Football Medic & Scientist Issue 6

FOOTBALL MEDIC & SCIENTIST

The official magazine of the League Medical Association

LEGAL AWARENESS The player as a patient

LMEDA CONFERENCE ANNOUNCED Full details inside

THREE LIONS’ PHYSIO Former England man Alan Smith

Issue 6: Autumn 2013

Contents Welcome 4 A Message from the Office / Members News

Editorials & Features 5 Touchline Rants / Diary Dates 6 Legal Focus When is a Player Not a Player?

When He is My Patient 10 Taking the Stand Legal Advice for Sports Scientists

EDITOR’S COMMENT/JON REEVES

S

o we’re back into the cut and thrust of the football season with the games coming thick and fast in all competitions. I’m sure you’ve all been extremely busy as the players strive for match fitness and many of them juggle the demands of club and international football.

A new season brings with it a new perspective for many of our members, who will be perhaps working with different players or managers and adjusting to new expectations, and this edition of the Football Medic & Scientist attempts to provide knowledge and assurances about some of the key challenges facing those who work in professional football.

12 On the Couch Roger Wylde

Our main feature focuses on the legal issues surrounding medics and sports scientists treating professional footballers. There are also interesting articles on groin pain, cartilage injuries and the new £3m Arthritis Research UK Centre for Sport, Exercise and Osteoarthritis.

15 Osteopathy & Professional Football

The exciting news that the inaugural LMedA conference will be held next year, during the weekend of the FA Cup Final, is also extensively covered in this issue, as the organisation builds towards its first major networking and socialising event.

16 Best of British Inaugural LMedA Conference 18 Groin Pain in Athletes 20 Where Are They Now? Alan Smith

All of these topics, plus some great insight from former England physio, Alan Smith, and current Stockport County physio, Roger Wylde, ensure that issue 6 is another bumper publication.

I hope that you enjoy the read and wish you all the very best of luck for the rest of the season.

Jon Reeves

22 Diagnosing Arthritis A Sporting Chance

WHO IS MY

26 Cartilage Injuries & Management

THE PLAYER

PATIENT? AS A PATIENT COVER STORY/

ON THE COUCH...

The word “patient” to Joe Public is likely to bring to mind someone who is sick and has medical problems needing (urgent or immediate) attention. It will not usually bring to mind the super fit and athletic football player. But healthcare professionals and sports scientists and other professionals interacting with such athletes through their clubs or federations/ associations, or indeed on a private advisory basis, need to know difference and beware!

28 Medical Guidelines for Referees

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6 6

s far as the law is concerned, a "patient" to whom a legal duty is owed to exercise due skill and care in professional interactions and advice, does not need to be sick at all. In the sporting context a "patient" to whom a duty is owed can be perfectly fit and healthy - but merely be someone who by reason of a contractual or other relationship comes under the care of the healthcare professional (physio, doctor, podiatrist, dietician, nutritionist, sports scientist etc) for advice and/or supply of medications or treatments or even supplements, and for referral to others for advice - in addition to actual treatment and/or recommendations for rehabilitation programmes or exercise advice etc.

In many cases the player who is subject to the professional interaction will be fit and healthy but will be receiving the advice or treatments on a prophylactic basis or to maintain good health and top fitness. In others the player will not be "ill" (or even injured) but rather recovering from a past injury and receiving advice or supplements or prescribed training and exercise programmes to return to what would be full (match) fitness for a footballer (but is already at the starting point beyond what would be recovery for a non-athlete and therefore a "healthy" person).

The law says the professional owes the player a duty of care and that the professional must exercise all due skill and attention required of the position

he, the professional, holds (or associated with the task - advice, prescription, treatment, onward referral etc - which he is undertaking). That duty arises where there is a contract on behalf of a club or federation for the professional to look after the health and welfare of the athlete/ player (or a team of players) or where there is such a contract with the athlete himself. However - and importantly - the duty may also arise under what is called the Law of Tort - even where the professional has no contract with anyone.

It is the Law of Tort which can come as a surprise to the healthcare professional in the sports context. He can find himself owing a duty "to do no harm" to an individual with whom he otherwise has no (apparent) legal connection or relationship and often as a result of affectively "assuming" a duty - either by the giving of advice (even generally or at large but in a context where the athlete relies upon it to his detriment) or by the making of recommendations or by (voluntarily) seeking to assist someone who appears to be injured. The classic example is the player down injured on the pitch and the professional from another team who runs on to help or indeed the match spectator who comes out of the stand as a medical professional to assist and lays on his hands or gives expert advice (an example being the cardiologist from the stands at Tottenham Hotspur on the day of the Fabrice Muamba collapse).

FOOTBALL MEDIC & SCIENTIST | 7

FEATURES/ROGER WYLDE 1. Profession I am a chartered physiotherapist working at Stockport County FC, where I have worked for the last 25 years.

2. Where did you train? What course?

When?

I trained at Salford University and was one of the ten students who qualified under the first part-time course that the Chartered Society of Physiotherapists had ever embarked on.

3. How did you get into football?

I was a professional footballer for 19 years, playing over 350 league games and scoring almost 200 goals, at a level that is now the Premier and Championship. I played at Sheffield Wednesday for 10 years, Oldham Athletic for three years, Sporting Lisbon for one year, Sunderland for a year, Barnsley for fours years and Stockport County for a year.

I was training as a physio at the end of my career and County asked me to ‘do’ the job there. I have been there ever since. I have officiated nearly 2,000 league games and rehabilitated back to full fitness, players’ with broken legs, ruptured ACL’s, etc. I have loved every minute of my time at the club.

4. Who has been the best manager you have ever worked with? .

Good question. As a player it has to be Joe Royle at Oldham Athletic, he showed me that a manager can also be a friend and get the best out of you as a player. I scored over 50 league goals in the Championship in just over 100 league games for him!

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

I have worked with many at County over the years and most have been an absolute joy to work with, but the best have to Dave Jones (now at Sheffield Wednesday) and Gary Megson. Both are very professional and demanded much from you as a physio, but both were also terrific personalities to work with.

6. How’s the job going at the moment?

My job at the moment is very different from what it has previously been. We, as a club and me as a physio are now part-time, and I am finding the situation very strange! This might seem an odd thing to say but I find it harder being a part-time physio than a full-

time physio! In essence you can get full-time players in every day, monitor, manage and progress their injuries daily then report the situation to the manager. Part-time means you only see the players three nights a week with the progression of treatment and rehabilitation not as continuous as I would like as a professional.

7. What’s your long-term career plan?

My long term plans are, at the moment are to help get County back into the Football League. My dream job, at this time in my life with all my experience in football both as a player and as a physio, would be to assist a younger physio at a bigger club and let him have all the ‘pressure’ of being the ‘Main Man’ in the medical department.

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The new spo

The firefly™ device uses s activate the muscle pump blood flow normally achiev Photos: mphotographic.co.uk

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

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Editor

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Chief Executive Officer

Eamonn Salmon

Senior Administrator

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Administrator

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IT

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Contributors

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FOOTBALL MEDIC & SCIENTIST | 3

After wearing the firefly™ for four ho getting home at 2am and being in ag

The lads using firefly™ reported DO

The firefly(TM) device is not cleared by the US FDA and not available for sale

A MESSAGE FROM THE OFFICE WELCOME/EAMONN SALMON I know it can seem like these articles are simply a medium to extol the virtues and successes of LMedA but in this case we have every reason to be shouting from the rooftops – again!

T

he new website has been launched and is proving a great success as well as being an impressive marketing tool for our association.

Companies are taking a keen interest in us now and we are hoping to announce further partnerships in the coming weeks as well as a lead sponsor.

Directors are now being appointed giving us the necessary infrastructure we need to secure the future of LMedA as an organisation. Each one is bringing a wealth of experience to the table in order to promote and push forward our ideas and philosophy.

And, as if that isn’t enough we are, in this issue, announcing the inaugural LMedA conference to be held at the end of the season. The direction of the course and structure of this event will be led by Dave Fevre and will incorporate the successful MDT event of the past two seasons within our conference. An AGM and committee meeting will precede the event and, as a season end occasion, the evening will be a great chance to network and unwind with colleagues.

Finally, please take note in particular to the member portfolio section of the website

where we explain how your CPD requisites are pretty much taken care of by LMedA. We are fairly certain that creating a portfolio of your CPD - as conducted through LMedA`s reflective practice reading material and by using courses listed on our site, will take a lot of weight off your shoulders.

But then that’s what we are here for.

Eamonn Salmon CEO League Medical Association

ANDY ‘ROLLS’ OUT FIRST PIECE W

est Ham United`s Head Physiotherapist, Andy Rolls, has become the first of our members to contribute to Four Four Two magazine’s performance section.

Cementing our relationship with this hugely popular magazine, we were able to facilitate an article on “warm ups” for players, now that the colder months are setting in.

Four Four Two’s editorial team submitted a remit of the type of article that would appeal to their readership and were delighted with Andy’s contribution.

The LMedA was given some acknowledgement and profile at the end of the article as well, which is great exposure for the association.

The readership of this publication is huge and for many this will be their first exposure to LMedA as an organisation. Who knows, perhaps it will help inspire the next generation of Medical and Science staff.

A big thanks to Andy for this and we hope many more of our members will make contributions in future editions.

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MEMBERS’ NEWS

Touchline sid!e Pete Rant hs

by Pitc JOB TITLES

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long time ago, when phones were still connected to the wall and there were only four TV channels, clubs would usually only have a Physio and a Doctor, who would roll up on a match day for a drink and a couple of sandwiches.

Nowadays – for the better I may add – the medical teams consist of a large mix of skills and specialties. The modern game has allowed the medical provision to players to be of the very highest standard in the world.

One thing that has changed considerably are the job titles of members of the medical team. No longer is there just a ‘Physio’ or ‘Doc’. In the Sports Science world, the title has changed from a simple ‘Fitness Coach’ to ‘Exercise Scientist’ or ‘Strength and Conditioning Coach’. Video Analysts were often joked as being the ‘Video Boy’, but now have a variety of colourful titles.

It seems outdated to call the Head Physio simply ‘Head Physio’ or ‘First Team Physio’ – Does this really help us? If you contact a colleague at another Club... how should you address them?

The strangest one I heard recently was ‘Head of Medical Development’ (although I believe that commonsense has prevailed and it has been changed to a more sensible alternative). What does this title actually mean? I’m not sure that I could offer you a straightforward answer.

But what of the future? Will we see titles like ‘Supreme Lord of the Medical Department’ or ‘Emperor of the Team of Medical Type Persons’?

Maybe a return to simpler titles may not be a bad idea... at least you know who does what!

DIARY DATES DATE 23rd October 2013

EVENT The ACL And MCL In 21st Century Football And Rugby

29th October 2013

Dynamic Taping (4 Hour Workshop)

30th November 2013

Rehabilitation for Runners

29th January 2014 19th March 2014 22nd–23rd March 2014

10th May 2014

Held at Kilmarnock Football Club. For more info email sire-cpd@hotmail.co.uk

London (LTA National Tennis Centre), 5pm till 9pm

For both - Contact Health Education Seminars on 01202 568898 or info@heseminars.com

Second Science & Medicine of Women’s Football

At Cardiff City Stadium. For more info contact Dr Andy Miles on apmiles@cardiffmet.ac.uk or 02920 416517.

Running 2014 - Managing running related hip & groin injury Kettering Conference Centre, Northamptonshire. For more info visit: www.professionalevents.co.uk

Football Medicine Strategies for Joint & Ligament Injuries For more information or to book email conference@isokinetic.com or visit www.FootballMedicineStrategies.com

From Pain to Performance 2014

A one-day International Sport and Exercise Medicine Symposium on the Upper Quadrant held at the London Heathrow Marriott.

For more information visit www.sports-rehab-and-education.co.uk/conferences.htm

For further details and other dates for your diary visit the official League Medical Association website - www.lmeda.co.uk

FOOTBALL MEDIC & SCIENTIST | 5

6

WHEN IS A PLAYER NOT A PLAYER? WHEN HE IS MY PATIENT COVER STORY/MARY O’ROURKE QC

The word “patient” to Joe Public is likely to bring to mind someone who is sick and has medical problems needing (urgent or immediate) attention. It will not usually bring to mind the super fit and athletic football player. But healthcare professionals and sports scientists and other professionals interacting with such athletes through their clubs or federations/ associations, or indeed on a private advisory basis, need to know the difference and beware!

A

s far as the law is concerned, a "patient" to whom a legal duty is owed to exercise due skill and care in professional interactions and advice, does not need to be sick at all. In the sporting context a "patient" to whom a duty is owed can be perfectly fit and healthy - but merely someone who by reason of a contractual or other relationship comes under the care of the healthcare professional (physio, doctor, podiatrist, dietician, nutritionist, sports scientist etc) for advice and/or supply of medications or treatments or even supplements, and for referral to others for advice - in addition to actual treatment and/or recommendations for rehabilitation programmes or exercise advice etc.

In many cases the player who is subject to the professional interaction will be fit and healthy but will be receiving the advice or treatments on a prophylactic basis or to maintain good health and top fitness. In others the player will not be "ill" (or even injured) but rather recovering from a past injury and receiving advice or supplements or prescribed training and exercise programmes to return to what would be full (match) fitness for a footballer (but is already at the starting point beyond what would be recovery for a non-athlete and therefore a "healthy" person).

The law says the professional owes the player a duty of care and that the professional must exercise all due skill and attention required of the position

he, the professional, holds (or associated with the task - advice, prescription, treatment, onward referral etc - which he is undertaking). That duty arises where there is a contract on behalf of a club or federation for the professional to look after the health and welfare of the athlete/ player (or a team of players) or where there is such a contract with the athlete himself. However - and importantly - the duty may also arise under what is called the Law of Tort - even where the professional has no contract with anyone.

It is the Law of Tort which can come as a surprise to the healthcare professional in the sports context. He can find himself owing a duty "to do no harm" to an individual with whom he otherwise has no (apparent) legal connection or relationship and often as a result of affectively "assuming" a duty - either by the giving of advice (even generally or at large but in a context where the athlete relies upon it to his detriment) or by the making of recommendations or by (voluntarily) seeking to assist someone who appears to be injured. The classic example is the player down injured on the pitch and the professional from another team who runs on to help or indeed the match spectator who comes out of the stand as a medical professional to assist and lays on his hands or gives expert advice (an example being the cardiologist from the stands at Tottenham Hotspur on the day of the Fabrice Muamba collapse).

FOOTBALL MEDIC & SCIENTIST | 7

In English Law there is no "Good Samaritan" law - and so the spectator - even as a highly qualified healthcare professional with professional duties ordinarily attached to the exercise of his profession (again the Muamba situation) - is not obliged in any way to go onto the pitch and help. However, if he voluntarily does so and "lays on his hands" (or for example gives advice to others which others rely on and follow (e.g. giving CPR as in the Muamba case) - then he assumes a duty of care to the player and will be judged by the standard of the reasonable average skilled person undertaking the role he does (with the skills and knowledge he has) in the circumstances which he has acted.

What should be of interest to those professionals involved with the player is his status as a patient and not as a sports star or celebrity (or someone of interest to the wider public). He therefore needs, when advising or providing advice and treatment etc, to do so against the background of potential legal liability to that individual, should the individual suffer harm (and that can arise in terms of damage flowing from any breach of confidentiality – e.g. discussing the player's condition with the media or others including other players or others at the club without the player's consent, as well as any harm suffered or delayed recovery suffered from advice or treatment or use of therapies or supplements etc).

That liability can be not just for any harm or injury actually suffered - but also for

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any consequential financial loss suffered resulting from the injury or failure to recover (for example loss of promotional earnings or sponsorship or other competitive opportunities which would have involved further financial reward) - provided directly resulting and reasonably foreseeable. In an era where footballers in particular are among the most highly rewarded in society, any claims by them for personal injury and loss can be as significant in financial terms as claims for obstetric injury and birth damage.

It is therefore very important that the sports healthcare professional understands: (1) to whom he owes duties (the player ahead of the club or federation); (2) when he owes duties (in respect of advice as well as actual treatment and when the player is fit and healthy if the advice, if followed and relied upon, could lead him to cause himself harm (e.g. badly thought out exercise programme or wrong diet or supplement); (3) to what standard he owes the duties (to the standard of the role he occupies or assumes - whether he is up to it or qualified for it or not if he holds himself out as being up to it); (4) that he will be judged by the circumstances applicable to his actions (if pitchside and thus emergency or in quieter circumstances of advice upon reflection); and (5) that his liability in monetary terms can include consequential losses if the player suffers some knock-on loss as a result of being out injured.

The professional needs also to be aware of the conflict of interests position where his employing club or federation may not have the same interests as the player/ patient - the club's interest being short-term and financial - and the player's being long term and health (although also of course financial). The law is very clear that the duty to the patient (the player) comes first for healthcare professionals - regardless of their other contracts with clubs or federations.

So what should the sports healthcare professional do - apart from decide to run away and treat less challenging and potentially less costly "patients"? The answer must be that working with footballers and athletes is rewarding and interesting (as well as challenging) and is usually undertaken by those with a real interest in (and love of) the particular sport.

They should not be deterred from following a vocation for such work but should ensure three things; (1) good professional advice as to the nature of the liabilities and professional obligations including duties and consequences; (2) good and appropriate professional indemnity cover or insurance - either on a personal or club/ employer basis; and (3) when in difficult situations seek advice from a professional colleague as to what they would do or think others in the profession would do in the same circumstances as presenting.

2 Science & Medicine of Women’s Football nd

Welsh Football Medicine Institute Where?

Cardiff City Stadium Cardiff UK

When?

Wednesday 29th January 2014 Presentations, Workshops & Case Studies for Medical, Coaching & Training staff involved in Women's Football

Delegate Fee: £150 Student Fee: £60 For more information contact:

OFFICIAL MEDICAL PARTNER

Dr Andy Miles Director of Welsh Football Medicine Institute Cardiff School of Sport | Cardiff Metropolitan University Cyncoed Road | Cardiff | CF23 6XD apmiles@cardiffmet.ac.uk | 02920 416517

SPORTS SCIENCE TAKING THE STAND FEATURES/CHRIS MORTLEY

P

erhaps the title of this article could have read ‘Sports Science in the dock’ - the dock is an old legal word for the Courtroom stand or bar where testimony is made. So sports science in the dock might mean “under scrutiny and making a case.”

The point is that, though sports science has risen as a profession and at a pace over this last decade, its rapid emergence has lead to inevitable confusion as to what exactly is sports science.

As Janine’s abstract article in the last edition highlighted, sports science, like it or not, still has some work to do in defining itself, its role and contribution to the world of sport. The blurred edges that embrace sports science mean the potential to step on other colleagues’ toes is huge and has already resulted in friction in many a club.

And the fact that the discipline wears so many hats also causes confusion. Are they nutritionists, sports psychologists, S & C coaches, rehabilitators, lab technicians, analysts, or all of them? Who really knows what a sports scientist is? It’s a fair question.

When a profession such as sports science emerges and grabs the attention at clubs (ref Sam Allardyce and his team of backroom staff 10 years ago), everyone it seems, jumps on the bandwagon and does the same. But where the emergence is sudden and dramatic there’s always the chance of a backlash and a sudden re-assessment that says, ‘wait a minute, do we really need them after all?’

This appears to have happened at several

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clubs of late so it`s a defining moment for the profession. There`s no point pretending everything is all right and trying not to rock the boat only to find that it is too late.

So defining the scope of practice for sports scientists is critical to their standing as a discipline. No blurred edges, not too many hats, but a clear and precise definition of their role and practice is needed in order to cement their position. It`s an onerous task but one that the profession has to grapple with if it is to flourish.

Another area where there are concerns for sports scientists is the lack of a mandatory representative body for the profession. The British Association of Sport and Exercise Scientists, (BASES), is an exceptionally well run group with international credibility for promoting sports sciences as a profession.

Yet there are a huge number of sports scientists out there working in professional football, rugby and elite sport who are not members of BASES and don’t wish to be since it is largely an academic institution.

This means they are currently practicing without any support network behind them and with no indemnity cover or protection.

Given that fitness training and rehabilitation is within their remit (two of their hats) the risk for injury with a player is very high.

It goes without saying then, that the potential for litigation is proportionally higher than say for the doctors or physiotherapists.

If this should happen and a sports scientist finds his/herself ‘in the dock’, how can

that individual demonstrate professional responsibility, show they have taken steps to address professional accountability and integrity or demonstrate personal endeavour to self-regulate along with evidence of CPD? Unless they align to an association of some kind, they probably can’t. In the dock will be a scary place. So what is the answer?

Well until the profession develops a mandatory regulatory body it will lack any sense of cohesion and a common thread.

Such a body may well materialise in time but, until then, LMedA can play a pivotal role for sports scientists in professional football.

LMedA CEO, Eamonn Salmon, says, “sports scientists are a significant part of our organisation and are held in equal regard with all disciplines and practitioners within the game. That the game is richer for their presence and that their contribution can only improve the fitness and wellbeing of players and clubs is, to me, unquestionable.

“We would like to encourage all sports scientists to join LMedA as it will instantly address some of their needs and ensure they keep parity with their colleagues who have recognised the value of professional body representation.”

As articles in this edition demonstrate, football is a precarious world and one in which we each have to take the necessary steps to look after ourselves and take responsibility for our own actions.

ON THE COUCH...

FEATURES/ROGER WYLDE 1. Profession I am a chartered physiotherapist working at Stockport County FC, where I have worked for the last 25 years.

2. Where did you train? What course?

When?

I trained at Salford University and was one of the ten students who qualified under the first part-time course that the Chartered Society of Physiotherapists had ever embarked on.

3. How did you get into football?

I was a professional footballer for 19 years, playing over 350 league games and scoring almost 200 goals, at a level that is now the Premier League and Championship. I played at Sheffield Wednesday for 10 years, Oldham Athletic for three years, Sporting Lisbon for a year, Sunderland for a year, Barnsley for fours years and Stockport County for a year.

I was training as a physio at the end of my career and County asked me to ‘do’ the job there. I have been there ever since. I have officiated nearly 2,000 league games and rehabilitated back to full fitness players’ with broken legs, ruptured ACL’s, etc. I have loved every minute of my time at the club.

4. Who has been the best manager you have ever worked with?

Good question. As a player it has to be Joe Royle at Oldham Athletic. He showed me that a manager can also be a friend and get the best out of you as a player. I scored over 50 league goals in the Championship in just over 100 league games for him!

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

I have worked with many at County over the years and most have been an absolute joy to work with, but the best have to Dave Jones (now at Sheffield Wednesday) and Gary Megson. Both are very professional and demanded much from you as a physio, but both were also terrific personalities to work with.

6. How’s the job going at the moment?

My job at the moment is very different from what it has previously been. We, as a club and me as a physio are, now part-time, and I am finding the situation very strange! This might seem an odd thing to say but I find it harder being a part-time physio than a full-

time physio! In essence you can get full-time players in every day, monitor, manage and progress their injuries daily then report the situation to the manager. Part-time means you only see the players three nights a week with the progression of treatment and rehabilitation not as continuous as I would like as a professional.

7. What’s your long-term career plan?

My long term plans are to help get County back into the Football League. My dream job, at this time in my life with all my experience in football both as a player and as a physio, would be to assist a younger physio at a bigger club and let him have all the ‘pressure’ of being the ‘Main Man’ in the medical department.

Photos: mphotographic.co.uk

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OSTEOPATHY AND PROFESSIONAL FOOTBALL FEATURES/DAVE MILLARD The evolution of sports medicine, and more specifically the sports medicine team, has led to the realisation that today’s athletes require a more holistic, multidisciplinary support structure in order to maximise their ability to recover from injury and also to perform.

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s such, more and more Premier League teams are seeking the advice of osteopaths in the club medical room. In recent times, clubs like Manchester United, Manchester City, Arsenal, Tottenham Hotspur, Liverpool, Chelsea and Fulham, to name but a few, have enlisted the help of osteopaths, most commonly on a consultancy basis but also, as in the case of Fulham, as a full-time member of the medical team.

So what is it that osteopaths do which makes these clubs seek their services and what discrete skills do they bring to the table which gives them value in the medical room and complements the existing skills which physiotherapy already provides?

Traditionally, osteopaths are associated with the ‘cracking’ noise which accompanies a high velocity manipulation, most commonly to the spine, and this particular skill is often sought after in the management of injuries with a spinal component. However, while this is a valuable tool in itself, and something osteopaths are extremely proficient in, the real answer lies in osteopathy’s system of diagnosis.

At the heart of osteopathic philosophy is the principle that the body is an integrated unit in which all parts function dependently.

Injury or dysfunction in one part can cause an associated change of function in another.

The skill of the osteopath is to identify this pattern of dysfunction through palpatory diagnosis and then to normalise function through manual treatment. It is the ability to recognise specific and precise dysfunction in the absence of pain or other pathological markers which makes the osteopath’s contribution a valuable one.

This palpatory ability is important not only in a diagnostic sense but also provides the osteopath with the feedback needed to be able to know when specific segmental, joint or soft tissue, function has been successfully normalised through treatment. It also means that osteopaths can have an important role to play in improving performance and potentially preventing injury.

In the same way that other sports such as athletics have used osteopaths to try to eliminate any areas of dysfunction which might impede the desired biomechanics, some football clubs now use osteopaths as part of their injury prevention strategy, as well as to try and maximise their players’ performance.

Osteopaths are also able to assist in the management of injuries. While the physiotherapist uses his expertise in the

management of tissue healing and the various progressions for rehabilitation, the osteopath can apply his expertise to unloading the injured structure by identifying and normalising any primary or secondary dysfunction and maximising the function of the associated kinetic chain. This serves to reduce any unnecessary stress on the injury, thereby hopefully allowing a speedier recovery.

For the partnership between osteopathy and physiotherapy to work, however, there must be mutual trust and respect. As with any complementary disciplines there is always likely to be an overlap in skill set.

However, the mark of a truly multidisciplinary team is its ability to recognise the strengths of its members and to utilise them in the most valuable and appropriate way.

The osteopath’s strength is the ability to identify specific dysfunction through palpation and observation and to correct that dysfunction through manual treatment. It is proving to be a valuable addition to sports medicine provision in the Premier League and accounts for the increasing number of osteopaths working at the top level in football.

FOOTBALL MEDIC & SCIENTIST | 15

Inaugural LMedA Conference Saturday May 17th & Sunday May 18th 2014 The inaugural League Medical Association Conference will take place on Saturday May 17th and Sunday May 18th 2014.

Giving members the chance to meet, share ideas and network, the conference will resurrect the popular close season conferences that were previously held at Lilleshall.

The venue is the brand new 5 star Radisson Blu Hotel East Midlands Airport which is one minute from the M1. With a stylish and contemporary feel the conference will feature...

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• • • • • • • • • •

Expert guest speakers Lectures and seminars Best practice talks Panel discussions Dinner and awards Community networking Trade stands Big screen FA Cup Final (with full bar facilities) The chance to meet, relax and socialise Meals and refreshments

The conference will commence at 1pm on the Saturday and finish at 12.30pm Sunday. Taking

place during the same weekend as the FA Cup Final, it will also provide members with football community networking in a relaxed and informal setting.

The clinical programme will be led by Dave Fevre, Head of Sports Medicine and Science at Blackburn Rovers FC, and, incorporating the MDT conference of recent years. It will be inspired by a ‘Best of British’ theme to celebrate the world class abilities of those working within the football medical and science professions within the UK. Retired and former football medical and science professionals will also be invited to meet up with colleagues and renew acquaintances.

The price of the Conference is £130 inclusive of VAT, dinner and refreshments. Early bird and 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.

Eamonn Salmon, Chief Executive of the LMedA, said: “This is exactly what we need to reinforce the community that is Sports Medicine in Professional Football.”

Jason Palmer, Chelsea Physiotherapist, added: “I feel, as a profession, we need to get back to the sense of community that we had 10 years ago. The LMedA Conference with its relaxed environment and lots of discussion will be a very powerful medium to achieve this.”

Venue Radisson Blu Hotel Pegasus Business Park Herald Way East Midlands Airport Derby DE74 2TZ

For more information visit www.lmeda.co.uk

FOOTBALL MEDIC & SCIENTIST | 17

Photo: mphotographic.co.uk

GROIN PAIN IN ATHLETES FEATURES/UEFA MEDICAL COMMITTEE Abstract by Dr Henrique Jones, member of the UEFA Medical Committee

O

wing to the complexity of the groin region’s anatomy, groin pathology is probably one of the most eclectic in sports medicine. Groin pain represents a “multiple pathology” paradigm and may involve many areas, including general surgery, orthopaedic surgery, urology, gynaecology and neurology.

This article will consider how groin pain may present in an athlete’s various activities, and how the appropriate conservative, or surgical, treatment can be applied. This will include discussion of an “all in one” surgical approach as a potentially preferable approach to complex groin pain.

Introduction Groin pain in elite athletes is a common yet challenging diagnostic and management dilemma for the sports clinician. Overall, groin pain accounts for approximately 5-18% of all athletic injuries. Sports where athletes are required to kick generally produce most of these injuries. Multiple pathologies often coexist, potentially causing similar symptoms, and several organs and systems can refer pain to the groin.

Athletes with groin pain may try prolonged rest and/or various treatment regimes, and often they will receive differing opinions

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regarding the cause of their pain. Despite advances in the prevention and treatment of these injuries, many athletes will need surgery to fully resolve the pathology.

a groin strain in the 2002 season. Ekstrand and Gillquist documented 32 groin strains in 180 male football players, accounting for 13% of all injuries over the course of one year.

Definition

Risk Factors and Groin Pain Pathogenesis

Groin pain in athletes refers to discomfort noted around the lower abdomen anteriorly, the inguinal regions, the area of the adductors and perineum, and the upper anterior thigh and hip.

Incidence Groin pain affects many athletes, particularly those participating in sports involving kicking, rapid acceleration and deceleration, and sudden changes of direction. The true incidence of groin injury is unknown, but some estimates are as high as 30-40% of all sportspeople.

Severe groin pain, defined as that which significantly disrupts performance and frequently requires surgical intervention, has a reported career incidence of 4-6% in professional football players. Studies in Scandinavia have shown a groin strain incidence rate of 10 to 18 injuries per 100 football players.

Giza et al. reported that 9.5% of all professional US male soccer players incurred

Several proposals have been made to help identify probable risk factors influencing the occurrence of pelvic overload injury. These include: 1. Muscle strength and balance: force imbalance (at the symphysis pubis and surrounding the pubic bone) between abdominal and adductor muscles; 2. Overuse: training regimen (including warm-up), fatigue, flexibility, body mechanics, sport specific activities, movement technique, previous injury and psychological state; 3. Positive feedback from secondary phenomena, such as chronic inflammation, calcification, herniation, increased compartment pressure and nerve entrapment, all of which may create greater muscle dysfunction.

Etiology – Most Common Groin Pathology in Sport It is very important to assess whether the

pain arises from above the pubic tubercle (upper groin pain) or below the pubic bone (lower groin pain). The pubic tubercle is the point of reference for distinguishing between upper and lower groin pain The most important local pathologies associated with groin pain are listed below.

1. Adductor strains: If most of the symptoms arise from the lower groin or perineal area, an adductor tendon strain should be considered.

2. Abdominal strains: This may be due to strains involving the attachment of the inguinal ligament, lacunar ligament, conjoint tendon and rectus tendon.

3. Osteitis pubis: This is very often overdiagnosed, but there is an extensive list of causes.

4. Sports hernias: Many specialists consider that athletes with groin pain have some kind of hernia and call it a “sportsman’s hernia.”

This is despite the fact that the athlete often does not have any kind of hernia problem.

5. Nerve entrapment: This is pain which starts around the inguinal ligament but radiates down to the inner thigh and adductor area. This is probably caused by referred pain in the obturator nerve. The lateral femoral cutaneous and ilioinguinal nerves can also be involved in local pain.

The Importance of Sports Hernias A weakening of the posterior abdominal wall, resulting in an occult direct or indirect hernia, causes a sport hernia. The precise cause of this injury is largely the subject of speculation, but the injury probably reflects numerous factors.

Theories cite overuse, muscle imbalance, increased shearing forces across the hemi pelvis, and possibly a genetically weakened inguinal wall. It is not known whether biomechanical abnormalities contribute to the condition. Some investigators believe sports hernias to be a rare cause of groin pain, whereas others believe that this condition represents the most common cause of chronic groin pain in athletes.

The sports hernia presents as a gradually worsening deep groin pain that is diffuse in nature. It may radiate along the inguinal ligament, perineum and rectus muscles.

Valsalva manoeuvres (such as coughing) and bending down may increase pain.

Radiation of pain to the testicles is present in about 30% of afflicted men. On physical examination, no true hernia is discernible, because only the deep fascia is violated.

Clinically, it is difficult to distinguish between the sports hernia, groin disruptions, distal rectus abdominus strains, adductor strains, stress fractures and osteitis pubis; however, with sports hernias, the pain may be located more laterally and proximally than with groin disruptions and distil rectus strains.

Groin Strain – The Real Problem?

A groin strain is analogous to “tennis elbow”, which has been shown to be due to an enthesopathy relating to the insertion of the extensor tendon into the periosteum of the lateral epicondyle of the humerus – i.e. the insertion (the enthesis) has become inflamed and pathological.

Like the conjoint tendon, the abdominal rectus and adductor muscles can suffer from

local strains or tendinosis that can be the real cause of groin pain.

Clinical Diagnosis Groin pain involves a complex and difficult anatomical scenario which is directly associated with numerous different diagnoses of athletic and non-athletic causes of the referred pain. Sometimes the same symptoms can be related to different pathologies and often two or more disorders can be identified (“differential diagnosis”) in the final clinical evaluation.

This shows the difficulty of evaluating athletes, even for experienced physicians, a point evidenced by the fact that in approximately 30% of cases the correct diagnosis remains unclear.

Non-Athletic Causes of Groin Pain When evaluating athletes with groin pain, several non-athletic disorders (listed below) must be considered as a differential diagnosis.

1. Intra-abdominal disorders: aneurysm, appendicitis, diverticulitis, inflammatory bowel disease.

2. Genitourinary abnormalities: urinary tract infection, lymphadenitis, prostatitis, scrotal and testicular abnormalities, epididymitis, gynaecological abnormalities, nephrolithiasis.

3. Referred lumbosacral pain: lumbar disc disease.

4. Sacroiliac joint disorders: arthritis, ligament injuries.

5. Hip joint disorders: Legg-Calvé-Perthes disease, synovitis, slipped femoral capital epiphysis in younger patients and osteochondritis dissecans of femoral head, avascular necrosis of femoral head, osteoarthritis, acetabular labral tears.

Physical Examination The clinical evaluation requires local muscle tests, namely tests on adductors and abdominal muscles, together with palpation around the pubis and hernia diagnosis manoeuvres.

Image-Based Diagnosis Groin pain has been investigated using standard radiography, dynamic ultrasounds, bone scans, computed tomography scanning and MRIs. The radiographic criteria for the diagnosis of osteitis pubis are as follows: observation of an articular surface irregularity, erosion, sclerosis and osteophyte formation.

Sonography or an MRI could be important to confirm a true inguinal hernia or local soft tissue abnormalities. Although MRI findings such as bone marrow edema, adductor muscle strains and hernias have been described in athletes with chronic groin pain, insufficient attention has been paid to a direct link between clinical findings and functional performance on the pitch.

Conservative Treatment Rest and correlated correction of biomechanical abnormalities (lumbar hyperlordosis, pelvis anteversion, leg length discrepancy, excessive pronation, etc.) are the first steps to be taken in terms of conservative treatment.

With conservative treatment, a return to

sport can be expected in four to eight weeks following an acute tendino-muscular strain and three to six months for chronic strains, depending on clinical silence, functional tests and strength. The timing of surgery is influenced by failures with conservative treatment, increases in pain and inability to play sport, the athlete’s motivation and economic factors. Surgery would normally be considered after three months.

Surgery on a Case-by-Case Basis A sports hernia is a painful groin pathology that affects male athletes. There is no visceral extrusion with a sports hernia and the pain is caused by irritation of the sensory nerve fibres of the ilioinguinal or genitofemoral nerve. Treatment should combine neurolysis of the sensory fibres (while preserving the motor fibres) and repair of the muscular defects. A laparoscopic or open herniorrhaphy should be performed.

In the majority of cases, the problem is insertional tendinosis around the pubis.

The treatment, in that case, should involve tenotomise and the drilling of holes if the pubic bone is affected.

In any given case, all potential pathogenic causes should be analysed and corrected.

The need to adapt the surgical approach on a case by case basis requires a multifactorial approach to surgery described by the author, in some cases, as an “all in one” surgical procedure.

Return to Sport After Surgery After surgery, up to 90% of athletes will return to their pre-injury activity levels. This can be achieved by means of a rehabilitation programme focusing on strength, flexibility, neuromuscular control, preventive exercises and sports integration. Once athletes have regained at least 80% of their strength and have a full – pain-free– range of motion, a return to sport may be allowed. A return to competition will take 8-12 weeks postsurgery.

Prevention Prevention continues to be the key factor in reducing incidence of groin pain in athletes. Specific exercises after training sessions and gym work have made a large contribution to the overall reduction seen in the incidence of groin pain in athletes in recent years.

Conclusions Groin pain represents a “multiple pathology” paradigm involving general surgery, orthopaedic surgery, urology, gynaecology and neurology. Physicians and surgeons must work together to ensure a correct diagnosis and proper treatment. This means that all physical examinations and complementary studies must be conducted in a systematic manner.

Surgical management has a role to play where conservative treatment of chronic groin pain fails, and more than one surgical approach should be considered. With various different pathologies coexisting, there are a number of surgical options to choose from, and sometimes specialists in different areas need to work together.

FOOTBALL MEDIC & SCIENTIST | 19

WHERE ARE THEY NOW? FEATURES/ALAN SMITH Former physio Alan Smith talks about his 31-year career in professional football, working with the England international team at major tournaments and reveals what he’s doing now.

But he begins by paying tribute to the late, great Sir Bobby Robson...

My England career started in 1979 when I was appointed to the England semiprofessional Team. In 1982 Bobby Robson was appointed manager of England and I was promoted to the Under 21 team and also to the B International team. Then in 1986 he awarded me my first full international against the USSR in Tbilisi on March 26th 1986, we won the game 1-0 with Chris Waddle scoring the goal.

During that trip I was treating Peter Shilton when Bobby came into the treatment room and asked if I would like a cup of tea.

I said yes and thanked him, thinking that he would have a pot of tea sent to the treatment room from the hotel kitchen. To my surprise he had gone to his room and made a cup of tea personally and brought it to me in the treatment room. Top class man management. Little things mean a lot to people.

In 1988 he awarded me four further

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Internationals with one of the games against Switzerland. Following the game there was a presentation of watches to commemorate the occasion. I was working and missed the presentation so Bobby being the type of person that he was, gave me his watch that he had been presented with. The England Doctor, John Crane told him that I had not received one. He was not only a great manager but a great person who appreciated his staff and the staff appreciated him.

I remember meeting Bobby shortly after he had received his Knighthood. We shook hands and I addressed him as Sir Bobby. He immediately corrected me and said, ‘Alan, it’s Bob’. That was typical humility that only a great person could carry with such modesty and dignity.

Alan first got into football in 1971 when he wrote a letter to Darlington manager, Frank Brennan, and was later offered the

job following a successful interview. He went on to work for Sheffield Wednesday and Blackburn Rovers at club level and with the England national team for eight years between 1994 and 2002, forming an extremely satisfying career, as he explained.

“It was a fantastic 31 years of employment doing a job that I Ioved. Working with great managers, players and members of the various backroom staff at both club and International level.

“There were many memorable moments but the three most prominent are; at club level with Sheffield Wednesday, when we beat Manchester United at Wembley to win the 1991 League Cup, England beating Spain to win the 1984 UEFA European Under-21 Football Championship and the day that I was appointed to the England Senior team in 1994, a great honour.”

As Alan’s insight into his time working with Sir Bobby Robson illustrated, he placed huge importance on receiving support and the trust of the managers in helping physios to work effectively.

“I always felt that I played an important part; getting players fit, keeping them fit so that they could play to their maximum, which is a vital requirement. In helping the players you are helping the manager and his coaching staff to get the best results possible.

“The physios contribution should not be underestimated. All of my England managers were good to work with and very supportive. I worked with Terry Venables at Euro 96, Glenn Hoddle at the 1998 World Cup, Kevin Keegan at Euro 2000 and Sven-Goran Eriksson at the 2002 World Cup.” One of the more amusing stories from Alan’s career in the game was unsurprisingly provided by the charismatic, Paul Gascoigne, as he revealed.

“There were always lots of laughs but the one player who stood out as a practical joker was Paul Gascoigne. Whenever you were in a hotel, training ground or travelling, Gazza was hyperactive.

“On one occasion with the under 21 team he approached the manager, Dave Sexton, and asked for his autograph. Dave apprehensively agreed to sign Gazza’s autograph book. He held the book open in position for Dave to sign and invited him to take the top off the pen which then exploded, creating hysterics from Gazza but leaving Dave ashen faced with shock! He eventually recovered and took the practical joke in good heart.

“Another of his antics was to throw a bucket of water over a team mate which he thought was brilliant, especially when the victim was taken by surprise.”

Having been involved in football during the huge advances in technology and professionalism ushered in by the modern day game, Alan reflected upon how things have changed.

“From a Physiotherapist’s perspective the main development is the advancement in technology. There is now computerised equipment for record keeping, treatment modalities and gymnasium equipment.

“There have been many changes in football over the years for the better, but the one I would select overall is the improvement

in our stadiums, from Wembley Stadium down throughout the leagues. The progression has been very good. The old grounds have been modernised or have been replaced with state of the art stadiums throughout the country.”

Since stepping down from his role with England in 2002, Alan has been busy, both inside and out of the game, as he explained.

“I am working in my own Sports Injury

Practice in Wickersley, Rotherham. For the last four years I have been Consultant Physiotherapist to Sheffield Wednesday. I also support grassroots football as Patron to Saltburn Athletic FC in my home town.

They have teams at various age groups and play in the Teesside Junior Alliance League.

They have a very good committee who also manage and coach the teams.

“I don’t miss the game full-time but I do

enjoy my role at Sheffield Wednesday. My eldest son Paul is the Head Physiotherapist at the club. We have a meeting on a Friday to discuss the clubs injury list. I also attend all the home games.

“I have weekly contact with Paul at Sheffield Wednesday and my youngest son Andy, who is a masseur with Aston Villa. I do like to keep in touch with people I worked with whenever possible as it is good to catch up occasionally.”

In a career filled with the highs of working within the top flight and alongside England’s finest, such as Alan Shearer, Michael Owen and David Beckham, and helping them recover for major tournaments, Alan can reflect upon a full and satisfying involvement in the game.

“I have absolutely no regrets. I enjoyed over 30 years in the game and was privileged to work with so many great people at every level, from the 1971/1972 season at Darlington in the old Fourth Division to the World Cup Finals in 1998 and 2002. I valued and very much appreciated my career.”

Alan Smith runs his private practice, Alan Smith Physiotherapy Ltd, from 135A Bawtry Road, Wickersley, Rotherham, South Yorkshire, S66 2BW. For more information visit www.alansmithphysiotherapist.co.uk This feature was kindly produced with assistance from Gavin Blackwell.

FOOTBALL MEDIC & SCIENTIST | 21

Diagnosing Arthritis A Sporting Chance FEATURES/ARTHRITIS TODAY Premier League and England striker Rickie Lambert is backing the new £3m Arthritis Research UK £3m Centre for Sport, Exercise and Osteoarthritis, which was launched in June.

T

eams at the new Arthritis Research UK Centre for Sport, Exercise and Osteoarthritis are aiming to reduce the impact of sports injuries incurred by elite and recreational players and understand why some sport and exercise injuries develop into debilitating osteoarthritis in later life.

The launch of the new centre – which has the mantra of optimising health, minimising risk – will be welcome news for all sections of the population who have an interest in keeping fit and active.

Rickie Lambert, who has experienced hip pain but has managed it successfully through exercise, is backing the new centre. He said: “Hip pain is one of the most common injuries among footballers, and some players have to retire early if they don’t get the correct treatment. I’ve been very lucky at my club; I’ve been given certain exercises that have helped me and improve the problems I’ve had.“ The fact that Rickie was the joint top English goal scorer in the Premier League last season is testament to the success of his treatment. He added: “Making sure young footballers get the right treatment in their teens is massively important and will improve their chances of succeeding in the game. If these problems can be picked up early by automatic testing, the better for everyone. On behalf of all professional footballers I’d like to show my support for the new centre’s research.”

Mo Gimpel, head physiotherapist at Southampton FC, added: “We’ve found that players’ hip and groin pains, including FAI symptoms, can be resolved through exercise specifically developed for the individual.

“To make this treatment even more effective, we need to examine these findings in a more robust and academic way with experienced researchers to help develop the knowledge base of our profession, and improve the care of players.”

Understanding the relationship between sports injuries and the development of osteoarthritis – and aiming to prevent it – will be at the heart of the new centre’s research programme. Researchers plan to develop better injury treatments and screening tools to predict an individual’s risk of developing osteoarthritis following sports injury.

The centre will concentrate on the two types of joint injury connected with sport and exercise: acute or traumatic sports injuries associated with contact or collision sports and over-use injuries associated with non-

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contact sports.

Centre director, Professor Mark Batt, Consultant in Sport and Exercise Medicine at Nottingham University Hospitals, said: “To date, research into the long-term consequences of sport and exercise injuries has been sparse, especially in the UK. There’s currently poor understanding as to why some people recover more quickly than others following sport and exercise injuries, and why some injuries develop into osteoarthritis, but others don’t.

“This is the first time in Europe that specialists in sports medicine and osteoarthritis are combining their expertise to understand why some sports injuries will go on to develop into osteoarthritis, and whether we can prevent or slow down degeneration of the joints.”

What Exactly Will the Centre do?

For the general public, the centre’s research focus will aim to reassure people that they can exercise safely by developing a simple method of predicting their risk of osteoarthritis in the GP surgery. As most of the population is expected to be low risk, it should encourage people to exercise without worrying that it will lead to osteoarthritis.

The centre’s research will benefit sports men and women by: • •

• •

Creating a model to help predict the risk of developing osteoarthritis for those who have had a joint injury.

Preventing injury by suggesting ways to avoid activities that might lead to an injury, including dietary and nutritional interventions.

Treating and managing injuries more effectively.

Reducing the risk of developing osteoarthritis after an injury.

Predicting Risk of Osteoarthritis in the General Public Researchers are aiming to develop a series of simple screening tools – one for the general population (plus a second for recreational athletes and a third for elite sportspeople) – which will accurately predict their various levels of risk.

“We want to identify as many risk factors for osteoarthritis as possible, for example vitamin D deficiency, being overweight, having lax ligaments, and so on, put all these

factors into the mix and then be able to say to the patient: Your personal risk is ‘X’,” explains Nigel Arden, Deputy Director of the centre and Professor of Rheumatic Diseases at Oxford University.

“It will be an online, user-friendly tool with about 10-15 questions that patients or GPs can fill in during a consultation. Ninety-five per cent of people using the tool will be at low risk of osteoarthritis, so it will be very much about reassurance, so that people can feel confident about exercising, and that it’s good for them. That’s a very important message we’re keen to get across. If someone is deemed at high risk because they are grossly overweight, for example, then they would be encouraged to lose weight to minimise their risk.”

The researchers hope that the first screening tool will be available within the next two to three years as the data necessary to complete this work is already available from national and international patient cohorts.

Predicting Risk for Professional Sports People The tool for professional sports people will be modified for specific sports. The idea is that if a particular risk factor emerges from a particular sport, the FA or other sports governing bodies would then be able to implement changes in training, taking a top down approach.

Professor Arden gave an example of how, ultimately, his team see the tool being used. He said: “An 18-yearold footballer has a knee injury and goes to the GP who uses the tool to predict his risk of osteoarthritis. The GP can then decide whether he needs to have surgery in the next 10 years, whether he needs intensive rehabilitation, or whether, in time, he’ll be fine.

“But to get to that point, we need to collect thousands, if not tens of thousands, of case studies so

we can work out these risk factors based on large amounts of evidence, which currently doesn’t exist.”

Working with Young and Retired Footballers – Getting the Ball Rolling Researchers want to find out why some ex-footballers who’ve had a joint injury, go on to develop osteoarthritis in later life while others don’t. Up to 15,000 ex-players on the Professional Footballers’ Association’s (PFA) database will be asked to fill in a basic questionnaire about their training regime and history of injuries.

Around 500 ex-players who have had a joint injury and developed osteoarthritis, plus another 500 who have had a joint injury but haven’t developed osteoarthritis will be x-rayed, and will undergo physical assessments and give blood samples.

Researchers in Nottingham will then investigate the factors that differentiate these two groups.

Preventing Common Groin Injuries in Young Footballers More than 80% of footballers suffer hip pain during their careers, and young footballers are at particular risk from a j

FOOTBALL MEDIC & SCIENTIST | 23

potentially career-ending form of groin injury called femoroacetabular impingement (FAI).

We don’t know the cause of this problem, but over-training as the bones are developing may play a role.

In FAI the head of the femur (thigh bone) rubs against the socket, leading to intermittent groin or hip pain in the short term, and potentially osteoarthritis of the hip in the longer term.

As part of the centre’s research looking at risk factors of injury in adolescent athletes, young footballers aged of nine and upwards, from a number of professional football academies, will be scanned, using state-ofthe-art MRI, for signs of FAI, every two years.

They will be compared to two other sameage groups – ordinary schoolboys and also young elite athletes from other sports.

The boys will also undergo a number of clinical tests in the lab to measure muscle activity and to measure the biomechanics of their movement.

“The benefit of using extremely sophisticated MRI is that you can pick up holes or cracks in cartilage much earlier, and as well as detecting structural damage it also picks up metabolic changes to cartilage and bone,” explains Mr Sion-Glyn Jones, consultant orthopaedic surgeon and senior clinical lecturer at Oxford University.

“By measuring and monitoring the activities these youngsters are doing during training that may give rise to these hip deformities, they could then be modified or avoided to prevent the injury occurring.”

This research feeds into a sports injuries preventative study led by Maria Stokes, professor of musculoskeletal rehabilitation at the University of Southampton, who is working closely with Southampton Football Club and others to design targeted training programmes aimed at reducing the incidence of injuries among academy and first-team players and protecting them from developing arthritis in later life.

This is a concept known in the sports medicine world as “pre-habilitation” and will involve developing ways of improving training and warm-ups to reduce the incidence of injuries such as pulled muscles and tendons, to ensure that players use their muscles correctly and don’t overload their joints during matches and in training. They hope their research will enhance current FIFA guidelines on warming-up.

Researchers will also take players into the biomechanics laboratory at the university and make precise measurements of their movements during various activities such as kicking a ball, using state-of-the-art 3-D technology.

Dr Martin Warner, Senior Research Fellow at the Southampton centre, said: “It’s important to determine the movements that are associated with this problem to fully understand the demand on the joints. This will help to inform which type of exercises are needed to correct the problem and reduce the load through the joints.”

One of the first pieces of research to literally kick off during 2013 will be a small clinical trial to test the effectiveness of surgery on FAI. Around 100 people under the age of 40 will be recruited in centres in Oxford and Reading. Half will undergo a hip

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arthroscopy, in which parts of the hip bone are removed or shaved, and the other half will have no surgery. The level of cartilage damage in the hip in both groups will be measured over a four-year period, via MRI. Developing New Treatment Packages for Sports Injuries Based on preliminary findings from previous work, Dr Jonathan Folland and colleagues at Loughborough University will be looking at the effectiveness of explosive strength training over conventional strength training.

“We’ve recently found explosive strength training to produce significant changes in the stiffness of muscle and tendon after only four weeks of regular exercise,” explains Dr Folland. “Stiffer muscles and tendons could help to improve function and performance as well as reduce the risk of injury. Stiffer tissues are considered to be better at transmitting force, which aids function and performance. They’re also thought to be more robust and less easily overstretched and damaged.

“The increased stiffness of muscles and tendons we found after just four weeks is substantially shorter than previous reports where stiffness only increased after 12 weeks of exercises, and it could be that the explosive aspect of the exercise works best for increasing stiffness.”

The researchers’ next step is to do a longer study to see if explosive exercises continue to produce greater changes in muscle and tendon stiffness over a more prolonged period and do a direct comparison of explosive strength training with conventional strength training.

Dr James Bilzon, exercise physiologist at the University of Bath, will develop a series of clinical trials aimed at testing dietary and nutritional interventions in athletes after an injury, and exercise interventions to prevent and manage injury.

Dr Bilzon and colleagues will be working with the Rugby Football Union’s Injured Players’ Foundation to work with players whose careers have ended through injury and are at risk of osteoarthritis.

“Through work we’ve done in other conditions, we know we can manage chronic low grade inflammation through diet and physical interventions so we’ll be looking at testing the effects of vitamin D and omega-3 fatty acids in trials,” he explains.

“We also want to find out if we can manage athletes following an injury, by working with them to manage a healthy lifestyle.

It’s important that they maintain their healthy body composition and keep their weight down to reduce any post-injury symptoms.”

Ankle Injuries – A New Study The ankle is the secondmost commonly injured joint after the knee, and ankle injuries

are common in many sports. Ben Ollivere, newly appointed trauma consultant at Nottingham University Hospital, aims to answer the question, following an ankle injury, what determines who does well and who does badly, who makes a complete recovery, and who goes on to develop osteoarthritis?

Mr Ollivere is recruiting up to 200 people with ankle injuries from accident and emergency departments in Nottingham: 100 people with fractures and a further 100 people with ankle sprains.

Using MRI ultrasound and x-rays, and looking at biomarkers from tissue, the team will look to predict likely outcomes and will follow up this cohort for a number of years.

“We don’t understand what causes posttraumatic degeneration of cartilage or when to treat or intervene, so we’re hoping this study will lay the groundwork for when to treat and intervene to offer the most benefit to patients,” says Mr Ollivere.

Working with Olympic Athletes Researchers at The University of Nottingham are in the fourth year of a study funded by UK Sport and the English Institute of Sport looking at current patterns of illness and injury in almost 550 elite sports men and women, to identify risk factors – specifically whether risk factors are related to their training activities or actual competition.

A three-year Arthritis Research UK PhD studentship will be allied to this on-going study.

For more information on Arthritis Research UK visit www.arthritisresearchuk.org

Professor Mark Batt, Centre Director

CARTILAGE INJURIES AND MANAGEMENT FEATURES/UEFA MEDICAL COMMITTEE

By Prof. Mehmet S. Binnet, Dr Mehmet Armangil and Dr Kerem Basarır, University of Ankara Medical School

I

t is important for footballers to have a life after their playing careers not marred by injury. Thankfully, health professionals can help protect these players’ musculoskeletal health so that they can enjoy an injury-free retirement as well as a satisfying playing career.

The general health of retired players should therefore be routinely evaluated, and issues related to the musculoskeletal system should be assessed separately from other diseases. A simple approach can be adopted for retired footballers, for whom a general health plan can be integrated into a personalised fitness programme.

Footballers tend to finish their playing careers with overloaded joints even if they have sustained no major injuries.

Microtraumatic cartilage injuries, for example, can lead to early degenerative arthritis, causing pain and disability in daily life. The main function of cartilage tissue is to provide a pain-free range of low-energy movement by decreasing friction. Healthy cartilage lays the foundations for a problemfree playing career in which footballers expect their bodies to continue to perform optimally under extreme loads and with extreme ranges of movement.

However, accidents do occur and unexpected trauma, in particular, can cause shear forces or impact resulting in cartilage injury. The knee is the most the frequently affected and the prevalence of knee osteoarthritis in athletes depends on the frequency, intensity and level of their sporting activity. The estimated rate of knee osteoarthritis among footballers is 19-29%, compared with 14-20% in long-distance runners and 31% in weightlifters. In a study

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by Kujala et al, the risk of knee osteoarthritis was found to increase five-fold in top-level male athletes with prior knee injuries.

In addition, secondary osteoarthritis of the knee develops at an earlier age in footballers than in other sectors of the population, with its origins traceable to ligament and meniscus injuries.

Common injuries such as meniscus tears and anterior cruciate ligament ruptures are also found to be associated with a higher incidence of osteoarthritis, according to several studies. Professional athletes who have undergone surgery for ligament reconstruction or meniscal pathologies are at particular risk of early arthritis.

This is seen at an earlier age than primary osteoarthritis, which is more common in elderly people, with an incidence of 2530% in the 45-64 age group and 85% at 65+. Primary and secondary osteoarthritis are both cartilage eroding and destructive pathologies. All evidence indicates that footballers require a strong muscle structure to avoid injury.

Weak muscles lead to major injuries and increase the after-effects of microtrauma to joint cartilage. The problem with cartilage injuries is the progressive nature of the pathology due to the unique properties of cartilage tissue, which contains no blood vessels, nerves or lymphatics and is 2-4mm thick. These properties lead to delayed or insufficient healing after injury.

In addition to the lack of blood and the lack of healing response from progenitor cells in the blood, cartilage cells have a limited capacity to proliferate and regenerate.

Cartilage injuries heal with a different tissue, known as fibrocartilage. This is

biomechanically inferior to the original hyaline cartilage in terms of replicating the functions of hyaline cartilage, such as absorbing shock and minimising friction.

Disturbed balance within the joint leads to pain during physical activity and can limit movement depending on the severity and location of the injury. Impaired cartilage function leads to increased loading in neighbouring areas and further damage to the joint. A full and pain-free range of movement under any loading condition is vital for any kind of sporting activity. A non-healing cartilage problem results in symptoms which usually worsen over time, leading to early osteoarthritis – as explained, a significant problem in football medicine.

Management of this disorder should be realistic and designed according to the lifestyle expectations of the patient. Nonsurgical methods are sufficient to treat most everyday problems, and obese ex-players should be encouraged to lose weight to avoid excessive loading of the knees and ankles.

As the number of footballers with osteoarthritic pathologies is increasing, it becomes increasingly important to prevent cartilage injuries during active playing careers and transitions into retirement. There are three major risk factors that can be managed with preventive measures: 1. Excessive musculoskeletal loading; 2. High body mass index; and 3. Previous knee injuries.

According to Hochberg, the prevalence of knee osteoarthritis could be reduced by 1530% by avoiding squatting, kneeling and the carrying of heavy loads. The Osteoarthritis

Research Society strongly recommends stringent weight control to prevent osteoarthritis, estimating that maintaining body mass index at 25 or below would reduce osteoarthritis in the population by 27-53%.

Prevention An appropriate response on the pitch can prevent complications later. Programmes for sports injuries, especially anterior cruciate ligament injuries, have recently shown promising results. According to Norwegian studies, it is possible to prevent anterior cruciate ligament injuries using neuromuscular training programmes. After retiring from professional sport, moderate or low-intensity exercise and weight control can be useful to prevent osteoarthritis. The most important preventive measure is to recuperate muscle power.

Dynamic muscle balance and force need to be regained with well-designed exercise programmes featuring isometric training.

Simple exercises with moderate weights play a key role in these programmes.

The sudden onset of knee and ankle pain can be managed with cryotherapy (cold-application), which can decrease inflammatory swelling. Cold-application may also be used as an analgesic agent. The most simple and widespread technique is to use ice or cloth-soaked in iced water. This technique is applied over four to six sessions, usually of 15-20 minutes an hour.

After the oedema and/or swelling has reduced, cold application should be terminated. Physical therapy and drugs are the next step in the event of persistent complaints, and advice from a professional physician can be helpful to determine the ideal dose and combination.

Nowadays, there are various way to evaluate the extent of cartilage injury.

Besides clinical examination, widely used techniques include X-rays, computerised tomography and, in particular, magnetic resonance imaging (MRI). After a definitive diagnosis through radiological imaging, age and level of physical activity are important factors when deciding on treatment.

Arthroscopic debridement, high tibial osteotomy (HTO) and arthroplasty (unicompartmental or total) are the main methods of treatment for older patients.

Technical, biological and scientific advances in recent decades have provided better treatment options for cartilage injuries, but a simple, effective and universally accepted method has yet to be discovered. Traditional treatments are based on the principle that stem cells in peripheral blood may promote the healing process in the defective area. In cartilage injuries not extending below the subchondral bone, there is no bleeding due to the avascular nature of articular cartilage.

This is especially helpful in defects smaller than 2-3cm². The techniques used in such cases are almost always arthroscopic and minimally invasive. In these kinds of minor cartilage injuries, pain and soreness are usually present in joints after normal everyday activities, but symptoms may be aggravated by meniscus ruptures.

Meniscus ruptures among older patients are different from those sustained during an active sporting career. The elasticity and durability of meniscal tissue decreases with age, when small forces may damage this structure. Meniscal pathologies may be diagnosed by a sensitive joint line on palpation, clicking noises during flexionextension movements and special physical examinations indicating a rupture.

In retired players, arthroscopic debridement can be useful for both meniscus removal and evaluation of cartilage, which is frequently damaged in patients with meniscus ruptures. Mechanical barriers to joint movement are cleaned with arthroscopic debridement and relief can usually be obtained as a result. This relief may also delay the need for joint arthroplasty in last-stage joint arthritis.

Subchondral drilling is based on making perforations in the subchondral bone with a wire and perforator, providing a passage from the injured area to bone marrow and blood. Microfracture surgery, meanwhile, is performed by making small fractures in

the subchondral bone to promote healing.

Both methods produce a limited healing response as they produce fibrocartilage, which is inferior and often cannot meet the expectations of a professional or amateur athlete.

HTO, another treatment option for cartilage lesions, is generally preferred in middle-aged patients and is indicated in single-limb malalignment leading to unicompartmental degeneration. In selected patients this is probably the best method for correcting altered load transmission. By performing knee arthroscopy at the same time it is possible to address meniscal pathology and loose bodies, which is strongly indicated in this group of patients. In the case of large chondral lesions, mosaicplasty using autologous ostoechondral grafts is widely applied and seems beneficial.

A recent innovation in cartilage injury management in orthopaedic surgery is the use of autologous chondrocyte implantation and mesenchymal stem cell (MSC) transplantation. This involves harvesting cartilage through an arthroscopic procedure, proliferating the chondrocytes in cultures and, finally, implanting the chondrocytes by direct injection or by matrix scaffolds in a separate procedure.

As for MSCs, these retain both a high proliferative potential and multipotentiality, including the potential for chondrogenic differentiation. A number studies have reported on the use of MSC transplantation on animals, but its application in cartilage repair is still at an early stage, with more clinical studies required. Both of the above procedures, however, will probably shape the future of cartilage injury management and provide hope for top players.

The other treatment option mentioned in this article is knee arthroplasty, which involves removing the arthritic parts of the knee joint and replacing them with prosthetic implants. A decision on which type of arthroplasty to use (total or unicompartmental) should be made before the operation. Factors affecting this decision include the patient’s age (especially when 60+), pain levels that limit the majority of everyday activities, and a recorded increase in physical limitations.

After total knee arthroplasty patients should limit their activities to make their repaired joint last longer. The key issue during any activity is to avoid excessive loading of the knee while nonetheless enjoying the activity. The challenge is to achieve the ideal balance between these two concerns.

To conclude, cartilage injuries in sport cause major problems and are common in football. When planning a treatment strategy for an ex-professional player, the patient’s expectations should be taken into account and managed, with the ultimate aim of achieving complete freedom in everyday life.

The patient should be encouraged to explore new interests and hobbies which avoid excessive loading of the knee. Preventive measures are key, but doctors also need to take into account the differences between a normal patient and one that has been a high-level athlete.

FOOTBALL MEDIC & SCIENTIST | 27

MEDICAL GUIDELINES FOR REFEREES FEATURES/REFEREES Modified from an Original Article by Mike Healy (Head of FA Medical Education) Copyright The Football Association

Preventing Player Injury Referees have a duty of care to the players and should not underestimate their responsibility in safeguarding them from injury. Firmly embedded within ‘The Laws of the Game’ is the acknowledgement of this injury prevention principle. Once the game has commenced, the application of the Laws further contributes to player welfare; a referee has an obligation to encourage fair play and discourage any serious foul play and violent conduct that may result in player injury.

Pre-Match Briefing It can be useful for the referee to engage in a pre-match dialogue with the club medical staff. This presents the ideal opportunity to advise the staff on the protocol relating to entering the field of play and the need to ensure that any ‘on-field’ injury is managed efficiently.

Stopping the Game Law 5 states that a referee should ‘stop the match if in his/her opinion a player is seriously injured and ensure that the player is removed from the field of play’. Such direction is subject to a referee’s ability to be able to discriminate a serious and nonserious injury.

Delaying treatment may potentially cause harm to a player. Referees therefore have a duty to allow the medical staff onto the field of play as soon as a player’s need for medical assessment is recognised. Referees should be particularly aware if the player is not moving following a challenge. The cautioning of a player should not be at the expense of allowing an injured player to be seen; the club medical staff need to be ‘called on’ first.

There is also the need for a mutual understanding that a potentially lifethreatening or limb-threatening injury requires immediate management by the club medical staff. Therefore, referees need to acknowledge and allow for the judgement of medical staff and the occasional real urgency to enter the field of play without permission.

In instances where there is player

28

congestion around an injured player, ushering players away from the site of the incident can greatly assist the medical staff and help optimise player care.

is the ‘treatment’ of an injury. Medical staff must be given time to evaluate an injury before the player is directed off the field of play.

Serious Condition or Injury

On-Field Treatment

Players who are unconscious, or who are not breathing ‘normally’, require immediate medical attention. Fractures, dislocations and suspected spinal injuries also necessitate prompt medical intervention.

No head injury should be considered ‘minor’ in nature; a player may have sustained a fractured skull, or a brain injury, as a result of a blow to the head and yet remain conscious throughout. Referees should acknowledge the need for prompt medical aid for a player who has sustained a head injury. It is most important that players who are rendered unconscious should not be allowed to return to play in that particular match.

In football environments, life-threatening bleeding is very uncommon. However, of concern should be the possibility that infectious blood-borne diseases can be transmitted from an injured player to a medic, or anyone who comes into contact with the blood. It is now accepted that any bleeding must be stopped and any bloodstained clothing changed before a player is allowed to return to play.

Injury treatment is considered to be any intervention, which takes place after an injured player has been assessed. In most instances treatment will not need to be administered immediately and it will be safe to have the player leave the field of play.

However, in cases where a player is seriously injured they should not be moved until the necessary pre-hospital treatment has been administered and the player’s injury/ condition is stabilised. It is important that the referee shows understanding and allows the medical attendants the time to attend to the injured player.

Manhandling Players

Conclusion

Referees should realise that moving an injured player may unwittingly cause further harm. Those in the vicinity of an incident should be discouraged from touching or moving an injured player.

Clearly there are many ways in which a referee can have an impact on player health and on the accessibility of medical care for an injured player. The default position should be that ‘Law 18’, ‘common sense’, should prevail in all instances and that referees (in ‘partnership’ with the attendant Club medical staff) should always act in the best interests of the players and ensure that prompt medical attention is permitted and administered.

On-Field Management of the Injured Player The potential diagnosis of any injury can only be made after the injury assessment process has been conducted. A referee is obligated to allow an injured player to be medically assessed before any required treatment is administered. To do this a referee needs to be able to differentiate between what is the ‘assessment’ and what

Removal of Injured Players from the Field of Play Referees have a responsibility to ensure that an injured player is allowed to be safely removed from the field of play. However, the ultimate decision and judgement to move an injured player and the method of removal is for the medical staff alone. When feasible, players who are able to stand upright and walk from the field should be allowed to do so.

Please note that whilst this article relates to matches where there are qualified medical staff in attendance, the principles and procedures apply to referees at all levels.

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