Football Medic & Scientist - Issue 7 by Football Medicine & Performance Association

FOOTBALL MEDIC & SCIENTIST

The official magazine of the League Medical Association

WORKING ABROAD The highs and lows

HEAD INJURIES

Who decides?

MEDICOLEGAL

Part II: Who am I Responsible to and for?

Issue 7: Winter 2013/14

Contents Welcome 4 A Message from the Office / Members News

Editorials & Features 5 Touchline Rants / Diary Dates 6 Working Abroad: The Inside Track 10 Legal Focus 12 Back into the Fold 15 Where Are They Now? Mike Varney 16 The LMedA Conference 18 Muscle Pain in Football 20 Northwest Football Awards 2013 22 Head Injuries… Who Decides? 24 Using Skeletal Ultrasound in Professional Football 28 Evaluating the Effectiveness of MRI as a Prognostic Tool for Hamstring Injuries

EDITOR’S COMMENT/JON REEVES

would like to take this opportunity to say Happy New Year to all LMedA members. I hope you had an enjoyable Christmas, which will have coincided with one of the busiest times of the year from a professional perspective.

The fixtures come thick and fast over the festive period, placing an even greater demand than usual on the medical and science team at football clubs at every level. Perhaps your thoughts may have turned to the benefits of a winter break or the temptation of working abroad. In this edition of the magazine our main feature focuses on the experiences of two English physios that have tried their hand at working in more exotic climes. You can read the highs and lows of their foreign adventures on page six. The Winter issue also focuses on the topical story of treating head injuries, further legal considerations that members need to be aware of and assesses the use of a number of treatments, including skeletal ultrasound and the effectiveness of MRI as a prognostic tool for hamstring injuries. Our regular ‘Where Are They Now?’ and ‘On the Couch’ articles feature former Tottenham Hotspur and QPR physio, Mike Varney, and current Crystal Palace Head of Sport Science and Strength & Conditioning, Scott Guyett and we also take a look at the conflict and confusion that often exists between referees and physios, and again preview the inaugural LMedA Conference taking place in May. So there’s plenty to keep you going over the next three months or perhaps to cram through on a particularly arduous away day journey! We’ll be back with issue 8 in the spring.

Jon Reeves WORKING ABROAD: THE INSIDE TRACK COVER STORY/GARY WEBSTER The opportunity to join a foreign club and work in another country is often an attractive one for our members. The chance to jet off to warmer climes and be involved with glamorous clubs with ambitious projects may only come up once in a lifetime and is seldom an easy decision to make. We speak to two members that have taken the plunge and opted to leave the UK to find out their experiences of working abroad. DOMINIC ROGAN/ANZHI MAKACHKALA

a couple of players that we’d both worked with. After we spoke, he basically offered me the job and said that he wanted me to start in two weeks! The appeal of the role was the ambition of the club. It was clear it was a project in its infancy. The owner had been investing for the last two years with measured success. Everyone is well aware of the big-name coups like Samuel Eto’o, but the running and structure of the club, including the medical department, was still in its inception – they didn’t even have a training ground at that point. Stijn explained to me that planning was well on its way for the development of a cutting edge facility and that starting around the same time as me would be five other members of staff to form a brand new medical team. I linked up with the team during a training camp in Austria at the start of July 2013. My first impressions were very good, there were two other English lads, Danny Flitter and Will Storey, who had started as masseurs two weeks earlier, so I instantly felt more relaxed. I remember being surprised at the diversity within the playing and coaching staff. There was a clear old/new divide in both camps, with the personnel connected to the Dagestan element of the club being the more established characters, representing the clubs progression from when it was based in its homeland, Makhahkala.

In contrast to this, was the stereotypical glitz and glamour disposition of the modern day footballer, emanating from the shores of Brazil, Cameroon, DR Congo, France, the Ivory Coast etc. It was an extremely different environment to Everton, and although the word ‘clique’ elicits a negative connotation, it’s understandable that they develop within such a widespread group of individuals. However, they were all similar in their approach to me; all very pleasant and welcoming. Things started to change at the club after Guus Hiddink departed. He was expected to leave in the summer after his previous two years at the club but signed a two-year extension only days before I arrived. Just three or four weeks later he was sacked after a relatively poor start to the season. It surprised everyone, but as is customary in football, we moved on quickly not thinking too much into it. Looking back now, it was clear that something wasn’t right. At this point, the club hadn’t folded, but the previous project had ended. The chairman, Suleyman Kerimov, made it clear he wanted to completely change the ethos of the club towards one of long-term, home grown, self-sustenance. All of that meant an immediate exodus of the big name players.

The future of the medical staff wasn’t made clear, provoking a period of stress in the department, which included rumours of the team moving to Dagestan. A couple of weeks later, the staff who decided they wanted out were allowed to leave and that was that. Now I’m living back home in the North West and looking for the next adventure. I’m keeping my options open during the job search and trying to remain as patient as possible, as I know it can be a slow market. It gives me the chance to develop and attend a lot of courses and conferences that I’ve previously been unable to go to. I’m also keeping busy working privately and at my local semi-pro football team, Bamber Bridge, which is always good fun. Overall I learnt a lot from the experience at Anzhi, including a little bit of Russian and that vodka will still give you a stinking hangover even when consumed in its motherland! Obviously, in hindsight, you have 20/20 vision but if an opportunity like that came up again I would still be very interested. You can’t live your life in fear and I’m glad I took the chance. You can never control your external circumstance, no matter what the situation.

SIMON MALTBY/BAHRAIN NATIONAL TEAM

fter seven years working on the medical team at Everton, English physiotherapist Dominic Rogan was given the opportunity to join emerging Russian side Anzhi Makhachkala in the summer of 2013. The club’s ambitious billionaire owner Suleyman Kerimov had grand plans for the future, appointing Guus Hiddink as manager and bringing in big-name signings like Samuel Eto’o, but things didn’t work out as planned and after the team struggled on the pitch and the club undertook a change of direction, several members of the backroom staff, including Dominic, departed the club. Dominic explained what happened in more detail, recalling his time at Everton, being

approached by Anzhi and finally returning to the UK from Russia… I loved my time at Everton. It’s a point that is made regularly, but the club is full of special people; the staff, players, everyone involved, plays a part in making it such a warm and welcoming place to work. I was one of four physiotherapists in the first team’s medical department. Everyone’s role was different and I guess the obvious one with mine was that I provided the match-day cover for home and away games. Collectively, as a department, we would always strive to ensure the players received the highest standard of medical and athletic care possible, and everyone played their own role in that.

I first heard of Anzhi Makhachkala’s interest when I received an impromptu phone call whilst camping in the off season from my would-be-boss, Stijn Vandenbroucke, who spoke with a thick Belgian accent. I had developed a high defence mechanism from my time working with the pranksters at Everton, so I presumed it was just the latest in a long line of scouse antics! But, I deciphered the accent and my guard dropped. We spoke for an hour about the project at Anzhi, how the team were aiming for Champions League success and how it needed to develop all departments of the club to facilitate this, with the medical department being of interest to me. He explained he was aware of me through

After spending eight years as Hull City’s physiotherapist, Simon Maltby opted to leave the club for pastures new in 2011. Just a week after departing the Tigers, he began a new experience in Bahrain, linking up with his former manager at the KC Stadium, Peter Taylor, who was coaching the country’s national side. Simon went on to spend 18 months in the Middle East, assisting Bahrain in their bid to reach the World Cup, before returning to England to set up his own private clinic. He talked about the challenges, the perks and the high-points of his Bahrain experience, getting out of his comfort zone and also provided advice for those thinking about plying their trade in another country. I still had a year on my contract at Hull

City and it was a hard decision to leave after eight great years. Going from Division 2 to the Premier League in five years was a great experience and achievement by everyone at the club. I struggled in the last year after our relegation from the Premier League and the subsequent collapse of the development of new training ground and medical facility. It was difficult having managed so long with what we had and then discovering that investment in the new facility wasn’t going ahead. I was the only full-time chartered physiotherapist at the club in 2011 and trying to do the first team physiotherapist role and head of medicine was quite difficult at that level. On reflection, I know I could have developed things on the medical side better

FOOTBALL MEDIC & SCIENTIST | 7

involved in football.” Mike, who lists former physios Bertie Mee and Fred Street as his inspirations, mainly has happy memories of his time involved in football, as he explained, “You get to travel to some fantastic places all over the world. At Tottenham, the management team of Keith Burkinshaw and Peter Shreeves were fantastic to work with. I particularly enjoyed the environment at the training ground and at White Hart Lane. Keeping players fit and getting them ready to return to play was a part of the everyday activities and doing that well helped the team to succeed.” Mike also spoke in more detail about his day to day role as a physio at a football club and how his background in the army assisted him. “I worked alone for several years before being a part-time helper and full-time assistant. I was able to adjust to the developments in areas like nutrition, massage and strength and conditioning due to my background as a member of the army physical training corp and being an athlete myself.” Talking about the modern day professional game, Mike ruled out a return, saying. “I’m too ancient to get back into physiotherapy at a football club on a day to day basis, even though it would probably be a doddle with the number of physiotherapists at the big club nowadays!” Mike remains in touch with a lot of the players he used to work with but declined to elaborate on any amusing anecdotes from his time in the game, admitting that, “There are many funny stories but they will remain untold until I write my book!” Mike has remained busy since departing his role at QPR, continuing to work for several of the practices he has established over the years, including the Varney Practice, which is now run by his son, Steve, and Mike Varney Physiotherapy. He has also become the chairman of Isthmian League Division One side, Ware FC, a role that is reliant on keeping a tight ship, as he explained, “As a chairman, particularly in the lower level of football, budgets are everything. Working to a tight budget is absolutely key.”

WHERE ARE THEY NOW? FEATURES/MIKE VARNEY During the past 30 years, Mike Varney has worked for various football clubs, including Tottenham Hotspur and Queens Park Rangers, where he finished his career as a full-time member of staff within a professional club.

ike, who has 40 years of experience as a practicing Physiotherapist, previously served in the army, where he qualified as a remedial gymnast before being accepted as a member of the Chartered Society of Physiotherapy and beginning his career in football with non-league Kingstonian. He now works at the Harlow Leisurezone physiotherapy practice, where he specialises in musculoskeletal and sports injuries. Mike, who remains involved in football as the chairman of non-league side, Ware Football Club, spoke to Football Medic and Scientist

about the highs and lows of being involved in the professional game. “The most memorable moments of my career came with Tottenham, where we won two FA Cups and the 1984 UEFA Cup, beating Anderlecht in the final,” Mike said. “The best part of football is being involved in a winning team. But, the biggest disappointments also came during the biggest games, such as having to give fitness tests to players before FA Cup finals and deciding that they weren’t fit enough for selection. That and the long hours I worked at Tottenham were the worst parts of being

For more information on Mike Varney and his practice, visit www.mikevarneyphysio.co.uk This feature was kindly produced with assistance from Gavin Blackwell.

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FOOTBALL MEDIC & SCIENTIST | 3

A MESSAGE FROM THE OFFICE WELCOME/EAMONN SALMON That our Inaugural Conference has resonated with so many of our members and colleagues is testimony to the work we are undertaking and the direction in which we are steering LMedA.

ith a strong emphasis on the ‘Community Spirit’ among us, we are bringing everyone together to re-create the camaraderie that was always so evident in years past. Of course, we are a much larger group now and in that sense it is even more important to nurture our network so we can begin to address some of the issues that concern us. The second article of Mary O’Rourke’s in this edition underpins some of these issues and sets out our stall as we establish our ‘raison d’être’. It is clear that no one individual can stick

Mark Gillett on Board as LMedA Committee is Finalised

ark Gillett has agreed to sit on the LMedA Committee, thereby filling a position earmarked for a medical representative from the Premier League. Mark is well known for his experience and knowledge within football medicine and is in an ideal position to push forward the medical involvement within the association and liaise with the current Premier League Doctors Group. Previously a Consultant in Emergency Medicine at Heart of England Foundation Trust, Mark is much respected in his role as Director of Medical Services at West Bromwich Albion, and is also involved in British Basketball and with various other sporting organisations.

their head above the parapet and comment on our current working practices and difficulties they encounter. But LMedA as an organisation can. Indeed, we must if we are to redress some of the conflicts that burden us as we attempt daily to integrate clubs ‘traditional’ practices into our work without compromising our ethical obligations. As highlighted in this issue, any practices we undertake beyond our scope technically ‘invalidates’ our Indemnity, leaving us in a precarious position to say the least. Yet we put ourselves in this situation every day!

Indemnity it seems is set to become a major issue for our members. Fortunately it is one that LMedA is already making great strides to address. Eamonn Salmon CEO League Medical Association

1000 Club

ave you officiated at 1000 or more games?

Congratulations to Gary Lewin

ongratulations to Gary Lewin who has recently clocked up his 200th game as England physiotherapist. It is a great achievement and testimony to his popularity among the players, staff and colleagues in the game. Indeed, Gary may be the one figure that embodies the national team since players and staff come and go and Gary, it seems, has been the only constant over the past 10 years.

If so you need to make sure you book a place over at our Inaugural Conference in May where there will be recognition of this outstanding achievement. You will be in good company with Rob Swire, Derek Wright, Dave Galley, Alan Smith, Mike Varney, Dennis Pettit and a host of other current and former colleagues who will be at the event. We would like to have as many recipients as possible for this award so if you know anyone past and present, make sure you point them in our direction. Email Nicola@lmeda.co.uk to notify us if you or one of you colleagues are eligible for the ‘1000 Club’ award!

MEMBERS’ NEWS

Touchline sid!e Pete Rant hs by Pitc

COLOURED GLOVES What is it with all the coloured gloves being worn by medical teams on the pitchside? I totally appreciate that if you have a latex allergy, latex-free gloves are essential. But where did everyone suddenly get latex allergies? Not long ago, gloves were not a compulsory piece of kit – It is great to see that everyone now wears them. The down side of gloves is the smell that mixes with ‘Deep-Heat’ after the game that takes extensive scrubbing to get rid of... and even then, not normally for 24 hours! Some Physios only used to wear one –

justifying it by saying that they would only use the gloved hand when dealing with blood! I’m not sure that you can ever be as certain as that. Are the coloured ones a fashion statement? Are they ‘bang on trend’ if they complement the sweat tops you wear? Would you wear simple white ones if the sweat top colour was different? Surely not everyone can be allergic to latex? Maybe it comes from wearing latex too often... but what you do on your days off is your business...

ON THE COUCH... FEATURES/SCOTT GUYETT 1. Profession? Head of Sport Science and Strength & Conditioning at Crystal Palace Football Club.

a slow start I believe we are starting to look a lot stronger and harder to beat. The new manager has instilled a real sense of belief into the players in the few weeks he has been here.

2. Where did you train? What Course? When? I started a distance learning Sport and Exercise Science degree through Manchester Metropolitan University back in 2004. 3. How did you get into football? I played professionally for about 12 years and it was while I was playing for Yeovil Town that I started my degree. Yeovil is a small town with not an awful lot to do so I thought it would be a good opportunity to start planning for my time after football. Because the degree was part-time and distance learning it took five years to complete. I can remember a lot of people saying to me at the time that I would never complete it. Thankfully I stuck it out. 4. Talk us through your career to date? As a kid I grew up in Australia but I always had an ambition to play professionally in England. When I finished school I decided to come to England and try and find a club. After a couple of years of playing Conference football I finally broke into the League and ended up having a reasonably good career at Oxford United, Yeovil Town and AFC Bournemouth.

5. Who has been the best manager you have ever worked with as a Sport Scientist? As a player I worked under some very good managers, three of them are still currently managing in the Football League and doing very well; Gary Johnson, Russell Slade and Eddie Howe. As a Sport Scientist I worked under Dougie Freedman when he was manager at Crystal Palace, who I thought was excellent. I’m currently working under Tony Pulis who has recently been named the new Crystal Palace manager. He brings a wealth of experience to the club and although he has only been here for a short time, I feel I can learn an awful lot from him. 6. How’s the job going at the moment? The job is going great. After promotion from the Championship into the Premier League last year it has been non-stop. After

7. What are your long-term career plans? For a start I would love to stay in the Premier League with Crystal Palace and build a good solid sport science department. Getting promoted last year was a wonderful achievement but, for me, the real challenge is staying here. I have been lucky enough to play in League 1 and 2 and work in both the Championship and Premier League, and the Premier League is simply on another level. Long-term, I want to continue learning and become more qualified. I have applied for next summer’s A Licence course at St George’s Park and I’m hoping to get on that. 8. What would your dream job be? I think I’m probably doing my dream job now. I live in London, just a short walk to the training ground and I love going into work every morning and working with the players. I always knew that planning for a career after football was important so I am very happy that I took the decision to study while I was still playing. Apart from that, I’ve always wanted to be in a rock band... so maybe the drummer for the Foo Fighters would be my dream job!

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Working Abroad: THE INSIDE TRACK COVER STORY/JON REEVES The opportunity to join a foreign club and work in another country is often an attractive one for our members. The chance to jet off to warmer climes and be involved with glamorous clubs with ambitious projects may only come up once in a lifetime and is seldom an easy decision to make. We speak to two members that have taken the plunge and opted to leave the UK to find out their experiences of working abroad. DOMINIC ROGAN/ANZHI MAKACHKALA

SIMON MALTBY/BAHRAIN NATIONAL TEAM After spending eight years as Hull City’s physiotherapist, Simon Maltby opted to leave the club for pastures new in 2011. Just a week after departing the Tigers, he began a new experience in Bahrain, linking up with his former manager at the KC Stadium, Peter Taylor, who was coaching the country’s national side. Simon went on to spend 18 months in the Middle East, assisting Bahrain in their bid to reach the World Cup, before returning to England to set up his own private clinic. He talked about the challenges, the perks and the high-points of his Bahrain experience, getting out of his comfort zone and also provided advice for those thinking about plying their trade in another country. I still had a year on my contract at Hull

FOOTBALL MEDIC & SCIENTIST | 7

towards the end; and I should not have put everything on the new facility being developed in 2011. But, I thought at the time I needed a change and, fortunately, a few days after leaving Hull, Peter Taylor phoned me to talk about working for the national team of Bahrain. I am so pleased I decided to go to Bahrain, although at first I found adapting quite hard. It was a great experience; working for Peter Taylor again was very good, and we had a great English staff out there. The team also had some success, winning two gold medals in Arab tournaments (the first time for a Bahrain team). On a personal note, being involved in a World Cup qualifying campaign had always been an ambition. However, it was difficult at times convincing players and local staff in many aspects of their medical rationale. For example, it was almost impossible to convince them that they didn’t need injections for every injury or minor illness! Emphasising the importance of regular injury prevention work and strength and conditioning programmes was also a challenge. Educating them on game preparation and recovery was a little easier although during periods like Ramadan it wasn’t so easy. Working in a climate where, for eight months of the year, it’s probably 40°C plus had its challenges, particularly so in Bahrain where they didn’t have an indoor football facility, so training could be as late as 9pm. As a staff, I do believe we had some success during our time out there in all aspects with the players’ preparation, conditioning, their professionalism and their mentality. Disappointingly we missed out on the next stage of World Cup qualifying by a point with Qatar equalising against Iran in the last couple of minutes of their game to knock us

out of the competition. One of the biggest positives was the amount of travelling I did and being able to experience other countries. I think I did 54 flights in 18 months as we visited and played in Azerbaijan, Qatar, the UAE, Iran, Kuwait, Saudi Arabia, Indonesia, Egypt, Hungary and Germany. In terms of the Bahrain FA they looked after the staff well. We had contracts drawn up from the start and it’s certainly important to take advice on contracts and liability insurance when working abroad. We were provided with apartments, which were very nice with swimming pools and satellite TV so we could keep up with English football. We were also provided with cars and telephones, as well as medical cover and three return flights to the UK each year. The cost of living was fairly similar to the UK except that it cost £8 to fill your car up! On arriving in Bahrain there was, and still is, some political unrest but we were never really exposed to any problems. The two areas where we lived were very safe. I never felt uneasy and the people I came across were always fine towards me. The obvious downside to working away is being away from family and friends, but you do adapt and after a year or so I became fairly settled. Obviously, having other English staff there helped enormously, especially when we were not at international camps. Perhaps the hardest thing to get used to is that everything is a little more laid back in relation to getting things done quickly and time keeping. But again you just adapt and try to effect things gradually where possible. My overall experience of Bahrain was very positive. Obviously working in the Middle East is very different culturally, and it’s important to respect the beliefs and lifestyles of the Bahrainis. Family and religion are a big part of the players’ lives and this was important to understand, but they were also really enthusiastic about football (except when it was a ‘cold’ 25°C) and especially loved the Spanish and English leagues.

Bahrain has a huge percentage of expats and seemed very relaxed in comparison to other Middle East countries that we visited. I would recommend to anyone to go and experience the Middle East if the opportunity is right, in terms of football or other areas of physiotherapy or sports science. It would be a good starting point for those pursuing a career in football or professional sport. I would consider returning to the Middle East in the future as I don’t think it hinders your career development and it can even improve aspects of your clinical reasoning and management of athletes. I think you can learn quite a bit about yourself by moving out of your comfort zone. Upon leaving Bahrain after close to 20 months there, there were no problems with any contract issues or return flights, and I am still in contact with some of the Bahraini staff and players. Since returning I have gone into partnership in a clinic with a friend who is a sports scientist, strength and conditioning coach, and sports masseur so hopefully we can offer a good service to the general public and sports people alike. Our practice is called ‘Premieractive Physiotherapy’ and we currently have a clinic in Sheffield. We’ve already had a wide variety of sports people into the clinic, including Ronnie O’Sullivan, an IBF champion boxer, a GB diver, and a few different level footballers and athletes. We hope to open a new clinic in the Hull area in the New Year but I have not given up hope of returning to football sometime soon in some capacity, as I really do miss being involved, and football has been without doubt the best experience I’ve had whilst working as a physiotherapist.

For more information on Simon’s clinic visit www.premieractivephysio.co.uk or for more information or advice on working in the Middle East, email Simon at malts13@gmail.com

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Who am I Responsible to and for? LEGAL/MARY O’ROURKE QC

or the ordinary employee these are usually pretty easy questions to answer. Responsible to a line manager and essentially the employer who pays the wages and is the other party to the employment contract – the Board if the employer is a company or a partner if a partnership or the individual if an individual owner. Responsible for is often fairly easy too – for subordinate employees (if in a management or senior role) and otherwise for your own actions only. For the healthcare professional at the football club (perhaps surprisingly) the answers are not so easy and often very different – and with potentially serious implications in terms of relationships and (legal and professional) responsibilities. The interactions with others at the Club can be (very) complex and the answer the law provides can be somewhat surprising – and certainly would be to friends and family who have the more normal employment relationships. The range of other people to be considered in terms of those to whom and for whom there are responsibilities and legal and professional duties may be owed (and relationships with legal implications exist) include (at least and not limited to) the players at the club, the manager, the Chairman, the Board, the other healthcare professions and coaches and even the fans/ supporters! Your actions or omissions can impact them all in different (and potentially costly) ways! Unlike the normal employment situation where the primary duty of an employee under his contract of employment (or contract to provide services if a self-employed relationship

by contract) is to the employer/ contracting party and to the exclusion and detriment of others due to the duties of trust and confidence and of good faith and fidelity (and even confidentiality) you as a healthcare professional at a club owe your first duty and primary duties not to the Club which employs you and pays your salary (though you do owe duties) but to the players you treat and care for on a daily basis. So an element of double whammy (as a matter of law!) That this is so was clearly established by the Court of Appeal in 2006 in the case of West Bromwich Albion FC v El Safty – a claim brought by WBA against the orthopaedic surgeon who had negligently operated on one of the club’s then players (Michael Appleton). The claim by WBA was struck out on the basis that Mr El Safty owed his duties to the player and not to the club and that there could be tensions and conflicts between any duty to a player and to his club as their interests (in the healthcare context) often will not coincide. That this will be so will be obvious to most healthcare professionals. The duty to the player (as a patient – see previous issue) is in respect of his ongoing health and welfare – and not just for the short term but for the long term (“to do no harm”/ not to injure etc). The Club’s interest in the player will usually be financial (as an asset that can be sold – as argued by WBA in the Court of Appeal - and also as a money making individual – drawing in the crowds and winning trophies and attracting sponsors). The Club’s interest will usually be short term – the duration of the player’s contract and any onward sale period (his career in the game at most). The player’s health will be of interest to the Club – but only for the (as a maximum) duration of his football career and value as a footballer. For the healthcare professional it’s his lifetime and not his career and his value as a fit and healthy human being (the patient). What is done (or not done) should not cause the player harm and injury (and consequent financial loss) either now or just as importantly - in 30 years (when he might

need a knee replacement or could end up disabled as a result of “football injuries” or treatments). The healthcare professional employed by the club to look after its players can therefore face some real dilemmas in performing his duties. He has the player’s welfare and long term health in his hands (literally!). He has the manager in his ear – screaming to get the player back on the pitch because his (the manager’s job) depends upon it. He has the fans (if it’s a pitch side incident eg Lloris in the recent Everton v Spurs match) wanting the player to play on and he has the Chairman and the Board wanting the value of their prize asset protected! So what does he do and who does he listen to? Well the law is pretty clear about it – both in terms of the legal duty of care he owes and also in terms of his professional duties monitored by his healthcare regulator (HPC for physios and GMC for doctors). His primary legal and professional duty is to the player as his patient. He has to exercise his own independent professional judgment as a healthcare professional – putting all other considerations out of his mind. He has to focus on the best long term interests of his patient and forget the club or the interests of others (or the score in the game or the upcoming match and the manager’s precarious position or even the Champions League final or the World Cup and the hopes of a nation!).

It’s not easy to do. Many healthcare professionals at football clubs (physios in particular) may feel they owe their jobs to the manager and have a particular loyalty to him. Others find themselves in their dream job – working at the club they have supported all their lives and being a supporter and employee. Others find they are working in a competitive environment with a “driven” manager and backroom staff – not averse to putting them under pressure to return the player to the field of play or to the squad by whatever means are required (and focussing only on the short term). Other pressures include the media – why is X still injured and when will he return (and score the winning goal for England in the World Cup!)? Are the medical staff getting it right? Again the recent Lloris case (followed within a week by the Vidic concussion) have clearly demonstrated how the focus of the media can turn sharply on the medical team. Issues of patient/ medical confidentiality can then come to the fore. The manager and Chairman want to know. So do the press and the fans. But the healthcare professional (you!) owes a duty of confidentiality to the player – respecting that knowledge of his state of health and well-being can also have huge financial implications for him (new and future contracts and sponsorship among other things). So – what do you do with the competing pressures and the dilemmas they may create? Remembering also the player is not

the best patient or best qualified to look at the bigger picture and longer term interests and he wants to stay on the pitch or play in the next match as his position also may be precarious and he too is under pressure from a “driven” manager (who thinks he is an expert on medical matters – and we all know they do (sadly) exist!). First and foremost make sure you have support from other professionals – someone to check your instincts with and to provide professional guidance and to be a check for what you think you want to do. Maybe an association or organisation like the LMedA. Secondly listen to your peers and other qualified and experienced professionals – not to the manager or chairman or fans (or media!). Thirdly never forget you are the expert – this is your field – your job, what you are trained to do – and so remember that and make your decisions on that basis and independently of other considerations and exercising YOUR professional judgment. Fourthly be guided by the most important factor - indeed duty – that the player is your patient and it is his health and welfare that you are focussed on and will be answerable for in a Court of Law or to your professional regulator. Finally – make sure you have appropriate professional indemnity cover in place and someone to defend you if the GMC/ HPC come calling (especially following some adverse media coverage)!

FOOTBALL MEDIC & SCIENTIST | 11

Back into the Fold FEATURES/MARK LEATHER Mark Leather, Head of Sports Performance at Bolton Wanderers, spent ten years out of football, before returning to the game with Bolton in May 2013.

life-long Wanderers fan, Mark was previously part of the club’s backroom staff during Sam Allardyce's time as manager and also worked at the likes of Liverpool, Sunderland, Preston North End and Burnley, before taking up various different roles and continuing to run his own private practice. Mark spoke to Football Medic and Scientist about his experiences, beginning with what led to him taking a break from the sport in the first place. “My last game was with Sunderland away to Aston Villa at the end of the 2002/03 season,” Mark explained. “I left after being offered reduced personal terms following the club’s relegation but, in all honesty, my heart wasn’t in the job. I had worked in club football on a day-to-day basis for over 17 years and I needed a change of direction.” After initially working for the NHS, Mark had first got into the game with semiprofessional football clubs, Ossett Town and Leek Town, before going on to take up a part-time role as first team physio for Port Vale in the old Fourth Division. Despite almost two decades involved in the sport, after stepping away from football, Mark soon found that he enjoyed the freedom of being away from the daily grind. “I didn’t miss the long hours and days, and it was great to be my own boss,” Mark said. “It was also great to be able to manage my time and take family holidays as and when I wanted to. I did continue to work in football, lecturing for the Football Association and working with the England Futsal team. I maintained an interest in my home town team, Bolton Wanderers, and continued to watch them as a season ticket holder with my three sons. “I also kept in touch with football through good friends and colleagues I’d made in the game and by attending various conferences. I enjoyed working at the Edge Hill University and was proud to help develop their sports therapy undergraduate programme and lead the MSc Football Rehab programme.” Despite resisting the overtures of several clubs over the last six years, Mark listened to both his head and his heart, when an offer came from Bolton Wanderers last year, as he explained. “I had no real desire to just jump back in but I had great affinity to Bolton Wanderers, being born and bred in the town and supporting the team. I was also very tempted by the role of Head of Performance, which provided a fresh challenge. “I was very impressed with the chairman’s vision, as well as the manager, Dougie Freedman, who I didn’t know personally but

met a number of times and felt that we could work together in trying to help the club to get back into the Premier League. “At the moment I’m fully enjoying it and feel as though I’ve made the right decision, but football is a funny old game so I still have my private business in the background just in case gardening leave beckons at some point!” As well as emphasising the changes he’s experienced since returning to the game, Mark provided an insight into what his role as Head of Performance, entails. “The game itself hasn’t changed but some of the technology and the treatment /rehab protocols have. We have excellent physios, conditioners, sports scientists and soft tissue therapists, plus a range of part-time consultants, who all do a first-class job. “My role is to bring everyone together, formulate policies and liaise with the coaches on a daily basis. My clinical role is with late stage, functional stage rehab and monitoring our ‘traffic light’ system in respect of

recovery, fatigue and prevention of injury.” After returning to football and now currently enjoying his first season back in the fold, Mark outlined what he hopes to achieve in the future at Bolton Wanderers. “I would like to have in place a first-class monitoring system which is supported with research and evidence and that actually works. So far we have seen good results in soft tissue injury reduction with increased fitness but it’s early days. “We currently have a graduate sports therapist enrolled on a PhD at the University of Bolton looking specifically at fatigue and recovery. I hope that her work will help achieve my key aim of reduced Injuries and increased performance levels.” If you have a similar story to Mark’s and would like to be featured in a future edition of the Football Medic and Scientist, please email info@lmeda.co.uk

ADVERTISE IN THE FOOTBALL MEDIC AND SCIENTIST...

And reach a targeted audience of medical and sports science professionals

For more information visit www.LMedA.co.uk Call 03334 567897 Or email info@lmeda.co.uk

For more information on Mike Varney and his practice, visit www.mikevarneyphysio.co.uk This feature was kindly produced with assistance from Gavin Blackwell.

FOOTBALL MEDIC & SCIENTIST | 15

Secure Your Place at the LMedA’s

CONFERENCE

There has already been huge interest in the inaugural League Medical Association Conference and Awards dinner, which will take place on the weekend of Saturday May 17th and Sunday May 18th 2014 at the stunning Radisson Blu Hotel East Midlands Airport.

iving members the chance to meet, share ideas and network, the ‘Best of British’ conference will resurrect the popular close season conferences that were previously held at Lilleshall. The 5 star Radisson Blu Hotel East Midlands Airport is one minute from the M1 and will ensure a stylish and contemporary setting at an event that is expected to attract an audience of up to 200 delegates. Taking place over the weekend of the FA Cup Final, which will be incorporated into the Saturday programme, a League Medical Association Awards Dinner will follow the Cup Final, where some of our most respected colleagues in football will be honoured. The

full programme of activities for the weekend is detailed opposite… The price of the Conference is £130 inclusive of VAT, dinner and refreshments (student rates are available). Additional room prices including bed and breakfast cost £79 a night for a single room or £89 for a twin room. Venue Radisson Blu Hotel Pegasus Business Park Herald Way East Midlands Airport Derby DE74 2TZ For more information visit www.lmeda.co.uk

Day 1 – Saturday May 17th 2014 Time 11.00 12.00 12.30 – 13.00 13.00 – 14.30

14.30 – 15.00 15.00 – 16.30

17.00

19.30 20.00

Activity Committee Meeting AGM Registration (with tea and coffee) Neil Roach ‘Are Sport Psychology issues relative to Sports Injury’ Lyn Booth ‘Clinical Lessons to be learned from London 2012’ Break (with tea and coffee) Bryan English ‘Is there really a need for injured players to go abroad for medical treatment?` Dave Reddin ‘Best practice - is it necessarily the Future?’ FA Cup Final (set up in conference suite) Big screen. Choose your team. Drinks for the winners. Full bar facilities available for the losers! Drinks reception (sponsored) Dinner and awards

Day 2 - Sunday May 18th 2014 Time 9.00-9.45

9.45 – 10.30

10.30 – 11.00 11.00 – 11.45

11.45-12.30

Activity “Great British Boxing” round 1 Grant Downie (Man.City) vs John Fearn (Chelsea) ‘Career Pathway ‘First Team to Academy vs Academy to First Team’ “Great British Boxing” round 2 Dave Fevre (Blackburn) vs Dr Duncan Robertson (Blackburn) Diagnosis of Injury ‘Clinical Assessment vs Radiological Assessment’ Break (Tea/Coffee) “Great British Boxing” round 3 Neil Roach vs Lyn Booth ‘Every injury has a psychosocial, biomechanical and biochemical issue’ vs ‘ Every injury has a biomechanical, biochemical and psychosocial issue’ ‘Great British Boxing’ round 4 Chris Neville v Steve Kemp ‘Final Stage Fitness Parameters-Sport Science’ vs ‘Final Stage Fitness ParametersPhysiotherapist’ Conclusion and End

For more information visit www.lmeda.co.uk

FOOTBALL MEDIC & SCIENTIST | 17

MUSCLE PAIN IN FOOTBALL FEATURES/Dr Pierre Rochcongar, member of the UEFA Medical Committee

uscle pain that emerges from playing football brings many patients into the doctor’s office. Pain in several muscles, most often symmetrical, is very frequently associated with DOMS and (in young footballers) very rarely indicates myopathy (glycogenosis or mitochondrial cytopathy). If the pain is local and is associated with the playing of football, besides intrinsic and extrinsic anatomical lesions, whose classification, diagnostic work-up and therapeutic management are now well known, a number of other hypo-theses should be considered. A rigorous clinical approach is required, and this alone can justify requesting the additional tests that are often necessary for diagnostic confirmation. Eventually, working through the features of a case of myalgia should make it possible to arrive at a therapeutic strategy that may occasionally be confined to changing the training regimen but may in rare cases lead to football being partially or even completely contraindicated. Overall, if local myalgia occurs regularly in a footballer, nerve or vascular involvement, a supernumerary muscle, chronic

compartment syndrome, and even stress fracture should be ruled out (the latter two conditions will not be discussed here). A – Nerve trunk involvement Less common than radicular involvement, nerve trunk involvement should be considered in the presence of local pain that is triggered by physical exercise and that disappears partially or totally when the exercise is discontinued. It is not always worse at night. Diagnosis is primarily clinical and electrophysiological tests may stay negative for a long time. In certain cases, the anesthesia test may be very useful for confirming the diagnosis. In the pelvis and thigh • Pyramidal syndrome, related to sciatic nerve compression, presents as gluteal pain radiating to the posterior aspect of the thigh and usually only triggered by running. It is often very long-standing pain. The pain is elicited by resisted contraction and deep palpation of the buttock. The diagnosis can now be confirmed by additional tests, ruling out a spinal cause and possibly revealing hypertrophy of the muscle on the symptomatic

side (MRI). • The syndrome described by Puranen is consistent with involvement of the sciatic nerve over the ischium. Pain is triggered in the seated position, but particularly with dynamic hip flexion and knee extension movements causingstretching of the hamstring muscles (when tackling,for example). The pain radiates to the thigh but also to the buttock. Electromyography rarely provides useful information. Additional tests (MRI,scan) are sometimes deceptive, or show tearing or fibrotic scarring. • Compression of the iliohypogastric nerve at the iliac crest is accompanied by lateral gluteal pain. This is an exceptional etiology in footballers. • Involvement of the lateral cutaneous nerve of the thigh is also exceptional, occurring with pain and hypoesthesia located lower down and occupying much of the lateral aspect of the thigh. • Anteromedial thigh pain should suggest femoral nerve involvement related to possible direct trauma and even compression such as from lipoma, which MRI readily reveals. • Compression of the obturator nerve

Photos kindly supplied by UEFA Medicine Matters

at the insertion point of the adductor muscles (Figure 2) is accompanied by pain on isometric contraction of the adductor muscles, which may wrongly suggest tendinopathy or pubic pain, associated with local hypoesthesia in the middle third of the internal aspect of the thigh. • At the medial aspect of the thigh, compression, stretching while tackling, or direct trauma to Hunter’s canal (subsartorial fascia) is often accompanied by pain in the medial aspect of the knee, rarely extending to the crural segment. This pain should not be confused with tendinopathy or with a patellar or meniscal syndrome. In the crural segment: • Pain in the anterolateral compartment is consistent with common peroneal nerve involvement (extrinsic or intrinsic compression due to an anatomical abnormality or a synovial cyst, for example). It may initially manifest as exertional pain incorrectly suggesting chronic compartment syndrome. Hence, the physical examination and tests should always be done after an exercise that triggers the symptoms in order to identify a transient strength deficit in the ankle dorsiflexors. The same approach can be recommended for electromyographic tests. • Posterior pain. This mainly concerns the sural nerve. This type of medial pain, radiating to the Achilles tendon and triggered by contraction-stretching movements of the gastrocnemius and soleus, is often mistaken for a repetitive

motion disorder. Examination may show Tinel’s sign. Electrophysiological examination of this sensory nerve is often deceptive. In certain cases, imaging reveals a cause such as a fibrous scar. An anesthesia test, while pain is present, is often necessary to confirm the diagnosis. In certain cases, neurolysis may be offered to the patient B – Vascular disorders In the crural segment: popliteal artery entrapment syndrome may in some cases incorrectly suggest muscle pain.In the initial stages it may present as intermittent, unilateral calf pain. The sports most often involved are cycling, walking, and swimming – sports in which intrinsic muscle trauma is rare, but the syndrome has been found, albeit less often, in footballers. If the pain disappears almost as soon as the exercise stops, this supports this diagnosis, which is confirmed by a resting Doppler ultrasound with the knee extended and the ankle dorsiflexed. Subsequently, the cause must be sought (abnormal path of artery, muscle compression, etc.) with MR angiography. C – Accessory muscles Described for over a century by anatomists, these supernumerary muscles can be responsible for exertional pain and their existence must therefore be thoroughly understood even though they can be difficult to diagnose Once again the clinical picture is fairly stereotypical: local muscle pain triggered by

initially near-maximum physical exertion, then within a few months by effort of decreasing intensity, with a tight feeling, pseudo-cramps, and the disappearance of symptoms within a few minutes or, more rarely, within a few hours. Physical examination shows increased limb segment volume (particularly in the case of the accessory soleus with a unilateral abnormality). Usually it is with isometric contraction against resistance that a swelling, hard on palpation, is found (this is often the case for the semimembranosus or the accessory medial gastrocnemius). If necessary, an electromyogram will confirm the muscular origin of the swelling, but an ultrasound and particularly an MRI scan will confirm the diagnosis and assist in the decision as to whether surgery is necessary. Conclusions Local muscle pain in a footballer always requires management and careful investigation. Usually the physical examination will be sufficient to distinguish between training errors and a true pathological substrate. In this case, it can also point to the appropriate additional tests, which will be helpful only if justified by the clinical features. In most cases, the diagnosis will enable effective treatment to be offered (nerve, vascular, or muscle involvement).

FOOTBALL MEDIC & SCIENTIST | 19

Northwest Football Awards 2013

n Monday November 4th, the 2013 Northwest Football Awards once again took place at The Point, at Old Trafford in Manchester to celebrate the best and brightest in the region. League Medical Association CEO, Eamonn Salmon, was again part of the judging panel,

and, alongside Preston North End striker, Kevin Davies, was on stage to present the The Fabrice Muamba Award for Medical & Sports Science Professional award, which was won by Manchester United Head Physio, Rob Swire, and collected by Diane Ryding (above left) Senior Academy Physiotherapist, as United

were playing in Europe on the evening. The Awards, managed by Journey9, were hosted by BBC Television’s Football Focus presenter, Dan Walker, and also saw the likes of Sir Alex Ferguson, Jamie Carragher and the Neville family recognised for their achievements.

Full list of Northwest Awards 2013 Winners… - Community Initiative of the Year: Bolton Wanderers Community Trust, Everton in the Community-Safe Hands - Community Club of the Year: Everton in the Community; Highly Commended: Morecambe FC - CSR Campaign of the Year: Liverpool FC - Contribution to Sport in the North West: The Neville family - Best Club Marketing Campaign: Everton FC - Best Club Sponsorship Engagement/Partnership: Liverpool FC - Business Services to Football: Rippleffect - Professional Services to Football: Brabners LLP; Special Award: Mark Hovell of Mills & Reeve - Football Journalist of the Year: Mark Ogden (Telegraph) - The Fabrice Muamba Award for Medical & Sports Science Professional: Rob Swire (Manchester United Head Physio) - Rising Star of the Year: Jerome Sinclair (Liverpool FC) - Manager of the Year: Sir Alex Ferguson - Women’s Player of the Year: Toni Duggan (Everton Ladies) - Player of the Year (Conference): George Horan (Chester FC) - Player of the Year (League Two): Jack Redshaw (Morecambe) - Player of the Year (League One): John Welsh (Preston North End) - Player of the Year (Championship): Jay Spearing (Bolton Wanderers) - Player of the Year (Premier League): Jamie Carragher (Liverpool FC) - Goal of the Year: Robin Van Persie (Manchester United) vs Aston Villa - Unsung Hero: Barrie Hipkiss (Chester FC) - Lifetime Contribution Award: Sir Alex Ferguson

How Far Have We Come in Sports Medicine? FEATURES/Danny Donachie In an exclusive column, Danny Donachie, Head of Medical Services at Everton Football Club, considers to what extent sports medicine and science has progressed in the modern eraâ&#x20AC;Ś

recent review of the current treatment used in elite sports medicine to treat hamstring injuries got me thinking about how far our profession has progressed in recent times. Despite massive investment and burgeoning auxiliary professions, many of the treatments we employ are no better than placebo under proper scrutiny. Anti-inflammatory medication for example is used widely in elite sport and yet more and more evidence suggests that soft tissue injuries may actually hinder rather than expedite healing. There has been a huge movement towards injury prevention and in my current role I am contacted daily by companies marketing their latest method of prevention. In this fast changing evidence-based culture in which we operate, how can we best serve the athletes we look after and, at the same time, serve the coaching staff and institution we are employed by? In my opinion and experience the foundations that have served us so well for hundreds of years remain the bedrock of effective practice and will remain so. The current literature and innovation must be considered and reflected upon, but the foundations must remain intact. It may bode well for us to reflect upon the part of the Hippocratic Oath that states: 'I will prescribe regimens for the good of my patients... And never do harm to anyone'. Competition and financial implications of success are irresistible in sport these days and the aspirations of the stakeholders involved in the care package of an athlete may not always appear to be aligned. However, I would contest that their aspirations are always aligned when the long-term health and well-being of the athlete is paramount, and this always has to be the case. All parties will be best served in the long run if this axiom is held true and any attempt to short cut this process will fail. It's not inconceivable to find yourself in a position where the athlete and the coaching staff are desperate to play in the next game and you know it's not in their best interest. This is when your communication skills come into play. By convincing the management it is the best thing for the player and hence the team and explaining and cajoling the player

into preparing for the more sensible option. Diagnosis has always been pivotal in the treatment of any patient and technology has made great strides in this direction. It is essential that we are using the very best imaging technology and have the most accomplished network of specialists available to interpret. In the sports arena we are at the mercy of our radiological specialists and technology. Although radiology is only a part of the diagnostic story, if misinterpreted it can lead to potential disillusion and re-injury in the rehabilitation process. Expectations are a natural human consequence and they can be difficult to manage if the radiology is slightly off centre. Working with elite athletes is incredibly rewarding and we are in a very privileged position to be able to serve them. Many of the latest technologies and ideas are based upon physical data and markers and are founded on a mechanistic view of the human being. I feel there is huge potential in treating the athlete in a truly 'holistic' manner in the future. Athletes are subject to the same human experiences as everyone and this is often overlooked in physically dominant world of sport. Aristotle suggested that 'soul and

body react sympathetically upon each other'. I thoroughly agree with this and without negating the physical data, which has equal importance, I feel that by looking more thoroughly at the heart, mind and soul of the athlete we create a more well balanced and happy athlete in the future. It has been quite striking how significant it has been for our players to experience deep relaxation. It has been significant for them because it is a new feeling and also because the majority of their experience is lived in a highly competitive world requiring effort. So much available literature supports the effect of the brain and emotions on the body and yet I feel it is an untapped resource in professional sport. It is difficult to imagine where we will be in the future of our profession, but it is an inescapable truth that we will have to affect the whole being of the athlete for optimum performance and I certainly hope there is a cultural shift in this direction. If you would like to submit an opinion piece to be considered for publication in a future edition of the Football Medic and Scientist, please email info@lmeda.co.uk

FOOTBALL MEDIC & SCIENTIST | 21

Head Injuries Who Decides? FEATURES/FC BUSINESS/DR. VINCENT GOUTTEBARGE, PhD The debate over whether Hugo Lloris, the Tottenham keeper knocked unconscious during a match against Everton at White Hart Lane in November, should have been allowed to continue the game has been fiercely debated over recent weeks. Dr. Vincent Gouttebarge, PhD, FIFPro health advisor takes us through some of the issues surrounding head injuries and the on-field decision making process should they occur. Head Injuries and the Possible Harm Concussion (or mild traumatic brain injury) is a condition defined as the physiologic disturbance of brain function as a consequence of a traumatic blow to the head or neck (Bahr 2012; Upshaw 2012). Concussion is common in contact and collision sport, trauma to the brain being either direct (head clash) or indirect (shoulder charge or tackle). Depending on the area of brain which is affected, several symptoms (reported) and signs (observed) might occur immediately or delayed in onset by hours or days after trauma (Bahr 2012; Upshaw 2012). Assessment Procedure on the Field Based on a paper developed after the first International Conference on Concussion in Sport held in Vienna, an updated consensus statement for sport-related concussions was produced in Zurich in 2012 (McCrory 2013). This statement was developed for use by physicians and healthcare professionals who are involved in the care of injured athletes, whether at the recreational, elite or professional level (McCrory 2013). As in other sport disciplines, the Zurich 2012 consensus statement is also meant to be applied in professional football, referring to the following if concussion is suspected (McCrory 2013). The player should be evaluated by a physician or other licensed healthcare provider onsite using standard emergency management principles and particular attention should be given to excluding a cervical spine injury;

- The appropriate disposition of the player must be determined by the treating healthcare provider in a timely manner; if no healthcare provider is available, the player should be safely removed from practice or play and urgent referral to a physician arranged; - Once the first aid issues are addressed, an assessment of the concussive injury should be made using sideline assessment tools; - The player should not be left alone following the injury and serial monitoring for deterioration is essential over the initial few hours following injury; - A player with diagnosed concussion should not be allowed to return to play on the day of injury. Different sideline assessment tools are available, from which the Sport Concussion Assessment Tool (SCAT) is the most known (latest version published in 2013, from McCrory et al). Such a sideline assessment relies on: - Questions (on the field) on symptoms (headache, neck pain, nausea, balance, fatigue, blurred vision, dizzinessâ&#x20AC;Ś) perceived by the players being suspected with concussion; - Questions (on the field) on physical signs, especially loss of consciousness and balance; - Validated questionnaire (sideline), the Glasgow coma scale (GCS), related to eye response, verbal response, motor response. - Validated sideline scale, the Maddocks Score, related to questions about the match/ game.

- Questions (sideline) related to orientation, memory, concentration; - Balance and coordination testing. Post Assessment and Evaluation After the assessment of the Sport Concussion Assessment Tool (SCAT), some problems might occur over the first 1-2 days. The advice is to not leave the athlete alone and to go to a hospital in case of a headache that gets worse, memory problems, vomiting, confusion or unusual behaviour, slurred speech. SYMPTOMS AND SIGNS OF CONCUSSION Pain Poor balance Visual complaints (seeing stars, blurry vision) Disorientation Dizziness Nausea or vomiting Headache Loss of consciousness Confusion (confused or blank expression) Slurred speech Fatigue Emotional liability Reduced ability to think Delayed response Amnesia (memory loss) Emotional disturbance Concentration problems Sleep disturbance

For return to play, the athlete should not be allowed to return to play on the same day of the injury but follow a stepwise procedure (McCrory et al. 2013): 1. Rest until asymptomatic (physical and mental rest) 2. Light aerobic exercise (e.g. stationary cycle) 3. Sport-specific exercise 4. Non-contact training drills (start light resistance training) 5. Full contact training after medical clearance 6. Return to competition (game play) There should be approximately 24 hours (or longer) for each stage and the athlete should return to stage 1 if symptoms recur. Resistance training should only be added in the latter stage. Whose decision should it be on whether the player stays on the pitch? The decision should be taken by a medical doctor or health professional… and not by coaches or players themselves. After the Lloris incident in November, FIFPro has called all football bodies and clubs to put the health and safety of the players first by respecting the international concussion guidelines in order to protect optimally the health and safety of the players.

FIFPro’s Perspective In order to safeguard the health and safety of footballers, FIFPro calls on all clubs to respect and apply the Zurich 2012 concussion guidelines (among other health and safety guidelines) and requires the international and national regulation bodies to monitor their proper application. In addition, FIFPro would like to emphasise the need to consider the implementation of some additional measures in professional football such as:

safety of footballers at stake by disregarding the guidelines; 6. The introduction of a baseline i.e. reference pre-season examination (cognitive and physical) for any players in order to allow comparison with eventual side line examinations performed during the season as a consequence of a suspected concussion, and in order to empower return to sport decisions.

1. The development of a monitoring system to assure and control the application of the Zurich 2012 concussion guidelines; 2. The systematic completion of a standardised and valid side line examination (cognitive and physical) on any player suspected to have suffered from a concussion; 3. The presence of an independent medic i.e. health professional on the sideline during competition matches to assess independently a player with suspected concussion in order to assure a proper health and safety judgement, independently from any other matters; 4. The possibility to replace i.e. interchange temporally any player undergoing the side line examination; 5. The possibility to sanction afterwards any clubs that obviously put the health and

Dr. Vincent Gouttebarge, PhD, health advisor to FIFPro, is a former professional football player (1993 – 2007) and medical scientist at the Academic Medical Center in Amsterdam. This article has been reproduced with the kind permission of fcbusiness magazine. It originally featured in issue 74, the January 2014 edition of the publication. For more information on fcbusiness, the business magazine for the football industry, visit www.fcbusiness.co.uk

FOOTBALL MEDIC & SCIENTIST | 23

Using Skeletal Ultrasound

in Professional Football

By Dr Duncan G Robertson MBChB MRCGP DCH PGCMsk & MedUltrsnd FCMI DFRSH MSc FFSEMUK, Consultant in Sports & Exercise Medicine and Club Doctor at Blackburn Rovers FC.

ccurate diagnosis is an essential part of the duties of any sports medicine team. The staple combination of history, examination and imaging is often now enhanced by reviewing video footage of injuries. In well-resourced medical teams the sports physician is normally the clinical lead on clinical investigations. And whilst magnetic resonance imaging is an invaluable tool in the diagnostic process, in-house ultrasound imaging by team clinicians augments diagnosis, reduces costly referrals, increases interventional options and enhances the clinician-patient connection. This article offers a glimpse of the huge potential and value offered by diagnostic and interventional ultrasound in the overall medical care of elite footballers. The sheer scale of the subject allows only a brief practical overview, and though guided interventions are mentioned, it is beyond the scope of this article to discuss them. The Range of Applications The potential for sports physicians and physiotherapists to perform competent skeletal ultrasound examinations of athletes has increased over the last decade. Away from the Premier League, funding equipment and training is always a challenge, but with imagination and suitable support, gaining competence in diagnostic ultrasound is achievable for many as part of an overall career in sports medicine. Equipment is ever improving, more portable and more affordable. Training courses are also more accessible to sports clinicians. Box 1. Suggested contributions of US towards the sports clinician’s work 1.Screening specific soft tissue structures at signing-on 2.Imaging Acute Muscle and other Injury 3.Imaging Chronic Injury 4.Guided Needle Interventions (inject, aspirate) 5.Reassurance (normal scans in anxious player) 6.Extra information prior to secondary referral 7.Monitoring progress 8.Biofeedback for the athlete (Ref 2-8) 9.Motivational tool to improve compliance with treatment 10.Advance diagnosis time (ie myositis) 11.Reduce risk of missed soft tissue pathology 12.Reduce unnecessary and costly MRI referrals 13.Enhances the player-clinician professional connection 14.Improve decisions on whether X-rays and radiation exposure required

In my experience almost all of the scans are performed at the training centre (unless perhaps the team is on an extended preseason tour for example). Most injuries occur to muscle, ligaments/joints and tendons. In most, but not all cases, pathology

generally tends to throw up a combination of abnormal tissue architecture, localised fluid or swelling (which appears as a blacker, lower echo signal – in short because there is less dense tissue for the ultrasound beam to bounce off) and abnormally lax joint movement (in ligament injury). An exception to this would be myositis ossificans, where osteoblastic activity produces a milky white appearance of dense osteogenic tissue that blocks the ultrasound signal and produces a shadow behind the lesion (Box 10).

fitness to train and play. On the other hand, when there is a significant injury that has perhaps has less obvious clinical signs, sharing the ultrasound images should help optimise compliance with treatment regimes.

Box 2. Potential range of uses for diagnostic ultrasound equipment in football • Acute muscle injury (from 24 hours plus) • Ligament injury • Tendon injury • Nerve contusion and neuroma/swelling • Joint effusion • Dynamic stressing of joint and ligament • Comparative scanning right to left • Superficial Bone fractures and stress fractures (especially tarsal & carpal bones) • Guided injections to muscle, tendon and joint • Synovitis (joint) • Neovascularisation (muscle and tendon) • Peripheral Joint (ie ganglion, meniscal fragment, meniscal split, erosion) • Testicular pain and swelling and skin lumps and bumps (only trained physicians) • Chronic Compartment Syndromes (exertion, ganglions and other) • Dynamic Instability (ie tendon subluxation)

• The condition should be an important health problem • The natural history of the condition should be understood • There should be a recognisable early symptomatic stage • There should be a test that is easy to perform and interpret, acceptable, accurate, reliable, sensitive and specific • There should be an accepted treatment recognised for the disease • Treatment should be more effective if started early • There should be a policy on who should be treated • Diagnosis and treatment should be costeffective • Case-finding should be a continuous process

Although muscle tissue commands by far most of the physical bulk of accessible superficial scan material, it is also invariably the hardest tissue to scan, especially in the early phases (it is best done 48 to 72+ hours post injury), and care needs to be taken in the correct interpretation of images and clips. The signal changes from high to low echo very quickly as the scanner moves over different fascial planes, and you can easily get caught out by a phenomenon called anisotropy. This in essence is where the angle of the scan beam and the tissue (or fascia) can conspire to interact in a way that produces an abnormally low echo (an artefact) and fools the examiner into thinking this is pathological when it is in fact healthy. This explains why ultrasound often has to take on the role of being a useful adjunct to the use of MRI of muscle injury A key aspect of effective ultrasound in the training centre (as opposed to a hospital department) is, in my opinion, its ability to enhance the quality of the diagnostic and therapeutic connection between the player and the clinician. A normal ultrasound scan can be a powerful tool to support benign clinical findings, and help staff more effectively reassure a player anxious about a knock or strain that the medical team are confident should not significantly undermine

Ultrasound Screening Box 3. Ultrasound screening of a range of occult ligament and tendon lesions, in the context of the care of elite footballers, satisfies most of Wilson’s screening criteria from the classic 1968 publication

Where resources allow, screening of athletes at the signing-on medical is worth considering. Alongside the clinical assessment, ultrasound can even help improve any decision making on what (if any) areas might merit MRI screening prior to a potentially expensive transfer being agreed. For example, in one pre-signing medical a chondral defect, associated with an anterior tibial osteophyte and an effusion, could be seen on the anterior talar dome. Further pathology was revealed on the medical and this had a significant impact on the decision over the transfer. Alternately, once the player has signed, a standard range of important anatomical structures can be scanned, and this only takes 15 minutes or so (Box 4). Many players have sonographic abnormalities that may well reflect chronic adaptive changes that are of no functional relevance. In addition, such an in-house exam helps the clinician gain an extra depth of knowledge on the players level of pre-existing wear and tear in some key areas. Overall, it is my view that it is worth knowing these ‘normal’ appearances at the outset so any new changes can be set against chronic lesions. A good example would be the presence of an asymptomatic common adductor tendinopathy/ enthesiopathy on ultrasound at signing. If the player suffers an acute extension on top of these pre-existing old changes (usually appearing as an acute low echo [black] cleft)

then the examiner can have much better confidence that sonographic appearances are or are not, significant, and manage the case accordingly. Box 4. Suggested sites that are worth considering for screening by a club clinician possessing suitable sonography skills and equipment. Goalkeepers - add elbow collateral ligament.

Box 5. Case 1. AITFL Grade 2 ankle injury on sonography. Figure A; this shows gapping of the inferior tibio-fibular joint on external rotation stress testing. Figure B; the joint in its closed-relaxed position. Sharing this visual biofeedback from the scanner is viewed by the author as a very useful tool in encouraging compliance with treatment, especially when it involves wearing an ankle boot for perhaps 3-5 weeks. Figure C; using the exact same machine settings, this helps highlight the difference between a normal flat and healthy AITFL (arrowheads) with injured one on left with swelling and low echo changes (circled). Figure D; axial view of guided needle (white dot, cross-section in between tibial and fibular edges) into lesion with a surrounding halo of PRP injectate (cloudy grey appearance). Figure E. This shows the matching surface view of the needle in D, and probe position. (* marks foot area. Sterile gel is use and the needle always moves into the scan-field – it is good practice for probe position to remain static, and keep needle entry point and probe apart.

Foot & Ankle CFL, ATFL, AITFL, Achilles Tendon Anterior Deltoid Ligament Knee Patellar tendon, MCL, LCL Groin Common Adductor Insertion Superficial Inguinal Ring (Strain) Testicular Screen

Real Clinical Examples of Ultrasound in Football Injuries Case 1. Ankle Injury A player who attended two days after an ankle injury. Initial assessment did not justify an X-ray, but after effective acute care, symptoms led to a request to scan (Box 5). There was a clear swelling over the AITFL/syndesmosis. The grade two injury showed 3mm of dynamic instability on external rotation. A grade one injury was also sustained at the neighbouring posterior ligament. Comparative scans helped demonstrate the pathology to the player. After further imaging and shared care with a surgeon, the player opted for conservative management with guided PRP injections (x2), a boot (x5weeks) and rehabilitation. The player had a stable and symptom free ankle in 7-8 weeks and played again at 10 weeks. Case 2. Hip Flexor Injury A young player attended with a five day history of persistent discomfort and Box 6. Case 2. This summaries a grade 2 iliopsoas (IlioPs) musculotendinous junction (MTJ) injury in axial views. Figure A. Just lateral to the axial tendon (T) there is a clear area of low echo haematoma from the tear (arrow). A comparative view of the uninjured left side is shown. Figure B. Arrowheads mark the guided PRP needle from lateral pectineal eminence into the tear – this shows the necessary accuracy needed for correct placement oif the PRP (confirmed in post injection views in Figure C). Figure D is the matching surface view of the probe. As in case two, the probe is static and is cleaned with antiseptic foam, or a bespoke latex probe cover can be used.

subjective loss of power on hip flexion. This had been correctly managed clinically with rest and physical therapy. But on showing little sign of improvement, an ultrasound was requested by the physiotherapy staff (Box 6). This showed a subtle but significant area of dark low echo in a horseshoe pattern around the supero-lateral aspect of the ilipsoas

tendon on axial scan views, suggesting a grade two MTJ injury. Comparative scanning confirmed the abnormality. Prior to further management an MRI was requested, especially to exclude additional pathology. A grade two MTJ injury was confirmed. The player was counselled on the option of PRP therapy and elected to proceed. Real-time ultrasound allowed accurate guidance of a 100mm spinal needle across the pectineal eminence and into the lesion. The player responded well to treatment and was back playing in just over five weeks. Case 3. Plantar Foot Pain A senior central defender started to complain of insidious-onset plantar foot pain. This was located anterior to the normal calcaneal location of plantar fasciitis. Ultrasound exam (Box 7) confirmed the presence of a symptomatic plantar fibroma in the midsole. The player was advised to rely on topical NSAID’s and taping to off-load the fascia. The player was reassured that the lesion was likely in its acute inflammatory stage, should settle. The symptoms gradually evaporated over 12 months and is now essentially asymptomatic. Case 4. Contact Lateral Knee injury A player was sprinting at full speed and shot at goal. He was tackled from the right, with a lateral force against his knee. He felt a sudden pain, and was substituted. The

FOOTBALL MEDIC & SCIENTIST | 25

Box 7. Case 3. Plantar Fibroma. Initially the player was diagnosed with plantar fasciitis. After 3 weeks he was referred for a scan. This showed a normal plantar fascia, with tenderness some 25mm anterior to the calcaneal insertion. Figure A highlights the typical fusiform swelling. Figure B shows the comparative views with the uninjured right foot (fascia between arrowheads). With most tendon and ligament pathologies, in the absence of a rupture, they appear enlarged and hypoechoic. The player was advised that as long as symptoms were tolerable, it would be best to avoid further referral or injection and manage the condition conservatively. He was reassured by this and has remained fit to play since.

Box 8. Grade 2 FCL injury. Figure A shows a longitudinal view. The ligament is damaged at the fibular end, with a low echo lesion seen running through the distal half of the FCL. Dynamic stress ultrasound confirmed that some of the ligament fibres tightened up and overall it was not totally torn. The player opted for bracing and PRP. Longitudinal (Figure B) and axial (Figure C, white dot) views of the needle are shown. As the injection is being done, the lesion shows up in real time with injectate almost acting as a second by second video-clip “contrast sonogram” of the tear. The premise of the PRP was to “try and improve the quality of the tissue recovery, not necessarily the speed”. The player returned fully fit at 10 weeks, with no symptoms or relapse after 6 months.

following day he was reassessed and found to have pain and laxity on stressing of the fibular collateral ligament (FCL). Ultrasound exam (Box 8) confirmed the presence of a high grade FCL injury; apart from a small medial bone bruise, no other structures were damaged. After further imaging with MRI, shared care with a sports knee surgeon and careful counselling on options. The player chose to proceed with injection therapy and bracing. He was fully fit again to play at 10 weeks. Case 5. MCL elbow injury goalkeeper A goalkeeper suffered an acute elbow injury in a midweek game when a shot forced

Box 10. Myositis Ossificans (MO). Figure A shows scan of contused and disrupted vastus intermedius at day 5. MRI was used to help differentiate the extent of the muscle tear. Figure B shows the same player return at day 14 with persistently slow resolution of the injury and the early appearance of myositis. X-ray was negative. The scan shows two dark low echo areas of resolving haematoma. Just deep to this is the denser high-echo “milky white” appearance of mixed fibro-osteo blastic zone phenomenon typical of early MO. And deep to this is the classic darkish area of shadowing – cause by the ultrasound signal being depleted blocked by the denser strip of MO changes. It is hoped that the extent of any calcification will be mitigated by the early diagnosis and management

and could be managed with appropriate strapping and anti-inflammatories.

the elbow into a sudden hyperextension. The player completed the game in pain but could not train the next day. The player was referred for a USS to provide more information on the nature and severity of the injury. USS showed a moderate grade two injury of the medial collateral elbow ligament. But the damage was restricted to the anterior portion of the anterior fibre bundle, and the more posterior and transverse fibres were contused but essentially intact. Dynamic scanning revealed some minor laxity compared to the uninjured side. With this information the consensus of player and medical team was that the joint was stable

Box 9. Ulnar Collateral Ligament Sprain. Figure A. This shows that the more posterior elements of the anterior UCL fibres are contused but intact. Figure B shows a fusiform swelling at the humeral attachment and low echo areas consistent with a fibre disruption at the anterior part of the main UCL. Dynamic scanning showed some laxity but overall integrity and reasonable medial joint stability. USbLT = ulnar sublimis tubercle attachment. CFs = common flexor tendons (lying superficial) and MEp = medial humeral epicondyle.

Case 6. Contact Thigh Injury A player presented to physio for treatment to a severely contused anterior thigh muscle after a collision with another player’s knee; a scan was request. The examination on day five showed a combination of marked vastus intermedius muscle contusion (low echo and swelling) with associated grade two muscle fibre disruption and altered architecture. The player was treated for both conditions and followed up two weeks later by the club doctor. Repeat scan at day 14 showed the appearance of a milky white signal (zone phenomenon) running along the deep surface of the muscle, adjacent to the femur. X-ray was normal. As suggested in the literature the scan had facilitated an early diagnosis of myositis ossificans - and the player is being treated accordingly with rest, diclofenac and regular careful follow up. Summary Effective and judicious use of imaging modalities is a key skill in assessing a wide range of injuries and symptoms in footballers. Ultrasound can add a huge amount to the quality of care, but will only ever work best when bonded closely with shrewd and canny clinical skills and experience. In practice, skeletal sonography is not easy – it demands much of operator skill and equipment quality and manipulation. But with the correct support, enthusiasm and resources it is an achievable skill and can become an integral part in optimising the day to day assessment and management of all manner of sporting injuries in footballers. Acknowledgements: The cases presented are all with the players’ consent, and courtesy of Blackburn Rovers Football Club.

FOOTBALL MEDIC & SCIENTIST | 27

Evaluating the Effectiveness of MRI as a Prognostic Tool for Hamstring Injuries FEATURES/DAVID EASTWOOD David Eastwood, a final year medical student at Newcastle University, carried out the following study to evaluate the effectiveness of MRI as a prognostic tool for the time professional footballers would be out of action after suffering hamstring injuries. The study was carried out at Sunderland AFC during the 2012/13 season and won the Tom Donaldson prize after being submitted to the British Association of Sport and Exercise Medicine. Introduction Hamstring injury is the single most common injury in professional football1. Better injury prognosis can assist the working relationship between medical staff and management because it may mean the difference between victory and defeat in the world of professional sport. MRI is commonly used to confirm diagnosis and provide an indication of the number of days injured, although clinical judgment is more established and is always used to assess injury. There is little evidence in current literature to compare the two. Aims To evaluate the use of MRI as a prognostic tool for time missed after hamstring injuries in professional football players at Sunderland AFC (SAFC) and compare it to the clinical judgment of team healthcare professionals. Method A retrospective study was carried out using the medical database of Sunderland AFC: a Premier League football club. I selected players that had a hamstring injury and that also had an MRI scan. The earliest injury occurred on March 7th 2009, with the most recent injury occurring on February 16th 2013. Current first team players, ex-first team players and ex-reserve team players were selected. I then found ‘individual time-loss’, ‘radiological findings on MRI’ and ‘clinical findings’ for each injury, in documentation by medical staff at SAFC. MRI findings were interpreted using a modified Peetron’s classification into four grades. More severe injuries were represented by the higher grades; grades 2 and 3 each represent clinical fibre disruption. An established system by Jan Ekstrand2 predicts time, in days, out of full contact training and playing football matches, based on Peetron’s grades. I used these values to analyse the accuracy of MRI and of clinical grading.

Results In total, 27 players had hamstring injuries, with all of them receiving an MRI scan and clinical assessment. In terms of MRI classification, 7.4% were grade 0 injuries,

Fig 2: Bar chart to show the number of hamstring injuries and how they were graded by the two modalities.

55.5% grade 1, 37.0% grade 2 and 0% grade 3. Clinical judgment assessed 3.7% at grade 0, 62.9% grade 1, 25.9% grade 2 and 7.4% grade 3. Therefore, clinical grading given by medical professionals did not always concur with grading reported from MRI. When using Erkstrand’s grading system to compare the accuracy of MRI grading versus clinical grading, it was found that clinical grading was more accurate in prediction of time out of action. MRI grading appeared to underestimate injuries; injuries assessed as low grade in fact led to more days injured than predicted. Overall, most injuries (18 out of 27) were given the same MRI and clinical grading, illustrating that there was only some variation between methods. Conclusion • MRI is helpful in verifying the diagnosis and prognosis of a hamstring injury. • My data suggests that clinical grading is more accurate than MRI grading in predicting number of days injured. • This data does not support the view that there is a significant advantage of clinical over MRI grading, however. (p value = 0.25, significant when <0.05). • “Under grading” may result in a tendency to inappropriately encourage players to train too soon as opposed to if management decisions were based on clinical grading alone. • More than 60% of hamstring injuries seen

Fig 3: Bar chart to show which modality of grading was more accurate in predicting lay-off times, when compared with actual time out.

were of radiological grade 0 or 1, meaning no signs of fibre disruption on MRI, but it is, in fact, these injuries that cause the majority of days injured. Limitations • Unforeseen factors such as re-injury and compliance with rehabilitation could have affected the number of days injured. • Small sample size (27 players). • The accuracy of clinical grading at Sunderland AFC is down to the ability and training of staff. This could be highly variable when comparing between different clubs. • Biased sample size (all players saw the same doctor for clinical grading). References

1) R D Hawkins, M A Hulse, C Wilkinson, A Hodson, M Gibson. The association football medical research programme: an audit of injuries in professional football BJSM 2001;35:43-47. 2) Jan Ekstrand, Jeremiah C Healy, Markus Walden, et al. Hamstring muscle injuries in professional football: the correlation of MRI findings with return to play Br J Sports Med doi: 10.1136/ bjsports-2011-090155.

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