Gary Lewin, Expert Football Physiotherapist – Rehabilitation on the Road in Elite Sport – Injury Rehab Network Event

The latest event (27th January 2021) of the Injury Rehab Network with BASRaT featured an insightful presentation from expert football physiotherapist, Gary Lewin.

One of the most experienced sports physiotherapists in the UK, Gary has over 30 years’ experience at the very top of football including 22 years leading the medical team at Arsenal FC and 8 years as Head of Physiotherapy Services at the FA, working with the England Senior Men’s team.

The event was fully booked with 500 sports rehabilitators and sports injury professionals from across the UK and included some of BASRaT’s members from around the world.

Watch the recording of Gary’s presentation – Rehabilitation on the road in elite sport

Starting Out in Football

Gary’s early career in football started at a young age where he played for Arsenal FC. Gary’s competitive playing days ended when he was released from Arsenal in his late teens. Gary then decided to pursue a career as a physiotherapist and began his training at Guys Hospital in London. During this time Gary continued to work with the academy and junior teams at Arsenal FC in a variety of roles.

On completing his Physiotherapy training at the age of 22, Gary was appointed as Head Physio at Arsenal FC where he worked from 1986 – 2008.

New Challenges

Gary moved from Arsenal FC to work with The FA in 2008 where he then spent the next eight years as Head of Physiotherapy Services, working with the England Men’s National team. During his time at the FA, Gary was fortunate to have the experience of planning and experiencing work as an elite sports physio on the road at Olympic Games, World Cups and European Football Championships.

From 2017 – 2018 Gary was Head of Medical Services at West Ham United before establishing The Lewin Sports Injury Clinic with his cousin and fellow sports physio Colin. Gary is currently Director at The Lewin Clinic, Affiliate FA Tutor ATTMiF and Consultant Physiotherapist for Arsenal Women’s Football Team.

Multi-Disciplinary Teams

Gary has learned through experience the importance of specialist expertise and teamwork as part of Multi-Disciplinary Medical Teams (MDMT). With the growth of professional/ elite sport and with it advances in sports medicine and sports science there has been proportionate growth of medical teams at sports teams. It is now common (and vitally important) for everyone in an MDMT to work closely together including:

Head of performance
Doctors (including specialist surgeons and Radiologists)
Physios
Masseurs
Osteopaths
Fitness, Strength & Conditioning Coaches
Sports Scientists
Video Analysts
Nutritionists
Psychologists
Podiatrists

If You Fail to Prepare, Prepare to Fail!

Gary described how planning and preparation for medical support at international sports competitions is essential. The medical team need to plan for all eventualities to ensure they can put their clinical skills into practice. Elite sports events are not clinical environments, and the medical team will need to source local medical support.

Physiotherapy Principles

The principles of Physiotherapy remain the same, whether in a clinical setting or on the road. Gary discussed the four core principles of injury prevention & performance optimisation, injury assessment & management, treatment & rehabilitation management, and load management. The effective implementation of physiotherapy principles is influenced by how they are delivered and by the compliance of athletes.

Pre-Tournament Planning

When planning ahead of a tournament, Gary and his team would usually start planning 6 months before. This would include assembling the Multi-Disciplinary Medical Team, logistics, developing Emergency Action Plans (EAPs), organising training and rehab equipment, player profiling, travel strategy, recovery strategy, nutrition/ hydration, doping control and researching environmental factors such as heat and altitude.

The MDMT are not only responsible for the welfare of the players but also the wider support team which could include up to 75 people of varying fitness levels.

Gary would usually visit venues ahead of a tournament and devise EAPs for each stadium and training ground. Due diligence is also required on kit and medical items to ensure they are compliant with any local legislation.

The Life of a Physio on the Road

Gary provided insight into the life of a physio when travelling and working at an elite sports event. A physio on the road should expect to work long and unsociable hours, to muck in and help with any jobs that need doing, to work under pressure and to work closely as part of a team.

Duties beyond the clinical role of a physio may include moving large amounts of kit. For example, it is not uncommon for a squad of 23 players to take over 400 pairs of boots to a tournament!

The Technicalities of Working with International Players

National teams ‘borrow’ players from clubs and Gary discussed the importance of having good communication and building strong relationships with clubs to have a shared understanding of each player and their requirements. The national team are responsible for the player whilst they are on duty.

Communication and Decision Making is Key

The multi-faceted environment on the road presents many challenges with good communication and relationships to be built with many people including with managers, players, within the medical team, operations team, security, clubs, FA/ FIFA/ UEFA and with local medical contacts.

When injuries happen, decisions need to be made quickly as the pressure of the media means any incidents will soon be in the public eye. It is important to therefore have a plan for how and who to communicate with and what information to record.

All decisions need to be made with priority given to the duty of care of the physio to the player and their profession of physiotherapy.

Medical Team Relationship with Management

The relationship between the management and medical team will always be focused on player fitness with managers keen to know when players are fit to play. As with decision making, the medical team need to use their clinical judgment and to ensure the duty of care of players comes first.

An accurate assessment of how and when a player can return to play is essential, but it should be clear that return to play will be continually reassessed based on each individual player’s progress with rehab. Continued dialogue is therefore essential between the medical team and managers.

The reality is that the physio is often the giver of bad news and therefore need to be prepared to take questions from management confidently.

Strategies to Minimise Injury

Gary shared his top strategies for an injury which are consistent with physio principles. Travel and consistently changing environments can place added stress on players so it is important to have a strategy and to stick to it.

Key strategies to reduce injury include:

Monitor training load
Use data effectively
Provide good nutrition – food first approach
Enable good sleep

The medical team should focus on what they can control. For example, training duration and intensity, nutrition, and sleep. Gary and his team often used both player and coach analysis of reported perceived exertion (RPE) of training sessions to help with planning for rehab and recovery.

There are many tools and equipment available to the medical team with reported impacts on recovery. The challenge for the medical team is to devise an effective recovery strategy and Gary is clear that the primary focus should be on good nutrition and sleep.

Any other strategies are likely to support marginal improvements and should therefore be promoted in addition to the focus on nutrition and sleep. Other strategies should be clearly communicated and supported by the medical team to ensure good adherence from the players.

The Return to Play Conundrum

Gary discussed the challenges physios face when considering return to play. Physios should be clear on what the end goal is – return to training or return to play (competitive football)? The players may well be fatigued from a rehab programme and as such a period of recovery may be required to ensure the player is ready for the intensity of training and matches.

The physio also needs to consider the fact that the player is returning into a competitive environment where the squad are training and playing at peak fitness and often high intensity. Rehab session should therefore try to replicate the competitive environment.

What Difference Can Physios Make?

Physios can make a difference through effective decision-making clinical skills to influence and support the treatment and rehabilitation of injuries and implementation of strategies to prevent injuries.

However, football is a contact sport with inherent risks. Injuries can and will occur, so the medical team need to be well prepared for when injuries happen.

Gary’s Experiences From South Africa 2010 and Brazil 2014

Gary has been fortunate to attend two World Cups with the England Men’s Senior Team and kindly shared his experiences from these tournaments.

Preparation for a tournament involves a pre-tournament training camp which provides an opportunity for screening, building on player profiles and developing relationships with the squad and all support staff.

Training venues and facilities are visited ahead of camps and tournaments and plans put in place for the setup and requirements of the team.

Scheduling meetings take place 6 months prior to a tournament, considering domestic and international fixtures and the demands on all players.

When going into a tournament the medical team should recognise that players will be at varying levels of fitness, having played at varying frequency and intensity in the weeks and months before. The medical team therefore needs to have different strategies for different players with some focused-on conditioning and others focused on rest. The overall aim is to have a squad of players at peak performance/ the level of fitness required to compete in international football.

When arriving at a tournament, the medical team may need to reflect on and adapt plans as there may be changes to facilities, travel arrangements and other factors to consider. Whilst in Brazil the team’s training camp was next to the sea and they were surprised by a visit from a nuclear submarine who were keen to watch England in action!

The Brazil World Cup was difficult for England and it was extremely tough for the team to accept an early exit from the tournament. Gary’s exit was even more painful as he broke his ankle when celebrating an England goal after tripping in a hole near the dugout!

Take-Home Messages and Q&A

Gary’s presentation was extremely well received and provided a unique insight into elite sport on the road and the work of a physio in international football.

Gary’s 4 take-home messages were:

Work as a Multi-Disciplinary Medical Team (MDMT)
You have a duty of care to the player first
You have a responsibility to your employer second
Plan – Do – Review

Those who joined the event fielded many questions including:

Question 1 – What is your advice for people starting out?
Answer – Volunteer to get experience and make your CV stand out.

Question 2 – How do you get buy-in from players?
Answer – Keep the club environment going and build trust through good communication with the club and player profiling.

Question 3 – How did you get the role at Arsenal FC?
Answer – Whilst training at Guys Hospital, Gary worked part-time in the evening as a football physio at Arsenal. With the support of a mentor, Gary was able to gain the skills and hands-on experience to put him in a strong position for the role.

Question 4 – What are your thoughts on changes in the sector?
Answer – There is no doubt that the sector has evolved and grown for the better. Training and support for professionals working in sports rehabilitation is much better.

Question 5 – How do you build a good relationship with managers and coaches?
Answer – It takes experience to have the confidence to work effectively with managers. Relationships are built over time and physios should work on their diplomacy skills to ensure they can effectively communicate with managers, coaches, players, and the whole team.

Question 6 – How much planning is required for domestic football?
Answer – Planning is usually just on a round by round basis with games planned into the wider schedule for the club. Research and planning may be required when the club is up against an unknown/ new team.

Question 7 – How is COVID affecting professional football?
Answer – COVID means that physios need to put in place a lot of new operational measures for infection control. In the planning for the Euros, the medical team would usually prepare with visits to the tournament venues, but this is not currently possible. As plans for international sport in 2021 unfold there will no doubt be new and additional factors for medical teams to plan and prepare for.

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If you did not get the chance to join the event you can watch the recording here.

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