medial meniscus. It then passes upwards, backwards and laterally attaching to the posterior part of the medial surface of the lateral femoral condyle. Its fibres are non-parallel with interlacing fascicles. It has an antero-medial bundle, which is tightest in flexion resisting anterior tibial translation, and a larger posterior-lateral bundle tightest in extension resisting hyperextension. In cadaveric studies (7) we know that the ACL is taut when the knee is fully extended and that the ACL acts as the primary restraint to anterior tibial translation. The hamstring group of muscles act as synergists to this ligament when the ACL is

excessively loaded. The hamstrings activation must be in synchrony with the quadriceps. The hamstrings must contract before the quadriceps to negate the anterior tibial drawer of the quadriceps. It is this dynamic stability and how it can be optimised which may hold the key to protecting the ACL from rupture. It is important to note that the hamstrings are thought to protect the ACL from injury at larger knee flexion angles. Pandy and Shelboume (8) estimated, via a cadaveric model, the changing ACL forces at different knee angles with different degrees of quadriceps and hamstring tensions. They found that at near full knee extension the hamstrings could not provide sufficient posterior shear force to resist anterior tibial translations relative to the femur and thereby protect the ACL. Anatomically this is because the hamstring muscles insert into the tibia at a reduced angle when the knee is near full extension. Latterly more focus has been around the increased knee abduction moment and assessment of this is incorporated in most screening protocols (11) Another aspect of much recent research has been looking at the static anatomical differences of knees of men and women, in particular intercondylar notch width. In general, women have smaller ACL’s and smaller notch widths, even when the woman and man are of equal size (9).This may play a part in increasing female athletes’ risk of ACL rupture. Authors differ in their interpretation of static measurements and in particular whether the narrower notch width simply reflects a smaller and more vulnerable ligament or whether a normal sized ligament is mismatched with a stenotic notch -so making it susceptible to tear. The hormonal influence on ACL function and rate of injury is complex and there is still no consensus in this area. Female sex hormones directly affect the ACL in its composition and biomechanical properties but they also affect neuromuscular control. This dual role may be responsible for the conflicting evidence of the relationship between the menstrual cycle and ACL injuries (10). In essence though it is the dynamic stability of the knee that is the important factor if we are to attempt to reduce the incidence of ACL tears. There have been a number of ACL prevention strategies put forward including the PEP programme and FIFA 11+. These have shown excellent results and injury prevention warm ups together with effective strength and conditioning should be part of any footballers weekly training schedule. References 1. Junge A, Dvorak J, Graf-Baumann T. (2004) Football Injuries during FIFA Tournaments and the Olympic Games, 1998-2001. Am J Sports Med , 32,pp 80-89. 2. Lohmander LS, Ostenberg A, Englund M, Roos H. (2004). High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players twelve years after anterior cruciate ligament injury. Arthritis Rheum, 10, pp 3145 -3152. 3. Aredt E, Dick R. (1995). Knee injury patterns among men and women in collegiate basketball and soccer. NCAA data and review of literature. Am J Sports Med, 2, pp 694-701. 4. Bjordal JM, Arnly F, Hannestad B, Strand T. (1997). Epidemiology of anterior cruciate ligament injuries in soccer. Am J Sports Med, 25, pp 341-345. 5. Zelisko JA, Noble HB, Porter M. (1982). A comparison of men’s and women’s professional basketball injuries. Am J Sports Med, 10, pp 297-299. 6. Hutchinson MR, Ireland ML. (1995). Knee injuries in female athletes. Sports Med, 19, pp288-302. 7. Li G, Rudy TW, Sakane M, Kanamori A, Ma CB, Woo SL. (1999). The importance of quadriceps and hamstring muscle loading kinematics and in-situ forces in the ACL. J Biomech, 4, pp 395 - 400. 8. Pandy MG, Shelbourne KB. (1997). Dependence of cruciateligament loading on muscle forces and external load. J Biomech, 30, pp 1015-1024.9. Shelbourne KD, Davis TJ, Klootwyk TE. (1998). The relationship between intercondylar notch width of the femur and the incidence of anterior cruciate ligament tears: a prospective study. Am J Sports Med, 26, pp 402-408. 10. Wojtys EM, Huston LJ, Boynton MD, Spindler KP, Lindenfeld TN. (2002). The effect of the menstrual cycle on anterior cruciate ligament injuries in women as determined by hormone levels. Am J Sports Med, 30, pp 182-188.11. Myer G, Ford K, Khoury J, Succup P, Hewitt T. (2011). Biomechanics laboratorybased prediction algorithm to identify female athletes with high knee loads that increase risk of ACL injury. Br J Sports Med 2011;45:245-252

FOOTBALL MEDIC & SCIENTIST | 17

F M A C O N F E R E N C E 2016

Tackling the Hip and Groin

a football and functional dilemma In association with Royal College of Surgeons Edinburgh 21-22 May 2016 Radisson Blu East Midlands Airport Plus day 2 keynote speakers on the Mental Health of Players

he FMA Conference, now in it’s third year, is set to be the best yet. The midday start gives everyone time to arrive at the venue and acquaint themselves with colleagues and organisers ahead of the afternoon programme. Each of the two Saturday sessions begin with keynote speakers followed by 15 minute presentations and question and answer forum. Once everyone has enjoyed the FA Cup Final in

the hotel bar, the Awards Dinner will again be the highlight of the weekend with recognition given to those of you who have been nominated by your colleagues. The two Sunday sessions follow a similar format with two keynote speakers on mental health/psychology. The Trade Exhibition is already sold out with some familiar faces and brand new

companies keeping you fully aware of the latest products and services available. We expect that this will be a full capacity event therefore we ask that you book early and indeed for those of you who are quick of the mark you can take advantage of our early bird rate until the end of February. Just visit the website www.footballmedic.co.uk to book online.

This is a sample of what previous year’s delegates had to say: “Thank you for arranging a fantastic weekend. All your hard work and effort I am sure was appreciated by so many people. It was great to meet old friends and talk about new techniques and methods. The course content was excellent, albeit that I missed a few to further my conversational skills! The evening I felt went really well and Les was superb. A big thank you too for the awards you gave out. It was really good to see that all the hard work a lot of people put in is being appreciated as you very rarely get a well done at a football club. I hope that was just the first of many.” Dave Galley

“I just wanted to forward my thanks for all your work behind an exceptional first conference at the weekend. The setting around and including the FA Cup Final and the ‘tone’ of the event and speakers was brilliant; relaxed but educational. The ‘boxing rounds’ on Sunday morning was again appropriate, informative and even entertaining. Please pass on thanks to Dave Fevre and those involved in planning the programme. It was relevant to whatever level of the football leagues we work in, and to whatever role we have in our clubs. We need the FMA to continue to lead this from our football ‘workplace’ perspective, and invite specialists to support us – not the other way round – as has been so in the past.” Joyce Watson

“Thank you so much for a fantastic evening and weekend. It was great to catch up with old friends. The format and organisation was absolutely top class.” Alan Sutton “Just a quick note to congratulate you on delivering an exceptional weekend at the Radisson Blu Hotel. It was great to see it well attended which demonstrated that there is a place for this conference every year.” Les Parry

Here are just some of the speakers already confirmed for this year’s event: Professor Per Hölmich MDDMSc Head of Research Consultant Sports Orthopedic Research Center – Copenhagen “Taxonomy diagnosis and treatment of groin injuries in football”

Alan Rankin Physiotherapist, Hamilton Academicals FC “Hip dysplasia, pathology, physical assessment and treatment options”

Chris Barnes Consultant Sports Scientist “An Interdisciplinary Approach”

Professor Graham Smith Society of Sports Therapists “Golden Nuggets from the Groin”

Andy Boles Sports Scientist, Motherwell FC “Hip dysplasia, rehabilitation and functional return to sport”

James Allen National Team Physiotherapist, IRFU “Rehabilitation strategies in tackling the hip & groin in field sports: from theory to practice”

Plus speakers from the fields of radiology, podiatry, mental health and exercise science. FOOTBALL MEDIC & SCIENTIST | 19

MAKING THE MOST OF COMMERCIAL PARTNERSHIPS FEATURE/COMMERCIAL PARTNERSHIPS : WINNERS ALL ROUND Commercial partnerships and sponsorships are, on the one hand, a vital source of revenue for any business and on the other, can provide a compelling platform for businesses looking to enhance their sales and marketing reach and communications strategy.

s an association it is vital for the FMA to have partners and suppliers onboard, to bring invaluable revenue to help support our administration. This revenue along with member subscriptions, allows us to employ staff and to function as an independent, membership organisation. Commercial activity is particularly evident in top class sport and professional football is no different. While player sponsorship sits well with consumer products, football medicine and science can offer companies with relevant products and seeking business to business

opportunities, some immediate rewards; not least high profile visibility and access to a niche market with buying power. Companies are therefore understandably very keen to get their products into Professional Football. However, it has led to an all too familiar scenario that many Heads of Department will immediately recognise. It’s the end of a long day at the training ground, most staff and players have long gone and in wrapping up the days work, several emails are yet to be answered. There’s also a raft of phone numbers from various companies on your desk, asking you to call them back

about an exciting new product that will do a 101 things its competitor cannot, or will have players back on the field in half the current time, or will provide energy where other well known products cannot reach, or will revolutionise player fitness and so on and on. So, you prioritise the emails, respond to some, delete others and the phone calls, well you will sort another day. If this is all too familiar then rest assured that you are not alone in handling the situation in this manner. So what about the “calls” you will sort later but are never made? Life is very busy in a professional football club and work

can be arduous at the best of times. In prioritising the demands of the job, returning a call or email to a company you have never heard of is understandably low on that list. This goes some way to explain why the FMA has ended up with a role that was definitely never envisaged at the outset. In short, we have become the “go to” for our Members who, savvy as they are, have realised that they do not have the time to spend setting up speculative meetings or reviewing unknown products. Instead many have passed the task to the FMA by directing companies to us and we are very happy to support our members in such a role From a company perspective instead of trying for several months to get a meeting with one Club, companies can now get their product in front of everyone through the FMA and in a variety of different way including the FMA magazine & website. The magazine is mailed to the FMA membership and every Head of Department in professional football receives a copy. It is also featured online. Opportunities are available for companies to come onboard as partners giving them much needed visibility and the chance to build credibility and long term relationships. A further development has seen the introduction of the FMA Product Appraisal System. Put simply, companies who wish to work more closely with the FMA as Business Partners or Club Members are given the opportunity to have a specific product evaluated by a pre-determined panel of FMA members. Panel members are selected from 2 Premier, 2 Championship, one Division I and one Division II Clubs. The Panel can vary throughout the season. The FMA team does due diligence regarding the company and the product prior to any testing being undertaken and, by working with Members, makes best use of their

skills and expertise, which are of course unique to the FMA. The Product Appraisal System enables companies to have their product evaluated in a practical, appropriate and “realistic” environment. The subsequent “market appraisal” report submitted by our members to the FMA is valuable feedback

for companies allowing them to assess their own product in a “real world” setting. Where a product is given resounding approval by the Panel, companies, at the discretion of the FMA, may be invited to take the process to the next stage with regard to use of the FMA logo to support that product. The value of this is that all practitioners within the game – and beyond – will see the FMA logo as a sign that this particular product has been independently evaluated by colleagues and that the product is considered to be of significant value to football medicine or science in the treatment, rehab and fitness of players. For a company such a seal of approval is invaluable. The FMA Product Appraisal system is already underway and we are now spearheading the football medicine and science market, helping to determine the value of products to the football industry and ensuring, with the guidance of our members, that the introduction of products to this arena helps to continue to raise standards of care across the game. This isn’t something we set out to do as an organisation but we are sure that it will form a welcome resource for companies and most importantly our members. Hopefully it will also free up some time for Heads of Department and relieve them of the need to respond to those numerous enquiries.

FOOTBALL MEDIC & SCIENTIST | 21

Pictured: Tottenham star Paul Gascoigne lies injured on the Wembley pitch, following an ill-timed and rash challenge on Nottingham Forest’s Gary Charles during 1991’s FA Cup Final.

MEDICINE & FOOTBALL

A PERSONAL PERSPECTIVE

PART 2

HALF A CENTURY IN FEATURE/PROFESSOR DAVID S MUCKLE DSC.MB.BS.MD.MS.FRCS.FRCS (ED).DPROF (HON)

Fifty years ago little scientific thought had been given to the physical demands of a football match, the biochemistry and pathology involved in an injury, the attainment of fitness and the player’s post-match care.

n 1971 I had just completed a three-year biochemistry thesis into muscle physiology and pathology. At Oxford, I felt that many aspects of sports injuries were folk-law, empirically treated and unscientific. A new opportunity beckoned in an association with Oxford United, the University and the FA who gave me a role within FIFA and UEFA. It was apparent, I reasoned, that the biochemistry of a soft tissue injury should respond to medication. The signs of tumor, dolor, rubor and calor (swelling, pain, redness and heat) were present in both infection and injury. A tablet, Phenylbutazone (Butazolidin), had been used in horses to aid recovery, but was found to have dangerous side effects including aplastic anaemia in humans and was eventually banned. One of the foremost biochemists of that era, Professor Stewart Adams, of the Boots Company had invented ibuprofen. Ibuprofen was similar in some ways to aspirin

and designed to take its place as an analgesic anti-inflammatory agent. I was approached by a Boots

Pictured: Typical stud marks and bruising in a professional footballer, which made quantification difficult.

representative. I had briefly thought about Indomethacin (Indocid) in 1967, but had discounted this tablet because of potential side-effects. The relatively new compound ibuprofen, with its low incidence of sideeffects, seemed ideal. So, after speaking with the Boots Company, I embarked on a trial to see if soft-tissue and joint injuries could be affected biochemically. This biochemistry is complex and I will not burden you with all the details, other than to mention prostaglandins - first identified in prostatic tissue. Since it was shown by Vane in 1971 that aspirin had an effect on prostaglandin release from the fatty acids (phospholipids) of the damaged cells, I reasoned that ibuprofen might have a similar action. What were the problems that had thwarted many scientific studies? And would soft-tissue injuries and joint trauma respond to medication?

FOOTBALL MEDIC & SCIENTIST | 23

The following points needed to be addressed. 1. The soft tissue injury to muscles, ligaments and joints had to be of significant magnitude to warrant treatment but not too large to be non-responsive to therapy. 2. The patient had to be free of both short and long term medication that could interfere with the therapy. 3. There had to be total compliance and supervision. 4. The dose had to be of sufficient strength to be effective and preferably taken over a short period of time. 5. Injuries had to be seen and treated, it was thought at the time, within 6, or at the latest 12 hours. Patients with such relatively minor injuries generally waited for days to see a doctor and frequently not until the injury had become chronic. 6. The extent of injury and its recovery had to be quantified. This proved to be the greatest stumbling block, because bleeding can be within muscles (intramuscular) or on the surface (intermuscular). The latter rapidly disperses as a bruise which can appear some distance away, confusing the picture. There was no point in measuring the volume of the limb after injury or even any localised bruising or swelling. Such measurements would prove useless because of discrepancy in limb size; or simply because the swelling was deep within the muscles. The answer was to have a record of fitness which would give a functional and dynamic aspect of recovery rather than rely on clinical signs. I reasoned that the solution resided in professional footballers – they were young, free from medication, seen immediately after injury, observed daily and their parameters of fitness were documented from pre-season and by monthly assessments. After detailed discussion with the Boots Company and the players and coaching staff of Oxford United, a double-blind trial was planned beginning in the 1971-1972 season using aspirin 3g daily and ibuprofen 1200mg daily (up to that time the daily dose had been 600mg).

Pictured: The meniscal tear identified before resuturing, the sutures are just visible before approximation.

Immediately after a soft-tissue injury to the lower limb the player received the standard therapy of cold compress, elastic or crepe support, and limb rest and elevation. In no instances was a plaster of Paris applied. In addition the players received a pack containing five day’s supply of either aspirin or ibuprofen presented as a white capsule, unmarked, in a packet with each tablet in a single foil wrapper. The player noted the pain level and was supervised throughout each day of the trial by the club trainer Ken Fish and assessed by the club doctor at the same time each day. Thus the supervision and compliance were vigorously enacted to ensure accuracy of data. Clinical signs of recovery were recorded three times per day while the dates to full training and a return to match play were noted. All players requiring additional procedures such as joint aspiration, ultrasound, manipulations etc., were not included in the trial but these amounted to less than ten percent. Injuries were designated “trauma” and “sprains” in the lower limb only. Of course fractures and wounds were excluded. With this dosage ibuprofen showed a marked analgesic effect and the effect for both sprains and trauma was significant at the 5% level of probability; with ibuprofen reducing the duration as well as the severity of pain significantly. This reduction of pain was important. It allowed an earlier

Pictured: Leicester City’s Emile Heskey lies hurt on the Filbert Street pitch during their 1997 league game against Blackburn Rovers.

application of remedial therapy (e.g. quadriceps exercises) and helped to combat muscle atrophy (especially in the vastus medialis with a knee injury). Thus there was an earlier return to training and match play, the players training on average two days earlier after ibuprofen (3.8 days) compared to aspirin (6.63 days) (p less than 0.001). The two-day difference had important practical applications, since professional footballers must be match fit within five days of injury to be considered for selection the following Saturday. Only squad a 16 players were used in main matches that season. Looking at the ibuprofen trial as a whole, it firmly indicated that there was a rationale for the use of non-steroidal antiinflammatories after soft tissue trauma. Other investigations were soon to be carried out on a world-wide scale and the treatment is universal today. Indeed around 150 million tablets of ibuprofen are purchased daily. The reception of the paper was not as muted as expected and 1,000 reprints were requested in the first year rising incrementally to 20,000 per year. The USA alone accounted for over 70,000 reprints according to the data supplied by the publishers. The final figure is not known but estimated as exceeding 100,000. It is worth briefly digressing to point out that the modern concept of rotating players to prevent fatigue following a few successive games, that four European Cup finalist (Aston Villa, Leeds, Liverpool and Nottingham Forest, who each played almost 60 games per season, generally used squads of 17 and less). Meanwhile orthopaedic techniques were advancing rapidly. Arthroscopy began as a diagnostic tool in the 60s and then therapeutically; so few cases were being carried out, that even in mid-70s the insurance companies were confused. They were classifying this procedure as minor and unable to accept meniscectomy as day case surgery. In effect, if an arthrotomy was performed, the payment trebled as did the in-patient fees. My 13 year study (1967-1980) into the effects of knee total meniscectomy, a favoured treatment then, showed that rather than preventing osteoarthritis in the affected compartment, the condition was enhanced. This theory led to great deal of contention

Pictured: Liverpool’s Czech forward Milan Baros is grounded with a knee injury, following a rough challenge from Tony Popovic during a Premier League tie versus Crystal Place at Selhurst Park in 2005.

in orthopaedic meetings, both nationally and globally, and caused a marked division of opinion in some of the lectures. Even more divisive was the concept of meniscal resuturing which I found to be an alternative treatment in selected cases. My first study showed a success rate of 80 per cent. Patients were give the pros and cons and warned that a second arthroscopic operation might be required; however they were informed that resuturing, when applicable, gave the best long term results. I still meet people who have had no problems with a sutured meniscus 30 years later. Resurfacing the condyles or the patella also followed from this long term knee study. In 1982 I became aware of nuclear magnetic imaging. On Teesside we had opened the first total Radiology Scanning Centre. Following the success of CT and ultrasound scanning, the new NMR proved of great interest and evolved as MRI scanning. It proved to be an unbelievable tool, first in knee and then in all skeletal pathology. We could not be without it today. Meniscal tears could be treated arthroscopically in minutes since their precise location was known. Recovery was rapid and although one player Kevin Beattie scored in a cup game for Middlesbrough five days after arthroscopic partial meniscectomy, I never liked a too rapid return. Indeed, contrary to advice, Gary Bailey trained with the England squad within a couple of weeks, re-injuring his treated knee. This injury led to a large FA insurance payout. It was at this time that the FA Medical Committee noted that players’ insurance for each England match, was hugely disproportionate to their club insurance. This discrepancy was corrected. A study using MRI scanning at Darlington and Middlesbrough showed the potential

relationship between spinal problems and ‘pulled muscles’ (especially hamstring injuries with lower lumbar nerve entrapment; and ‘frozen shoulder’ and ‘tennis elbow’ with neck problems). Finally with regard to my research into nutrition; a chance encounter at Oxford with Prof Hans Krebs (of the Citric Acid Cycle fame) gave the opportunity to study blood sugar biochemistry during sport and especially football. Oxford United players and University sportsmen were tested in the laboratory at the Radcliffe Infirmary. Thus I was able to publish in 1974 the first paper on blood glucose levels in football with regard to team performance. This study used the cooperation of the Beecham Company and produced a sugar/nutrition drink called ‘Dynamo’. Later they changed the name to Lucozade Sport. As an anecdote: one of the young recruits to Lilleshall, Michael Owen, went on to advertise the product for many tens of thousands of pounds. The trial received only two thousand pounds from the company, but such are the vagaries of life. I said at a University Degree Congregation in December 2014 that my parents were born when horse and carriages were the norm and electricity was almost unknown. My first computer at University in 1967 was the size of a lounge and was virtually an adding machine. Thus the current football medical and scientific staff have a wonderful time ahead. Advances in the next decades are unimaginable today. Hand held blood and tissue scanners will give an instant metabolic analysis and thus rapidly define an injury and suggest treatment; robotic surgery will take some of the pressure off surgeons. These are but two examples.

There is much to look forward to in football medicine and when someone compiles their reminiscences in 2060 of ‘Half a Century in Medicine & Football’, all of today’s advances will seem as vintage as my reminiscences are now. 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.

FOOTBALL MEDIC & SCIENTIST | 25

Pictured: Leicester City’s German defender, Robert Huth, emerges from the CryoAction Chamber. Whole body cryotherapy has become key recovery aid at the club this season.

CRYOACTION THE COOLEST PEOPLE IN FOOTBALL “

performance to date, especially given the fact that last March, Leicester were fighting to avoid relegation. Around that time, Leicester’s head physiotherapist, Dave Rennie, adopted whole body cryotherapy to help players to recover from fatigue as well as speeding up rehabilitation from soft tissue damage. These were key factors, as having a player out during those last 10 games would have been critical to the balance and performance of the squad. As we now know, performances, supported by a training programme, including cryotherapy, were successful and the club avoided relegation.

ADVERTORIAL/CRYOACTION

CryoAction are delighted to be partner with the Football Medical Association. We recognise the impact that medical personnel have in ensuring the players are fit and ready to meet the challenges of the modern game.

number of Premiership and Championship teams have integrated whole body cryotherapy into their training, with some accessing BOC’s mobile service. As a result, many clubs are now

seeking to extend their use of cryotherapy and adopt a permanent solution. One such club was CryoAction client, Leicester City. We are all aware of the amazing story of Leicester’s Premiership

The benefits of cryotherapy speak for themselves, providing players with rapid recovery from muscle fatigue and soft tissue injuries

It comes as no surprise that this season, whole body cryotherapy has become key equipment at the club. Leicester invested

in a transportable unit from CryoAction and the team’s performance, thus far, has been exceptional. Dave Rennie commented, “The CryoAction cryotherapy unit has become an integral part of the recovery and preparation culture at the club”. Jamie Vardy, the new record holder for scoring in consecutive Premier League games, has thanked the club for investing in the chamber, which has helped him play despite a hip injury, commenting “The cryotherapy chamber is absolutely freezing but it helps you in your recovery, so fair play to the club for getting it,” he said. “I was very close to not playing but the physios have been brilliant. I don’t think even some of the brainiest men in the world would understand the name of stuff they’ve been doing but they’ve been working constantly on me all week.” Could cryotherapy help clubs like Leicester City and others, gain an advantage over their competitors? Some naysayers would cite a recent study stating that the current research is inconclusive and perhaps surprisingly, we would agree( in part). There is an absence of high quality, football-specific research and that which has been undertaken, leverages redundant technology that cannot deliver the benefits, such as those we see in daily operation at our partner’s medical facilities in Poland, where cryotherapy is in daily widespread use, treating diverse ailments such as arthritis, rheumatism, fibromyalgia and multiple sclerosis. In order to remedy this situation, CryoAction are commissioning research into cryotherapy in football. However, the anecdotal evidence is overwhelming supportive, with endorsements from across multiple elite sports. Modern football is about marginal gains, we cannot expect those clubs yielding the benefits of cryotherapy, to release data on the upsides that they are achieving. In time, we expect our own research to confirm those benefits. But perhaps the question should be for those who have, as yet resisted purchasing their own unit - can you afford to dismiss all the anecdotal evidence and improved performance of your competitors or is it entirely coincidental? Whole Body Cryotherapy units, as supplied by CryoAction, are in high demand, and many clubs are now seeking to leverage the benefits for themselves. CryoAction build chambers inside treatment areas at training grounds or provide a bespoke, external chamber. A 3 person chamber can treat a squad of 24 in under an hour, whereas a 6 person chamber could treat a squad inside 20 minutes. The treatment is quick, appreciated by players and can be used several times a day, during training breaks, offering many advantages when compared to traditional treatments such as ice baths.

Pictured: Captain of Leicester City and Huth’s centre-back partner, Wes Morgan, immediately after his cryotherapy session.

Director of CryoAction, David Morris explains “The benefits of cryotherapy speak for themselves, providing players with rapid recovery from muscle fatigue and soft tissue injuries. The quicker the player can recover from fatigue, the more time they have with coaches to train and to learn tactics. Similarly, the quicker they can recover from injury, the speedier their return to the pitch.“ David Morris continues, “Our latest clients are expecting their unit to be delivered before Christmas, and through a mobile chamber are already doing very well in the Premiership. Other orders are scheduled for May, ready for players returning to preseason training. Our factory is very busy, and already we are preparing for units to be delivered for some of the world’s biggest sporting events. One thing is for sure that by this time next year, there will be many more Premiership clubs using their own cryotherapy units compared to this season”.

Who will win the Premiership? It’s too early to say, but for those clubs who can, day in day out, play their first 11, aided by daily cryotherapy treatments, you would have to say their probability of success is far higher than those who, as yet, have not made the investment into whole body cryotherapy. For more information visit www.cryoaction.com

FOOTBALL MEDIC & SCIENTIST | 27

Pictured: AFC Bournemouth’s Callum Wilson is fouled by Stoke City’s Philipp Wollscheid in September, 2015. It later transpired Wilson ruptured the ACL in his right knee, leading to 6 months on the sidelines.

CRITICAL CONCEPTS IN KNEE J OINT STABILITY FOR THE FOOTBALL CLINICIAN FEATURE/NICHOLAS C. CLARK, PHD, MSC, MCSP, MMACP, CSCS.1,2,3 Senior Lecturer, Sport Rehabilitation, St Mary’s University, Twickenham, London. Group Lead, Knee Injury Control and Clinical Advancement (K.I.C.C.A.) Research Group, St Mary’s University, Twickenham, London. 3 Knee Consultant Physiotherapist, Integrated Physiotherapy and Conditioning, London. 1

Email: nicholas.clark@stmarys.ac.uk Twitter: @DrNickCC

Introduction Football is the most popular sport in the World and is played by men, women and children of all levels of ability from novice to professional.(1) Football is an agility-biased sport that requires players to advance into the opponents’ territory whilst keeping possession of the ball, avoiding opposing players’ attempts at interception, and delivering the ball into the opponents’ net to score a goal. Effective movement of the ball from one end of the football pitch to the other requires a variety of physical activities including walking, running, highspeed running, sprinting, rapid changesof-direction, kicking, tackling, jumping and heading.(1,2) Due to the multi-directional and close-quarters nature of the physical activities required of football match-play, injuries can occur to all parts of the body. (3,4) The knee joint is a common site of first-time injury in adult football players,(3,5) with approximately 50% of all knee injuries classified as being of “moderate” to “major” severity.(5) Knee joint re-injury is also common,(5) and the prevalence of post-injury

knee osteoarthrosis can be high in male and female football players relative to the general population.(6–8) Because knee joint first-time injury, re-injury and osteoarthrosis can be common in adult male and female football players, an understanding of knee joint stability, stages of rehabilitation and return-to-play decision-making is critical for all clinicians working at all levels of football. This article is the first in a series of four articles addressing knee joint stability, stages of rehabilitation and return-to-play decisionmaking. This article will begin the series by specifically introducing critical concepts in knee joint stability, sensorimotor control of knee joint stability, and assessment of both mechanical and functional knee joint stability for the football clinician. For the purpose of these articles, the term ‘knee’ is used with a focus on the tibiofemoral joint although many concepts can also be applied to the patellofemoral joint.

Knee Joint Stability The term ‘joint stability’ is commonly used in clinical practice. The term is, however,

often poorly defined and incorrectly applied, resulting in miscommunication and misunderstanding between different clinicians as well as between clinicians and players. Joint stability refers to the ability of a joint to remain in or rapidly return to correct alignment.(9) The key term here is ‘alignment’, referring to how the boneends forming a joint are aligned with each other. If the knee bone-ends (proximal tibia, distal femur) move too far away from ideal alignment during football training or match-play, then soft tissue injury can occur (e.g. medial collateral ligament (MCL) tear). Joint stability is composed of mechanical joint stability and functional joint stability. (9) Mechanical joint stability is the result of the non-contractile tissues that give a joint its unique shape and structure.(9) The non-contractile tissues include the boneends, joint capsule, synovium, ligaments, hyaline cartilage and intra-articular accessory structures (e.g. menisci), and are termed the ‘static restraints’.(9) Functional joint stability is the ability to maintain joint stability during functional tasks (e.g. cutting to change direction) without any sense of apprehension,

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Pictured: Southampton’s Fraser Forster is attended to by medics before being stretchered off in a game versus Burnley in March,2015. Forster damaged his patella tendon during the incident.

pain or giving way.(9,10) Functional joint stability is the result of optimal mechanical joint stability combined with the appropriate action of any skeletal muscle that can influence the alignment of the joint.(9,11) Muscles that can influence the alignment of the joint are termed the ‘dynamic restraints’. (9) From a joint stability perspective, the primary role of the dynamic restraints is to “stress-shield” non-contractile tissues from excessive forces that could cause injury.(12) Thus, knee functional joint stability in football is the overall result of an interaction between the knee’s static and dynamic restraints. Deficiency of the static restraints (e.g. MCL laxity) and/or the active restraints (e.g. muscle weakness) can affect knee functional joint stability during football training and/or match-play. It is important, therefore, for the football clinician to have an understanding of how the knee’s static and dynamic restraints interact to produce knee functional joint stability.

Static Restraints: Bone Components The bone components of the tibiofemoral joint are the bone-ends of the proximal tibia and distal femur. When reviewing the bony contribution to joint stability, consideration is for bone geometry and congruence of the joint surfaces. The tibiofemoral joint is formed by the tibial plateaus articulating with the femoral condyles, where the tibial plateaus are relatively flat and the femoral condyles are convex in shape.(13) The tibiofemoral joint is potentially unstable in all planes of motion because of the incongruence of the reciprocating bony surfaces.(13)

Consequently, the tibiofemoral joint is highly dependent on capsuloligamentous structures for its mechanical joint stability.(13) It is important, therefore, for clinicians working in football to have an understanding of the anatomy and function of the tibiofemoral joint capsule and ligaments.

Static Restraints: Capsule Components Unlike other joints in the lower limb (e.g. hip), the tibiofemoral joint is not completely surrounded by a dense, fibrous joint capsule. The joint capsule is deficient anteriorly to allow for the presence of the patella, the anterior tibiofemoral joint and synovium instead being reinforced by expansions from the anterior muscles’ tendons and patellar retinaculum.(13) Anteromedially, the tibiofemoral joint and synovium are reinforced by expansions from the medial patellar retinaculum.(13) Anterolaterally, the tibiofemoral joint and synovium are reinforced by expansions from the lateral patellar retinaculum and the iliotibial tract. (13) The tibiofemoral joint capsule itself begins medially and laterally attaching to the margins of the tibial and femoral condyles, being reinforced by the MCL and lateral collateral ligament (LCL), respectively.(13) Posteriorly, the joint capsule also attaches to the margins of the tibial and femoral condyles and the intercondylar notch being reinforced by the oblique popliteal ligament and arcuate popliteal ligament.(13) Because the tibiofemoral joint is not completely surrounded by a dense, fibrous joint capsule, it is particularly dependent on ligamentous structures for its mechanical joint stability.

Static Restraints: Ligament Components There are four tibiofemoral joint ligaments that function as the primary knee static restraints. The anterior cruciate ligament (ACL) provides an average of 86% of the total restraining force to anterior tibial shear from 30° to 90° knee flexion.(14) The posterior cruciate ligament (PCL) provides an average of 95% of the total restraining force to posterior tibial shear from 30° to 90° knee flexion.(14) The MCL provides an average of 78% of the total restraining force to valgus displacement at 25° knee flexion.(15) The LCL provides an average of 69% of the total restraining force to varus displacement at 25° knee flexion.(15) Thus, for the sagittal and frontal planes, the ACL, PCL, MCL and LCL provide the majority of the tibiofemoral joint’s mechanical joint stability. For the sagittal and frontal planes, the remaining percentage of restraint is provided by a combination of the remaining tibiofemoral ligaments and portions of the joint capsule.(13–15) For the transverse plane, and depending on the direction of motion, anteromedial, anterolateral, posteromedial and posterolateral tibiofemoral mechanical joint stability is provided by various complex combinations of the collateral ligaments (MCL, LCL), cruciate ligaments (ACL, PCL) and joint capsule (medial, lateral, posterior).(16) Because the cruciate and collateral ligaments provide the majority of the tibiofemoral joint’s mechanical joint stability,(14–16) and because of the multi-directional nature of football,(1,2) it is necessary for the football clinician to perform a thorough assessment of

the collateral and cruciate ligaments in order to determine the status of the tibiofemoral joint’s mechanical joint stability and how it may relate to the knee’s functional joint stability during actual football training and/or match-play.

Static Restraints: Hyaline Cartilage Components Hyaline (articular) cartilage covers the ends of bones that form synovial joints and can affect mechanical joint stability (alignment). Hyaline cartilage thickness varies according to the load-bearing (weight-bearing) requirements of the joint,(13) and pushes two bones apart in a way that maintains a specific distance between their respective ligament attachment points.(17) Tibiofemoral joint space narrowing as a result of, for example, early osteoarthrosis can result in an apparent increase in varus-valgus laxity (decreased frontal plane mechanical stability) because erosion of hyaline cartilage brings the bones and ligament attachment points closer together thereby slackening the collateral ligaments.(17) In addition, during weightbearing, unicompartmental tibiofemoral joint space narrowing can result in a closing-down on one side of the joint and opening-up on the other side of the joint in a way that produces increased tilting of the tibia and/or femur in one direction or another. The tilting of bones in one direction or another is seen as increased tibiofemoral varus or valgus angulation and abnormal weight-bearing frontal plane alignment. Thus, the thickness of hyaline cartilage can affect tibiofemoral mechanical joint stability with regards to both apparent changes in collateral ligament laxity as well as changes weight-bearing frontal plane alignment.(17) Because hyaline cartilage thickness can influence apparent varus-valgus laxity and weight-bearing frontal plane alignment, the football clinician should consider the status of hyaline cartilage when making judgements about apparent tibiofemoral varus-valgus laxity and weightbearing frontal plane alignment.

Dynamic Restraints: Local Muscle Components

Dynamic Restraints: Remote Muscle Components

The local muscle components of the dynamic restraints include muscles that directly cross a joint. Muscles which directly cross a joint are capable of restraining excessive joint motion in specific directions and are, therefore, also capable of maintaining joint stability (alignment). The hamstrings and quadriceps muscles together are particularly well-positioned to restrain, for example, tibiofemoral varus-valgus displacement.(21) The hamstrings muscles alone are particularly well-positioned to restrain anterior tibial displacement.(22) The quadriceps muscles alone are particularly well-positioned to restrain posterior tibial displacement. (23) Thus, muscles which directly cross the tibiofemoral joint are able to function together or in isolation to restrain excessive joint motion that could cause injury to the static restraints (non-contractile tissues). Because different muscles are responsible for maintaining tibiofemoral joint stability in different directions of motion, it is necessary for the football clinician to perform a thorough assessment of the tibiofemoral joint’s individual local muscles in order to determine the status of the local dynamic restraints and how their current function may relate to the knee’s functional joint stability during actual football training and/or matchplay.

The remote muscle components of the dynamic restraints include muscles that do not cross the joint of interest but, instead, cross other joints in the same limb. Muscles that cross other joints in the same limb are biomechanically capable of indirectly restraining excessive joint motion in specific directions. For example, during functional and weight-bearing movements, knee valgus displacement is associated with hip adduction and internal rotation. (24) Excessive hip adduction and internal rotation displacement can be restrained by, for example, the gluteus medius and gluteus maximums muscles.(24) Therefore, the gluteus medius and gluteus maximus muscles can function indirectly as remote dynamic restraints to excessive knee valgus motion.(24) Because muscles that cross other joints in the lower limb are biomechanically capable of indirectly restraining excessive tibiofemoral joint motion in different directions, it is also necessary for the football clinician to perform a thorough assessment of muscles remote from the tibiofemoral joint (e.g. gluteus medius, gluteus maximums) in order to determine the status of specific remote dynamic restraints and how their current function may also relate to the knee’s functional joint stability during actual football training and/or match-play.

Static Restraints: Intra-Articular Accessory Structure Components Intra-articular accessory structures refers to intra-capsular accessory structures that contribute to mechanical joint stability. The menisci increase tibiofemoral joint congruence and surface area over which contact forces are distributed.(18) In the ligament-intact knee, the menisci do not appear to make a major contribution to mechanical stability of the tibiofemoral joint. (19) In the ligament-deficient knee (e.g. ACL-deficient (ACL-D)), however, the menisci do provide a contribution to, for example, anterior-posterior mechanical stability of the tibiofemoral joint.(19,20) Partial and complete meniscectomy can, therefore, greatly affect tibiofemoral mechanical joint stability in an already ligament-deficient knee.(19,20) Because the menisci can contribute to mechanical stability of the tibiofemoral joint under specific conditions, the football clinician should carefully consider the status of both the ligaments and the menisci together when making judgements about the findings of a clinical examination of the tibiofemoral joint.

Pictured: Arsenal’s Santi Cazorla is injured against Norwich City in November. Cazorla damaged ligaments in his knee, requiring surgery.

FOOTBALL MEDIC & SCIENTIST | 31

Pictured: West Ham United’s Diafra Sakho clutches his knee after he goes down injured during their match against West Bromwich Albion at Upton Park in November 2015.

Sensorimotor Control of Knee Joint Stability As described previously, knee functional joint stability in football is the overall result of an interaction between the knee’s static and dynamic restraints. Appropriate and co-ordinated interaction between the knee’s static and dynamic restraints is the result of sensorimotor control of knee joint stability. Sensorimotor control refers to central nervous system (CNS) control of whole body movement patterns, whole body and limb alignment, and local joint stability.(25–27) Sensorimotor control functions on a ‘sensorymotor’ basis, being composed of sensory, CNS processing and motor components.(9,12) Thus, before an appropriate and co-ordinated motor output can be generated by the CNS, appropriate sensory input is required.(9,12) The sensory component of sensorimotor control is proprioception.(9,12,28) The motor component of sensorimotor control is neuromuscular control.(9,12) To understand the mechanism of interaction between the knee’s static and dynamic restraints in maintaining knee functional joint stability during football training and/ or match-play, it is necessary for the football clinician to understand the fundamentals of proprioception and neuromuscular control.

the skeletal muscle-tendon units (dynamic restraints) and include the muscle spindle and Golgi Tendon Organ (GTO).(31) Sensory nerve fibres from joint and muscle mechanoreceptor nerve endings extend to the spinal cord and synapse with the cell bodies of alpha and gamma motor neurons that stimulate extrafusal and intrafusal muscle fibres, respectively.(32) Thus, mechanoreceptor (sensory) feedback to the CNS can result in co-ordinated skeletal muscle (motor) activation. Understanding of this basic level of sensorimotor circuitry gives the football clinician a better understanding of how the static and dynamic restraints interact on a fundamental level to provide knee functional joint stability. Because multiple non-contractile and contractile tissues are innervated with mechanoreceptor nerve endings, the football clinician can use both passive and active intervention techniques to access the sensorimotor system.(12) The football clinician’s use of both passive (e.g. joint mobilisations) and active (e.g. balance training) intervention techniques at different stages of the knee rehabilitation process can facilitate an appropriate interaction between the tibiofemoral joint’s static and dynamic restraints with a view to restoring an injured player’s optimal knee functional joint stability.(12)

Proprioception

Neuromuscular Control

Proprioception is composed of the sense of joint position (joint position sense (JPS)), sense of joint movement (kinaesthesia), and sense of force (force sense).(9,12,25) All components of proprioception result from mechanoreceptor stimulation in musculoskeletal tissues.(9,12,25) A mechanoreceptor is a specialised sensory nerve ending sensitive to mechanical stimuli (e.g. tension, compression).(9,12,25) Mechanoreceptors can be found in the knee’s non-contractile tissues including the joint capsule, synovium, ACL, PCL, MCL, LCL, menisci and even fat pad.(29,30) Mechanoreceptors can also be found in

Neuromuscular control is composed of feedforward and feedback neuromuscular control.(9,33) Feedforward neuromuscular control is activation of and force generation by the dynamic restraints before joint motion and loading.(9,33) Feedforward neuromuscular control activates the dynamic restraints in a preparatory role to increase stability of the underlying joint so that it is ready to move and safely accept a range of tension, compression and torsion loads. (9,33) Feedback neuromuscular control is activation of and force generation by the dynamic restraints after joint motion and loading.(9,33) Feedback neuromuscular

control activates the dynamic restraints in a reactive role to reacquire joint stability after motion and loading have occurred because the joint may potentially be moving out of ideal alignment.(9,33) Thus, feedforward neuromuscular control is important for maintaining joint stability (alignment) before potentially dangerous motion and loading has occurred, whereas feedback neuromuscular control is important for recovery of joint stability (alignment) after potentially dangerous motion and loading have occurred. Feedforward and feedback neuromuscular control are constantly operating during all joint motion and loading that occur within activities-of-daily-living, exercise and sport. (9,33) Following both feedforward and feedback muscle activation, muscle force generation characteristics (e.g. rate of force development) are then also of great importance with regards to rapidly generating sufficient force to decelerate and ideally stop potentially dangerous joint motion.(9,33) Thus, for the football clinician, it is important to recognise that both muscle activation and force generation characteristics combine to result in clinically effective feedforward or feedback neuromuscular control of knee functional joint stability. A mixture of exercise therapy training methods (e.g. strength training, balance training, plyometric training) is recommended to restore overall sensorimotor control of knee joint stability. (12,28,34)

Clinical Methods of Assessing Knee Mechanical Joint Stability As described before, mechanical joint stability is one part of functional joint stability and is the result of the integrity of the noncontractile tissues that give a joint its unique shape and structure.(9) Also as described before, mechanical joint stability of the tibiofemoral joint is principally the product of the joint capsule, ligaments and menisci. Because knee mechanical joint stability is a component of optimal knee functional joint stability, it is clinically important to assess

the structural integrity of the tibiofemoral joint’s static restraints before any judgement can be made about how the knee’s mechanical joint stability may or may not be contributing to a player’s knee functional joint stability during training and/or matchplay. Therefore, the football clinician should undertake a plinth-based passive assessment of, for example, the tibiofemoral joint capsule and ligaments’ structural integrity. The assessment must be passive in nature in order to best separate out function of the static restraints from the dynamic restraints. A wide range of tibiofemoral joint capsule and ligament structural integrity tests exist for the football clinician to choose from including, for example:(16) Slocum test with foot laterally rotated 15° for the posteromedial capsule; Dial test for the posterolateral capsule; valgus stress test for the MCL; varus stress test for the LCL; Lachman test and anterior drawer test for the ACL; posterior sag sign and Reverse Lachman test for the PCL. When the football clinician has performed an assessment of the tibiofemoral joint’s mechanical stability, a greater understanding of a player’s knee functional joint stability can result and more informed intervention decisions can then be made.

Clinical Methods of Assessing Knee Functional Joint Stability As described before, allowing for knee mechanical joint stability, optimal knee functional joint stability is also the product of appropriate sensorimotor control that results in co-ordinated and effective activation of and force generation by the dynamic restraints. (9,12,33) As such, knee functional joint stability is the product of an accumulation of functions in different body systems and includes mechanical stability, proprioception, neuromuscular control and player confidence. (11,35) Clinical assessment of knee mechanical joint stability has been outlined in the previous section. Clinical assessment of proprioception and neuromuscular control as separate components of sensorimotor control is highly challenging outside of a laboratory environment due to the need for sophisticated and expensive equipment. (28,36) More research is needed in order to develop clinic-friendly reliable and valid methods capable of selectively assessing specific proprioception and neuromuscular control characteristics.(28,36) In essence, there is no universally-agreed gold standard for defining or measuring knee functional joint stability. For the purpose of clinical and laboratory research, knee functional joint stability has historically been defined and assessed using single-leg hop tests. (11,35,37) Single-leg hop tests are preferred as clinical methods for assessing sportsrelated knee functional joint stability versus agility-biased running tests (e.g. shuttle-run, T-test).(11,37) Single-leg hop tests are preferred because agility-biased running tests are consistently unable to identify unilateral performance deficits in previously injured versus uninjured knees. (37) Single-leg hop tests are reliable and valid methods for assessing knee functional joint stability,(11,35) are significantly associated with patient self-report of functional ability and quality-of-life,(38,39) and can identify

those who will regain knee functional joint stability after injury.(39,40) Although singleleg hop tests clearly have good clinical utility as just described, they must be recognised as ‘indirect’ measures of knee functional joint stability. This is because clinical single-leg hop tests are measured using variables such as, for example, distance hopped, and so do not yield data about actual knee joint alignment. Because knee functional joint stability is also defined by the absence of apprehension, pain or giving way during functional tasks,(10) it is important for the football clinician to also employ methods to assess subjective aspects of knee functional joint stability. Subjective aspects of knee functional joint stability can be measured using questionnaires that investigate aspects of apprehension, pain, giving way and player confidence. (41,42) Fear of re-injury, athlete confidence and psychological readiness have received more attention in recent years because of the mismatch between high proportions of athletes who achieve good outcomes defined by impairment- and activity-based assessment methods compared to the low proportions of athletes who achieve good outcomes defined by actual return to preinjury level of sports participation.(41–43) Because knee functional joint stability and actual return-to-sport of athletes with knee injuries possess both physical and psychological components, it is important for the football clinician to recognise that players’ knee functional joint stability should, at a minimum, be assessed using single-leg hop tests and appropriate questionnaires that include items relevant to apprehension, pain, giving way, fear of re-injury, player confidence and overall psychological readiness.

Summary Football is a multi-directional sport that can commonly result in knee first-time injury, reinjury and osteoarthrosis. Because knee joint first-time injury, re-injury and osteoarthrosis can be common in football players, an understanding of knee joint stability is critical for the football clinician to be able to perform safe and thorough assessment and rehabilitation of football players with knee injuries. Knee joint stability is composed of mechanical joint stability and functional joint stability. Knee mechanical joint stability is the result of the integrity of the tibiofemoral joint static restraints. Knee functional joint stability is the result of the action of the tibiofemoral local and remote dynamic restraints. Knee joint stability during strength and conditioning drills, skills training and actual match-play is the overall product of optimal sensorimotor control that effectively co-ordinates interactions between the tibiofemoral static and dynamic restraints. Intact proprioception and co-ordinated feedforward and feedback neuromuscular control are necessary for optimal sensorimotor control of knee joint stability. In order to make accurate judgements about a player’s knee joint stability, the football clinician should be capable and competent in assessing the integrity of the tibiofemoral static restraints and the function of the local and remote dynamic restraints. The football clinician should also be capable and competent in administering single-leg hop

tests and appropriate questionnaires. As outlined in this article, an understanding of knee joint stability, sensorimotor control, proprioception, neuromuscular control and methods to assess knee mechanical joint stability and functional joint stability will enable the football clinician to make more accurate diagnostic judgements and more specific intervention recommendations for the football player with a knee injury.

Biography and Continuing Professional Development Nick is a Chartered Physiotherapist with more than 17 years of clinical experience in lower limb and knee injury prevention and rehabilitation and more than 23 years of practical experience as a Gym Instructor and Certified Strength and Conditioning Specialist. Clinical and practical experience has been gained in private health clubs, the NHS, private practice, elite sport and the British military. Nick also has more than 19 years of sports medicine and military injury prevention and rehabilitation research experience in UK and US universities. Research experience has been acquired with amateur, elite and professional athletes as well as military Special Forces. Nick has taught continuing professional development courses in the UK, US, wider EU and Asia for more than 15 years. Courses include: Open and Closed Kinetic Chain Exercise in Early-Stage and Middle-Stage Knee Rehabilitation, Proprioception and Neuromuscular Control in Knee Functional Joint Stability, Clinical Plyometrics in Knee Injury Prevention and Rehabilitation, and Re-Injury Prevention and Return-to-Play Testing Following Knee Joint Injury. He has also provided bespoke inservice training to private hospitals, professional sports teams and the British military for more than 13 years. Contact Nick directly if you are interested in attending or hosting one of the courses or would like to arrange an in-service training.

Contact Information Follow Nick on Twitter via @DrNickCC. Contact Nick Directly at nicholas. clark@stmarys.ac.uk

FOOTBALL MEDIC & SCIENTIST | 33

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Citroen C1 Hatchback 1.2 PureTech Feel - 3 Door £87.98 +VAT rental per month Business lease £122.09 incl VAT per month Personal lease 6 + 17 rentals, 10k pa

BMW 1 Series Diesel Hatchback 116d M Sport - 3 Door [Nav] £199.99 +VAT rental per month Business Lease £249.99 incl VAT rental per month Personal Lease 9 + 23, 8k pa

Mercedes Benz GLA Class Diesel Hatchback GLA 200 CDI AMG Line - 5 Door Auto £239.00 +VAT rental per month Business lease £311.36 incl VAT rental per month Personal lease 6 + 23, 10k pa

Land Rover Range Rover Evoque Diesel Hatchback 2.0 eD4 SE - 5 Door 2WD £229.99 +VAT rental per month Business lease £287.08 incl VAT rental per month Personal lease 9 + 23, 8k pa

BMW 4 Series Diesel Coupe 420d [190] M Sport 2 Door [Professional Media] £268.71 +VAT rental per month Business lease £322.55 incl VAT rental per month Personal lease 9 + 35, 10k pa

Jaguar XF Diesel Saloon 2.0d [180] Prestige 4 Door £294.73 +VAT rental per month Business lease £353.68 incl VAT rental per month Personal lease 6 + 35, 10k pa

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Personal and business deals at fleet car prices for FMA Members

FMACARS In association with www.keyfleet.co.uk