Jonny recently returned from an International football tournament tour where he was providing Physiotherapy and Medical cover for a Premier League Football Academy team. We couldn't resist asking him to write a blog post about it. He's also shared some injury management case studies from the tournament at the end of the article.
Ilike to think of Sports Physiotherapist as not a diagnostic rehabilitator but instead of someone who pushes performance of amateur sports people to elite athletes. The players, the coaches, parents and those who support the club all want either a good gloating session or pride in their teams accolades. Your role as a Sports Physio is a very important, big cog in the team’s performance.
Working as a Sports Physiotherapist has always been a dream of mine and to find myself working for a Premier League Football Academy going on European tours is a dream come true. It is a different and new experience from a 9-5 NHS Musculoskeletal Physiotherapist job and one that definitely has challenges. There are courses and resources which you should cover so you are practicing within your scope of practice. Lots of preparation comes from the knowledge of those before you and me. So if you are planning on being a Sports Physiotherapist possibly on tour have a read, prepare, seek further advice and mentoring including contacting me through QualifiedPhysio (firstname.lastname@example.org), but most importantly enjoy what you’ve got yourself into.
I was providing Physiotherapy and Medical cover for the team playing in a Euro International football tournament that had 18 teams from 16 different nations across the world. So I guess it is a ‘World Club Cup’ despite the engravings on the trophy. Rules stated there were team sizes of 8 vs 8 with rolling substitute playing 18 minute a match, using UEFA football rules unless otherwise provided in the rules and information packs. What’s the offside rule? If you don’t know what the offside rule, don’t worry, it’s not being used luckily. The tournament was split into two halves. Day 1 in Germany the teams were divided into 3 groups of 6 teams with all teams of a group playing each other. The 1st and 2nd placed teams qualified for the Gold Cup, the 3rd and 4th placed teams for the Silver Cup and the 5th and 6th placed teams for the Bronze Cup. Day 2 teams travelled to Czech Republic and the teams battled it out in a second group round to get to the Final and hopefully leaving victorious. But, we all know it is about the taking part, right?
Be Your Best
There are lots of additional resources, pre-reading, preparation and continued personal development that will undoubtedly all help you. I strongly recommend for not just football but other sports to enrol in the FIFA Diploma in Football Medicine (http://fifamedicinediploma.com) which will give you current and relevant information to learn and take forwards whilst touring as a Sports Physiotherapist. With 42 modules (all free) I have selected some of the key ones below to add to your already growing clinical MSK knowledge:
- Medical bag – know what you need and are expected to have in your kit bag above and beyond a bit of tape and check you are well supplied.
- Touchline care & General Emergency modules – be well prepared for the unexpected!
- Head and Neck & Concussion modules – unless you work in an acute sports clinic with a concussion clinic you are very unlikely to have come across this in abundance.
- Environment & Team travel modules – hopefully a lot of the important stuff will be covered and summarised within this blog but you may use it as a revision tool and take the quiz at the end (you need 100%)
- Nutrition – beyond the day to day planning but more around the ins-and-outs of food groups and the effectiveness on energy systems and recovery from injury. Well worth a read and an area I have started to develop further within my own CPD.
Probably the biggest part of any Tour is the preparation. You’re going into a foreign country with different languages, perhaps not knowing all the players personally, in an unusual environment with lots of potential risks. The preparation checklist:
- Review players fitness and recent injuries including discussion with treating Physios and checking on their performance with the coaches
- Have access to electronic notes where possible so you don’t have paper flying everywhere
- Take hard copies of all medical history of the players and coaches including GP contact and parents contact details
- Make sure you have up to date allergy information
- Contact the venue to check what medical facilities they are providing, if any, and know where the nearest hospital and trauma hospital area.
- No joke, know the countries emergency number. So easy to over-look.
- If you are staying over-night assess the risk of a hotel. The 5th floor balcony is not where you want your academy players fooling around.
- Take your passport…!
Language / Sprache / Jazyk
It was probably no surprise that in the hills of Czech Republic not everyone spoke English. We do have a certain expectation that medical professionals at an event would perhaps have good English but good preparation will ensure you don’t slip up. On this tour and with most there were some players who had food allergies including serious allergies with history of having to use their own EpiPens.
It is a great idea to translate a couple of key questions and phrases into each language and print them off. For example…
“Má jídlo nějaké ořechy?”
“Jeden z hráčů má alergii na ořechy.”
Try saying that with conviction and you are going to get a clear and confident response. So now you definitely know there are no nuts, and the chef knows someone has a nut allergy. Just think of all the medically-related, important things you will need to know when you are there that won’t be in a pocket hand book then use Google Translate to create a personalise pack of phases. That is a very handy tip I wish someone told me on my first international tour but one I won’t be forgetting any time soon.
Daily Plan: Nutrition
With performance comes planning. Every player will have been training regularly over the course of the season, hitting the conditioning sessions, speed work, ball control and technique; then follows heavy post-match analysis… not to forget going down their local pitch to ‘skin’ a few of their mates.
As I sat on the mini-bus the day before the tournament I was analysing the problems that we may encounter. Kick off was at 9:30am, a heavy schedule of games with a lunch squeezed in the middle of all of this. Depending on what food, how big the meal was and how long certain food types take to metabolise our planned breakfast was looking a little close to the first match. Now, making a call of waking up an hour early whilst you are an hour ahead was not one the coaches were keen on. But, if you sell it to them as it will aid performance they will lap it up and you’ve got them on board straight away. If you can allow 2-3 hours from eating to playing then you have energy on your side (the real 12th man).
High-exertion competitive football is going to be tiring. If we consider that breakfast was now at 06:30am and lunch was not until 1:50pm then well-timed snacks and electrolyte drinks are needed. After the players finished their 2nd of 4 morning matches at 11:10 a relaxation session and intake of fruit and cereal bars were obviously timed to perfection (they won their next two matches heavily). A mid-afternoon replacement of energy is also required, remember the players will be exerting on close to empty. Relative energy deficiency in sport (RED-S) is a massive cause of injuries and poor performance in tournament football.
Day 1 and 2 were very different in terms of weather. From 29 degrees blue-skied summer’s day to a chilly and windy overcast 18 degrees, the players are going to have a much different demand of water hydration.
Children have higher water consumption than adults for their body weight. They also have less ability to recognise the first signs of thirst and dehydration. In addition to this, boys going through puberty have a higher metabolising rate of foods and, subsequently, water! Enough of the geeky facts. It is often difficult to get young adolescents to drink any water, let alone what might appear like excess amounts. These are all reasons why planning ahead, researching about holes in your knowledge and enforcing a strict hydration program will need to be taken into consideration for optimising hydration and performance.
There are a few ways that you can assess for hydration levels. Without having to inappropriately observing the colour of urine, I had devised a plan to ensure the entire playing team had drank a minimum of 5x500ml bottles of water each. As the daily recommended volume of water for boys aged 9-13 is 1.5-1.7 litres daily (Natural Hydration Council) and the probable sweat loss must be up to 1 litre. If you ‘over-do it’ a little the worse that will happen is there will be a couple more bathroom breaks.
Injuries Management / Case Studies
At the end of the warm-up match on the previous day our Captain, and recent Player of the Tournament, presented with left sided mid-hamstring pain which he believed was due to overstretching. His assessment was consistent with a hamstring strain: The was pain on active resistance, passive stretch, palpation and his strength was marginally weaker. His lumbar spine was cleared and there were no neurological symptoms or right sided pain. The player was managed with PRICE with compression bandage used for 3x12 minute periods with observation of the skin prior to applying each occasion that evening. He was assessed to have NRS 2/10 pain that evening and was functioning without issues. Still, I was not feeling confident we could turn this around for the start of the tournament.
The Captain was assessed individually in Physiotherapy the next morning. He did not present with on-going pain and on assessment he had equal strength. His jogging, sprinting, acceleration and deceleration were excellent. He was then able to demonstrated good kicking, reaching control on stance and effected leg and striking power (bilaterally) without any pain. Shocker! It was still important to discuss his fitness with the coaches and cleared to play with on-going monitoring. Such a fantastic result that he did not have any more complaints for the rest of the tournament and was given the internal Player of the Tournament award, again. I will be watching out for this kid in a few years!!
At the end of 4th game of the first group stages presented with NRS 7/10 pain predominantly in his heels and plantar fascia bilaterally and also mildly in his Achilles. I think a little covering up of his pain beforehand was reasons behind his fairly severe pain. This is something that is very hard to watch out for. The player found it difficult to run and within 10-20 minutes found walking painful. He reported he has had these pains since he was about 6 or 7 years old and hurt mostly in the mornings and after lots of activity and sports. He stated his dad has the same pains, as does his sister and has been told it is due to ‘flat feet’. The player does not wear insoles but his family does which helps to manage their symptoms.
On assessment the player has medial deviation of his talus and a pronating STJ and everting calcaneus with pain on palpation positive for plantar fasciitis bilaterally. Differential diagnoses were not positive.
Initially the player’s feet were iced and he sat out the next game. The coaches were okay with this considering he had played a good amount of minutes in the previous fixtures and there were squad rotation options. However, knowing these players capabilities at coming in off the wing and his one-on-one technical abilities there were very adamant he was to return as soon as possible.
Player B received taping techniques to support his medial arches and he reported his pain as NRS 2/10. He could run whilst not increasing the pain and reported he was happy with the treatment. As the player warmed up he did not look laborer or effected by the pain and it was discussed that he would be available for restricted minutes in the final 2 games of the 1st day. I was a bit apprehensive that he would cause a flare-up and be out for further minutes in next day so close monitoring was carried out. In the evening he was treated with paracetamol for comfort and icing again. He declined the taping until the morning.
The next day Player B reported his foot pain had reduced to its ‘normal’ morning level of pain and stiffness. Application of the tape reduced his symptom to NRS 1-2/10. He was available for the rest of the tournament with ongoing monitoring.
Now the crucial part. Performance. Player B reported that his symptoms were fine however his performance technically was not as good as the first day and he was not played as much in the final games. It was debated between Coaches and Physiotherapist whether the foot pains caused this problem however it was unclear as physically he was agile and fast as we would expected. Whether this was a distraction, he just had an off second half to the season or he was covering up his pain it is very hard to tell unless the player is straight with you. What I am slowly learning more and more is that the Physiotherapist is perceived as the person who stops the players from playing; putting players on the side-lines instead of out there playing for your team. A challenge across the entire game, I’m sure.
Player C presented to Physiotherapist at the end of the 7th and final game of the 1st day with mild head pain NRS 4/10 l which lasted about 20-30 minutes. This was after an observed an uneventful heading of the ball. There was no LOC or other contact. During this time he was assessed in line with child concussion guidelines. His Maddock score was normal at 4/4 and this was tested extensively with conversation. The player did not present with any 5Ds or 3Ns, he was not drowsy, confused, no difficulty concentrating (also objectively). Initially he had mildly tender scalp but this was then no longer tender on final assessment (15-20 minutes later). A Scat-3 child assessment was conducted as a precaution and the player did not present with any abnormalities.
As this player was not well known to me I could not give a baseline of behavior. Luckily the player’s father was present and the coaches who all know him better were happy with his cognition and his behavior did not seem unusual. For precaution the player was treated as a concussion and advised not to run and to relax. Timed hourly subjective monitoring did not find any new symptoms. The player was assessed in the evening before bed and did not have any symptoms whatsoever.
The morning of day 2 Player C was re-assessed as he had no pain or other symptoms. He had further assessment and monitoring during warm-up where he was fully functional with no problems or reoccurrence of pain. I signed Player C as fit for play; no concussion at the time or after the event, and it was diagnosed that he had either a non-specific and brief headache or some very mild scalp bruising. However, a challenge, wouldn’t you agree? I felt that for my own reassurance I would contact the on-call club doctor for advice. They agreed, it was a very minor heading of the ball and there were no symptoms of pain beyond 20 minutes and there were never any neurological signs or symptoms. A sigh of relief. If in doubt, give someone a shout.
Overall a 5th place finish against some older, bigger and technically gifted players especially from Ajax Amsterdam and Bayern Munchen. A great weekend and a great experience. An outstanding performance of professionalism from all players. Collectively a tour which I am sure they can learn from and one I certainly did. As a Sports Physio I have helped maximise the player’s performance on the day. All the coaching, tactics, training and natural ability out there may not be enough if your players don’t have a good sports medicine team and physiotherapy behind them.
I hope you have found this blog of interest and that you continue to pursuit a career in Sports Physiotherapy. As part of my role in QualifiedPhysio I would like to offer you a chance to contact and discuss any questions you may have. You may also log on to the QualifiedPhysio Facebook page to view the live recording of my talk on Career Goals in Sports Physiotherapy.
About the author
Jonny Sumner, Academy Physiotherapist for a top premier league football club in London, started his career after graduating from the University of East London in 2011. He also works in outpatients for a busy hospital in East London. From university to touring with a top professional sports team, he's talked about his experience of elite sports, more specifically football, at several of our seminars. If you're interested in Sports Physio, don't hesitate to get in touch with him via our email address.