Keeping your finger on the pulse

football medicine & performance The official magazine of the Football Medicine & Performance Association

Issue 25 Summer 2018

Exclusive:

How can we make it work in the elite football environment?

In this issue: 2018 FMPA Conference Review Long-Term Injury & Mental Health

Legal

Football Medical Association, 6A Cromwell Terrace, Gisburn Road, Barrowford, Lancashire, BB9 8PT T: 0333 456 7897 E: info@footballmedic.co.uk W: www.footballmedic.co.uk

Chief Executive Officer

Eamonn Salmon Eamonn@footballmedic.co.uk

Executive Administrator Lindsay Butler Lindsay@footballmedic.co.uk Project Manager

Angela Walton Angela@footballmedic.co.uk

Design

Oporto Sports - www.oportosports.com

Marketing/Advertising

Charles Whitney - 0845 004 1040

Photography

PA Images, Liverpool Football Club, Football Medical Association

Contributors

Jack D Ade, Jill Alexander, Andy Barker, Paul S Bradley, Georgie Bruinvels, Mark Evans, Andy Laws, Scott Pearce, Mayur Ranchordas, Damian Roden, Andrew Wiseman

Print

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Contents Welcome 4

Members’ News

Features 8

5th Annual FMPA Conference & Awards 2018

15

Hand Injuries in Goalkeepers Sam Haines, Raj Bhatia

18

Great Toe Plantar Plate Injury Mr loan Tudur Jones

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Why long-term injury to players is a mental health problem Dr Misia Gervis

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Nordic hamstring exercise - how can we make it work in the elite football environment Adam Johnson

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Musculoskeletal ultrasound: a summary of its uses, limitations and training opportunities Stuart Wildman The 5th Asian Indoor and Martial Arts Games: Ashgabat, Turkmenistan (2017).

FMPA members’ experiences of working as part of the event medical team Richard Evans, Kevin Petersen, Alan Rankin

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Keeping your finger on the pulse!

Jim Moxon

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Lisfrang injuries in watersports Nick Savva

CHIEF EXECUTIVE OFFICER As we start the new campaign there is real sense of irony in that we are already collating figures for the number of members who have departed from Clubs in this 2018/19 season.

We gather these figures from the 1st June, and even as players and staff report back for training, we still see staff being released while the initials on their kit are still drying.

While we might all suspect there will be a lull in this regard, as the training programme gets underway, and that should indeed be the case, but this is football, and you never know.

You will notice that when talking about our members leaving clubs we refrain from using the word “sacked”. This is because in general the word infers that someone has done something wrong or has failed in their job and, while this might be appropriate for some industries to use this term, it rarely fits with the departure of our members from the game.

As the table in our article on page 4 suggests, the vast majority of our members (60%), exit a club when a new manager is appointed, as this is a time when they are likely to bring their own personnel with them. Notably, the number of backroom staff following their managers, particularly international ones is on the rise, as illustrated by Arsenal and other leading clubs in recent weeks.

While the introduction of overseas personnel can be an illuminating feature within the backroom team, we need to also recognise the disruption this can cause to the existing set up. Upheaval is never in the best interests of a Club or player and indeed players themselves value the stability of the medicine and performance teams when a new manager is appointed and there is uncertainty around the club and even their careers.

Clearly there is discussion to be had surrounding this situation but ultimately it is up to the clubs to value and protect their medicine and performance teams while still allowing a manager to bring in his own personnel, who might then act as a conduit between the incumbent and the established.

Eamonn Salmon CEO Football Medicine & Performance Association Football Medicine & Performance Association 6A Cromwell Terrace, Gisburn Road, Barrowford, Lancashire, BB9 8PT T: 0333 456 7897 E: info@fmpa.co.uk W: www.fmpa.co.uk

Chief Executive Officer

COVER IMAGE

Liverpool’s Mohamed Salah reacts after picking up an injury during the UEFA Champions League Final at the NSK Olimpiyskiy Stadium, Kiev.

Nick Potts/PA Wire/PA Images Football Medicine & Performance Association.

All rights reserved.

The views and opinions of contributors expressed in Football Medicine & Performance are their own and not necessarily of the FMPA Members, FMPA employees or of the association. No part of this publication may be reproduced or transmitted in any form or by any means, or stored in a retrieval system without prior permission except as permitted under the Copyright Designs Patents Act 1988. Application for permission for use of copyright material shall be made to FMPA. For permissions contact admin@fmpa.co.uk.

Eamonn Salmon Eamonn.salmon@fmpa.co.uk

Executive Administrator Lindsay Butler Lindsay.butler@fmpa.co.uk Project Manager

Angela Walton Angela.walton@fmpa.co.uk

Design

Oporto Sports - www.oportosports.com

Marketing/Advertising

Charles Whitney - 0845 004 1040

Photography

PA Images, Liverpool Football Club, FMPA, Ashgabat 2017 / LAUREL Photo services, Paul Hazlewood

Contributors

Sam Haines, Raj Bhatia, Mr Loan Tudur Jones, Misia Gervis, Adam Johnson, Stuart Wildman, Richard Evans, Kevin Petersen, Alan Rankin, Jim Moxon, Nick Savva

Print

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football medicine & performance

feature

KEEPING YOUR FINGER ON THE PULSE! FEATURE/ DR JIM MOXON - LIVERPOOL FC ACADEMY DOCTOR SUMMARY This case report details a case of a pseudoaneurysm of the dorsalis pedis in an academy player at Liverpool FC. These types of vascular malformation are very rare, with only 30 cases ever reported in the literature (Maydew, 2006).

He was otherwise fit and well, with no relevant past medical history or family history.

ON EXAMINATION A 2cm x 2cm pulsatile, non-reducible, non-tender swelling was present on the dorsum of his mid-foot.

HISTORY A 15-year-old male academy footballer presented with a gradually evolving painless swelling over the dorsum of his right foot, which had been developing for around 4 weeks. He recalled being stamped on by another player around 5 weeks ago, but he didn’t regard this as a significant injury at the time. In the intervening period between injury and our assessment he had been training and playing games with no obvious issues.

There was a small scar over this swelling, which is likely to have corresponded to the recent incident of being stood on. Active and passive foot and ankle movements were all normal and pain free.

The distal foot and digits felt warm, sensation was normal and capillary refill was less than 2 seconds.

Figure one - Depicting the pulsatile swelling on the dorsum of the foot. (Amended from Vlachovsky, Staffa and Novotny, 2017)

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feature

Figure two – Longitudinal ultrasound view showing the pseudoaneurysm of the dorsalis pedis of the right foot.

Figure three – Transverse ultrasound view confirms the presence of the pseudoaneurysm.

Figure four – Longitudinal ultrasound left dorsalis pedis artery in left mid-foot

Figure five – Longitudinal ultrasound colour flow doppler image, showing turbulent blood flow within the pseudoaneurysm

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info@fmpa.co.uk

football medicine & performance IMAGING A B-mode ultrasound scan was performed of the pulsatile swelling at the Liverpool FC academy, which revealed a hypoechoic saccular protrusion from the dorsalis pedis artery in the right mid-foot region, as shown in figure two and three.

Figure four shows the equivalent scan of the left mid-foot, which provides a useful comparison of how a normal dorsalis pedis artery should appear. Colour flow doppler scanning of the region shown in figure five reveals turbulent blood flow within the lesion, in a classic ‘yin and yang’ configuration (Thurman, Brown and Ferre, 2012).

We selected diagnostic ultrasound as our initial form of investigation because it is non-invasive, quickly accessible and facilitates dynamic scanning. A diagnosis of post-traumatic pseudoaneurysm of the dorsalis pedis artery was made, secondary to the trauma to the arterial wall induced by the previous stamp injury 5 weeks earlier.

MANAGEMENT We decided that conservative management of this injury would not be a viable option, as untreated cases will generally result in the expansion of the lesion, with further haemorrhage and thrombosis (Maydew, 2006).

The position of the lesion on the dorsum of the foot meant that it would be vulnerable to further trauma from ball striking and tackling.

Following discussion with a vascular surgeon we opted for an intra-position veinbypass graft. This involved a reconstruction with an end-to-end anastomosis with an autologous graft, using the great saphenous vein to form a by-pass graft.

Other surgical techniques include the ligation and resection of the damaged segment of the artery without grafting, however we wanted to preserve the vascular anatomy to improve future outcomes if our player was to develop diabetes, or arteriosclerosis in later life (Bogokowsky et al., 1985).

DISCUSSION This type of injury occurs either as a complication of ankle and foot surgery or via blunt trauma to the dorsum of the foot (Maydew, 2006).. The main presentation is a painless pulsatile swelling, however

impingement on other structures such as adjacent nerves may cause pain or parathesia (Nishi et al., 2004). A pseudoaneurysm forms due to a breach in the arterial wall, which then results in a blood filled cavity only enclosed by the fibrous wall, whereas a true aneurysm involves the complete arterial wall layers (Özdemir et al., 2003).

REHABILITATION Following the surgery our player was advised to remain non-weight bearing in a boot for 2 weeks and was prescribed 75mg aspirin once daily for 4 weeks. We modified our rehabilitation program to ensure that any striking of the ball came at the very end of his return to play protocol. He was able to commence a lowers program 6 weeks after his surgery and he returned to full training 12 weeks after the surgery.

Dr Jim Moxon: Academy Doctor, Liverpool FC

As there have only been 5 paediatric cases ever reported in the literature (Bozio et al., 2009), we struggled to obtain advice regarding his post surgical rehabilitation, especially regarding recommended timescales for return to play. We were the conscious that there is a very little subcutaneous fat to protect the superficial vessels of the dorsum of the foot. This region of the foot is vulnerable to injury, and is a key area for ball striking and tackling. We explored a number of options including the modification of the football boots, to provide more protection for the dorsum of the foot and using protective dressings over the dorsalis pedis. However, we were very conscious that too many modifications could have an adverse effect on the player’s peripheral sensation and comfort.

In this particular case, it appears that there was a latent phase of around 4 weeks between the moment of trauma and the swelling appearing, however this phase can be up to two years (Yamaguchi et al., 2002). This provides a significant challenge to medical staff in detecting and managing this type of problem. To minimise any future delayed presentations, we have proposed a policy of an interval review of 4, 8 and 12 weeks for any traumatic injury to the dorsum of the foot, utilising ultrasound scanning to monitor the integrity of the dorsalis pedis artery wall.

This player is now 12 months post injury and has no further complications, he has maintained his status as an academy player at Liverpool football club.

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Bogokowsky, H., Slutzki, S., Negri, M. and Halpern, Z., 1985. Pseudoaneurysm of the dorsalis pedis artery. Injury, 16(6), pp.424-425.

Bozio, G., Tronc, F., Douek, P., Bozio, A. and Louis, D., 2009. Dorsalis Pedis Artery Pseudoaneurysm: An Uncommon Cause of Soft Tissue Mass of the Dorsal Foot in Children. European Journal of Pediatric Surgery, 19(02), pp.113-116.

Nishi, H., Miyamoto, S., Minamimura, H., Ishikawa, T., Katoh, Y. and Shimizu, Y., 2004. Pseudoaneurysm of the Dorsalis Pedis Artery Causing Neurological Deficit. Annals of Vascular Surgery, 18(4), pp.487-489.

Maydew, M., 2006. Dorsalis pedis aneurysm: ultrasound diagnosis.

Emergency Radiology, 13(5), pp.277-280. Özdemir, H., Mahmutyazıcıoğlu, K., Özkökeli, M., Savranlar, A., Özer, T. and Demirel, F., 2003. Pseudoaneurysm of the dorsalis pedis artery: Color Doppler sonographic and angiographic findings.

Journal of Clinical Ultrasound, 31(5), pp.283-287.

Thurman, R., Brown, A. and Ferre, R., 2012. Progressive Foot Swelling and Pain. Annals of Emergency Medicine, 59(6), pp.556-560.

Yamaguchi, S., Mii, S., Yonemitsu, Y., Orita, H. and Sakata, H., 2002. A Traumatic Pseudoaneurysm of the Dorsalis Pedis Artery: Report of a Case.

Surgery Today, 32(8), pp.756-757.

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THERAPIES. HAND IN HAND. www.bsnmedical.co.uk

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