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

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

Issue 18 Autumn 2016

In this issue: Gordon Guthrie: A Tribute Managing Recovery ACL Reconstruction Wales at the EUROs

Feature:

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Examining the Manager/Doctor Partnership

FMA FOOTBALL MEDICAL ASSOCIATION SPONSORED BY

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Contents

FMA FOOTBALL MEDICAL ASSOCIATION

Welcome 4

Members News

Features 8

SPONSORED BY

FA Premier League Player Care Conference David Horrocks

12 The Future of Football Medicine Mike Davison 14 Considerations for ACL Injury In Female Football Players Andrew Walker 16 ACL Reconstruction in Footballers Mr. Andy Williams 18 Gordon Guthrie: 1930-2016 A Tribute 21 Management of Medical and Cardiac Incidents Dr Vincent Gouttebarge 24 The Management of Recovery Status in Football Carl Wells

CHIEF EXECUTIVE OFFICER This summer saw the departure of a number of FMA members from their posts in Professional football. It has become a familiar scenario at the end of each season and, as we know, it is often purely down to circumstance and nothing to do with the medic.What was a little unusual this time round was the high profile of some of those members at top Premier league clubs. So it just goes to show that no one it seems is totally safe. This of course is a regular theme for the LMA and their managers and indeed for the PFA whose members, more than anyone else, are frequently released from clubs and out of the game. It`s football. It’s what happens. For FMA members there are traditional options which they can take up should they find themselves in this position. Doctors can generally revert to their practices or their speciality in medicine. Therapists are very likely to move into private work and make best use of their profile in professional football to kick start their practice. Sports Scientists can also find private work or take up teaching roles. This is where the FMA can continue to help and support members even if they are no longer at a club. The FMA has created a Football Medicine Register for medical professionals who are members of the FMA or who wish to become Members. Through the register we will be able to showcase a member’s experience in the game and put them in front of thousands of players and supporters. The register will also be a valuable resource for those currently in the game to find practitioners, of whose services they are in need. There will also be opportunities for registrants to submit articles of interest for our magazine Football Medic & Scientist, highlighting their own expertise within their discipline. Remaining a member will keep their name in focus allowing colleagues to know where they are now working and maybe even to keep in touch. Just because someone is currently not at a club does not mean they are not part of football and the FMA. Eamonn Salmon CEO Football Medical Association football medic & scientist

sports science

feature

high-level sprinters (who train following an identical periodised training regimen), targeting the same main events in the same competitive season (unpublished data) (Figure 2). Taken together, this evidence brings into question the role of periodisation in optimising actual performance during the planned peaking phase and reinforces the need to identify better strategies to control and improve the athletes’ sporting capability.

26 The Club Doctor and Team Manager Partnership Dr Mark Weller Pictured: Barcelona’s Luis Suarez during a training session at St George’s Park, Burton in July. Barcelona used the centre as a training base before games in the International Champions Cup. Pictured: Former Liverpool defender Daniel Agger retired at Brøndby in May this year aged 31, admitting long-term overuse of anti-inflammatory drugs in order to combat joint hypermobility.

28 Training Periodisation: An Obsolute Methodology Irineu Loturco and Fabio Y. Nakamura

IS THE ABUSE OF MEDICATION

THE NEXT MAJOR CONCERN

IN SPORTS MEDICINE? FEATURE/DR SEAN CARMODY “Also, be aware of the pills you take. If you take sleeping pills to overcome jet lag, before you know it, you’ll be taking them every night. When your arm is sore and you’re given medication for it, throw that bottle away. Those pills will give you a painful, persistent ulcer. Be aware of what you put in your body.” Pete Sampras, Letter to My Younger Self, June 29th 2015

n August 2013, sports medicine made headlines around the world as the NFL reached a settlement to contribute $765million to provide medical help to more than 18,000 former players who may have been affected by concussion. It catapulted the condition into the public conscience, and drove the governing bodies of the world’s most popular sports to enforce policy change to protect the health of their athletes. With all the scrutiny on concussion over the last few years, the use and sometimes abuse of medications in sport is an issue that has often been overlooked. This could

be about to change as eight retired NFL players are suing the league for unethically providing them with pain medications throughout their career. They allege that these medications were taken without prescription or knowledge of side effects, and were used to mask serious injuries. The individuals filing the lawsuit are now believed to suffer from renal failure, dependency and chronic pain among other ailments, as a result of medical mismanagement during their playing careers. The allegations being made in this lawsuit are supported in the literature.

A 2011 paper in the journal Drug and Alcohol Dependence concluded that NFL players who misused opioids during their career were most likely to misuse in later life. Interestingly, misuse of opioids in this population was associated with more chronic pain, undiagnosed concussions and alcohol abuse. This is not exclusively a problem of American sports. Research published in the British Journal of Sports Medicine highlighted the alarming incidence of medication abuse at major football tournaments, which has not declined despite several preventative campaigns.

28 Wales At EURO 2016 Sean Connelly

COVER IMAGE Wales manager Chris Coleman and Head of Performance Ryland Morgans celebrate Hal RobsonKanu’s goal against Belgium in the 2016 European Championships Mike Egerton/PA Wire/ Association Images Football Medical Association. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, or stored in a retrieval system without prior permission except as permitted under the Copyright Designs Patents Act 1988. Application for permission for use of copyright material shall be made to FMA.

TRAINING PERIODISATION:

AN OBSOLETE METHODOLOGY? FEATURE/IRINEU LOTURCO AND FABIO Y. NAKAMURA, BRAZIL GENERAL CONCEPT Periodisation is probably the most important and fundamental concept in sports training. Typically, it consists of a ‘training cycle’ divided into different training phases (Figure 1) – with distinct physical and physiological objectives – to enable the best performance from athletes in a competition (i.e. peak performance). Theoretically, using the periodisation concept, peak performance occurs in a controlled way, as a result of the summation of the particular adaptations provided by each training phase (mesocycles)1-4. In fact, several studies have reported that different periodisation regimens are superior to non-periodised models for improving performance in elite athletes5,6. However, from a practical point of view, this research is limited by the fact that the authors – throughout the experimental period – only investigated the changes in physical capacities (i.e. muscle strength and power), but not in actual sports performance (competition results). Therefore, it is accepted that programmed training interventions produce greater enhancements in athletes’ fitness scores than unplanned (non-periodised) exercise regimens. However, when examining the role of the periodisation concept in achieving the maximum specific

performance in selected sports events (season’s best result), an important drawback emerges: very low rates of effectiveness. In a unique study published in New Studies in Athletics, Bartonietz and Larsen7 presented these low rates statistically, after comparing the results obtained in the ‘peak oriented phase’ with all other results attained by the

athletes throughout the competitive season (Table 1). More specifically, the number of athletes achieving their personal season’s best during the target competition of the year (World Championship) varied between 17 and 25%. In addition, a further dissimilarity has been identified between peak performance and performance variation obtained by

Figure 1.

THE PHYSIOLOGICAL PARADOXES: BASIC OR CONCURRENT CAPACITIES? The traditional periodisation model assumes that a relatively prolonged period of basic training (general preparation) is a prerequisite to a more specific phase (special preparation)8-15. During general preparation, strength and conditioning coaches aim to improve cardiorespiratory endurance and strength-endurance, even in athletes competing in power-speed sports disciplines (sprint and long jump events). This is surprising, as it has been known since the early 1980s that high volumes of endurance training are capable of attenuating the chronic gains in muscle strength and power, principally in highly trained subjects16-21. Although the molecular aspects of this interference effect have been extensively debated in sport sciences19-21 and still need to be fully elucidated, it seems that the multiple signaling responses induced by endurance training are capable of inhibiting protein synthesis and muscle hypertrophy, which is possibly related to the antagonism between the adenosine monophosphate activated protein kinase (AMPK) and mammalian target of rapamycin complex 1 or mechanistic target of rapamycin complex 1 (mTORC1) signaling cascades19. Another common belief related to strength-power development, is that the socalled ‘strength foundation phase’ will provide positive transfer of maximum strength to the ability to produce muscle power in the subsequent training phases22. To date, there is no strong evidence supporting this belief, mostly held in traditional literature written at best on the basis of authors’ personal experiences and not supported by research work3,23-26. Conversely, there are extensive studies showing that training using heavyloads (i.e. maximum strength training) results in improvements only in the high-force/ low-velocity portion of the force-velocity curve, without necessarily affecting the ability to produce higher amounts of force at high velocities (muscle power)27-31. In effect, it appears that the parametric relationship between force and velocity (i.e. the higher the load, the lower the velocity) plays a key role in modulating chronic neuromechanical adaptations32. Some studies have even reported significant decreases in power-speed related motor tasks (i.e. short sprints, agility tests and peak velocity in vertical jumps) after periods of heavy strength training33,34. Importantly, the theoretical and speculative ‘delayed training effect’ concept assumes that training basic capacities at earlier phases of the periodisation cycle has positive effects on actual performance long after this period of general overloading. The question that remains to be answered, is whether

Table 1. these unwanted adaptations (i.e. decreases in power-speed abilities) are really able to boost future (and targeted) neuromuscular training responses. The same holds true for specific endurance adaptations. The research does not support the existence of some physiological posterior (and also enhanced) positive effect, by showing that the ‘fatigue valley’ induced by high-intensity training sessions is not effective at increasing VO2 max or inducing peak performance in highlevel endurance athletes35. Surprisingly, for this selected group of non-elite but highlytrained athletes, the management of levels of fatigue at non-detrimental levels was more effective in provoking performance improvements. Furthermore, physical capacities gained in ‘shock microcycles’ were moderately to largely reduced only a few days after the last exposure to highintensity training sessions36. Therefore, the delayed training effect is not completely supported by the scientific literature and its use as a tool to improve actual results is highly controversial, as its outcomes are very unpredictable35. To be more succinct, there is no physiological basis to sustain the idea that the body is ‘compartmentalised’ into basic and specific capacities and that the overloading of a given basic capacity will suddenly ‘supercompensate’ later in the training cycle. Essentially, we can state that so-called basic training may potentially be a period of concurrent training stimulus. The predicted effects (high endurance level and impaired strength-power characteristics) are detrimental to the desired training targets in the subsequent seasonal phases, especially due to the absence of solid scientific evidence regarding the delayed training effect and its purported benefits. Strength and conditioning coaches should ask themselves whether basic training is a real basis for competitive performance in their respective

sports disciplines, or whether it is a loss of precious time to athletes37-41, sometimes causing malfunction of the systems mobilised during actual performance. For instance, in endurance sports, athletes appear to benefit from performing high volumes of low-intensity training (i.e. below lactate thresholds41) during their basic/ specific periods of preparation. Furthermore, the role played by prolonged periods of basic training on muscle-tendon tissues and injury prevention37,38,40 cannot be ignored. However, it is likely that these positive adaptations in muscles and tendons may also be obtained by typical strength power exercises, which can be directly implemented during the course of the season42,43. On the other hand, the counterproductive effects of prolonged basic preparation phases in team sports were recently evidenced by the impairments in the speed capacity presented by elite athletes during their pre-season training44,45, with faster players (at baseline) presenting higher levels of deterioration in the maximum sprinting performance in comparison with their slower peers45. In this regard, it is important to note that sprinting speed is a key component of match performance in many team sports46. More importantly, the accumulated effects of several years of heavy and long-lasting concurrent training each season might have a role in the performance ceiling effect experienced by most athletes during their careers. It is possible that the ability to sustain progress in sporting capability over years will benefit from training strategies that are less aggressive and targeted i.e. concurrent, making the sports training process more economical, simple and focused on the specific physical capabilities that really matter to actual competitive outcomes.

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

Senior Administrator

Lindsay McGlynn

Administrator

Nichola Holly

Francis Joseph

Contributors

Sean Connelly, Mike Davison, Dr Vincent Gouttebarge, David Horrocks, Irineu Loturco,Fabio Y. Nakamura, Andrew Walker, Dr Mark Waller, Carl Wells, Mr Andy Williams

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MEMBERS’ NEWS FMA FOOTBALL MEDICAL ASSOCIATION

SCIENCE & FOOTBALL CONFERENCE SET TO MERGE WITH THE FMA

he highly regarded Science & Football Conference which has been held annually with huge success is set to merge with the FMA Conference in 2017. This is a significant development for the FMA Conference which is already recognised

as the event for Medical and Science staff in professional football, and the merger illustrates the esteem to which the FMA Conference is now held. The Conference presentations are to be arranged by Dr Bryan English and Tony Strudwick and once again will have equal focus on Medicine, Therapy and Science.

We are aiming to ensure that the event is 100% relevant 100% of the time irrespective of a delegate’s profession. With this in mind delegates can expect a slightly different format this time round, though the high quality we have all come to expect will undoubtedly remain.

NEW WEBSITE TO BE LAUNCHED

new website is currently undergoing the final touches and is likely to be completed by the end of October.

This is our 4th website since we began and illustrates just how quickly we have grown and the diversity of the services we have developed The site will see some new and some familiar features but the biggest adaptation to the one we currently use is in the administration and management of the site.

As we have grown in member numbers the need for those members to be able to change their profile and details has become ever more important and this is reflected in the new management programme hosted by the site. There will also be a forum for use by members allowing for ease of communication and an opportunity to seek advice and host information as well as a place to comment on those issues that concern us.

football medic & scientist

CONFERENCE SET FOR 27TH/28TH MAY 2017

he annual FMA Conference and awards dinner will be hosted at the Radisson Blu Hotel East Midlands Airport on cup final weekend. This year’s event is set to be even bigger and (if possible) better than in previous years and is likely to be a sell out event. Following on from last years success the Awards evening will continue to host a ”Medical and Science Team of the year”

category for each of the 4 divisions. Teams will be nominated by members and the top 3 nominees from each division will be invited to attend the presentation, with the winners for each announced on the night. Bookings for the event will open at the beginning of December, and delegates are advised to book early in order to secure their place and accommodation at this popular venue.

SCOTTISH BRANCH

he FMA are to announce the creation of a Scottish branch of the association. This will be primarily to deal with member issues and organise training events for those members based in that region and to deal with issues specific to the Scottish leagues. Member benefits north and south of the border will be identical in every way since we are all colleagues within professional football. However, there are bound to be issues that pertain specifically to the Scottish and English leagues eg funding, sponsorship etc and in anticipation of this it was felt that this format would work best.

Leading the Scottish Branch will be Alan Rankin. Alan has worked in professional football for 21 years at both Club and International levels. He is based in Glasgow so is easily accessible. “I will be contacting all our members based in Scotland with further updates. In addition, as we are actively pushing an increase in membership for this Branch I would urge members to speak with colleagues to raise awareness of the FMA and to encourage an uptake in membership so that we have a vibrant and sizable representation moving forwards.”

NEW APPOINTMENT AT THE FMA

he FMA would like to announce the appointment of Natasha Reedy to the post of Business Co-ordinator. Natasha brings with her excellent customer service and sales background and is highly motivated and enthusiastic with regards to the work of the FMA. With the ever growing membership numbers and increased commercial interest Natasha will be a great asset to the FMA team. Lindsay McGlynn, Senior Administrator said: “Natasha is focused and driven and comes highly recommended. I am sure that her appointment will be of huge value to our growing team”.

NEW CLUB MEMBER

enew health are now on board as a Business Club member for the 2016/17 season.

Many of you will be familiar with their UK distributor Steve Jones who worked previously with Bodyflow.

Full details of this exciting new product are available on the FMA website.

FOOTBALL MEDICINE REGISTER T his project has taken some time to get off the ground but has now received new impetus that could see an official launch in the next few weeks. The forthcoming website has in fact been built around this project in order to make its administration and management seamless as well as a user friendly medium.

To recap, the register will host only those practitioners who have worked in the professional game or those who have offered professional services to the industry in an official capacity.

for current members to seek fellow professionals but as a vital tool for grassroots players and fans alike to seek out those who have worked for their club and at this elite level.

As a bespoke register therefore it will serve to flag up a practitioner’s credentials and become a useful resource not only

More will follow in the next few weeks.

PIONEERING SPORTS MEDICINE PHYSIOLAB PUBLICATION TO GET UNDERWAY RENEW FMA PARTNERSHIP

“I

am delighted to announce the inception of a new pioneering sports textbook provisionally entitled A Comprehensive Guide to Sports Physiology and Injury Management: an interdisciplinary approach. The proposed textbook will be split into two parts, Part 1: Physiology and Part 2: Injury Management. Together with Stuart Porter (Lecturer, University of Salford), Nick Southorn (Pain Physiotherapist, NHS) and Rita Demetriou-Swanwick (Senior Content Strategist at Elsevier), we are working on recruiting potential subject Editors and Contributors for the book. Therefore, we are inviting expressions of interest along with any insight you may have which would shape the book” Johnny Wilson

The FMA has pledged to support the initiative and indeed endorse the production of what will be a flagship reference for practitioners not just in football but throughout sport. Interested parties should contact Johnny Wilson Head of Sports Medicine Notts County Football Club 07807 694 556

or admin@footballmedic.co.uk

Physiolab have been great supporters of the FMA for the past two years, sponsoring awards and hosting an exhibition stand at our annual Conference as well as maintaining their status as a Business Partner.

he FMA are delighted to announce the continued partnership with Physiolab for the 2016/15 season.

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Pictured: Current FA Premier League Cup trophy winners, West Ham United U23s, celebrate with the cup after beating Hull City on penalties in April.

FA PREMIER LEAGUE

PLAYER CARE CONFERENCE FEATURE/DAVID HORROCKS, INTERNATIONAL CENTRE FOR FOOTBALL RESEARCH -UCFB The FA Premier League (FAPL) hosted a two day “Player Care” conference on 19-20 April 2016 at Brandon Hall, Coventry. All member clubs were represented by staff from safeguarding, player support and education and welfare roles.

he FA Premier League (FAPL) hosted a two day “Player Care” conference on 19-20 April 2016 at Brandon Hall, Coventry. All member clubs were represented by staff from safeguarding, player support and education and welfare roles. The typical qualifications of such staff being, qualified teachers, psychologists and former social workers. Other industry partners present included The PFA, Sporting Chance Clinic, Sport Chaplaincy UK, industry specialist academics, FA Premier League club support managers and education and welfare staff. Over the two days industry updates, current initiatives and future proposals were presented. The conference was delivered in an open and sharing environment with reflection and critical analysis encouraged. The ultimate objective of the player care initiative is to provide extended support from a

humanistic perspective as a core facet within the world’s largest professional football youth development and education system. The FA Premier League have invested £340 million in the Elite Player Performance Plan (EPPP) launched in 2012 to revolutionise player development and education. The model is evidence based with key influencers cited by Head of Youth Ged Roddy being Gagne (1985) conditions of learning and Dweck (1986) growth mind-set. The current system houses some 12,000 prospective elite players aged 8 to 21 throughout professional football across the UK. Within the EPPP clubs are categorised from 1 to 4 this being determined by varied criteria including, staff provision, past player production, facilities, staff qualifications, adherence to regulations, operational records, player records and documentation and review

of working practice. Clubs are subject to an ‘OFSTED’ style audit every two years at which point you may improve or be demoted from your existing category status. The conference had varied content including Sporting Chance Clinic, PFA Helpline, Heart4More Foundation, Mental Health Ambassador launch, leadership, sex education and discrimination awareness (Lime Culture). Player care and educational content delivered over the two days also included accredited industry professionals (Law, Medical, Education, RAF) and former players currently in remission from core contemporary issues on the mental health spectrum. At the end of day one all attendees were invited to the premier of “The Cost of a Player” a play written by Alex Gwyther, (Tip of The Iceberg Theatre Company) a production

football medic & scientist

Pictured: Former PFA Chairman, Clarke Carlisile, appeared at the event. He has spoken openly about his own mental health struggles both during his career and in the period following retirement.

exploring the mental health of young athletes. The close of the conference saw an emotional and thought provoking reflection of the life and journey of a professional footballer with mental health issues from Clarke Carlisle chaired by The FAPLs head of education and welfare Martyn Heather. What was clearly evident throughout the conference was how far player care and development has come since the inception of The EPPP in 2012, the open minded and reflective nature of the FAPL senior staff, and the holistic interaction of all 20 member clubs and supporting bodies present. Player development and the improvement in numbers of home grown players playing first team football in the FAPL is the core business of the organisation, however developing honourable, rounded, educated human beings is clearly one of the key components that is recognised as being an important part of this journey. Career advice, help, encouragement and support was also evident in abundance for those young men who may not make the grade. Gone are the days of exit stage left and welcome to the scrapheap. Two key contemporary issues in sport were showcased with the highest levels of competence professionalism and knowledge. Kim Doyle (LIME Culture) a former Crown Prosecution Service Barrister provided insightful knowledge and education in the topic of sexual violence, sexual consent, sexting, the law, and global culture surrounding the topic along with related issues currently arising in professional football.

Mental health was raised as a topic of importance by ‘If You Care Share’ and then dealt with in a novel, informative and accurate manner by The Tip of The Iceberg Theatre Company in a context relative theatrical production. Alex Gwythers play followed two young players Dan and Matt through the medium of theatre in their journeys as youth players and the pressures they would have to cope with both on and off the pitch. The play was reviewed by several former players along with the industry professionals present and was a resounding success. It was clearly evident how when delivered to youth team players they would see themselves in the eyes of the actors. A self-awareness would be generated amongst the target audience and ultimately an open, nurturing and proactive environment would be facilitated in the academy football setting. This in turn would then help to professionalise through modern techniques the nurturing of these vast numbers of talented young footballers resident in the UK system. The conference was expertly summarised by former professional player and former chairman of the PFA Clarke Carlisle. Clarke played over 550 professional games in a 16 year career, represented his country at under 21 level, and is a recovering addict (gambling and alcohol) and a survivor of two suicide attempts. Clarke possesses 10 grade A GCSEs and studied A Level maths and politics and is a respected member of the media fraternity having made several documentaries and public awareness films as well as providing professional commentary on football for the BBC.

Clarke’s summary was complimentary, offered warning and advice, praised the governing bodies and its members for their openness and participation, and commended all presenting parties for the contributions made over the two days of the conference. The key recommendation, was that The FAPL continue to operate with an open mindset (A practice encouraged in Ged Roddy’s opening address), that the evaluation of and use of research and evidence based practice is key, and that the commissioning of bespoke football specific research projects should be considered by governing bodies to compliment the already existent and highly progressive work on show. Professional football and its governing bodies all too often are subjected to bad press and suffer uneducated accusations on the practices being adopted within the game. To close this review article I make no hesitation in stating that the future of the game is in good hands and that footballers are with the utmost of certainty being seen as human beings by their governing body. The televisions billions are not being frittered on luxuries and grandiose extravagance, the game does have a heart, and educated, professional and sensible people are in key positions driving the future of our national league and game. Player care is a key aspect of the FA premier leagues development journey and the governing body aim to create educated and rounded individuals as well as talented players to improve the future prospects and prosperity of the national game in The UK.

football medic & scientist

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Pictured: Wales’ Gareth Bale jogs with Head of Performance Ryland Morgans (right) during a training session before their European Championship semi-final tie versus Portugal.

THE FUTURE OF

FOOTBALL MEDICINE FEATURE/MIKE DAVISON, MANAGING DIRECTOR, ISOKINETICS, LONDON Football Medicine has never been in a better place. And I say this is both with the head and from the heart.

s we watch the best of European football compete in France this summer, we need to look beyond the tricks and flicks on the field, and focus on the team behind the team. Not just the personalities that sit on the bench close to the coaching staff and substitutes, but the processes and player preparation techniques that are executed daily during the tournament after months of strategy, planning and dry runs. The days of players being evacuated from the pitch piggy-backing the physiotherapist or an ex-player with a diploma and a “magic sponge” are gone forever. Now Football Medicine leads the development of Sports Medicine globally. It performance cycles and travel schedules are the most challenging of any sport, its players are some of the highest paid on the planet and

the number of stakeholders involved (from managers to agents, to t0 commentators to extended families back in the player’s homeland) is often mindboggling and complexifying in the same vein. The future of Football Medicine is for sure bright, but there are challenges ahead. Before considering the future we need to think about the past and present of Football Medicine. The biggest single influencer on the development of Football Medicine has been Broadcast Revenues, led by the Premier League. The game is awash with funds, but not always blessed with the right sense or instinct to spend it wisely. Very often the administrators of the game are accused of too much money “going out of the game”. Football Medicine though has benefited

and been challenged in the same breath. In 1994 when FIFA established the F-MARC department (FIFA Medical Assessment and Research Centre) through a collaboration of Professor Jiri Dvorak (then the team physician for the Swiss National Team at the World Cup in the USA) and a certain Roy Hodgson (who was coaching that same team and they exited early, so had time to discuss together), the size of the medical department at the top level club could be counted on one hand. The ratio of physiotherapists to players was often 1:20, and the doctors were part-time and in most situations without any qualifications specific to the care of Footballers and their injuries. In the domestic leagues, the manager’s nationality was most likely the same as the country of the team, and there would be 2-3 international players

Pictured: Birmingham City Head of Sports Science, Dave Carolan, leads players Michael Morrison, Ryan Shotton, Stephen Gleeson, David Cotterill and Jonathan Grounds through a pre-match warmup.

in the squad. Language skills were not seen as an important part of the job for the Football Medicine team. Opportunities also for continued professional development were scarce and infrequent, and little research was being published in this area. Turn the clock forward 20 years, and we find ourselves in a different world. Yes the game has changed in his speed and demands, especially the number of expanded cup competitions and increased associated workload. But the most significant change has been in the size, dimension and sophistication of Football Medicine. This is both in respect to staff, facilities and collaboration. Now there are 50 FIFA Medical Centres of Excellence, monthly articles in the British Journal of Sports Medicine, and the largest Sports Medicine conference in the world (2000 delegates from 80 countries) is focused on Football Medicine strategies for player care and injury management. Football Medicine doctors are now front page news, as they defend their right to obey the ethical code of medicine and the laws passed by the game itself. Ratios of physiotherapists to players is now down to 1:5 in many clubs and staff often converse in French, Spanish and German. Where does the discipline go next though? The “Future of Football Medicine” is the title of our next conference at Barcelona’s Camp Nou in May 2017. It is not simply a title, it is a call to action to envision the next 10 years, campaign for a better future for players and practitioners, and decide upon real actions to see this vision reached. At the highest level for sure we will see an even greater level of investment, which in turn can only help give us the opportunity to enhance player

Figure 1 care. We must though be careful not just to invest in fashionable technologies but in “know-how” and things that really make a difference. Alongside this there will be increased attention and scrutiny of medical practice and scientific advancement, especially as it is foreseeable that there will be live broadcast data for physical and physiological data such as heart rate, stress levels and effort expended. It is therefore in the themes of clinical governance and risk management, injury prevention and communication (internally and externally) that much of the focus needs to be. Clinical governance and risk management seem to be from another type of industry, like construction. Through agreed new standards on minimum qualifications, safety equipment and protocols, insurances and reporting, the end should be always performance related in both the athletic and behavioural aspects. Sitting alongside this is the underpinning

of availability of players. Managers, Chief Executives and fans alike demand the opportunity to see the best players in the team pitted against the opposition. Prevention is much more ethical, sustainable and cost-effective than treatment and cure. The issue is how do we better prevent injuries, or more so, how to we avoid many of the injuries, especially the non-contact, that often blight the game ? We have to as a community face the facts that hamstring injuries lead to the highest number of games missed, and have done for 20 years. Despite all of the investment into space-age knowledge and facilities we have not made a dent. We have to find a way to individualise the injury prevention interventions and improve our communication on the WHY of the exercises to both players and managers. Without improved compliance and quality of execution, we are wasting our time and resources. It is though communication where Football Medicine needs to improve in order to make another step change in development and contribution. Communication is not what you say, it is what the other person hears or interprets. This can be clinician to clinician, from clinician to player, from clinician to manager or executive manager. Get it wrong or be untimely and it can impact injuries and team performance. UEFA’s injury study group this year identified communication as the 4th most significant risk factor for non-contact injuries amongst 33 Champions League clubs. The success of Leicester’s title run this year was fundamentally based upon excellent departmental and club wide communication. I invite you therefore to come to Barcelona next May, to one of the homes of football, to help plot this future.

ISOKINETIC AD

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Pictured: England’s Ellen White against Japan in the 2015 FIFA Women’s World Cup. White ruptured her ACL for the second time in April, 2014 and spent nearly a year in rehabilitation.

CONSIDERATION FOR

ACL INJURY PREVENTION IN FEMALE FOOTBALL PLAYERS FEATURE/ANDREW WALKER, HEAD OF MEDICAL DEPARTMENT, SCARLETS RUFC ACL injuries are common in female athletes and the number of female athletes incurring non contact ACL injuries exceeds males by 2 to 8 times indicating, gender specificity (Mandelbaum et al 2005). This is largely due to biomechanical issues, Q angle and increased valgus alignment, and associated weaknesses in the musculature.

e need to consider history, kinetic chain assessment (KCA) and posture with an holistic approach for prevention of injury. A history of medial tibial stress syndrome that is symptomatic could have contribute to injury. Medial tibial stress can lead to a change in gait and movement patterning due to the kinetic chain trying to offload or reduce the ground reaction force to the area and subsequently reducing pain. In most cases this issue can lead to a change in foot mechanics (pronation) and issues further up the kinetic chain including hypomobility of the lateral structures which can in turn change the Q angle or weakness of important stabilizing groups in knee control such as the hamstrings or quadriceps

through pain inhibition or movement control. These factors increase the risk of a possible knee injury or ACL rupture and therefore it is important an elite athlete can communicate pain or issues early to a Medical professional allowing for intervention or appropriate management. Postural assessment is important, we know that athletes sometimes have bilateral pronated feet and increased lumbar extension. Lumbar extension or lordosis is associated with a possible anterior pelvic tilt which coupled with the weakness of the hamstring muscle group is connected to poor control or weakness of the gluteal muscles. These postural issues weaken the hip extensors (gluteus maximus, long head of biceps femoris, semitendinosus

and the semimembranosus, posterior head of adductor magnus and glut medius) which in turn can lead to being atrophied either unilaterally or bilaterally. These weaknesses can be a result of the change in position of the pelvis to anterior tilt and the subsequent lack of stabilization, and in turn can lead to an altered knee position and a greater incidence of knee injuries. Therefore observing and testing the kinetic chain objectively as well as subjectively can help prevent ACL injuries. An imbalance between the hamstring and quadriceps ratio or atrophy in these groups can lead to greater risk of ACL injuries. A muscle such as the rectus femoris is involved in both hip and knee extension, if this is weak it can demonstrate an extension lag of the knee.

football medic & scientist

Pictured: Former Arsenal and England captain Faye White lifting the FA Womenâ&#x20AC;&#x2122;s Cup in 2008. During her career White had two ACL operations, one on each knee

This will also affect the hip flexors, which in turn alters pelvic tilt as already seen and discussed with the increased lumbar extension in the KCA. This alteration changes the length relationship of the hamstrings and firing of the gluteus maximus. This can lead to injuries in the whole kinetic chain and possible ACL rupture. Atrophy of the gastrocnemius, hamstring and quadriceps is also an issue and possible contribution to cause and effect. The 2 joint muscle of gastrocnemius being weak allows for greater hyperextension of the knee joint. This has a secondary affect on the ankle and gait during the push off phase, as indicated by Neumann (2010). The weakness of this reduces the posterior support around the knee joint and coupled with a weak quadriceps could increase knee hyperextension. The issue with greater knee hyperextension is that the femur does not continue to roll anteriorly but tilts forward creating anterior compression between the femur and tibia. This also produces tension on the ACL where it is acting as an important stabilization mechanism of the knee. This can lead to a greater incidence of ACL injuries due to the increased torque through the frontal plane at the knee joint (Biggs 2007). We also know that on functional assessment with the use of objective tools or apps that there can be a decrease control on a single leg squat through the frontal plane which again increases possible risk of ACL injury. Therefore having objective measures or standardised screening is important in both pre season and during season to reduce the risk of injury and if required put in place appropriate injury prevention strategies in respect of biomechanics, strength, movement or corrective exercise training, recovery etc.

A large number of non contact ACL injuries occur during cutting in the deceleration phase when torque is applied in a varus-valgus motion at a knee that is flexed at 10-30 degrees and is related to a valgus position of the lower extremity with the added variable of ground reaction force (Mandelbaum et al 2005). With this consideration an assessment of frontal and transverse plane functional single leg squat with an added overhead squat assessment is appropriate which may demonstrate knee internal rotation and adduction. These are contributing factors for possible ACL injury and need to be addressed. An individual with poor quadricep and hamstring strength and knee alignment issues indicates strength and tightness deficits, this with a poor stabilization of the hip and pelvic complex increases the risk of a non contact ACL injury. Deficits and movement pattern issues require consideration for intervention strategy approach, with being mindful of load, schedule, exercise choice (set, reps, tempo) and the athlete themselves. Improvements in proprioception through training can decrease the incidence of knee injuries (Mandelbaum et al., 2005; Zazulak et al., 2007) and therefore it is a necessary component in all forms of integrated training approaches. Therefore to decrease cause and effect for football players it is important to address the frontal and transfer plane inadequacies on a single leg squat and start with control and stabilization of the kinetic chain. It is crucial to address the weaknesses and musculature tightness through a Optimal Performance Training model. Developing neuromuscular control of the lower extremity through plyometrics, strengthening and sport specific agilities may address the

deficits in the female athletic population of proprioception and biomechanical issues (Mandelbaum et al 2005). This can be highlighted by, atrophy in the hamstrings, quadriceps and gastrocnemius, and the pronation of the feet, with poor control of the core musculature, such as multifidus, due to the trunk rotation on overhead squat assessment. We therefore as clinicians and Performance enhancement specialists need to consider the kinetic chain with each individual and the possible whole system inadequacies, which can increase the risk and possible cause of ACL rupture. References Biggs, A. 2007 Current Concepts in Rehabilitation of ACL Injuries. In Touch (The Journal of Physio First). 119, 10-15 Mandelbaum, B.R., Silvers, H.J., Watanabe, D.S., Knarr, J.F., Thomas, S.D., Griffin, L.Y., Kirkendall, D.T., & Garrett, W. (2005). Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes. The American Journal of Sports Medicine. 33(7):10031010. Neumann, D.A. 2010. Kinesiology of the Musculoskeletal System. Foundations for Rehabilitation. Second Edition. Mosby Zazulak, B.T., Hewett, T.E., Reeves, N.P., Goldberg, B., & Cholewicki, J. (2007). The effects of core proprioception on knee injury. A prospective biomechanical â&#x20AC;&#x201C; epidemiological study. The American Journal of Sports Medicine. 35(3):368-373

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Pictured: Chelsea’s Kurt Zouma lies injured after hyperextending his right knee during a game against Manchester United in February. The injury was later confrmed as a ruptured ACL.

ACL RECONSTRUCTION IN FOOTBALLERS FEATURE/MR ANDY WILLIAMS, CONSULTANT KNEE SURGEON - FORTIUS CLINIC I have the privilege of having developed a very unusual practice with a high concentration of elite athletes. Half the ACL operations I carry out are in this group, and so I have learnt a lot from treating them.

rofessional athletes, footballers in particular, will test your judgement and your surgery to the limit, because of the enormous pressure they are under to return quickly to play, and the amazing things they have to do in play. ACL rupture is a rare injury in a first team player. Usually a predisposition to ACL rupture is identified in the young injured player. It is really ‘natural selection in action’- their knees can’t cope with the necessary loading. They often re-rupture after ACL reconstruction. And they will not make it to the top level even after successful surgery. This failure may be more to with missing a critical season in their development however. An established first team player in whom so much has been invested will be ‘waited for’.

When a professional footballer with a fresh ACL tear comes to clinic, they are deeply affected by the injury. They are often sad, scared and suspicious. Missing their sport to have an operation is like bereavement. They maybe wary of a surgeon they don’t know. At the first consultation, the surgeon must be properly prepared, to create an atmosphere of competence, confidence and reassurance. Show that you appreciate the pressures on an athlete by asking when the player’s contract ends and what major tournaments are imminent. Know when you can operate before the consultation starts as rightly the player and the club medical team from his club need to know as soon as possible. Don’t hide bad news, but present it in an honest, positive way. Don’t exaggerate. Tell them that return

to play will probably be between six and nine months, but that the chances of returning to their potential level of sport are very high. It is essential that the player believes in you and respects you, but this has to be earned and quickly. With regard to the general population with ACL tears a decision between surgery and non-surgical treatment must be made. Of course a bad operation is generally worse than no operation. But for a professional footballer with an ACL rupture, it is essential that they have a stable knee to perform at their peak. There is no place for non-surgical treatment of ACL ruptures in these athletes. Timing is important and here, nature rules. If the knee is angry and inflamed, it may never come straight after surgery, so waiting

football medic & scientist

Pictured: Stoke City’s ibrahim Afellay in action against Spurs in April. In training just four days later, Afellay went on to suffer ACL damage for the second time in his career.

until the knee has settled, and has full active extension, is crucial. However why wait if the knee is ready, and they often are. For most ACL reconstructions in the general population I use a hamstring graft. It is the best option for patients who are still growing, to avoid growth arrest from premature fusion of the growth plate. The hamstring graft is also best for athletes playing sports, which feature lots of jumping, like netball, as harvest of this graft avoids damaging the extensor mechanism. It is preferable for sports, which involve lots of kneeling, like judo. However, I use a patellar tendon graft for footballers. They have half the re-rupture rate with this tendon compared to results using a hamstring graft in my experience. A footballer with a second rupture, and a second season missed, is looking at the end of their career. But, patellar tendon surgery comes with an increased incidence of anterior knee pain and involves a slightly more technically demanding harvest procedure. But as it’s a more rigid graft than a hamstring, it’s better for footballers, and for other patients with significant MCL laxity, or who have more ligament laxity than average. Patellar tendon ACL surgery has improved enormously in the last twenty years. Nowadays the surgeon effectively lifts the graft off the fat pad and proceeds to an arthroscopic procedure to implant the graft. We don’t use chisels any more, we don’t cut out the fat pad, we don’t wrap them in plaster for weeks! We get the patient and their patella mobile.

The post-operative process is hugely important. The patient needs to be able to move the limb as soon as they wake up, and this depends on the skill of the anaesthetist understanding and managing their pain relief, and use of gentle surgical technique, high quality equipment (especially saws) and infiltration of local anaesthetic. I won’t let the athlete go home too quickly, it’s best to take time- gain control of the situation. With correct supervision and pain relief, the player can start passive work, with stretches and prone hangs to restore full extension, and more importantly active isometric quads contraction into full extension, as soon as possible. Failure to achieve full active extension is the most common cause of problems after ACL reconstruction. After restoration of full active extension as soon as possible, swelling is the biggest concern. Don’t let players return to play too early to minimise the risk of re-rupture. I have many players who have returned very early to play, but this is not the norm, and return without adequate time for healing maturation of the graft and restoration of neuromuscular control increases the risk of graft re-rupture. The whole treatment of ACL rupture is a joint project between surgeon, sports physician, and physiotherapist. The surgeon shouldn’t dump the patient on the physio and forget about him. They should be involved, know what’s going on, throughout the treatment. We need to trust each other, to be in complete accord about process and progress, particularly when dealing with pressure from

the player, their advisory team and coaching / administration staff at a club. Following rehab, the player must be fit, they must trust their knee completely, there should be no swelling and they have to be strong, before they return to play. The player should feel able to twist and turn equally on both knees, with perfect symmetry. Restoring symmetry of function is critical. Then they are ready to do their magic once more.

Mr Andy Williams Consultant Knee Surgeon MB BS FRCS (Orth) FFSEM (UK) Mr Williams specialises in knee ligament problems. He works with many sports professionals including most Barclays Premier League football teams and Aviva Premiership rugby clubs. He has particular expertise in knee ligament problems and is a renowned lecturer and prize-winning researcher of knee-related issues.

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Gordon truly was ‘Mr. Reliable’ at the club

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GORDON 7 A D! 1930-2016 D

erby County “legend” Gordon Guthrie sadly passed away recently aged 86 years old. As Derby’s longest serving staff member he spent more than sixty years at the club, primarily as Club Physiotherapist. However, like most who served in the years leading up to the late nineties his role extended way beyond that to include coaching, match day preparation and lending an ear to all at the club as a trusted ‘confidant’. Throughout the years many managers valued Guthrie’s presence and expertise at the club, including favourites such as Brian Clough, Arthur Cox and Dave Mackie. Former Derby County manager, player and England international, Roy McFarland who signed for the Rams in 1967, said Mr. Guthrie had Derby County “running through his veins”. He later went on to state: “It’s a shock to hear this and my thoughts are with his family. Gordon truly was ‘Mr. Reliable’ at the club. The hours he spent at the ground over the years were fantastic” Derby’s Chief Executive Sam Rush also joined the tributes: "It goes without saying, everyone at Derby County is saddened to learn of the passing of Gordon”

Former Derby and England player Colin Todd, who later also managed the Rams, said that Guthrie was a "lovely person" and “an absolute gentleman”.

“

He was a great physio and ambassador for Derby

Todd in a moving account also said of Guthrie: “he was one of those people who had time for everybody. He was one of those people which every football club needs, very loyal and hardworking. Hearing the news of his death is very sad. Thousands of people respected him. He was a great physio and ambassador for Derby." Former Derby Managers Nigel Clough and Nigel Pearson were also amongst the many who have paid tribute to Gordon in recent weeks.

Gordon was bestowed with numerous accolades throughout his career and he is likely one of the most decorated physiotherapists in the game. In 2009, he was given the Merit Award by the Derby County past players Association which was topped later in that same year when he was awarded an MBE. Gordon was also presented with the League Managers Association ‘Services to Football Award’ in 2015 in recognition of his longstanding and meritorious service to the game. Nonetheless, perhaps his highest accolade received was the naming of a stand after him at Pride Park in 2013, a fitting award for man who displayed endeavour and commitment to his Club above no other. Valued by managers, colleagues, players and fans, Gordon truly was ‘one of a kind’ and demonstrated more than anyone else just how valuable and respected the ‘medic’ is considered within football. A minute’s silence was held before Derby’s recent EFL Cup game against Liverpool in yet another accolade befitting of one of Derby’s leading lights.

FMA FOOTBALL MEDICAL ASSOCIATION

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Pictured: Arsenal’s Francesc Fabregas celebrates scoring a goal against Everton in 2009 with a tribute to his friend and fellow footballer Daniel Jarque. Days earlier, Jarque, the Espanyol captain, suffered a heart attack in the team hotel during a pre-season tour of Italy and never recovered.

MANAGEMENT OF MEDICAL

AND CARDIAC INCIDENTS FEATURE/DR VINCENT GOUTTEBARGE PHD, CHIEF MEDICAL OFFICER - FIFPRO With the new season underway there is more focus than ever before on the health and well being of football players. Dr. Vincent Gouttebarge PhD, Chief Medical Officer of world players’ union, FIFPro discusses some of the issues concerning both players and clubs. There have been a number of fatalities in recent months from cardiac related incidents or accidents in the field of play, what is being done to reduce the risk of this happening? The main strategy to reduce the risk of cardiac related incidents is the screening of players for cardiac pathologies. Before the 2006 World Cup in Germany, FIFA asked the physicians of all participating teams to conduct a precompetition medical assessment in order to detect risk factors challenging players’ health with regard to (among others) sudden cardiac arrest i.e. sudden cardiac death (SCD). This pre-competition medical assessment is mostly based on the Lausanne Recommendations, including anamnesis (self-reported medical history), physical examination, blood analysis and rest-electrocardiogram (ECG). A few years later, in order to improve the (predictive) value of the assessment and conforming to the latest scientific medical standards, FIFA replaced the rest-ECG by a stress-ECG and added echocardiography as it has been shown of unchallenged value in the diagnosis of cardiac risk.

Is this pre-competition medical assessment mandatory in professional football? The pre-competition medical assessment has been made mandatory by both FIFA and UEFA for all their international and continental competitions (men, women, and youth). By contrast, the pre-competition medical assessment is only recommended for other UEFA competitions. At national level, the pre-competition medical assessment has been included as a requirement in regulations of several national associations or in the Collective Bargaining Agreement. This is well regulated in football top countries. However, based on a recent survey, FIFPro found that only 65% of the national footballers’ unions were aware that a pre-competition medical assessment had been made mandatory in their national competitions. Even more, national football federations might be using the Lausanne Recommendations without the stress-ECG and adding echocardiography.

in professional football. In a scientific paper published in 2014, FIFPro showed that from all fatalities that occurred among active professional footballers from 2007 to 2013, 25% was due to suspected cardiac reasons. From those due to suspected cardiac deaths, around 55% was directly related to football participation (that means that those deaths occurred during or shortly after training/ competition).

What are the concerns of FIFPro about reducing the risk of cardiac related incidents? In the past years, FIFPro has been intensively following the occurrence of sudden cardiac death

Equality of all professional footballers: FIFPro – the voice of more than 65,000 professional footballers worldwide – emphasises that professional footballers, being workers i.e.

Predictive validity of the pre-competition medical assessment: the validity of the precompetition medical assessment following the Lausanne Recommendations has been repeatedly questioned, especially the predictive value of the rest-electrocardiogram (ECG). Even if the cost-effectiveness issue might be relevant, the pre-competition medical assessment in any professional football organisation should involve, conformingly to the FIFA regulations, additional examination such as echocardiography.

football medic & scientist employees in the eyes of the law, should have the same rights from one employer to another for any matters, especially with regard to health and safety. Consequently, the governing bodies within professional football (FIFA, UEFA, AFC…) should not only consider the necessity of pre-competition medical assessment (including echocardiography) for players participating in the highest international or continental competitions but for all professional players participating to any professional national competitions, regardless of continents or countries. Compliance with the mandatory character of PCMA in national competitions: the governing bodies within professional football (FIFA, UEFA, AFC…) have made pre-competition medical assessment mandatory for players participating in the highest international and continental competitions, and only recommended for other competitions. At national level, precompetition medical assessment has been made mandatory by the football associations in many countries through regulations or Collective Bargaining Agreement. However, it seems that the mandatory character of pre-competition medical assessment is not fully respected by all professional clubs. Consequently, FIFPro is concerned that clubs i.e. employers do not comply strictly with (national) regulations and might jeopardise the health of our players. What initiatives would FIFPro like to see introduced for the new season? Because of our concerns related to the quality and implementation of the pre-competition medical assessment in professional football, we expressed several recommendations: Further research should be conducted about the validity of pre-competition medical assessment for the prevention of undesirable complications during football and for the reduction of SCD. Especially, the added value and predictive validity

should be made mandatory at all professional levels (including women’s football) by the (inter)national governing bodies regardless of continents or countries. In addition, cardiac evaluation based on detailed personal and family history and on thorough physical examination should be made mandatory to all youth players from any professional football club academy, starting by an age of 12-14 years old.

Pictured: (Above) Japanese defender Naoki Matsuda at the 2002 World Cup. Matsuda held 40 caps for Japan. In 2011 he suffered a cardiac arrest during training at club side Matsumoto Yamaga. He passed away days later aged 34.

of echocardiography to the standard Lausanne Recommendations should be evaluated, while attention to the quality and interpretation of the results should be given. In addition, the selfreported medical history through questionnaire should be followed by an in-depth interview in order to avoid any potential misunderstanding by players. The pre-competition medical assessment protocol in professional football across continents and countries should be standardised conforming to the latest scientific evidence. As FIFPro advocates the equality of all professional footballers across continents and countries, it is hard to explain to our players – all employees from the sacme occupational category – why they could be assessed differently within the same club (international players vs. non-international players) or from one club (employer) to another. The pre-competition medical assessment

The mandatory character of the pre-competition medical assessment for all professional footballers (including youth) previously advocated should be guaranteed. Therefore, evaluation committees should visit worksites in order to control and monitor the application and quality of (among other) preventive cardiac evaluation in professional clubs. A potential sanction system should be developed and implemented by the governing bodies within professional football (FIFA, UEFA, AFC…) in case a professional club jeopardises the health and safety of its employees i.e. professional footballers. There is a lot more awareness of the risk of cardiac arrest in football, but what else can be done to protect players at all levels of the game? At all levels, preventing sudden cardiac death is important but remains difficult. Making a precompetition medical assessment mandatory at all levels might not be feasible but a mandatory medical history and physical examination by a GP could be a good start. For instance, in several countries, you need a GP declaration to participate insome running events. Why not for footballers at amateur level? For footballers that might be at an increased risk for cardiac pathologies (with family history, at older age, with higher BMI), a pre-competition medical assessment might be conducted prior to football participation. In addition, medical equipment such as automated external defibrillator (AED) at all sport venues/grounds must be available, while proper first aid education should be given to players and coaches so that they can perform cardiopulmonary resuscitation. When an incident does happen is it vital that clubs and medical have a joined up strategy in place to deal with incidents quickly and effectively. Yes, the accepted rule is that you have two minutes to act when a sudden cardiac arrest occurs. In this two minutes, you need to recognise immediately the potential occurrence of sudden cardiac arrest (for instance when a player collapses without any collision or other players involved). Then, the emergency medical plan should be activated, cardiopulmonary resuscitation performed, automated external defibrillator as soon as possible applicate and the collapsed player should be transported to the nearest medical centre as soon as possible. For the health and safety of all professional footballers worldwide, it remains essential with regard to cardiac-related incidents to: (i) train medical staff properly in order to act adequately and efficiently when a sudden cardiac arrest occurs, (ii) provide all clubs with all necessary medical equipment, especially automated external defibrillator.

Pictured: (Above) Retired footballer Fabrice Muamba, who went into cardiac arrest on the pitch during an FA Cup match in 2012 -with Dr. Andrew Deaner (left), one of the men who helped to save his life.

This article was kindly reproduced with permission from fcbusiness magazine

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Pictured: England’s Gary Cahill and Danny Drinkwater during a training session at St George’s Park prior to their World Cup Qualifier against Slovakia.

THE MANAGEMENT OF RECOVERY STATUS IN FOOTBALL: A HOLISTIC APPROACH FEATURE/CARL WELLS - PERFORM, ST. GEORGES PARK Effective management of a player’s physical status is a key strategy for success due to the direct influence it has upon performance.

lthough the physical demands of elite football have been well documented, recent research has highlighted that high-speed running distance and sprint number in the English Premier League have increased by 30% and 85% respectively during the last seven years (2007 to 2014). Such evident progressions in the mechanical loads endured by players makes the assessment of recovery status more important than ever if chronic fatigue is to be prevented and injury prevention enhanced. However, the 10 month duration of the football season combined with the high number of competitive fixtures makes the process of managing appropriate levels of physical load difficult. For a scientist or medical

practitioner working within professional football, perhaps it is the detection and subsequent management of recovery status during the competitive season that is key and a more realistic scenario than the elimination of fatigue altogether!

understanding of an individual’s recovery status. Some key methods of recovery assessment are outlined below with guidance on how they are most effectively applied to gain informative data. Perceived Wellness

Methods of Assessing Recovery Status As the assessment of fatigue has become an area of focus within sport science, a number of methods for assessing recovery status have emerged, ranging from perceived wellness scores to measures of physical output and biomarkers of physiological stress. Sport Science and medical practitioners have various methods available to gain a holistic

The use of wellness questionnaires provides a highly individualised measure of perceived recovery status and can be tailored to gain information on indices that have a direct impact on an individual’s ability to recovery such as sleep quality and dietary habits. It is key that any information provided via a wellness questionnaire is an honest representation of how a player feels

football medic & scientist

Pictured: Charlton Athletic manager Russell Slade with players during pre-season training; they all wear monitoring devices.

with regards to the indices in question. Therefore the removal of peer pressure and development of trust between the athlete and practitioner is crucial if accurate data regarding recovery status is to be obtained. Physical Output A measure of a playerâ&#x20AC;&#x2122;s activity profile is the most tangible indicator of recovery

status as the development of fatigue will have a negative impact upon physical output that is objectively measurable. Key metrics that highlight physical output decrement due to fatigue manifestation are associated with reduced performance in high-intensity activities such as accelerations / decelerations, sprint count, high-intensity running distance and mechanical load asymmetries. It is

Figure 1. Representation of how physical load and recovery management impact upun player status,

important to closely monitor physical output data to ensure the onset of performance decrement due to fatigue is identified quickly to allow for the necessary adjustment of physical load. Neuro-Muscular Function A recent innovation has been the implementation of a simple movement screen, pre or post training / games, involving tests of neuro-muscular function in key areas of flexibility, mobility and dynamic strength. Although it has been noted that such screening tests have limited functionality, they can be more sensitive to changes in physical function than less clinical tests and therefore provide valuable information to a practitioner regarding recovery status. Heart Rate Variability It is well documented that the repeated exposure to high physical loads with insufficient recovery triggers a stress response that disrupts the bodyâ&#x20AC;&#x2122;s homeostasis. Research has revealed that the autonomic neural system and heart rate variability (HRV) in particular is sensitive to changes in homeostasis and hence can be used as a tool to detect recovery status. It is important to note that a substantial period of baseline data is required if HRV measures are to be effectively used, with several researchers recommending the use of a seven day rolling average to provide superior results compared to one off assessments.

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Pictured: A good relationship between the doctor and manager will last long after one party has departed the club.

THE CLUB DOCTOR AND TEAM MANAGER PARTNERSHIP FEATURE/DR MARK WALLER Some years ago following my rather nervous performance at interview, for the post of team doctor at a Premier League club, imagine my delight when my telephone rang and the manager offered me the job.

here was a condition attached to the offer however. The manager informed me that I was not to attend the training ground when the players were in for training until after 2 p.m. I respectfully asked why he had suggested such a stipulation for the post.

His rather curt riposte was; - “because I don’t want any medical men stopping my players training or playing with minor problems. If it is bad enough they will wait for you but most of them won’t”. My medical training had fortunately been sufficiently thorough to understand that

there are times to question a response and times when diplomacy is a more appropriate path to follow. Two weeks later I arrived at the training ground at exactly 2 p.m. having waited patiently around the corner in my car until the allotted time. After just one extremely enjoyable week in the post, with no coercion from myself, players had asked the manager if I could go in earlier so they could discuss a plethora of issues. It was with some trepidation that I waited outside the manager’s office, after the summons to see him was relayed to me by the first team physiotherapist. It was akin to standing outside my old headmaster’s office, which I recall happened a number of times, awaiting chastisement for some minor misdemeanor in my school days. The mouth was just as dry and the palms just as sweaty as I was called into the inner sanctum to be greeted not just by the manager but also his assistant and a Centre of Excellence Director. I was asked to sit, an offer never made by my headmaster making my previous analogy somewhat spurious. To my immense surprise my manager informed me that they had all been talking and perhaps it would be better if I could be in a little earlier if I could make it, understanding my other medical commitments. The subsequent comment surprised me even more; “tell me more about this prevention of injuries idea you’ve been talking about to the coaches?’ Thus started an extremely fruitful and amicable partnership with my first Premier League manager. I am aware that much has changed in the world of professional sport since that time. Many of the changes are for the better but not all. I have worked with some wonderful people in the sporting world, from many countries. My own role has expanded immensely over a number of years from a very part time commitment in combination with a part time physiotherapist to a full time position with a substantial medical department. Medics must not overemphasize their importance as part of the team but nor must they disparage their significance in their team’s achievements. I would suggest the analogy of a watch where the medical staff are just one of many wheels in the movement. Some constituent parts are more important than others but all parts of the watch are essential if it is to run with precision and accuracy. The relationship between the team doctor and team manager must be built over a period of time. The days when a doctor was revered just because of his or her title are long past. Respect must be earned and this does not occur swiftly. I fondly recall my old professor of paediatric surgery who had a large poster above his desk, which read: - “ Out of my last 1000 decisions if 999 were correct, which one do you remember?” This is so true of all doctors. We cannot afford to make mistakes and we all strive to limit the

football medic & scientist

possibility, as any mention of such will drive through the dressing room faster than a bushfire in the Serengeti. As well as professionalism and competence a manager expect honesty from their doctor. There is no place in the medical room for a doctor who is a sycophant. We should have no time for obsequious senior medical staff who merely want to be told what to do and have no original thought themselves. Healthy discussion on player’s injury management should be encouraged but we are clearly aware that ultimate responsibility for player’s care lies with the team doctor if he or she is leading the department. I am sure there are legal nuances with this statement but I believe that many of the managers I have worked with would agree with my opinion. As doctors we are obviously involved in diagnostics, treatments, rehabilitation, prevention of injury and many others areas in patient management. Ultimately though we manage risk. It is often not just our decision if a player is deemed ‘fit to play’. We have to be able to discuss with the player and the manager what is the risk involved if he or she plays with an injury. We have to try to quantify this risk. In our current state of knowledge this is not something a computer or algorhythm can tell us. It is not something we can look up in a book or read in a journal. It is what some of my academic colleagues frown upon, as it cannot be quantified, called clinical acumen. It is a combination of knowledge and experience that allows decision-making on complex issues. Managers look to us to advise them on medical issues but not to pick the team. In taking risks we must be aware that

Pictured: Ultimately our principal role is to care for our patients.

our own kudos may be damaged. The press can be scathing if a player breaks down with a re-injury and our peers and colleagues may also be critical despite a dearth of knowledge of the case involved.

This cannot dissuade us from offering these options to our manager and players. A quality I believe helps to cement a good relationship with our managers. When running a medical department at a football club, at times, we tread an extremely delicate path. We have a potential conflict of interest with players as we have a duty to the club as our employers, an obligation to our manager as he is in charge of the team, all members of which we care for. Ultimately though we have a duty of care to our patients (players), which must always be our principle concern. It is essential that in our discussions with our team manager these concerns are understood. I am indeed fortunate that this has rarely caused conflict between my manager and myself but I am aware that this is not universal. Football is a profession analogous to few others. At times such elation but at others such melancholy. However, the relationship with our colleagues, the comradeship our profession inspires makes the job such a wonderful experience. As I indicated earlier in this article, the role of the club doctor has undoubtedly changed during my years in post. The values we should adopt, as doctors, must not. Our fundamental role is to care for our patients as suggested as long ago as the fifth century BC by Hippocrates. Ultimately this will be a quality team managers will admire.

Pictured: With Netherlands striker Dirk Kuyt in April, 2010

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Pictured: Barcelona’s Luis Suarez during a training session at St George’s Park, Burton in July. Barcelona used the centre as a training base before games in the International Champions Cup.

TRAINING PERIODISATION:

Figure 1.

football medic & scientist high-level sprinters (who train following an identical periodised training regimen), targeting the same main events in the same competitive season (unpublished data) (Figure 2). Taken together, this evidence brings into question the role of periodisation in optimising actual performance during the planned peaking phase and reinforces the need to identify better strategies to control and improve the athletes’ sporting capability. THE PHYSIOLOGICAL PARADOXES: BASIC OR CONCURRENT CAPACITIES? The traditional periodisation model assumes that a relatively prolonged period of basic training (general preparation) is a prerequisite to a more specific phase (special preparation)8-15. During general preparation, strength and conditioning coaches aim to improve cardiorespiratory endurance and strength-endurance, even in athletes competing in power-speed sports disciplines (sprint and long jump events). This is surprising, as it has been known since the early 1980s that high volumes of endurance training are capable of attenuating the chronic gains in muscle strength and power, principally in highly trained subjects16-21. Although the molecular aspects of this interference effect have been extensively debated in sport sciences19-21 and still need to be fully elucidated, it seems that the multiple signaling responses induced by endurance training are capable of inhibiting protein synthesis and muscle hypertrophy, which is possibly related to the antagonism between the adenosine monophosphate activated protein kinase (AMPK) and mammalian target of rapamycin complex 1 or mechanistic target of rapamycin complex 1 (mTORC1) signaling cascades19. Another common belief related to strength-power development, is that the socalled ‘strength foundation phase’ will provide positive transfer of maximum strength to the ability to produce muscle power in the subsequent training phases22. To date, there is no strong evidence supporting this belief, mostly held in traditional literature written at best on the basis of authors’ personal experiences and not supported by research work3,23-26. Conversely, there are extensive studies showing that training using heavyloads (i.e. maximum strength training) results in improvements only in the high-force/ low-velocity portion of the force-velocity curve, without necessarily affecting the ability to produce higher amounts of force at high velocities (muscle power)27-31. In effect, it appears that the parametric relationship between force and velocity (i.e. the higher the load, the lower the velocity) plays a key role in modulating chronic neuromechanical adaptations32. Some studies have even reported significant decreases in power-speed related motor tasks (i.e. short sprints, agility tests and peak velocity in vertical jumps) after periods of heavy strength training33,34. Importantly, the theoretical and speculative ‘delayed training effect’ concept assumes that training basic capacities at earlier phases of the periodisation cycle has positive effects on actual performance long after this period of general overloading. The question that remains to be answered, is whether

A COMPLICATED METHOD VERSUS A COMPLEX PHENOMENON The periodisation structure is quite complicated and is centred on a series of rigid and inflexible concepts which emphasise the necessity to progress (within the same training cycle) from basic to particular aspects of the specific sports performance8,43. Indeed, for most sports disciplines, the current congested competition (and training) schedules44,47 make it extremely difficult for strength and conditioning coaches to adopt this classic and theoretical method. Even recent ‘undulated periodisation training regimens’48,49 are difficult to implement in high-level sports, where the preparatory events are qualifiers for the main competitions (e.g. competitions during an Olympic training cycle) and/or tournaments where all matches have the same importance (e.g. a national soccer championship). To meet the needs generated by this increased competitive demand, some authors have proposed the use of the ‘block periodisation model14,50 – a periodisation regime based on the original idea of exclusively concentrating a specific training target during a block (e.g. a maximum strength block), in order to reduce the possible concurrence between two or more physical capacities. In fact, this training model showed to be more effective than the traditional periodisation in achieving positive adaptations in certain aspects related to specific sports performance51,52. Nevertheless, this ‘specialised training system’ usually requires considerable amounts of time to be implemented (4 to 5 weeks per block), which highly compromises its usefulness in toplevel sports. In addition to the ‘periodisation puzzle’, actual competitive performance in elite sports is somewhat complex and depends on a wide range of unpredictable and changeable factors53. Therefore, considering the technical hitches that arise from the problematic combination of managing training schedules and controlling peak performance, seeking simpler and more effective methods than the segmented programmes of periodisation is highly recommended to train professional athletes, who frequently have to maintain their peak or optimal performance. TRAINING TO THE POINT Identifying practical measures which best correlate to actual sports performance in elite athletes may assist strength and conditioning coaches in selecting appropriate tests to monitor variations in peak performance and choose the best methods/exercises to enhance athletes’ competitiveness. For instance, Loturco et al54 found that simple and timesaving vertical and horizontal jump tests are strongly associated with competitive performance in the 100 metre sprint. When combined in a multiple regression linear equation, squat jump height and lower limb muscle power (assessed in the squat jump exercise) could be good predictors of Paralympic sprinters’ competitive results, besides being directly related to their performance peaks55. Furthermore, loaded and unloaded jump tests have been extensively associated

with sport-specific motor skills such as punching acceleration in karate56, punching impact in boxing57, swimming speed in sprint swimmers58 and change-of-direction ability in rugby players59. From an applied perspective, coaches could use these rapid field measurements to increase or decrease training volume and intensity, in individual or team sports according to the performance presented by a given subject during a particular test. Moreover, since actual athlete performance may be directly related to a determined capability (e.g. vertical jumping ability)60, coaches could simplify their training regimes, by adopting methods/exercises able to improve this specific capacity. Certainly, further studies should be carried out to identify other functional assessments or simple physiological measures to predict sports performance in a wide range of sports disciplines61. It is suggested that sports practitioners should interpret these training outcomes in the context of the loads applied to the athletes. Since large inter-subject variability in ‘internal training load’ can be observed within a squad submitted to similar external training loads62, the quantification of individual physiological and perceptual demands is highly advisable. In this sense, heart rate-derived training impulses63 and session rating of perceived exertion64 methods have been spread among athletes and teams. The observation of these useful concepts may contribute greatly to the development of better and more applied strategies for training elite athletes. LOOKING FOR THE OPTIMUM TRAINING ZONES In traditional modes of strength training, loading intensity is commonly based on different percentages of one repetition maximum (1RM)65-67. For instance, at the start of a training cycle, the athlete usually performs resistance exercises using lower percentages of 1RM (40 to 60% 1RM), gradually increasing these ratios as the macrocycle advances and the competition gets closer (70 to 95% 1RM). Although this sequence of loading has been recognised as a classic ‘periodisation methodology’ for more than 5 decades68, little is known

Figure 2

about the exact importance/role of this temporal training pattern in the subsequent fitness improvements. In fact, previous studies have already reported that distinct temporal organisations of the strengthpower exercises69,70 promote equivalent enhancements in numerous neuromechanical capacities such as maximum strength, muscle power and sprinting speed. In addition and perhaps more importantly, the determination of 1RM values is very time consuming and it has been suggested that this measurement may expose those being assessed to increased risk of injury71-73. With these limitations in mind, coaches and sport scientists have been trying to find more practical and effective methods to train and optimise the neuromuscular abilities of their athletes. In this regard, it was reported that training at the ‘optimum power zone’ produces similar performance improvements to traditional strength training in moderately trained subjects74 and can reduce the decrements in speed and power capacities that commonly occur in elite soccer players during the short pre-seasons44. Importantly, in a recent study, it was observed that this training regime is superior to a classic strength training model in increasing the neuromuscular performance of top-level soccer players throughout an in-season training period75. Of note, for training at this optimum zone (i.e. range of loads capable of maximising muscle power production) the athlete does not have to perform any 1RM tests44,54,60, which greatly simplifies strengthpower training prescription and control. Importantly, it seems that this training regime may provoke positive adaptations at both ends of the force-velocity curve (high-velocity/low-force portion and lowvelocity/high-force portion)34,74,76,77, without compromising the athletes’ ability to apply force at any velocity. In addition, it has been reported that the power outputs collected at these zones – and even the magnitude of the optimum power loads – are highly associated with performance in a wide range of sport-specific movements57,60,61,78-80, which possibly increases the importance of training in these zones. However, since this load varies according to the exercise performed

Pictured: Newcastle United manager Rafael Benitez oversees a fitness session ahead of the start of the new Championship campaign at their Darsley Park training centre in June.

(e.g. squat or bench-press), it is essential to carry out further analysis to identify the best training zones for each specific movement. Moreover, detection of optimal loads depends on the specific kinematic devices (accelerometers or linear encoders), which could be a problem for practical field measurements. Indeed, it is clear that the optimum power zone method calls for effectiveness trials81 to further confirm its usefulness in various sports settings, especially application in the long-term and in athletes of different ages and competition levels. Even with these limitations, the optimum power zone may be an applied and efficient alternative to traditional modes of strength training periodisation. TAPERING STRATEGIES Tapering is probably one of the few constructs in the periodisation methodology which is widely supported in the literature82. Periodisation theorists state that ‘performance supercompensation’ is the final outcome of this method, purporting that it is accumulated across different training phases, through the summation of expected and predictable delayed effects. In fact, there is strong evidence demonstrating physiological and performance enhancements after planned reductions in training volume and increases in training intensity35,82,83 and this strategy is commonly used by coaches as a ‘pre-contest’ approach. Importantly, similar effects are also observed both during active and complete training cessation during the transition phases (i.e. the off-season periods)84,85. Therefore, it appears that improvements in athletes’ performance can be observed independent of the strategy adopted to diminish the training loads, occurring even after short periods of

‘detraining’. It is very plausible that improved sport form after periods of reduced training take place because the concurrent (and sometimes detrimental) effects of general (non-specific) and specific (fatiguing) training are partially withdrawn. Thereafter, athletes are able to present greater improvements in their competitiveness, since it is expected that this ‘unloading training strategy’ potentially allows full expression of their non-fatigued physical, technical and tactical capabilities. CONCLUSION AND PRACTICAL APPLICATIONS It is evident that this article will not resolve the controversies and debates which surround the conceptual basis of training periodisation. However, it highlights a clear need to develop more applied, effective and realistic methods of training (and developing) professional athletes, who compete several times per year and need to maintain near peak performance throughout the macrocycle. Even for athletes and teams with a low number of competitions/matches during a given period, the periodisation concept should be revisited, since its rate of effectiveness to control and attain the athletes’ peak performance is very low. From a practical standpoint, monitoring athletes using tests which best correlate to actual sports performance is much more important than following theoretical concepts, which subjectively state that form might be predictable and controlled. With this simple and applied thought, strength and conditioning coaches may select better ways to control fluctuations in the competitiveness of individuals and teams, besides the already well-established variations in traditional training components (i.e. volume and intensity). It will help

coaches to detect unexpected adaptations in the athletes’ fitness traits and adjust training loads according to these measured responses. In this regard, the use of validated methods for daily assessment of the internal training loads might be a useful strategy to quantify/modulate training intensity and its respective dose-response relationship with the specific changes in physical qualities64,86. Further studies are necessary to develop more effective and applied methods to train and develop high-level athletes for longterm success, in order to better enhance their form, according to their specific athletic requirements. Finally, coaches are strongly encouraged to seek more accurate and practical methods to control peak performance on a daily basis, guided by feedback from simple measures, since the subjective and empirical concepts of training periodisation are not able to predict this crucial ‘point’ of athletes’ training cycles. Irineu Loturco Ph.D. Director of Sport Science and Research Leader Fábio Y. Nakamura Ph.D. Senior Physiologist Nucleus of High Performance in Sport São Paulo, Brazil Contact: irineu.loturco@terra.com.br

This article was originally published in the Aspetar Sports Medicine Journal, available from www.aspetar.com/ journal. All copyright is property of Aspetar and may not be reproduced without permission.

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football medic & scientist

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Pictured: Sean pictured during the national anthems in the match against England at Euro 2016.

WALES AT EURO 2016 FEATURE/SEAN CONNELLY, WALES PHYSIOTHERAPIST

Wales had qualified for the 2016 Euro’s after a successful 2 year campaign that had seen some memorable matches. Qualification for the first major tournament since 1958 was finally secured versus Bosnia thanks to favourable results elsewhere in the group.

he planning began; It was going to be a new experience for all concerned players, staff and of course the majority of the Welsh supporters. A lot of the football and medical staff were not full-time employees of the FAW, just the manager and his assistant. So from that point

onwards organizing everything would be left to the full-time members of the FAW with continual liaising with the football and medical staff on their needs for the tournament. Whilst this wasn’t ideal, I think all involved will agree that everyone did a fantastic job and everything ran well.

FITNESS & INJURIES As the end of the 2015/16 domestic season quickly arrived, there were still questions that needed to be answered. Who was fit and who wasn’t? And when were the players finishing at their respective clubs? We had players participating in a variety of leagues, who all finished at different times. This was going to be an issue, as players would be at different levels of fitness when they were due to report. However, I know that Dr Ryland Morgans had carefully planned a route for all of the players, so that when the players arrived for screening we had a much better idea of where the players were at. In terms of injuries, the only player who was a major doubt for the tournament was Joe Ledley of Crystal Palace. It just so happens that I was his physiotherapist there, so I had some further insight on his condition. Joe had sustained a fracture to his left fibula in the premier league fixture against Stoke City. There were five weeks between his injury and the first game versus Slovakia, and only three weeks until Chris Coleman had to name his final squad, so were all up against it on every front and we knew it. It was a once-ina-lifetime opportunity for Joe and so we did everything we could to maximise his chances. I went away and spoke to several experts, did some research on bone healing and came up with a personalised accelerated rehab program. If he was to make it in time, then he would have to be in training with the team the week starting June 5th. That left me just four weeks! His first week was spent in a Aircast boot, so that left me with only three weeks. Well, as we all know, Joe came on during that first game, was involved in the winning goal and the rest after that they say was ‘history’. It was an amazing story and there are a lot of people who helped me along the way, but throughout it all Joe committed himself to what we were doing and worked hard in all aspects of his rehab. Joe got his just rewards in the end by being part of such an amazing journey; he even managed to throw in a few decent dance moves on the way too! PREPARATION Before the Euros we met up and travelled to Portugal for a week for our pretournament camp. We then returned to Cardiff for one week before flying to Sweden for our only pre-tournament game, which unfortunately ended in defeat. After this we flew to our camp base in Dinard, France. Apart from the players, our team consisted of two medical doctors, three Physiotherapists, three soft tissue therapists, two Sport Scientists, two Analysts and one Head

of Performance - not to mention the countless coaching staff, ground staff and all other members of (Head of International Dept.) Mark Evan’s team that were there to provide continual support us all. When we arrived in Dinard it was all setup! At the training ground the FAW had a erected a purpose-built marquee for day-to-day use by the medical and sport science department, this also included a gym and treatment area. The hotel itself was excellent and tucked away in a beautiful corner of Brittany overlooking the sea. Lots of branding had taken place and so the hotel was set up to make all the staff and players feel at home. Inside, there was the usual table tennis table and a gaming room with a giant screen to watch the matches on. I think if you ask the players, boredom never really sunk in, and the boys were just enjoying the fact that the games came around so quickly and that they were doing so well in the competition. To be honest, there wasn’t any time to become bored. In fact, speaking to the players after the tournament revealed that they found it harder in the weeks following, as they were missing the whole tournament experience and the camaraderie of all being together. THE EXPERIENCE I’ve been in professional football for over 25 years as a player and physiotherapist and have had some amazing experiences,

Pictured: Wales players and staff in celabratory mood in a picture taken by Sean during the tournament.

but the summer of 2016 will always be up there with the best of them. During the competition, I cant remember a testing moment or a time when I thought ‘I’ve had enough’. Yes, I missed the family,

Pictured: Sean pictured with Joe Ledley, whom he helped overcome a fractured fibula in time to play in Wales’ Euro 2016 opener.

who wouldn’t? But we all realized that we were taking part in history and we were enjoying every minute of it. Once the tournament had kicked off it became about training, playing and recovery. We travelled the day before every game and the advance parties had set everything up for us, so there were never any issues. After the games the boys soaked-in the post-match celebrations and by the time we’d all finished the boys had also returned and had finished their mandatory drug testing, everything ran smoothly . Each time we went back to Dinard on cloud 9 and prepared for the next game. Obviously the England result was disappointing, but the boys reacted well and responded to produce a magnificent display against Russia. The planning for training was meticulous and was a big part of the reason why we didn’t pick up any major injuries and our availability percentage for the tournament was 98%. The staff worked tirelessly to find a way through for all the players. The modern game demands different things from these players and the job of the whole multidisciplinary team is to work together to ensure the coaching staff and manager has his best players available when he most need it. I believe we were able to do that because of the whole support system that was in place to look after not only the players and staff but for those that were supporting us. It was a truly magnificent team effort from everyone and I think that was obvious to those looking at us from the outside.

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