David Fevre – Pitch Side Injuries: No Time to be Injured – Injury Rehab Network Event

Accountability in Professional Football

David commenced his presentation with a fascinating story about Eric Cantona and his infamous flying karate kick. In a fractious game against Crystal Palace, there was a red card and Eric Cantona was being heckled by a Crystal Palace fan. Eric reacted and launched into the crowd with a flying kick to the fans chest. The Manchester United kit man had been tasked with ensuring that Eric kept his cool and chased after Eric as he left the pitch and made his way to the dressing room. David described how, on reaching the dressing room after the match, the atmosphere was unsurprisingly frosty. When the manager, Sir Alex Ferguson arrived, David was expecting Eric to be in the firing line but the blame was apportioned to the kit man. Rightly or wrongly, the accountability for the player’s behaviour was with the kit man.

Decision-Making Triangle – Fit or Not Fit?

The physio must work closely with the player and the manager to inform decision making around a player’s fitness to play. He described how professional football physios have the luxury of the best facilities and time to work intensively with injured players, often spending a whole day with one player.

The Role of the Physio on Match Day

David described the role of the physio on matchday and during the match, where they must focus on and respond quickly to any first aid and emergency issues. Physios must be qualified to manage trauma in football and should train and practice the techniques regularly. For football, The FA qualification Advanced Trauma Medical Management in Football (ATMMiF) provides doctors and physiotherapists with the skills required to lead a team and manage trauma in the event of an emergency. Other governing bodies and training providers also offer training in emergency care.

The most important tools a physio has are their eyes and hands. On match day the physio should keep an eye out for injuries amongst the action on the pitch and be ready to respond to injuries including broken bones, cardiac arrest, head injuries and unconscious players.

David discussed the perception of contact sports and noted how football and rugby should more accurately be termed as collision sports as this is how most injuries occur in a fast-paced and competitive environment.

When trauma occurs, the physio must put in action what has been practised to provide emergency care and to lead the team of medical staff. He discussed that whilst it may seem daunting to treat an unconscious player in a packed stadium in front of 60,000 fans, this is quite a low-stress situation so long as the physio and team follow the protocols and put in place what has been practised.

David said that whilst emergency care standards are high in English professional football it is sometimes surprising and concerning to see mistakes being in the management of trauma in other countries.

Post-Injury Decision Making

The factors to be considered by the physio and player following an injury are:

Diagnosis and surgery
Maximum/ moderate/ minimum protection phase
Return to work/ training/ play

Different Levels = Different Environments

David discussed the different levels of football and how physio teams may be limited by technology and people, but the most important factor is the clinical skills of the physio and as mentioned previously to use their eyes and hands for the treatment and rehabilitation of injuries. He described that at the very top level it may be a fantasy world with no limitations, but bottomless resources are not essential. David’s preference is to avoid too many gadgets or items including a 3-pin plug and to make use of basic equipment such as dumbbells.

Personal Values

It was described how David regularly reflects on his personal values which are currently:

Professional
Provocative
Reflective
Honest
Innovative

David encouraged anyone working in sports rehabilitation to reflect on their personal values regularly too as these values provide a foundation for good clinical practice and leadership in sports medicine. Values are likely to change over time.

Pre-Operative Exercise

The importance of players putting in hard work prior to an operation was discussed, as this can help to maximise recovery, ensure rehabilitation, and return to play is as quick and as safe as possible. David described the key areas to focus on including:

Mobility
Stability
Controlled mobility
Load
Skill

Exercise as Medicine

David described how exercise is now classified as medicine with proven effects on healthy and injured tissue. Physios should consider the basic principles of exercise load including frequency, intensity, and duration. It was noted that the fragile nature of injured tissue may only require small progressions as low as 2%. He also described the differences between professional athletes and untrained athletes where recovery and rehabilitation programmes and timelines may be vastly different and as such should be personalised.

Muscle strength rapidly decreases when the body or a limb is immobilised due to injury, so players should exercise and start loading as soon as is safely possible.

Maximum Protection Phase

During the maximum protection phase, it is vital to protect the repaired tissue and David described how therapists can aim to initially reduce post-operative inflammation and pain, restore range of movement, and prevent muscle inhibition.

David described how the physio will work with the player to restore mobility with restrictions and that unused joints can be likened to a rusty hinge which when not used requires oil to help it move freely. The body has its own ‘oil’ in the form of synovial fluid which through regular movement will help to restore mobility.

Moderate Protection Phase

During the moderate protection phase, the aim is to continue to protect the repaired tissue whilst restoring the full range of movement. Work should focus on the primary joint stabilisers to build strength in the main muscles around the injured joint.

Minimum Protection Phase

David described how players should only advance to the minimum protection phase if they have a full range of movement, are pain-free and have good strength. Rehabilitation exercises at this phase may include gym work with weights, swimming, and functional activities on the training ground.

Return to Training

Stage 4 of rehabilitation was discussed, and how players should only advance to this phase if strength is equal to 85% of the contralateral limb, cardiovascular fitness levels should be back to the pre-injury state and players should achieve all Return To Train (RTT) agility goals.

Is Return to Play the Only Consideration?

David discussed the differences between professional athletes and semi-professional or amateur athletes where the priorities for the athlete and the physio may differ. For most people, a priority for their rehabilitation will be to return to work and this should be considered at the beginning and end phases of the programme. Dave described how the physio can work with the athlete to help them initially return to work on a phased/ light duties basis and at the end of the programme to be able to return to work fully.

Professional athletes can focus purely on working through the phases of RTR (return to running), RTT (return to training) and RTP (return to play). Whether it be a professional or amateur athlete, the physio should work with the player to put together the pieces of their rehab ‘jigsaw.’

Rehabilitation Begins…

…with screening. David discussed the importance of screening to assess players at various points including in the academy, in signing on medicals for new players, pre-season, in season and for new contracts. Screening tests can inform areas where work is required to improve strength or range of movement and to help prevent injuries before they happen.

David showed a range of simple baseline skeletal tests that provide data in relation to flexibility and can be performed with just the aid of a plinth and chair. When assessing players David recognises varying levels of flexibility in a seated legs straight spinal assessment. Young players with limited flexibility may be able to make good improvements with hard work overtime, whereas older players are likely to only see limited improvement during the remainder of their careers. As such the medical team will support the older players but will work more intensively with younger players where progress can be made.

Normal functional movement of the ankle was discussed. For running the full range of movement to 20 degrees of dorsiflexion is required whereas only 50% of the range of movement is required for plantarflexion. David described how dorsiflexion is therefore a key consideration in rehabilitation for return to running.

David presented a table of data prepared by the sports science team at a club and described how formulas are used to identify players who may present a higher risk of injury. This data then informs injury prevention work.

Sequel to Injury

The sequel to injury is often injury reoccurrence. In non-elite athletes, the likelihood of returning to competitive sport 12 months after surgery is low with around only one-third able to return to competition. David described how in contrast almost all professional football players in Europe return to their pre-injury level within a year following ACL surgery.

David described the need for those working in sports rehabilitation to self-reflect when injury re-occurs and to review whether they may be accountable and if a different approach may now be required or could work better in future.

Building Effective Professional Relationships is All About the Detail

The presentation was finished with a story about when he first started as a physio at Manchester United where he was asked to review the gym equipment required. David’s response was that after watching Mark Hughes play, he knew that football involved a lot of pushing away and therefore traditional gym equipment where people pull weights is not fit for purpose. In response to this David carefully sourced some high-quality boxing equipment in the club’s colours and arranged for these new items to be installed at the gym.

David was pleased with his work and the players loved using the boxing equipment as it was fun and added a new dimension to their training. However, David was called to see the manager, Sir Alex Ferguson who asked David to look again at the boxing equipment. After looking at the equipment David still could not see any problem so returned to the manager’s office where the manager marched him back to the gym and pointed out that the same boxing bags the players were enjoying punching aggressively, had the name Alex on them! This was laughed off and provided a good foundation for David’s work at Manchester United. David pointed out that the lessons here are to ensure exercises are specific to the sport and to always focus on the detail.

Summary

The key points from David’s presentation are:

Importance of a strong relationship and effective communication between player, physio (+medical team) and manager
A therapists most important tools are their eyes and hands
Be qualified and practice emergency care skills regularly to be prepared for pitchside trauma/ injuries
Be creative with the equipment and resources available. Only limited equipment is required for good rehab
Reflect on your personal values
Exercise is medicine = movement is essential pre-op and in rehab
Work through phases of protection and only advance to the next phase if goals have been achieved
Return to work is an important consideration for most people
Rehabilitation begins with screening
Self-reflect to learn and improve

Follow David Fevre

LinkedIn: David Fevre

Injury Rehab Network Events

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3^rd March 2022 at 7pm – Michael Blackie BDS (The Park Practice)
6^th April 2022 at 7pm – Steve Kemp (Lead Men’s Physiotherapist England Senior Football Team)
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