Diane Ryding – Physiotherapy in an Elite Football Academy: Beyond injuries – Injury Rehab Network Event

Diane’s presentation as part of the recent Injury Rehab Netowork event looked beyond injuries in an elite football academy including:

• Understanding growth, maturation and performance of body and brain
• The IDT and athlete-centred approach
• Physiotherapy within an academy – beyond rehab phases

Anatomical Differences

Diane described the significant anatomical differences between children and adults with x-ray images of a child and adult knee clearly showing the growth plate and developing bone in a child. Bone growth was described by Diane with cartilage being calcified and replaced by bone.

Understanding Growth and Maturation

Therapists need to understand both the chronological age and biological (skeletal) age of children and young people. In studies, a third of players were shown to be outside of the normal maturity category. There are also different maturity rates in different ethnic backgrounds and earlier osseous maturity in female adolescents.

Diane discussed the pubertal growth spurt which peaks in females at around age 12 and in males at approximately age 14. She also described how peak high-velocity growth is the period of time when adolescents experience their fastest upward growth.

Assessing Growth and Maturation

Non-invasive methods are used to assess and predict growth and maturation with measures of age, height, weight, and parental height used to help estimate peak high-velocity growth and predicted end height.

Pubertal growth spurts are monitored by the academy medical team to assess which players are pre–Peak High Velocity (PHV) growth, currently in the PHV window and post PHV. Parental information helps to inform predicted height.

Diane described that whilst two children may be the same age and same height, they may still be at different maturation levels when looking at current height in relation to predicted height.

Adolescent Awkwardness

There is an awkwardness, or ‘Bambi’ effect, that often occurs as the result of the adolescent growth spurt, leading to a temporary decline in performance or disruption in motor coordination.

Adolescent awkwardness is the rapid growth of limbs causing reduced proprioception as the ‘body map’ changes in young people. This can then lead to a decline in motor skills as the player needs to get accustomed to their new body. Young people may get frustrated with the temporary performance reduction.

Positive Effects and Implications of Maturation on Performance

Diane described the positive effects of maturation on performance including strength and power gains, increased cardio and aerobic capacity and speed and power gains. Early maturers therefore have a competitive advantage.

The Relative Age Effect (RAE) can be seen in the distributions of players with earlier birth dates in professional and youth football players. Players born early in the selection year are favoured. RAE is also found in academic disciplines. Academy staff should recognise the differences and implications of RAE and the maturation effect.

Diane described the effects of maturation on performance with evidence showing that physical performance is related to biological maturity. Maturity status has a much greater influence on performance with physical fitness associated with biological maturity.

Late maturers are physically disadvantaged and may struggle to compete against physically stronger and more able peers. She described how this could lead to young people dropping out of sport and that late maturers should not be excluded or missed in selection. Late maturers often develop exceptional technical and tactical attributes to ‘survive’ and continue to compete against their peers.

Managing Training and Physical Development

Diane discussed how different methods have been evaluated to manage training and physical development to accommodate and provide a level playing field for early and late maturers. Bio-banding is the process of grouping players on the basis of their physical attributes rather than chronological age. Players are grouped together using the percentage of predicted adult stature within an agreed maturation band.

The experiences of academy players in a tournament bio-banded for biological maturation was also discussed. Players agreed that bio-banding created a more equal playing field. Bio-banding encouraged a style of play that was more technically and tactically oriented.

Early maturers were more physically challenged in the games and provided a better test of their touch and ability. Late maturers found the games less physically challenging and had greater opportunities to use and develop their technical, tactical, and physical competencies.

Diane discussed the key points for managing training and physical development including:

• Flexibility for coaches to play players up or down
• Education required for parents and players
• Gym ‘robustness’ programmes
• Regular IDT meetings
• Maturation and age to be considered in any decisions about retention and release of players

The professional physiotherapist described how therapists can best support players around PHV and personalise training load. The whole IDT should have awareness of each players PHV to provide a personalised approach and should also give consideration to external loads (of activities) outside of football.

The Developing Brain

Diane discussed how the frontal cortex is involved in planning, rational decisions, controlling emotional responses/ impulses and problem-solving. Adults use this part of the brain to effectively make decisions. Teenagers’ brains are different, and they are therefore unable to use the frontal cortex properly or consistently.

She described how the teenage brain develops from back to front with the frontal lobe being the last part to develop. Brain maturation occurs around the mid-’20s. Teenagers may rely on the amygdala to make decisions whilst the frontal cortex is developing and the amygdala is associated with the stereotypical teenage emotions and behaviours e.g., impulses, aggression, risk-taking. Positives of the developing brain are that it enables increased exploratory behaviours, with usually positive consequences for learning and social interaction. Teenagers’ brains are open to change and ready to learn with adolescence a key time for the development of self.

The IDT and the Athlete-Centred Approach

Diane discussed the interdisciplinary team (IDT) which takes a collaborative approach to player development with the full range of professionals and family associated with the player and club working together with defined roles but an appreciation of other skills.

The athlete-centred approach was talked about, which is where the needs of the players/ athletes are placed first and importantly before interests and pressures imposed by the club, school, or parents. This approach empowers players and ensures they are engaged in their own development as part of a problem-solving approach. Players plan for the long term and accept short term setbacks for long term gains. This approach was highlighted as not just about letting players do what they want and not about allowing players to be undisciplined.

Diane described how the athlete-centred approach is not a win at all costs mentality but working together to define success and support the evolving needs of the player, enabling them to reach their potential. It was mentioned how important it was to develop staff to support this approach with a robust induction, access to external courses, annual refresher training and staff rotations to enable the team to develop a strong skill mix.

Tournaments

At tournaments, staff are responsible for players wellbeing and must wear many hats, from advising on nutrition, providing emotional support, and making sure they are protected from the elements e.g., sunscreen.

Diane described how staff are given the responsibility to develop and produce emergency action plans for travel and tournaments.

Physiotherapy in an Academy Setting

She described the principles of physiotherapy and rehabilitation with the following phases:

1. Acute (diagnostic)
2. Strengthening
3. Power and control
4. Functional/ sport-specific
5. Return to training/ play

Diane discussed how a criteria-based approach guides the transition between phases.

Secret Sauce

She discussed the ‘secret sauce’ and additional factors beyond the clinical aspects of academy physiotherapy including:

• Child-centred approach
• Avoid over medicalisation
• Communication
• Ownership and empowerment
• Fun and motivation
• Functional activities

Diane described the importance of consistent club values and how this is about developing people.

Child-Centred Assessment

The child-centred physiotherapy assessment was discussed and how a subjective assessment should use appropriate questions giving consideration to the child’s perspective e.g., ages ago could mean 10 days ago! When assessing children, the physiotherapy team should investigate and consider other contributing factors to injuries such as the school or home environment, other sports the child takes part in and other activities they may do in their free time.

Diane described how parents should be involved and kept informed at all times. The IDT may also be able to provide insightful information such as eye witness, video analysis and information about physio room attendances.

How subjective assessment and pain scales can be used to rate pain was also talked about, but this should be treated with caution as children may not have experienced significant pain. Visual and numerical scales can be used to assess pain.

Avoiding Over-Medicalisation

Diane described that whilst the academy players have access to world-class medical equipment, the physiotherapy team aim to avoid over medicalisation. Investigations, scans, and referrals are only used when clinically indicated.

She discussed how the team take an active approach to taping and manual therapy to avoid creating a dependency.

Safe Environment

Diane discussed the importance of safeguarding and how the academy works with many partners to provide training and support to staff, players and everyone involved. This includes the occupational governing body e.g., CSP, sport governing body (The FA) and the NSPCC Child Protection in Sport Unit. Safe practices are in place including chaperones, referral pathways, record keeping and policy for social media.

Communication

Communication and ensuring that language used is age-appropriate is important. The medical team will use visual aids and confirm understanding with young people. How questions are phrased will generate different responses as ‘do you have any questions?’ may create a silent response whereas ‘what questions do you have?’ will prompt thought and a response.

Diane described the developing brain and how adolescence is a key time for the development of ‘self.’ Children should be empowered to take pride in who they are rather than what they do.

Psychological maturation needs to be considered when communicating with young people as a player may be the size of an adult but is still a child.

Non-verbal communication is extremely important when communicating with children and Diane described the need to be aware of visual signs that a child may be struggling with. A child that is feeling down may also be more susceptible to the pain of injuries with a small injury making them feel bad.

Diane described the importance of good communication with parents through education sessions, online and informally in the café or even car park. These informal opportunities for communication provide some of the best opportunities for parents to ask questions and raise any concerns.

She discussed some of the challenges faced in COVID times including the need to communicate online and the impact of wearing PPE which covers the face and causes a loss of facial expressions.

Top tips for engaging injured players were provided including:

• Facilitate learning about their body/ injury
• Confirm understanding
• Keep them involved with the team
• Provide feedback
• Include the parent
• Visual and relatable
• Encourage independent work
• Peer support
• A sweetener e.g., a message from first-team player

Diane described how rehab can provide a window of opportunity to create ownership from the player. In discussing ownership, the need to ensure that ownership is true and not simply perceived was highlighted.

It is good to remember that the road to recovery is rarely smooth, but players can be resilient to control their attitude and to use motivation and discipline to work hard at their rehab.

Make it Functional

Diane discussed how therapists can make rehab functional with a focus on load, volume, intensity, and duration together with technical and cardio activities specific to football. Exercises should be developmentally appropriate and challenging but not beyond their capability. In addition, exercise should be position-specific and draw on the coaches knowledge base.

She described return to play and the continuum from rehab to performance with the athlete, coach and rehabilitation professionals all working together as a team/ shared decision-making process.

Make it Fun

Diane described how rehab can be made fun through working together and against teammates, offering incentives or forfeits and using games.

Club Philosophies and Values

Manchester United are passionate about developing people not just footballers with a focus on the club values:

• Personal and social development
• Time management
• Integrity
• Resiliency
• Respect
• Hard work

Diane showed how players are encouraged to engage in cultural activities when they travel. Diane discussed how all team members are custodians of the club with a clear philosophy that sets the expected standards. Values are upheld on and off the pitch, including in rehabilitation.

Her colleagues in the medical team work hard to ensure that the long-term development of the player takes precedent over any external or internal pressures and short-term gains.

Diane commented that kids will be kids, that we should expect kids to make mistakes and that rehab is a learning opportunity.

Further Reading

You can read the three chapters of the book Sports Physiology and Injury Management that she has contributed to, including:

• An introduction to working in an elite football academy
• Growing bones: anatomy and fractures
• Growing bones: Osteochondroses and serious paediatric conditions

Summary

Diane summed up with a reminder that those working in academies require a clear understanding of the child-centred assessment including growth and maturation. Therapists should encourage players to take ownership and an active approach to their rehabilitation and Diane hopes this will have a positive effect on any further rehabilitation required as they develop in their career in football.

Follow Diane Ryding

Follow Diane at the links below:

Twitter

Diane Ryding – @dryding

LinkedIn

Diane Ryding

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