Football Medic & Scientist Issue 8

FOOTBALL MEDIC & SCIENTIST

The official magazine of the League Medical Association

MEDICS IN FOCUS

Who decides when a player should be substituted?

SHOULDER INJURIES

Severity, occurence and recovery time

SPORTS SCIENCE: A PLAYERS VIEW A discussion with Middlesbrough FC’s George Friend Issue 8: Spring 2014

Contents Welcome 4 Members News

Editorials & Features 5 Touchline Rants / On the Couch 6 Football & Osteoarthritis Jane Tadman 10 Who Decides When a Player Should be Substituted Mary O’Rourke 15 Where Are They Now? Roger Spry 16 Best of British: The LMedA Conference 18 A Friend in Science George Friend in discussion with Adam Kerr 20 Conflict, Collision & Confusion Ken Goldman 22 Serious Shoulder Injuries in Professional Football David Hart

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.

W

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 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

WHERE ARE THEY NOW?

26 Recovery, Readiness & Resilience Nigel Stockill

WHO DECIDES

FEATURES/ROGER SPRY

SHOULD BE SUBSTITUTED?

Specialisation is a crucial part of modern football.

Some clubs, for example, have defensive coaches, attacking coaches, recuperation coaches, dieticians, video analysts, data and statistics coaches. In days gone by the manager and his assistant had onwe physio, one doctor and they were expected to do everything.

When you first arrived at Sheffield Wednesday, the fitness coach was revolutionary and unique in the late 1980s…

I was the first full-time fitness coach in British football, and was looked upon with a great deal of scepticism because it was so radically different from the norm.

LEGAL/MARY O’ROURKE QC

A

10 10

applaud the ‘brave’ player trying to ‘run it off’ and ‘carry on’, there is no doubt that save in exceptional circumstances (the under pressure and weak manager courting popularity) the fans really have no say and cannot dictate changes in on field players or formations (though they may get it right in terms of calling for a substitution which was about to happen anyway and thus claiming credit for it).

Certain Chairmen/Owners or Chief Executives (and the libel laws prevent me giving you named examples but I am sure those reading this article can think of a few) will also believe that substitutions are matters on which they can, and should, be heard and will voice their opinions to their managers (including on the timing of the substitution during the match since substitutions before the 60th minute cost the club more in terms of match bonuses than those after that time as a result of specific clauses in the standard PFA player contract - so ‘let him carry on if he can run it off’ or ‘don’t make your tactical swap yet’) – but again, unless the manager is exceptionally vulnerable or weak or under extreme pressure at the time – this really won’t be the case and their influence will be more imagined or indirect.

Therefore, not the fans and not the owners – so some might say the only other

‘interested party’ is the player himself – and we can all think of examples of players unwilling to come off or pointedly and blatantly refusing to come off (in injury situations) and unhappy about being taken off in other tactical or personnel situations. Certainly, many managers in injury cases are quick to give players a say in whether they are ‘ok to carry on’ or ‘can run off the injury’ and whether they ‘should see how they go’ – especially with a star player.

The key question is whether they should do so and whether the player should be allowed to have any say in the matter or even more importantly, whether in the case of injury or suspected injury the manager himself should have any say, or actually has anything to contribute.

The ordinary match going supporter who would express surprise at the question who decides as to a substitution, would probably be equally surprised at the answer I would give on whether the player or manager should have any say - that in the case of injury or suspected injury the decision should primarily, if not exclusively, be one reserved to the medical team – the pitchside team doctor or physio. My answer is not given as a 20 year plus season ticket holder at a major Premier League club – but as a 30 year

FOOTBALL MEDIC & SCIENTIST | 11

How were medical departments structured abroad back in the day?

Most top clubs abroad were years ahead of the UK in terms of their staff. Specialisation was the norm even 30 years ago for them; specialist goalkeeping coaches, fitness coaches, regeneration coaches, multi-staffed physios, masseurs, nutritionists, sleep doctors, we had them all at Sporting and Porto.

How was the relationship between the manager and his medical and backroom team?

The fitness coach is viewed very differently abroad. He is not just an athletic trainer, he is much more integrated in his work, including technique, power, injury prevention, individual programme prescriptions for every player, collective team (swarm fitness). He is second only to the Head Coach and is rewarded accordingly.

His relationship with the rest of the backroom staff is excellent.

WHEN A PLAYER

sk even those who barely follow football this question and they will probably look at you as if you have lost your mind and say “what a silly question - the manager of course!”

In the case of tactical substitutions, that answer will of course be correct, but in the case of injury substitutions that answer – certainly in terms of issues of medical ethics and legal responsibility – will be wrong, though many in the game (and particularly some medical staff) do not fully understand that this is so or more importantly the legal and indemnity implications of it. This article seeks to address the misconceptions where potential substitutions are injury related.

The recent ‘concussion’ cases of Hugo Lloris of Spurs, at Goodison Park at the beginning of November, and then shortly thereafter of Nemanja Vidic, brought the ethical and medical questions to the fore and prompted significant media debate, including causing the head injury charity Headway, to weigh into that debate and criticise the medical staff involved.

Whilst many supporters think they can influence substitutions – injury or tactical – why else do they waste their time chanting the names of players on the bench in a blatant attempt to influence the manager and coaching staff, or

Did you have a mentor who you looked up to and who inspired you?

Only one. The great Brazilian luminary, Gilberto Tim.

Clockwise from top-left: Roger and a young José Mourinho at Sporting Lisbon; Roger with the late Sir Bobby Robson; Roger with revolutionary Ajax and Netherlands coach, Rinus Michels; Roger with former Real Madrid manager Carlos Queiroz.

Previous clubs?

I worked for Aston Villa, Sheffield Wednesday, Vitoria Setubal, Sporting Lisbon and F.C. Porto (all Portugal), A.E.K. Athens and Panathinaikos (both Greece), Vissel Kobe (Japan), and the national teams of Kuwait, Scotland and Austria, before working for UEFA as a coach educator.

What are you doing now?

I’m a Fitness Coach for the Austrian National Team and also Head of Coach Development, whilst being a Consultant to UEFA.

How have things changed in the game?

I was the first full time ‘fitness coach’ in English football in 1982, and now every club has an array of Sports Scientists and analysts, so this area has changed completely.

Best and worst part working in football?

The best part has to be working all over the world with some fantastic players, coaches, managers and technical staff. Probably the worst part would be the hours spent travelling and arrogant close-minded coaches.

How did you get in to football?

I was dissatisfied with traditional methods, so I learned Portuguese and studied the methodology from Brazil and Portugal. I used these methods with great success at my gymnasium, and had players from all over England come to learn them.

I was invited by the F.A. to conduct seminars and demonstrations and then was invited to various clubs, like Manchester City and Arsenal to teach them these alternative methods.

What’s the most memorable moment of your career?

I’d have to say, being part of the F.C. Porto team that broke the record of winning the Portuguese Championship for five consecutive years.

What was your biggest disappointment in the game?

Leaving F.C. Porto to return to England because of a family illness.

15

Finally, the importance of good relationships with players was surely no better emphasised than your role looking after Paul McGrath both in terms of injury and in general?

There is a vast difference between being pronounced clinically and medically fit by the doctors and physios, than being ‘training and match fit’. My role with Paul was to make sure he was able to train, and play, not to deal with his medical side.

Are you still in touch with players, managers or staff you have worked with?

Yes, I still remain in contact with a host of players, coaches and medical staff from all of the clubs I have worked with.

Do you have happy memories of your time in football?

Football has taken me all over the world, and I have met and worked with some amazing players, and coaches and I have loved every minute.

For more information on Roger Spry and his work, visit www.rogerspry.com This feature was kindly produced with assistance from Gavin Blackwell.

FOOTBALL MEDIC & SCIENTIST | 15

Football Medic & Scientist Gisburn Road, Barrowford, Lancashire BB9 8PT Telephone 01282 614505 Email info@lmeda.co.uk Web www.lmeda.co.uk

Cover Image Gregg Blundell, Tranmere Rovers physiotherapist.

Jon Buckle/EMPICS Sport League 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 retreval 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 LMedA.

Editorial

Oporto Sports - www.oportosports.com

Chief Executive Officer

Eamonn Salmon

Senior Administrator

Lindsay McGlynn

Administrator

Nichola Holly

IT

Francis Joseph

Contributors

Mary O’Rourke QC, Gavin Blackwell, David Hart, Jane Tadman, Neil Mellor, Ian Mellor, Roger Spry, George Friend, Adam Kerr, Ken Goldman, Nigel Stockill, Simon Farnworth, Arthritis Today, The Northern Echo, The Birmingham Mail, The Ilkley Gazette

Design

Soar Media - www.soarmedia.co.uk

Marketing/Advertising

Charles Whitney - 0845 004 1040

Published by

Buxton Press Limited

Photography

LMedA, PA Images, Arthritis Today

FOOTBALL MEDIC & SCIENTIST | 3

MEMBERS’ NEWS

FROM THE OFFICE

ASTLE’S FAMILY SEARCHES FOR ANSWERS

T

he daughter of West Bromwich Albion legend Jeff Astle (pictured, above right) – killed by years of heading heavy leather footballs – is searching for other ex-players who suffered similar injuries.

Dawn Astle is writing to every professional football club as she fights for justice for her dad. She hopes to find details of other explayers who suffered the kind of brain disease which ultimately killed her father.

The initiative is part of the Justice for Jeff campaign, launched to demand answers from the Football Association over the impact of heading old-style balls.

Jeff’s widow Laraine spoke out after it emerged a ten-year study into the impact of heading footballs had never been published.

The FA later admitted the work, a joint venture with the Professional Footballers’ Association, had fallen apart when the young players involved failed to make the grade.

Jeff died aged just 59 in 2002. As his condition deteriorated, he was unable even to remember the names of his grandchildren.

A coroner later found the former England striker died from “industrial disease” caused by heading footballs.

Adapted from a news story within The Birmingham Mail

FORMER LEEDS MEDICAL OFFICER PASSES AWAY

A

former GP who served as Leeds United’s medical officer during the club’s Don Revie heyday has died at the age of 82. Ian Duthie Adams (pictured, above centre), passed away at Burley Hall Nursing Home, Burley-in-Wharfedale, last month.

Dr Adams qualified from Leeds Medical School in 1956 and in 1957 he started two years of National Service and passed Airborne Selection course to become a Captain in 2 Para, serving in Cyprus and Jordan. But it was his 15-year spell as medical officer at Leeds United which many more remember him for.

Described as being a pioneer in the field of sport medicine, he helped keep Leeds players

4

in good health through some high-profile campaigns in the 1960s and 1970s – under celebrated manager Don Revie.

In addition to his work for Leeds Utd, he became medical officer for international athletics, gymnastics, karate, cricket test matches plus Leeds Rugby League. He went on to be elected chairman of the British Association of Sport and Exercise Medicine as well as to the executive of the European Federation of Sports Medicine Associations.

Dr Adams retired in 1994 at the age of 62 and the same year completed a marathon in three hours and 12 minutes.

Adapted from a news story within The Ilkley Gazette

O

ur Inaugural Conference in just a few weeks’ time is understandably dominating our workload at the moment. We are busy making sure we put everything in place but this event goes beyond a typical conference.

As well as organising speakers and their presentations we also have the awards dinner to plan, not to mention the social side of things which of course are vital. Extra ‘kegs’ have been brought in, in anticipation of a great afternoon watching the FA Cup final and the evening event to follow.

Award nominations have been received these past few months and all categories now have the winners allocated; and much deserved they all are too!

We are hoping to have one or two announcements at the event but all in all, this is a conference about the Members, and for the Members, who have supported us these past four years.

Personally, I look forward to putting faces to the names of so many of you who I have spoken and corresponded with since the beginning – and maybe likewise with our staff!

Finally, delegate spaces may be limited so please book a place(s) during the next two weeks so we can finalise everything.

Looking forward to seeing you all there.

COMMERCIAL INTEREST GROWING

D

iscussions are on the way with several high profile companies who are expressing an interest in our Association. Talks have been made with the likes of Lucozade, Powerplate, Maxi-nutrition and Soccerex in recent months and as our profile grows so will their interest. It would be terrific to get a key sponsor on board and show that we are being taken seriously as an entity in the game.

Touchline Rants! e

by Pitchside Pet

Pitch side management and referees Naturally for us as Medics, we always try to take up a position in the dugout, technically as near to the halfway line as possible.

When a player becomes injured and requires assessment, we run the length of the touchline and get in line with the player waiting for the referee to call us on. The referee will always look to dugout to give you the call to go on, and do a diagonal run to the injured player. All common sense and this should be a standard protocol getting in the correct position to gain quick access to the field of play.

Why is it then that the assistant referees want to control things and say ‘wait until he calls you!’, as if you haven’t done this before!

So, you end up waiting for the referee to call you on, which is usually after he has cautioned the opponent for the foul.

Wouldn’t it be easier get us on whilst he cautions the player? Of course, we could take rugby’s lead and go on while the game continues? Then again, the players would probably see who could be the first one to ping the ball at the Physio; maybe not such a good idea after all!

ON THE COUCH...

FEATURE/SIMON FARNWORTH 1. Profession?

Head Physiotherapist at Morecambe FC.

keen to listen and take advice on something.

As physiotherapists we know that this makes progression much easier.

2. Where did you train? What Course? When?

The PFA set up the physiotherapy degree at Salford University and I was part of the first cohort in 1990. Many well known physios attended that inaugural course including Mick Rathbone, Mark Taylor, Roger Wilde and Geoff Clarke to name but a few.

3. How did you get into football?

I started my career as an apprentice at Bolton Wanderers FC and went on to play over 120 league games for the club. I then moved to Bury and Preston North End before finishing my playing career at Wigan Athletic and becoming their first team physio when I was 35 years old.

4. Talk us through your career to date?

Whilst still at Wigan I would work part-time for the outpatients department at the local infirmary. We achieved promotion at Wigan in my first season there and I worked there for two more years until I was offered the Liverpool Academy head physiotherapist job. I spent 13 great years at Liverpool travelling to great places such as Shanghai, Adelaide and Abu Dhabi with a brilliant group of people led by Steve Heighway. Standards were exceptionally high and the quality of players that came through in those years was excellent. I still see

a lot of players who are playing in leagues in the UK and around Europe and they are always complimentary about those years.

At Liverpool I had the pleasure to work with great physios and people such as Mark Leather, Dave Galley, Mark Browse and Rob Price and had access to great doctors such as Mark Waller, Steve McNally and Dave Perry. I picked up so much information and knowledge working with experienced medical staff and those years were a vital part of my education as a physiotherapist.

I’ve now spent 5 years at Morecambe and we are definately a developing club, but at the same time we are always keen to improve ourselves as medical staff.

5. Who has been the best manager you have ever worked with as a Sport Scientist?

Jim Bentley is a forward thinking manager who embraces sports medicine and is always

6. How’s the job going at the moment?

Morecambe has many good hard working people within the club and I would like to see them optimise their time in league football.

There are 2 sports therapists who work with me, Anne Taylor and Gareth Thomas; along with sports scientist Chris Squirrel and club doctor Trevor Fleet. We are all keen to learn and are always looking to improve individually and as a group.

7. What are your long-term career plans?

My own aspirations at the moment are to help the manager and coach move the club forward as far as possible and hopefully if this happens they will be able to move on to bigger and better things.

8. What would your dream job be?

I would like to remain in physiotherapy for the foreseeable future. As I have matured I have become more interested in furthering my skills in soft tissue therapy and acupuncture. I have been surprised at how acupuncture in particular has become an everyday part of many players daily ‘treatments’ and would like to expand my knowledge and skills within this field.

FOOTBALL MEDIC & SCIENTIST | 5

6

Football AND

osteoarthritis study kicks off FEATURE/JANE TADMAN As our new study examines why so many ex-professional footballers end up crippled with osteoarthritis, two former players talk to Jane Tadman about their experience of injury…

P

rofessional footballers can enjoy lucrative and successful careers playing a game they love and often getting well paid for it, but they can pay a heavy price, usually after they’ve retired.

The roll-call of ex-pros struggling with painful hips and knees in the years after they’ve left the game is lengthy, and a number of high-profile former players have needed knees or hips replacing, including Sir Trevor Brooking and Bob Wilson.

It’s hardly surprising. After aging and obesity, injury to a joint is the third major risk factor for developing osteoarthritis, which is the main reason for replacing a worn-out joint.

These days it’s probably fair to say that professional football is less of a contact sport than in the days when pros routinely and legally kicked lumps out of each other. Nevertheless, today’s players still undergo long periods of intense physical training to earn a living, and their knees are put under constant strain and are prone to injury.

But until now, very little research has been done to find out exactly why so many footballers develop osteoarthritis – and why others don’t.

Now a new five-year study, the first of its kind, aims to find out how common

the condition is among ex-professional footballers compared to the general population. And the findings could have implications far beyond the relatively small world of professional football and lead to greater awareness of how to avoid and prevent injuries for people who play sport at whatever level.

The study, Osteoarthritis Risk of Professional Footballers, is one of the biggest projects being carried out as part of the Arthritis Research UK Centre for Sport Exercise and Osteoarthritis, partly funded by FIFA and supported by the FA. The study has the backing of Sir Trevor Brooking, who says: “A few years ago I had a knee replacement for my left knee and have benefited enormously from that successful operation in my daily work commitments. There’s very little research on this important topic, and the study will be of immense benefit to the current football community, and will help to direct the game for future generations of footballers.”

Based at Nottingham University, the study is led by clinical biomechanist, Dr Gwen Fernandes, in the department of academic rheumatology.

“Professional footballers appear especially prone to arthritis due to the intensity of the sport they play and the

injuries sustained during their playing careers,” explains Dr Fernandes. “They seem more likely to develop early onset osteoarthritis of their knee joints, for example. The results of our study will establish the prevalence of osteoarthritis among professional footballers compared to the normal male population and hopefully identify the specific risk factors for knee osteoarthritis in footballers.”

As part of the first phase of the study, the research team will work with football associations to recruit at least 18,000 ex-professional footballers over the age of 40 and ask them to fill in a questionnaire.

Questions will include how many games they played, how many hours they spent training, how long they played and at what level, whether they were injured, and whether they now have osteoarthritis and so on, enabling researchers to build up a detailed picture of their playing careers.

A further 900 players will then have their knees x-rayed (courtesy of Spire Healthcare’s research arm, Spire Perform, based at FA headquarters at St George’s Park) which will provide evidence of structural changes in their knees. This information will be mapped against the self-reported pain in the questionnaires.

The results of the questionnaires and the x-rays will then be compared against

FOOTBALL MEDIC & SCIENTIST | 7

a control arm of 500 healthy volunteers recruited from the community cohort in Nottingham.

As well as having an impact on the way that footballers train, practice and play, the results will throw a fascinating light on training regimes and attitudes to fitness in the world of professional football, and how they have changed over the past 20 or so years.

The research will dovetail in with other work being carried out at the centre for sport, exercise and osteoarthritis’s University of Southampton site. Professor of musculoskeletal rehabilitation, Maria Stokes, is working with Southampton Football Club in designing targeted training programmes aimed at reducing injuries among players and protecting them against developing osteoarthritis in later life.

Pictured: Neil Mellor on the ball for Sheffield Wednesday. Neil scored 20 goals in 43 appearances for the Owls.

8

Ian and Neil Mellor – a footballing father and son’s experience of injury

I

an Mellor is typical of many exprofessional footballers of his generation.

The former Manchester City, Norwich City and Sheffield Wednesday winger retired from the game in 1984. Now 63, Ian has had both hips re-surfaced, surgery on both knees, and an ankle replacement, all as a consequence of osteoarthritis. He also has metal plates in both forearms as a result of an accident in training.

“It was very different in my day to how it is now, and players put up with all sorts then – it was our job and quite normal,” he recalls.

“If you twisted your ankle you’d wrap it up and out you went – we were on appearance money then. And I’d have injections before a game if I was in pain and still go out and play.”

Ian was lucky to remain fairly injury-free between the ages of 17 – when he damaged the cartilage in his knee – and 29, when he suffered a serious Achilles injury (something he attributes to being tall and slim), but says his problems really started when he retired.

To keep fit after leaving the game at the age of 34, he took up road-running and squash, which may also have contributed to his later joint problems.

Ian worked for the Professional Footballers’ Association (PFA) in Manchester for 20 years until he retired last year and has seen countless players require help and support when they have had to retire early because of injury.

One is his own son, Neil. Neil Mellor was a striker at the top of his game when he was forced to retire at the age of only 29 last year following an injury during a match between Preston North End and Milton Keynes Dons.

The former Liverpool player damaged his cartilage and cracked some bones in his knee.

“I knew something was wrong but I didn’t think it was that serious,” says Neil, now 30. “I had an operation on my knee and the surgeon said that the worst case scenario was that I would have to stop playing.

When I tried to come back I knew straight away that I couldn’t. I’d been jogging for 15 metres, then changed direction, and my knee just swelled up. It happened just at the point in my career when I was doing really well and I was ready to move back up a level.”

Neil Mellor’s enforced exit from the game he loved is evidence, that despite all the changes in the way that footballers train and play, and the emphasis on nutrition and fitness, injuries and accidents can still happen in football and still wreck careers.

Neil, who signed for Liverpool when he was 16, after being a youth player at Manchester City from the age of 10, has very different memories to his dad of his days as a pro.

“My era was more scientific, and the training was more specific to the individual, depending on your build and position,” he explains. “In my dad’s day it was more: ’go out and do 10 laps’. We were taught about injury prevention, and the physio got us to

Pictured: A young Ian Mellor poses for a photo during his playing days at Manchester City.

do lots of stretching and strengthening.

There’s also an emphasis on nutrition. And at Preston we had hydration tests before training, because if you were dehydrated it was more likely to lead to injury.”

Ian concedes: “Neil’s era was better for things like training and warming up, no doubt. When I was an amateur player I’d have fish and chips before a game. And I used to hide before a game because they wanted us to warm up – I thought running around for 90 minutes was enough! There’s a lot more awareness now and the PFA run lots of training programmes.

“Neil couldn’t even take a Locket before a game because it was regarded as a drug.

Their generation is very lucky because they’ve been educated, and now even lower

league teams are more into that kind of thing. The modern game is a lot better than it used to be.”

Neil now works part-time for the PFA and also has a fledgling career as a Sky Sports commentator. “I’m focused on other things now rather than thinking about what I can’t do any more,” he says. “I can’t change what happened.” He can no longer run – he played in a charity match last summer and couldn’t walk for two weeks afterwards – but enjoys yoga and Pilates, and plays golf. Having his dad around to advise him has also helped him keep his feet on the ground.

Asked whether he’d do it all again knowing how serious his osteoarthritis would be later in life, Ian, who was a postman before starting his professional career at

Manchester City, says: “Ask any 16-year-old and they’d say yes. You don’t think that far ahead and you think you be the one who doesn’t get injured. And if you ask most men what they’d rather be – a postman, a warehouse man or a footballer…?”

Both are very supportive of the new study, although Neil is too young to take part. He says: “Research like this might help players in 10-15 years’ time so they have fewer injuries and better everyday health. It might educate coaches how to train players better and provide an evidence base to help players play more safely. That’s got to be a good thing.”

This article has been reproduced with the kind permission of Arthritis Today

FOOTBALL MEDIC & SCIENTIST | 9

10

Who decides

when a player

should be substituted?

LEGAL/MARY O’ROURKE QC

A

Ask even those who barely follow football this question and they will probably look at you as if you have lost your mind and say “what a silly question - the manager of course!”

In the case of tactical substitutions that answer will of course be correct. But in the case of injury substitutions that answer - certainly in terms of issues of medical ethics and legal responsibility - will be very wrong, though many in the game (and particularly some medical staff) do not fully understand that this is so or more importantly the legal and indemnity implications of it. This article seeks to address the misconceptions where potential substitutions are injury related.

The recent “concussion” cases of Hugo Lloris of Spurs (at Goodison Park at the beginning of November) and then very shortly thereafter of Nemanja Vidic brought the ethical and medical questions to the fore and prompted significant media debate.

Whilst many supporters think they can influence substitutions - injury or tactical - (why else do they waste their

time chanting the names of players on the bench in a blatant attempt to influence the manager and coaching staff or applaud the “brave” player trying to “run it off” and “carry on”) there is no doubt that save in very exceptional circumstances (the under pressure and possibly weak manager courting popularity) the fans really have no say and cannot dictate changes in on field players or formations (though they may get it right in terms of calling for a substitution which was about to happen anyway and thus claiming credit for it).

Some Chairmen/ owners or Chief Execs will also believe that substitutions are matters on which they can (and should) be heard and will voice their opinions to their managers (including on the timing of the substitution during the match since substitutions before the 60th minute cost the club more in terms of match bonuses than those after that time as a result of specific clauses in the standard PFA player contract - so “let him carry on if he can run it off” or “don’t make your tactical swap yet”) - but again, unless the

manager is exceptionally vulnerable or weak or under extreme pressure at the time - this really won’t be the case and their influence will be more imagined or indirect.

Therefore not the fans and not the owners - so some might say the only other “interested party” is the player himself - and we can all think of examples of players unwilling to come off or pointedly and blatantly refusing to come off (in injury situations) and unhappy about being taken off in other tactical or personnel situations. Certainly many managers in injury cases are quick to give players a say in whether they are “ok to carry on” or “can run off the injury” and whether they “should see how they go” - especially with a star player. The question is whether they should do so and whether the player should be allowed to have any say in the matter or even more importantly, whether in the case of injury or suspected injury the manager himself should have any say or actually has anything to contribute.

The ordinary match going supporter

FOOTBALL MEDIC & SCIENTIST | 11

who would express surprise at the question who decides as to a substitution would probably be equally surprised at the answer I would give on whether the player or manager should have any say - that in the case of injury or suspected injury the decision should primarily (if not exclusively) be one reserved to the medical team - the (pitch side) team doctor or physio. My answer is not given as a 20 year plus season ticket holder at a major Premier League club - but as a 30 year qualified lawyer with some expertise in sports medico-legal work. That puts me in conflict with supporters sitting around me when the issue presents on the pitch as it has in several significant instances.

The key question is (and ought to be) whether a player should have had any right to a say in the decision. It is one thing for the medical team to assess the player and determine that medically he appears fit to continue and then to check with the player that he does want to continue if and when the staff are satisfied of fitness. It must also be correct

12

that any on-pitch medical assessment (where the means of assessment especially in head injury cases is limited for the medics with no scanning facilities on the pitch) how the player says he is and feels and what his attitude is will necessarily form part of the appropriate medical assessment of fitness to continue.

However the danger for the medical staff is in letting the player’s wishes and own assessment or statements as to fitness to influence the healthcare professional’s objective decision (or indeed dominate it). The healthcare professional needs not only to resist the player’s “agenda” (whatever it might be) but also any baying from the crowd for the player to get up and carry on or entreaties from the manager that he does not want to make a substitution. The situation will be even more acute if towards the end of the match and all 3 substitutions have already taken place such that removal of the injured player will reduce his team to 10 men.

It is not just a question of attracting comment in the media after such an event that should be of concern to the healthcare professional - but rather what else might happen.

In the last 15 years I have been involved in at least 2 medico-legal cases which serve to illustrate the risks to the Club medical staff.

The first involved an Australian semipro rugby league player in the south east of England (Greater London area). He sustained a head injury in a match and the evidence was he was “knocked out” for maybe a minute or so. Back when this happened the relevant rules required all games to have a medical officer in attendance - but there were no rules as to what discipline that medical officer should be or what training (s)he should have.

The doctor in question for the relevant match was a Consultant Obstetrician and Gynaecologist and was roped in as she was the wife of one of the home team players 9and the home team bore the obligation to provide the medical officer).

She allowed the player to “play on” despite rugby rules requiring 21 days away from play after a concussion head injury which involved a loss of consciousness.

The referee (despite rugby rules requiring him to ensure the withdrawal of a concussed player) deferred to the medical opinion and the player’s wishes (he was a star import and the game an important one).

12 hours post match he attended a DGH A & E to be diagnosed with a subdural haematoma (and Glasgow Coma scale score of 8/15) and was rushed in a blue light ambulance to central London and a major neurological centre where after operation he was left with permanent left sided hemi-plegia and lost his career in rugby and in computers. He sought my advice as to who he could sue.

The other case is a current one (due for hearing in the London High Court towards the end of 2014). It relates to club doctors and physios being involved in the care of a player in 2005/2006. In this

case - brought on behalf of the player (he has no capacity himself) – the Club has already joined as parties (what are called Third Parties) to the proceedings the Club doctors of the time (and are seeking to pass liability to them) and it seems consideration may be given to also joining in the physios involved in the player’s care on behalf of the Club and when employed by the Club.

Lessons to be learned as the healthcare professional from these 2 examples:(1) the player staying on the field and telling you, the healthcare professional, he is ok to do so is no bar to him subsequently seeking to sue you and claiming how would he know what was in his best interests medically and it was your job to make an assessment and look after his longer term health and foresee what potential consequences or repercussions there might be for him and that you breached your duty of care to him and he suffered injury and loss as a consequence!

(2) that your Club employer (despite anything said by the manager or other executives or despite their own roles and failings in the incident) will and can turn on you and blame you when the big claim presents (especially if you have moved on in the meantime as is the situation in my current case) and you will then need your own indemnity and representation.

Finally the referee and FA. In my rugby case there were questions of suing the RFL and / or the referee - for the rules not protecting players and the referee not taking the decision away from the player and club provided doctor.

So - what do you do and what is the answer to the question posed in my title?

You tell the player and manager (and anyone else who asks!!) that you owe a duty to the player as to his (health) best interests and the decision whether he is fit to continue is therefore yours and yours alone. And you make sure you have appropriate indemnity cover and access to a good lawyer!!

FOOTBALL MEDIC & SCIENTIST | 13

WHERE ARE THEY NOW? FEATURE/Roger Spry

Did you have a mentor who you looked up to and who inspired you?

Only one. The great Brazilian luminary, Gilberto Tim. How were medical departments structured abroad back in the day?

Most top clubs abroad were years ahead of the UK in terms of their staff. Specialisation was the norm even 30 years ago for them; specialist goalkeeping coaches, fitness coaches, regeneration coaches, multi-staffed physios, masseurs, nutritionists, sleep doctors, we had them all at Sporting and Porto.

How was the relationship between the manager and his medical and backroom team?

The fitness coach is viewed very differently abroad. He is not just an athletic trainer, he is much more integrated in his work, including technique, power, injury prevention, individual programme prescriptions for every player, collective team (swarm fitness). He is second only to the Head Coach and is rewarded accordingly.

His relationship with the rest of the backroom staff is excellent.

Specialisation is a crucial part of modern football. Some clubs, for example, have defensive coaches, attacking coaches, recuperation coaches, dieticians, video analysts, data and statistics coaches. In days gone by the manager and his assistant had one physio, one doctor and they were expected to do everything.

When you first arrived at Sheffield Wednesday, the fitness coach was revolutionary and unique in the late 1980s…

I was the first full-time fitness coach in British football, and was looked upon with a great deal of scepticism because it was so radically different from the norm.

Clockwise from top-left: Roger and a young José Mourinho at Sporting Lisbon; Roger with the late Sir Bobby Robson; Roger with revolutionary Ajax and Netherlands coach, Rinus Michels; Roger with former Real Madrid manager Carlos Queiroz.

Previous clubs?

I worked for Aston Villa, Sheffield Wednesday, Vitoria Setubal, Sporting Lisbon and F.C. Porto (all Portugal), A.E.K. Athens and Panathinaikos (both Greece), Vissel Kobe (Japan), and the national teams of Kuwait, Scotland and Austria, before working for UEFA as a coach educator.

What are you doing now?

I’m a Fitness Coach for the Austrian National Team and also Head of Coach Development, whilst being a Consultant to UEFA. Best and worst part of working in football?

The best part has to be working all over the world with some fantastic players, coaches, managers and technical staff. Probably the worst part would be the hours spent travelling and arrogant closed-minded coaches.

What’s the most memorable moment of your career?

I’d have to say, being part of the F.C. Porto team that broke the record of winning the Portuguese Championship for five consecutive years.

What was your biggest disappointment in the game?

Leaving F.C. Porto to return to England because of a family illness.

How have things changed in the game?

I was the first full time ‘fitness coach’ in English football in 1982, and now every club has an array of Sports Scientists and analysts, so this area has changed completely.

Are you still in touch with players, managers or staff you have worked with?

Yes, I still remain in contact with a host of players, coaches and medical staff from all of the clubs I have worked with.

Finally, the importance of good relationships with players was surely no better emphasised than your role looking after Paul McGrath both in terms of injury and in general?

There is a vast difference between being pronounced clinically and medically fit by the doctors and physios, than being ‘training and match fit’. My role with Paul was to make sure he was able to train, and play, not to deal with his medical side.

How did you get in to football?

I was dissatisfied with traditional methods, so I learned Portuguese and studied the methodology from Brazil and Portugal. I used these methods with great success at my gymnasium, and had players from all over England come to learn them.

I was invited by the F.A. to conduct seminars and demonstrations and then was invited to various clubs, like Manchester City and Arsenal to teach them these alternative methods.

Do you have happy memories of your time in football?

Football has taken me all over the world, and I have met and worked with some amazing players, and coaches and I have loved every minute.

For more information on Roger Spry and his work, visit www.rogerspry.com 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.

G

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

16

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 Phil Hayward vs Chris Barnes ‘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

A FRIEND

IN SCIENCE FEATURE/GEORGE FRIEND

The growth of sports science has transformed the way that a footballer trains. Middlesbrough defender George Friend spoke to the club’s head fitness coach, Adam Kerr, to discuss the appliance of science…

A

typical day’s football training isn’t what is used to be 20 years ago, the game has changed significantly. The weekly routine of a modern day player is hugely different to that of a footballer playing in the early 1990s.

At Middlesbrough’s Rockliffe Park training ground, Adam Kerr, head fitness coach, and his colleagues in the sports science department, ensure a specialised sports-science based programme is in place, enhanced by highly technological equipment and expert guidance.

“We monitor all the players daily, on the training pitches and in the gym,” said Kerr.

“It’s important that everything is in place and set up to try and keep players free from injury and able to train to their maximum.”

Professional football is a hugely competitive, multi-million pound business, so it’s no surprise that every team and player is searching for the slightest edge over their rival.

Here at Boro, the club has developed its sports science department in the hope of increasing performance and aiding injury prevention, giving that added edge to the training and match days.

Kerr has an abundance of sports and fitness qualifications, and through the 2012-2013 season, he worked at Arsenal as the lead

18

academy sports scientist and fitness coach.

“I was part of the backroom staff here at Boro two years ago and since my return I’ve seen huge changes in the sports science department,” said Kerr. “The scientific involvement, facilities and fitness side of the club isn’t too dissimilar to Arsenal and I think we’re making great progress and a huge impact here.”

Sports science in football can be divided up into the following areas: gym conditioning, nutrition, recovery, the monitoring of work rates/loads and fitness testing.

The Boro training programme is devised to incorporate each of these areas on a daily basis so that optimum results can be achieved by every member of the squad.

“Gym conditioning is really important for professional athletes, however every individual has different needs and requirements,” said Kerr.

“Here we personally configure weights and stretching programmes specific to each individual, these include upper body and leg work exercises.

“We collaborate with the medical department to identify areas of physical strength and weakness in the players and adapt an individual’s programme where

appropriate.”

Nutrition in football, and sport in general, is an area of sports science that can often be overlooked by those in and outside the profession, but Kerr re-enforces how crucial it is.

“It’s so important, mainly because apart from sleep, it’s the second best form of recovery,” he said. “It’s vital for our players to eat well straight after training and matches.

“We use protein shakes, energy drink supplements and some tablets like multivitamins and fish oil omega 3 capsules, all in a bid to raise performance and aid recovery.”

Recovery sessions are paramount in a footballer’s routine between matches, and something Kerr has to plan and constantly think about.

After discussions with the coaches and the medical team, it’s important that the right balance is maintained in the player’s schedule.

“On a Sunday, following a weekend match, those who have played do a recovery session,” explained Kerr.

“This involves a light jog and ball work, followed by spinning on the gym bikes and stretching, there is also opportunity for a massage.

“In terms of rest days, players are off on a Monday if there is no Tuesday night game, this again gives the body further recovery before returning to intense training.”

The monitoring of work rates and loads is a side of football that has been significantly enhanced over the last decade.

Wearing heart rate belts has been a common theme among top professional clubs for a number of years.

However, the monitoring of players has now evolved with the use of GPS systems worn in training.

“This is probably the biggest, most significant change in football training from a sports science aspect,” said Kerr.

“The GPS devices track the players’ every movement, their changes of speed, distance covered and heart rate.

“So we can see in detail, how fast and for how long a player is running, even their weight transfer and what foot they’re predominantly using. The GPS units also provide data for me and the other coaches to analyse at the end of each training session.”

Players aren’t just monitored in training either.

There’s certainly no hiding on a match day, with a semiautomated tracking system used in

many stadiums.

“Similarly to the training data, we follow players on a match day using Prozone software, which is installed in most Championship and Premier League stadiums,” said Kerr.

“It’s a program that monitors these same movements and distances and after every game a box of data is presented, displaying each player’s workout.”

“We measure minutes played, the total amount of kilometers covered, the amount of distance covered at a high intensity (>19.8km/ hr) in meters, the total number of runs at full intensity (>25.2km/hr) and the average time between high intensity efforts during the game.”

Fitness testing is an area of football that is crucial in a player’s development and record of progression. By testing players in a number of different ways, results can be logged and compared at a later stage.

“We do a number of different tests here, from an endurance-based exercise like the ‘yoyo test’ to more power work in the form of jump and isokinetic testing,” said Kerr.

“We also carry out bodyfat percentage examinations and functional movement screening, which measures flexibility and core strength.

“The testing is really important because when a player is returning from injury we can assess how close they are to full fitness by re-testing the individual and comparing their previous results.”

At Boro, the number of injuries has fallen in comparison to previous seasons, and Kerr believes the influence of sports science is a contributory factor.

“The science aspect is so important, if the staff and players can appreciate and buy into what it’s all about then so many positives can be taken from it,” he said.

“We’ve had fewer injuries and have been able to monitor work loads and fatigue, which in turn can only benefit the outcome of the squad’s performance.”

In football, where a match can be decided by the finest of margins, it’s the intricate work of sports science that can give that edge in making a difference.

At Boro, that attention to detail and a combined determination to leave no stone unturned, all accumulates towards the club’s drive for success.

This article has been reproduced with the kind permission of The Northern Echo.

FOOTBALL MEDIC & SCIENTIST | 19

Conflict, Collision and Confusion FEATURE/KEN GOLDMAN Ken Goldman, the Editor of The Normidian the magazine of the North Middlesex Referees’ Society, who was formerly the lay member on the committee of FARMS (South), has written the following article on the relationship between physios and match officials.

W

hilst it would be extremely pleasant if every member of the football fraternity was at all times in tune with one another, unfortunately things just do not work like that. Thus, when referees who are required under Law 5 to manage the game, come up against physiotherapists who have a distinctive job to do treating injured and potentially injured players on the pitch, the two parties are often on a collision path with each other.

This is because the referee has a set number of rules to follow which encompass continuing play if a player is only slightly injured but stopping it in more serious cases and then inviting the physio or doctor onto the pitch and is the one with the sole power to permit anyone to enter the field of play. It is his/her responsibility to have an injured player removed from the field and not treated on it which causes of course the most serious conflict between referees and physiotherapists. This is because the latter’s main aim is to get onto the pitch and assess the pathology of the injury and resolve it as quickly as practicable.

This, after having ascertained the seriousness of the injury and how best to treat it taking into account how the injury occurred and his/her own experience of the type of injury sustained. Thus we have two people disagreeing as to how long the injured player should remain on the pitch and sometimes this collision of concepts and needs, where the referee is stopping his watch and agitating for a resumption of play, can lead to quite a heated argument.

Confusion can also arise where there are exceptions to the rule about players being removed after injury. These exceptions apply when a goalkeeper is injured or where the keeper and an outfield player collide and immediate treatment is needed or where the same thing happens with two players of the same side.

Many players wishing to return find it frustrating that they cannot get the attention of the referee for permission to return and one has seen instances of the physio jumping up and down trying to gain that attention immediately after play has restarted, which upsets both sides. This particularly applies where the player is bleeding from a wound and has to report to the referee before he can return. Incidentally a player refusing to leave the field when injured will be cautioned by the referee for unsporting behaviour.

20

Pictured: Referee Mick Russell speaks with injured Blackpool player Tom Barkhuizen and Blackpool’s Head Physio Phil Horner.

Additional difficulties arise when the referee who is the sole time-keeper has to decide in his capacity of protecting and safeguarding the welfare of the players, which is paramount, as to whether any of them are actually feigning injury and/or time wasting. In that event he will try to prevent the physio from entering the field, causing more clashes.

How different from years back when the then ‘trainer’ rushed onto the pitch and administered to the fallen player the ‘magic sponge’ and then ran off again.

There was little or no confusion then but as time has progressed and so has the knowledge of the physiotherapists they have wanted more quality time to assess and tend to the injured player. Contrast this at the highest levels against those of the lowly grassroots side of the game where there is less pressure on time but fewer qualified people in attendance to help an injured player.

Whilst at the top we have seen physios and doctors called onto the pitch and lives actually saved, no such facilities are normally available on park pitches and players are lucky if someone has been on a first aid course. In those circumstances referees are advised not to try to treat an injured player unless it is to save life, for fear of being sued afterwards for negligence, but instead to stop or abandon the game and call for an ambulance.

What therefore can be done to improve relationships between referees and physiotherapists? The answer is reasonably simple and is all about dialogue. There are a number of Referees’ Societies throughout the country, who usually meet on a monthly basis where physios at all levels could be invited to speak or just attend and likewise referees could be invited to talk at Medical Societies meetings.

One such dialogue was created a couple of month’s back at the North Middlesex Referees’ Society when they extended an invitation to Arsenal’s main physiotherapist Colin Lewin, cousin of England physio Gary Lewin, who himself had previously been a guest. A fascinating evening ensued with an enthralled audience of referees listening to what could be done to bring both groups together. Colin also had the chance to enter a plea for referees to firstly get physios on very quickly for potential head injuries whilst then clearing everyone away from the injured player and secondly to try, when the weather is really hot, to create a drinks break.

I am sure that that type of exchange of ideas would enable progress to be made in identifying each other’s problems and reducing any conflict to as little as possible.

For more information on the North Middlesex Referees’ Society visit www.northmiddlesexreferees.org.uk

22

Serious

shoulder

injuries

in football professional

FEATURE/David Hart

BACKGROUND

S

houlder injuries account for a relatively small proportion of injuries in professional football, as small as 2% (Ekstrand, Hagglund & Walden, 2011). Of greater significance, however, is the severity of shoulder injuries; the Ekstrand et al. study also demonstrated that a third of all shoulder injuries result in unavailability from training and matches for 28 days or more. The implication for a medical team working in football is that they will be presented with an injury of high severity that is far less familiar than the majority of lower limb injuries, albeit possibly on an infrequent basis.

Over a consecutive three-season period, I worked as part of medical teams managing three shoulder dislocation injuries, one per season. This was a fairly high incidence when the 2% statistic is considered but of greater interest to me was the mechanism involved in all cases. Hudson (2010) reports that serious shoulder injuries in an athletic population occur in a position of combined glenohumeral abduction against a force of external rotation and horizontal extension resulting in an anterior dislocation. All three of the injuries I worked with had anteriorly

dislocated but away from a positional extreme and in an apparently low-energy situation. Two players were central defenders in aerial challenges with their arms abducted but in a position of neutral rotation with minimal impact. The third was a striker running away from a defender, arm at his side, and dislocating whilst having his arm tugged by his opponent.

All three underwent surgery and I found that research to guide rehabilitation was limited to studies involving athletes of other disciplines. This experience suggested to me that perhaps the characteristics of serious shoulder injuries in football were different to other sports; certainly football has divergent upper limb demands to the upper limb dominant sports that contribute to the existing research base. It seemed appropriate to carry out research to guide the management of shoulder injuries, both prevention and rehabilitation, for the footballer specifically.

THE STUDY

I

n conjunction with Professor Len Funk, Manchester, I conducted a research project to try and identify the key

characteristics of serious shoulder injuries in the football player to provide some grounding for further football specific research. The study was a retrospective case series (all cases had been managed

by Professor Funk) of professional football players from the top four divisions in English football. 52 players were reduced to 25 meeting the inclusion criteria and the following data was reviewed: • • • • • •

Previous injury information Clinical findings Radiology findings Surgical findings Surgical intervention Return to participation time

As all players were managed by the same surgeon, return to play protocols were identical, however, non-prescriptive.

The protocol was defined as guidelines with expected key progressions and milestones but acknowledged that the players’ individual physical condition and the interpretation of such guidelines from autonomous medical teams allowed for a high degree of variance.

FOOTBALL MEDIC & SCIENTIST | 23

Pictured: Former Liverpool defender, Jamie Carragher, receives treatment for an injury to his shoulder by first-team doctor Zaf Iqbal.

RESULTS

S

erious shoulder injuries (lasting 28 days or more) in professional football have the following characteristics:

• • • • • •

• • •

The majority are labral injuries (84%) The majority are dislocations (88%) Previous injury is a risk factor (32% had relevant history) Serious injuries are most likely to occur during match play (64%) Forced external rotation and abduction under a high load accounts for over half of all serious shoulder injuries (56%) A quarter of these injuries occur under a low load away from a positional extreme (24%) and do not affect goalkeepers A fifth of serious shoulder injuries in football have a gradual onset (20%) Outfield players and Goalkeepers return to participation in just over 11 weeks The risk of recurrence is low (No subjects reinjured within 90 weeks of surgery)

24

The study concludes that football does indeed have different characteristics to other sports where serious shoulder injuries are concerned. 11 weeks is a shorter rehabilitation time than 4 months in professional rugby (Funk, 2008) for example and the incidence of labral injuries is far higher than in other sports. The mechanism of injury for half of the subjects is consistent with the

high-energy forced external rotation and abduction situation. However, with this subject group of footballers, a significant number of low-energy situations away from a positional extreme occurred that could be deemed preventable. For clarification, the table below provides examples of such lowenergy injuries.

Table 1 Mechanism Arm tugged during running Minimal contact while in midair (heading) to underside of upper limb

Upper limb position Glenohumeral extension with neutral rotation, elbow flexion Glenohumeral abduction with internal rotation, elbow flexion

Glenohumeral abduction Arm moved back as part of ball with external rotation, elbow striking action—no contact extension Glenohumeral joint in mid Minimal contact to back of flexion/extension and neutral shoulder joint rotation

FURTHER IDEAS

P

hysical conditioning of the professional footballer is a broad subject and a high degree of variance will exist within clubs between players, and even more so where inter-club comparisons are made due to differing, and in some cases, contradictory methods employed by medical and science staff based on individual philosophies. Such variety promotes innovation and augments the evolution of our profession.

Accounting for the range of conditioning methods across clubs, there is far less emphasis on upper limb conditioning when compared to lower limb conditioning, which is logical based on prioritising needs. Upper limb low-threshold training is an area of particular deficiency in my own experience and from informal discussion with peers at other clubs. For example, ‘pre-hab’, ‘injury prevention’ and ‘activation’ are terms used to generally describe training drills aimed away from strength and power development, more stability through range of movement. Proprioception, single leg stability and landing mechanics are a few categories of exercise routinely employed for lower limb conditioning whilst often overlooked for the upper limb.

Shoulder injuries can result in a significant period of unavailability and at the very least should be afforded greater consideration where conditioning programmes are concerned. Upper limb dominant sports do not have a reported incidence of low-energy shoulder injuries.

The study reported above found that goalkeepers similarly do not sustain lowenergy injuries. A key difference between an outfield football player and athletes in upper limb dominant sports, including goalkeeping, is the exposure to regular upper limb perturbation and plyometric activity. A goalkeeper has regular ball-tohand contact and must be able to control landing efficiently. Such actions are common in rugby, American football and volleyball. As a consequence of this, the stretch-shorten cycle and eccentric torque available through range of the rotator cuff muscles is expected to be different to that of an outfield football player. The ability to recruit these stability muscles in positions described in table 1 may be the reason why upper limb-dominant athletes have a contrasting aetiology of injury. This is speculative at this stage, however, the integration of exercises aimed at injury prevention for the shoulder can easily be integrated into existing sessions. Single leg stance work can be supplemented with theraband shoulder exercises for example and proprioception drills can incorporate throwing and catching work with medicine balls. Many practitioners will be addressing this requirement already but hopefully upon reading the study, medical and science professionals working in football will see the potential value in doing so.

If anyone would like to offer feedback on the study, or has any suggestions for further work in the area, I would be grateful to hear new ideas.

Knee Surgery, Sports Traumatology, Arthroscopy December 2013 DOI 10.1007/s00167-013-2796-1 Serious shoulder injuries in professional soccer: return to participation after surgery David Hart, Lennard Funk Author information Medical Department, Coventry City Football Club, Sky Blue Lodge, Leamington Road, Coventry, CV83FL, UK Dave.Hart@ccfc.co.uk Abstract PURPOSE: An evidence base for the management and prevention of shoulder injuries in soccer is lacking. The aim of this study was to demonstrate the type, mechanism and recovery time after surgery associated with serious shoulder injuries sustained in professional soccer to build an evidence base foundation.

METHODS: Fifty-two professional soccer players underwent shoulder surgery for injuries sustained during match play. Of these, 25 fulfilled the inclusion criteria. Data were collected for injury mechanism and type; clinical, radiological and surgical findings and procedures; and return to full participation. Subjects were all managed by the same surgeon.

RESULTS: Labral injuries represented the most common injury type affecting 21 (84 %) subjects; two rotator cuff (8 %) and two combined labral/rotator cuff (8 %) injuries were less common. Fourteen (56 %) subjects sustained a high-energy trauma injury in a combined abduction and external rotation position. Six (24 %) subjects sustained a low-energy trauma mechanism in variable positions, while five (20 %) had a gradual onset of symptoms. Twenty-two (88 %) subjects reported a dislocation as a feature of their presentation. All of the subjects with high- and low-energy trauma mechanisms reported a dislocation occurring at the time of injury. Eight (32 %) subjects had sustained a previous significant shoulder injury to the ipsilateral side. Goalkeepers did not sustain low-energy trauma injuries. Outfield players returned to full participation in a mean time of 11.6 weeks, while goalkeepers did so in 11.1 weeks post-surgery. Return to participation time ranged from 7 to 24 weeks with a median of 11 weeks.

CONCLUSION: Professional soccer players can expect a return to participation within 12 weeks postsurgery. The majority of serious shoulder injuries in soccer occur at a positional extreme of external rotation and abduction in high-energy situations, while a significant number occur in low-energy situations away from this position. Most serious shoulder injuries in professional soccer are dislocations. Previous shoulder injury is considered a risk factor.

LEVEL OF EVIDENCE: IV.

FOOTBALL MEDIC & SCIENTIST | 25

Recovery, Readiness

and Resilience FEATURE/Nigel StockilL

W

ith the ever increasing demands of being a professional footballer, the concepts of recovery, readiness and resilience are becoming critical to support staff who have responsibility for maximising the assets they look after – the players.

Weight, hydration status, resting heart rate, saliva, HIMS and vertical jump testing have all been used and have their merits but, in isolation, only provide a piece of the jigsaw rather than the full picture. What hasn’t been done until more recently, is 24/7 Athlete Monitoring.

The aforementioned metrics MAY provide us with an insight into the players’ readiness status (WHAT) but they don’t explain causality (WHY). Ultimately, it is getting to grips with WHY that allows us to coach the players to be better at looking after themselves, in order to achieve resilience and sustained performance.

So how can we complete the jigsaw puzzle that is athletic readiness? Firstbeat has developed a platform that allows us to connect together information on training, recovery, sleep, travel and lifestyle and in essence explore the WHY. By simply wearing

a Bodyguard recording device a player’s sleep and activity patterns can be monitored, recovery checked and readiness status determined.

Of course it is impractical to monitor every athlete every minute, every day, so Firstbeat has developed a Quick Recovery test (QRT) that assesses their Readiness Status prior to training. When the QRT score is mapped against Training Loads (e.g. Training Effect, TRIMP, distance covered) it is possible to identify individuals who are outliers from squad norms, monitor them for 24 hours and start to differentiate and identify problems areas. Is the training load too heavy? Is sleep of poor quality? Are the demands of long car journeys on a daily basis becoming a drain? Is playing ‘Call of Duty’ for 2 hours before bed really the perfect recovery strategy!?

The graph below demonstrates a new Firstbeat feature that provides an immediate view on training load and recovery status and allows for players to be bench marked against other players or the squad. Here, Player 3 is compared to 4 other midfielders and quite clearly is running into problems So to summarise, Firstbeat is a single platform that can supply not only extremely accurate and reliable Training Data (either real-time or via a range of other devices), it can also provide you with a 5 minute Readiness Test (that you can perform on all your Squad at the same time). Firstbeat will help professionals piece together information on training, sleep, recovery, stress and readiness and more importantly allow them to move on from simply having a set of numbers to a more in depth understanding of why the numbers are what they are!

Nigel Stockill Performance Director Firstbeat UK www.firstbeat.com/professional-sports/individual Tel 0207 135 2421

26

FOOTBALL MEDIC & SCIENTIST | 27

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

The Inaugural LMedA Conference Saturday May 17th and Sunday May 18th 2014 At the stunning Radisson Blu Hotel East Midlands Airport

“It’s a great idea to bring everyone together at the season’s end and we look forward to all the department attending the event for both the conference programme and the social get together.”

Rob Swire, Manchester United, Head Physio

These are just some of the clubs who will be represented at the event: Newcastle United Aston Villa Northampton Town Brighton & Hove Albion Blackburn Rovers Bolton Wanderers Swindon Town Huddersfield Town Tottenham Hotspur

“This is a great opportunity to reward the staff for all their hard work this season and the concept and programme is fantastic.”

Neil Sullivan, Derby County, Head Physio

Liverpool Manchester City Sunderland Middlesbrough Crewe Alexandra Derby County Carlisle United Manchester United Chelsea

“Great format; really looking forward to the event.”

Steven Feldman, Huddersfield Town, Club Doctor

and many, many more…

“It’s a great opportunity to reinvigorate the community spirit that has been lacking over the last ten years.”

Jason Palmer, Chelsea, Manager of Therapy Services “The venue, location and programme all look firstclass, so we will definitely have a presence.”

Lee Nobes, Manchester City, Head Physio

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.

For more information visit www.lmeda.co.uk or contact 0333 4567897