SEPTEMBER 2006 – No.13

IN THIS ISSUE

PUBLISHED BY UEFA’S FOOTBALL

DEVELOPMENTDIVISION

HIGH-RISK – BUT LOWER-RISK

AUTOLOGOUSCHONDROCYTEIMPLANTATION

WE CAREABOUT FEET

CARING ABOUTFOOTBALL PLAYERS

MEDICINEMatters

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COVERAtem Milevskiy played for Ukraine in the European Under-21Championship Final Round and then represented his country againin the World Cup in Germany. Any player who takes part in twotop-level tournaments one afterthe other needs to be monitoredclosely by the medical staff.PHOTO: M.RIOPA/AFP/GETTY IMAGES

This means that there are vitally im-portant lessons to be learned from in-jury statistics, social commitment andanti-doping measures. Action is neces-sary and will almost certainly continueto increase in scope. I am thinking of support being given to the nationalassociations, not only financially butalso through the provision of know-how and doing more in the shape of grassroots sport, mini-pitches, fur-ther education courses, anti-dopingmeasures and much more besides.

UEFA’s second seminar for doping control officers (DCOs), which tookplace recently in Nyon, is a good example of UEFA’s endeavours tomake constant improvements andconsolidate what has been done so far. The objective is to eradicatedoping from football. In Europe, UEFA has 35 experienced, well-trainedDCOs who took refresher courses or undertook further training at theseminar. In addition, training wasgiven to 11 new candidates, exclu-sively doctors (men and women) whoalready have professional experience.

Since any doping control with a posi-tive result has wide implications, UEFAhas insisted since the outset that con-trols should be carried out in an ab-solutely professional way. In the last

EDITORIAL

The need for football stars to showself-discipline has become evengreater in view of the media omni-presence. Players at the World Cupsometimes found it hard to remem-ber that their every move on thefield of play was being recorded byover a hundred cameras. Dives thatmight not have been spotted in clubfootball were suddenly and totallyexposed to public scrutiny. Everyspiteful gesture, every argument,every single word can be picked upthrough directional microphones or lip-reading. Every player’s conductcan have an immeasurable impact.

The increase in footballers’ incomehas entailed an increase in their social responsibility. Every player involved in a World Cup or EuropeanChampionship is a role model and he needs to be repeatedly remindedof this responsibility throughout hiscareer.

Measures need to be taken not only to prevent injuries, illness anddoping but also to penalise miscon-duct and the failure to act as a rolemodel. Both UEFA and FIFA are ac-tively involved, including financially,in the fight to keep football fair, free of doping and fit to be regardedas an example of sporting values.

BY DR URS VOGEL

ERADICATINGThe FIFA World Cup 2006 is over. And the matches in Germany and the emotions and events generated by them have given us a lot to digest. As Albert Camus said, it was football that taught him all he knew about moral values.CHAIRMAN

Dr Urs Vogel, Switzerland

VICE-CHAIRMENProf. Jan Ekstrand, SwedenProf. W. Stewart Hillis, Scotland

MEMBERSProf. Mehmet S. Binnet, TurkeyDr Pedro Correia Magro, PortugalDr Helena Herrero, SpainDr Alan Hodson, EnglandProf. Wilfried Kindermann, Germany Dr Mogens Kreutzfeldt, DenmarkDr Jacques Liénard, France Prof. Paolo Zeppilli, Italy

UEFA MEDICALCOMMITTEE

Dr Urs Vogel, Chairman of the UEFA Medical Committee.

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few years, we have been constantlyadding to our experience so it is nowhard to imagine doing without suchseminars, both for training purposesand for the exchange of experiences.

In over 22,000 controls worldwide,the cases which have tested positiveamount to the tiny proportion of0.4%. Last season, UEFA carried outover 1,300 controls, of which one-third were out-of-competition con-trols and two-thirds in-competitioncontrols. Two of the seven positivecases have limited relevance, as they were the result of doctors sim-ply omitting to record a TherapeuticUse Exemption (TUE) before the control. It can certainly be said thatfootball, fortunately, has a low inci-dence of doping cases.

But it is also important not to over-focus on the stars at the peak of thefootballing pyramid – and the articleswithin this issue of Medicine Mattersreflect our growing concern for ensuring well-being at other levels aswell. Controls have been extended to youth teams. Unfortunately, in theUnder-19 and Under-17 categories,there have been two positive casesinvolving cannabis and two involvingcocaine. This obviously reflects a social reality. Many years ago, the useof stimulants such as amphetamines(‘speed’) in football was also a reflec-tion of a social phenomenon. Mostinstances of this kind of doping were

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eliminated through controls – whichwas a positive development since the pathological aggression inducedby these drugs was potentially dan-gerous for opponents.

Nowadays, other kinds of hard andsoft drugs are concerned. But this is precisely what is alarming and itunderlines the importance of raisingthe awareness of footballers at anearly age. There is a German sloganwhich translates as “making childrenstrong” which shows us the wayahead. Taking pre-emptive measuresagainst doping in youth and grass-roots football is the important taskfor today, especially for the nationalassociations. Drug abuse is largelyunder control in top-level profes-sional football and players in Europeare well informed. But what is thesituation in grassroots and youthfootball?

We have to think about the best way to tackle the problem. Being themost popular sport in the world,football is the ideal environment forconveying the anti-doping message.It also means that in football wecarry a particularly heavy responsi-bility. Directives need to be drawn up and offences must be penalised.But, of course, every case that testspositive has to be considered on itsindividual merits. There are still afew twists and turns to negotiate butwe are certainly on the right track.

DOPING FROM FOOTBALL

Doping ControlOfficers seminar in Nyon.

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October 13 – 1425th BRUCOSPORT Congress(Bruges)

November 28UEFA Medical Committee (Istanbul)

November 28 – 304th UEFA Medical Symposium (Istanbul)

20th anniversary of founding action of theUEFA Medical Committee

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HIGH-RISK – BUT LOWER-RISKThere can be no doubt that top-level football is a ‘high-risk occupation’ in that the incidence of injury corre-sponds to something between six and nine injuries per 1,000 hours of exposure. As in industry at large, ‘injury’ can be defined as an absence from work – training or match-play in this case. If workers at a factory wereexposed to the same injury risk as professional footballers,six to nine workers out of every 25 would suffer injuriesthat caused absence from their workplace.

If we define injury as “an injury sustained in any football-relatedactivity which causes the player to be absent from full training orfrom a match”, a squad of 25 pro-fessional players can expect, as arough figure, 45 injuries per sea-son. Of these 45, two dozen arelikely to be minor injuries implyingan absence of less than one week,and half a dozen are likely to bemajor injuries causing an absenceof more than four weeks.

Statistically, an individual playersustains one or two minor injuriesa season and can expect a major injury every third season.

The high-risk nature of professionalfootball was the main reason forthe UEFA Medical Committee’scommitment to an in-depth studywhich started in 2001 with thestated aim of trying to help foot-ball to become an even safer sportby detecting and highlighting riskand injury patterns. Last season, 17 major clubs participated in theinjury study: Arsenal FC, Chelsea FC,Liverpool FC and ManchesterUnited FC from England; ParisSaint-Germain FC from France;

AC Milan, FC Internazionale and Juventus from Italy; AFC Ajaxand PSV Eindhoven from theNetherlands; FC Barcelona andReal Madrid CF from Spain; FC Porto and SL Benfica from Portugal; Club Brugge from Bel-gium; BV Borussia Dortmund from Germany; and Rangers FCfrom Scotland.

Several of these clubs have par-ticipated for a full five seasonsand it goes without saying thatthe injury study has now reacheda stage where meaningful statis-tical conclusions can be reached.

Injury risk is not increasing

It is a commonly cited myth thatthe risk of injury in top-level foot-ball is steadily increasing. There areno figures to back up such state-ments; in fact, the UEFA ChampionsLeague study is the first to followtop teams over several seasons. We now have results for five con-secutive seasons and, as seen in Figure 1, the total risk of injuryhas actually decreased over thefive-year period. The variations aresmall from season to season but the trend is a constant reduction in the injury risk. The risk of injuryduring the 2005/06 season was 22%lower than in the 2001/02 season.We do not know the reason for thelower injury risk but one could spec-ulate that the increased knowledgeabout injuries gained from thisstudy and the increased communi-cation between club medical teamshave been a contributory factor.

BY PROF. JAN EKSTRAND, MD, PHD

AN UPDATE ON THE UEFA INJURY STUDY CONCERNING PROFESSIONAL FOOTBALL IN EUROPE

Fig. 1 • Total risk of injury during the five-year study period(Expressed as the number of injuries per 1,000 hours of exposure)

Injuries / 1,000 hrs of exposure

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Injury risk in training

We have found an average of three to five injuries per 1,000hours of training in this study.There are only small variationsfrom season to season. From otherstudies we know that the risk of injury during training is approx-imately the same regardless of the level of play.

Injury risk in matches has dropped by 14%

It is well known that the risk of injury is greater during a gamethan during training and also thatthe risk of injury in match play increases with the level of play. At top level (national teams andmajor European leagues) the risk is reported to be about 30 in-juries/1,000 hours of exposure. Thereason for the increased risk of injury at higher levels of football

is probably that most match in-juries occur in contact situationsand the forces created in contactsituations are stronger the higherthe velocity of the players (ac-cording to the law energy = bodymass x the square of the velocity).

In the UEFA Champions Leaguestudy, the risk of match injury has been between six and eighttimes higher than the risk of injury in training. There is a ten-dency towards a lower risk ofmatch injuries during the studyperiod. The risk was 31.1/1,000match hours during the 2001/02season compared with 26.8 in 2005/06, a reduction of 14%.

Major injuries (absence > fourweeks) and performance

In an earlier study in the SwedishSuper League during the 2001and 2002 seasons, a positive cor-

relation was found between per-formance (league position) andthe number of major injuries inthe top six teams. It seems clearthat injuries affect performance(or is it the other way round?)and teams who can avoid majorinjuries are more successful.

During the 2001/02 season, teamshad an average of nine major injuries, causing an absence of 77 days on average. The totalnumber of days of absence dueto these severe injuries amountedto an average total of 693 daysfor a club with a squad of 25players. On average, each teamalways had two players absentdue to a major injury.

The risk of major injuries has suc-cessfully been lowered during

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The risk of injuryduring training is similar regardlessof the level of play.

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Despite the ever increasing stakes,the risk of injury in the UEFAChampions League is on the decline.

Fig. 2 • Risk of match injury during the five-year study period(Expressed as the number of injuries per 1,000 hours of exposure)

Injuries / 1,000 match hours

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23.5 26.8

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the five years of study. During the 2004/2005 and 2005/06 seasonsthere were six or seven injuries per team on average, i.e. (as a clubaverage) total absence of 570 days.This means that the absence (indays) due to severe injuries hasdecreased by 18% during the five-year period. The number of playersunavailable for matches and train-ing sessions has been reduced,thus increasing the possibility foroptimal team performance.

Risk of ankle sprain reducedby 50%

Ankle injuries are among the mostcommon in football, with pre-vious studies indicating that theyaccount for 11% to 20% of all injuries. In a study of the Swedish

Super League in 1982, the risk of ankle sprain was found to be1.6 /1,000 hours of exposure,meaning about ten ankle sprainsper team per season. Further studies of the same league duringrecent years have shown that the risk of ankle sprain has beenreduced by 50% (see Fig. 3 be-low), which means that nowadaysa team can expect about five such injuries a season. The risk of ankle sprain in the UEFA Cham-pions League study is the same(0.8 injuries per 1,000 hours of exposure, an average of five injuries per team per season).There was no significant differencebetween different countries.

Ankle sprains are normally not severe, the average length of

absence from training being twoweeks in our study. The problemin football is the frequency ratherthan the severity of ankle sprains.

The lower risk of ankle sprain and the short rehabilitation period found in this study suggestthat top teams have a thoroughknowledge of optimal treatmentand prevention. But the recur-rence rate of ankle sprains was21% in our study. This indicatesthat monitored rehabilitation andtests are important before return-ing to training and matches.

Thigh muscle injuries – the mostcommon at top level

Muscle injury to the thigh is thesingle most common injury sub-type in top-level football and ac-counts for 23% of all injuries. Therisk of sustaining a thigh muscleinjury is 1.6/1,000 hours of expo-sure, which means that a squad of 25 players can expect (on aver-age) ten such injuries a season.

Typically, injuries to the posteriorthigh muscles (hamstrings) occurduring a fast burst of speed andthe frequent occurrence of theseinjuries in top-level football mayreflect the speed and velocity ofmodern top-level football.

Since this is an injury that createsgreat problems for top clubs, weare striving to obtain more infor-mation with a view to prevention.

Muscle strains are among the most frequent types of injury in professional football.

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Fig. 3 • Risk of ankle sprain in the Swedish Super League(Expressed as the number of injuries per 1,000 hours of exposure)

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During the last two seasons wehave gathered detailed informa-tion about thigh muscle strains(strain = injury to the muscle-tendon unit). At this level, allplayers with muscle injuries areexamined by MRI (magnetic reso-nance imaging) or ultrasono-graphy. Hamstring strains thatdisplayed normal ultrasonogra-phy or MRI scans recovered fully(back to full team training ormatch play) within one week and had a low risk of recurrence.Hamstring strains with patho-logical findings on ultrasonogra-phy or MRI scan caused longerabsence (two to four weeks onaverage) and almost one third ofthese led to recurrences, meaningthat the severity of the injury wasunderestimated. These re-injuriescaused longer absence than theinitial injuries.

Fracture of the fifth metatarsalbone – an increasing problem?

During recent years several well-known players have sustainedfractures of the metatarsal bonesof the foot. The cause of such injuries is either direct trauma oroveruse causing stress fractures.The fracture of the fifth meta-tarsal bone has a worse prog-nosis than fracture of the othermetatarsal bones. The reason for this is that the short peronealtendon attaches to the upperpart of the bone. When moving,a displacement of the fracture

can occur, causing a risk of de-layed healing. The treatment offifth metatarsal fractures is eitherconservative, with immobilisation,or surgical (screwing the fracturetogether). During our study, wehave followed 20 fractures of the fifth metatarsal bone. The average length of absence fromfull training or match play was 76 days but the absence varied between 63 and 116 days. The absence was the same whetherthe fracture was treated with orwithout surgery but the recur-rence risk was lower after surgery.

Currently, we do not know themechanisms behind this type of injury. There are speculations that the injury could be related to shoe wear or surfaces or

connected with tissue fatigue in footballers playing manymatches.

2006/07 season

For the 2006/07 season, UEFAhas invited 21 clubs to partici-pate in the study: the 17 clubsfrom last season as well as FC Bayern Munich (Germany),Olympique Lyonnais (France),RSC Anderlecht (Belgium) andCeltic FC (Scotland). The specificstudies into thigh muscle strains,groin injuries and cruciate ligament injuries will continueand, since the injury had causedconcern at many top clubs, a special study of fractures ofthe fifth metatarsal bone will be initiated.

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Ankle injuries are very common.

Fig. 4 • Fracture of the fifth metatarsal bone treated with surgery.

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AUTOLOGOUSCHONDROCYTEIMPLANTATIONSadly, there is no shortage of football players who are forced to hang up their boots due to some kind of cartilage damage in their joints – especially in their knees, where bones have a large contact area and strongforces applied to them. The knee articular cartilage is a few millimetres thick yet distributes the load in the joint, providing a low-friction surface for the gliding and rolling of joint surfaces against one another; in fact, its friction coefficient is calculated to be lower than that of ice on ice.

A torn cartilage, quite frequent infootball, is usually associated withpain and swelling in the short term,making it difficult or impossible for the player to continue an activesporting life. One is tempted to assume that chronic problems arelimited to the amateur game and,possibly, lack of adequate diagnosisand treatment. This is often noth-ing to do with medical skills butrather the player’s reluctance toseek advice. But young players atthe beginning of professional careers also run the risk of a pre-mature end to their career due todamaged joint cartilage that canlead to osteoarthritis, a conditionthat can have a dramatic impacton the quality of the player’s dailylife. It is distressing to see foot-ballers not only obliged to leavethe game but to also face restric-tions in physical activity due topainful and limited joint motion.

Articular cartilage responds differ-ently to injury than other tissues. It has limited regeneration capacitydue to the absence of blood vessels,lymphatics and nerves. Cartilage cellscannot migrate to the site of injury

as cells in other tissues can. Articularcartilage injuries that do not pene-trate the bone and thereby providea flow of blood do not heal. Thereparative scar tissue consists of sub-optimal fibrocartilage, which doesnot have the same biomechanicalproperties as original hyaline car-tilage, usually leading to fast break-down of newly formed tissue.

Many techniques have been indicated for facilitating articularcartilage healing. The conven-tional method of treating a full-thickness chondral lesion was toproduce a suboptimal fibrocarti-lage scar repair by penetratingthe subchondral bone to elicit ableeding response. Fibrocartilageis much less resistant to mechani-cal wear than normal hyaline cartilage, especially in the weight-bearing areas of the knee. Mostof these procedures which providescar tissue for healing, includingdebridement, chondroplasty,abrasion arthroplasty, and micro-fracture, improve pain and func-tion in the short term. However

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Long-term solutions for cartilage injuries

BY PROF. MEHMET BINNET / DR KEREM BASARIR

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these results deteriorate in thelong term.

Different treatment modalitiesproviding articular cartilage withsimilar mechanical properties wereintroduced in time, such as mosaic-plasty. Small defects in the kneecan be repaired with cartilage/bone plugs from other non-weight-bearing areas of the knee.However this modality is not suitable for larger lesions locatedin the weighted portion of thejoint, because the source is limitedand because they may causedonor-site problems.

The challenge facing orthopedicsurgeons today is how to effec-tively treat larger chondral injuriesin young, active football playersand avoid significant morbiditywith repeat operations and life-quality problems. A new tech-nique for treating full-thicknessarticular cartilage defects in theknee was introduced in late 1990s,based on taking healthy cartilagecells, sending them to a laboratoryfor culture, and then returningthem for implantation in the dam-aged area with a view to encour-aging the growth of healthy cartilage. This entails two surgicalprocedures – one to harvest thetiny fragment of normal material,and a second, some weeks later, to perform the implantation. Thedamaged area is surgically cleanedand then a fragment of fibrous

material (periosteum) is takenfrom a superficial bone like thehip to be sewn over the defect,the cells from the laboratory areinjected behind the fibrous re-straint, where they start to growinto a sheet of normal cartilagecells. It is called autologous chondrocyte implantation (ACI). It entails a period of four to six weeks of post-surgical physio-therapy but the majority of patients report good or excellentearly results.

Success of this treatment is meas-ured by the patient’s ability to return to an active, productivesports life without experiencinglimiting symptoms. These resultshave been extended in Europe and replicated in the United States in several centres in intermediate range follow-ups (up to ten years).

Autologous chondrocyte implan-tation has been performed onfootball players in Turkey since2000 and cell culture facilities havebeen constructed in the Biotech-nology Institute of the Faculty of Medicine at Ankara University.This followed years of laboratoryand animal research performed by Prof. Mehmet Binnet, Dr KeremBasarir (orthopedics department)and Prof. M. Elcin (tissue engineer-ing). Although physical prepara-tion and training methods improvewith time and cartilage injuriesshould, hopefully, become less frequent, these injuries do occurand there is a good chance ofachieving long-lasting successfulresponses via autologous chondro-cyte implantation.Chondrocyte implantation.

Cell transplantation.

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In today’s society image appears to be everything. It is thus unsurprising that footballers can spend hours selecting boots and training shoes based upon their appearance, rather than comfort, fit and function.

WE CAREABOUT FEETBY MIKE HEALY, CHARTERED PHYSIOTHERAPIST, MCSP MSC, FA MEDICAL AND EXERCISE SCIENCE DEPARTMENT

The more privileged footballersmay be contracted to wear a cer-tain manufacturer’s footwear, butthat does not mean they can just step into their shoes. Manyplayers may need to have orthotics(foot supports) inserted to correct‘biomechanical imbalances’ and to make them wearable. Despiteinsuring their feet for huge sumsof money, many footballers givethem very little attention unlessthey begin to hurt. Yet a few min-utes care may avoid days, weeks,or even months lost through in-jury. In a full career, a footballercan cover over 300,000 km on thetraining ground and football pitch.Through the appropriate selectionof footwear and high standards of foot hygiene, the player canmaximise his playing time.

The anatomy of the foot

The human foot is comprised of 26 bones, a wealth of ligamentscovering an expanse of joints, four intrinsic ‘layers’ of muscles,and 12 major muscles which originate in the lower leg andwhose tendons descend into thefoot. In order for the footballer to achieve their best, all thesecomponents must work with synchronised precision. The footmust act as an adaptor on a varietyof surfaces, as a shock absorber, as a rigid lever for propulsion, and withstand the effect of a phys-ically demanding and punishingdaily workload. The foot must be respected.

Foot hygiene and skin care

The skin on the sole of the foot is highly specialised and adaptedto perform a number of impor-tant functions. To protect the foot against the stresses of stand-ing, walking, running, twisting,turning, and landing from aheight, the skin is much thickerthan on any other part of thebody. This thicker skin provides resilience against friction and localised trauma, and is relativelyimpermeable to water. The footalso has to receive many incomingsensory signals that help us tomove and balance over a wide

variety of surfaces, hard and soft, wet and dry. It is beneath the superficial outer layer of skin (the epidermis) and within thedeeper layer (the dermis), that the vital blood and nerve supplies,hair follicles and sweat glands are found. In order to perform,the player must take great care of the skin overlying the deeperstructures of his feet.

Within a human foot are some250,000 sweat glands producingabout 50 millilitres of sweat a day.Foot odour occurs when perspira-tion from the feet intermingleswith the bacteria within boots or

Footballers use their arms for balance but it’s their feet that takes most of the strain.

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will be heightened. The wound will need to be managed with theuse of antiseptics and sterile dress-ings and monitored carefully. In all instances, players are advised toconsult a qualified medical practi-tioner. Players should be advisedthat no clinical proof exists as tothe effectiveness of soaking thefeet in ‘skin hardening’ substancessuch as potassium permanganate.

Calluses and corns

Calluses and corns are a result ofexcessive friction and pressure cre-ating areas of hard skin. Ill-fittingfootwear, structural abnormalitieswithin the foot or biomechanicalabnormalities may predispose aplayer to these. Typically, a callus

training shoes. The resulting mix(if not challenged) can lead to skinand nail complaints. The followingmeasures can help to avoid this:

■ nylon socks should be discour-aged; alternatively, cotton socksshould be worn underneath to absorb sweat, reduce frictionand improve the comfort offootwear;

■ clean socks should be used forevery training session or match;

■ non-slip shower ‘sandals’ shouldbe worn in ‘wet areas’;

■ feet should be washed daily withsoap (carefully and quickly, nosoaking) and rinsed thoroughly;

■ skin should be dried gently and thoroughly (particularly theweb spaces between the toes);

■ foot powder may be applied; ■ waiting a few minutes before

putting shoes back on can bebeneficial;

■ try to avoid wearing the samefootwear every day (it can take over 24 hours for shoes to dry out);

■ sharing towels with other players should be discouraged.

Blisters

Blisters may occur at any site offriction between the skin and anexternal source. Typically, ill-fittingshoes, inappropriate footwear orpoorly applied plasters, strappingor bandage are the main offend-ers. Blisters develop when super-ficial layers of skin separate and fill with serous fluid (sometimesblood); these may burst, leave apainful, raw exposed area and create a risk of infection. To help

prevent or reduce blister formationthe following may help:

■ socks should be inspected forrough, worn, damaged areas;

■ footwear of the correct ‘last’,width and length fitting must be worn;

■ check the inner sole is intact; lift it to check that stud fixationsare not sharp;

■ studs should be of even height(level on a flat surface);

■ laces must be tied with the right tension (the foot must notslide around inside the boot and impair stopping, starting and stability);

■ new footwear must be intro-duced progressively (start with 20 minutes) and worn in trainingbefore use in a game;

■ protective tape, skin-care pads or petroleum jelly (smeared overthe sock) may be applied to potential sites of friction prior to training or playing;

■ the most appropriate boot for surfaces or conditions must be worn.

Blister management is governed by whether or not the skin is bro-ken. If unbroken, the area may becleansed with an antiseptic solu-tion. For training and match situa-tions, a zinc oxide tape, a skin-carepad, or the application of a cotton-backed tape, followed by a foampad with a hole cut to the size ofthe blister, may be applied. Fluid-filled blisters may be punctured anddrained with a hypodermic needleand syringe, prior to the applica-tion of a protective dressing. If theskin is broken, the risk of infection

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has a thick, yellowish, oval appear-ance and is found underneath theforefoot and on the tips and topsof the toes, usually causing onlymild discomfort.

Treatment involves identificationand modification of the cause ofthe excessive friction and pressure.Hard skin may be treated by theuse of moisturisers such as lanolin,or medicated discs and plasters,which can be purchased from achemist. Trimming or paring of theskin by a chiropodist may be neces-sary. Should there be a biomechan-ical problem, the player shouldseek assistance from a physio-therapist or a podiatrist, who mayneed to construct an orthosis.

Corns have a very similar appear-ance to calluses. The essential dif-ference is a well-defined, roundedappearance with a central core of hard skin, which often causessignificant discomfort and is moretender when pinched.

Again, it is important to recogniseand address what has led to theproblem. Ointments, solutions,medicated plasters and pads canbe used to help ‘dissolve’ the corn.Alternatively, protective foam, felt or gel pads with a hole cut inthem similar to the size of the corncan be used. In severe instances,surgical removal may be per-formed by a qualified chiropodistor podiatrist.

Verrucae (plantar warts)

Verrucae are warts usually foundon the sole of foot and caused by

papovavirus. They are highly contagious and are contracted by contact with floors in ‘wet areas’ such as showers or swim-ming pools. They have a slightlyraised, brown or white cauli-flower-shaped head that may have small black dots in the centre, can occur singly or ingroups, and may be painful onweight bearing.

Verrucae are self-limiting. Theywill eventually disappear when thebody’s immune system addressesthe problem (usually four or fivemonths). If they are painful, theycan be tackled by medicationsfrom the chemist or be removedby a chiropodist through lasertherapy, cryosurgery (freezing) orelectrosurgery. To avoid contami-nating fellow players, verrucaeshould always be covered.

Athlete’s foot

Athlete’s foot or ‘Hong Kong Foot’(tinea pedis) is a fungal infection of the outer layer of the skin. Theinfection thrives in a warm, dampenvironment such as training shoesor football boots. Harmless, it isusually only a minor irritation tothe skin on the bottom and sidesof the foot and between the toes.Although it can become itchy anduncomfortable and cause large areas of the skin to become white,soggy, blistered, cracked and topeel. If untreated, the infectioncan be transmitted to other play-ers, particularly if they walk bare-foot in ‘wet areas’.

Treatment typically involves theuse of anti-fungal preparationswhich come in spray, powder orcream form. Signs and symptoms

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Young players have to take great care of their feet.

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will often disappear within threedays, however, treatment shouldcontinue for a full 21 days to com-pletely eradicate the infection.Training shoes, boots and socks alsoneed to be treated to ensure thefungus is eradicated and the foot is not re-infected. The wearing ofwell-ventilated footwear when notplaying or training is advisable.

Problem toenails

The most common complaints involving the toenails are the ingrown toenail (onychocryptosis)and ‘runner’s toe’/‘black nail’ (subungual haematoma).

The ingrown toenail occurs as a result of poor nail cutting, abnor-mal nail growth, trauma to the nailor abnormal shoe pressure. Thesharp, ragged edge of the growing

nail, usually the first toe, pierces the adjacent skin causing acutepain, redness, swelling, a possibledischarge between the side of thenail and the skin (infection), andtenderness on gentle palpation. To avoid this, toenails should notbe cut too short, or rounded, butbe cut square, or with very slightrounding following the contour of the toe and left long enough to cover the nail pulp. For infectedcases, antibiotics may be required.In instances of recurring injury andinfection, removal of the nail maybe indicated.

‘Runner’s toe’ is a condition whereshearing of the nail causes bleed-ing under the toenail and usuallyresults in the nail turning black. Itoccurs when a shoe or boot is tootight or where the foot slides for-ward in a shoe and jams the end of

the toenail against the end of theshoe (particularly on artificial sur-faces). Alternatively, a direct blowor crushing of the toe may cause animmediate bruise beneath the nail;this may be painful due to the in-creased pressure in the area, whichmay be relieved by perforating thenail, but this procedure should onlybe performed by a medical practi-tioner. The nail may eventually die,grow out and drop off but shouldbe preserved for as long as possibleto serve as a ‘biological dressing’ toprotect the new nail growing un-derneath.

It is important to note that withany infection of the feet there maybe an associated pain and tender-ness in the inguinal region; this isdue to the lymphatic drainage sys-tem within the limb and the lymphnodes that are situated in this area.

Foot-note

To maximise their participation infootball-related activities, a playermust take care of their feet. In con-junction with appropriate footwearselection and high standards of per-sonal hygiene, minimal disruptionto participation will be achieved if players are encouraged to reportany symptoms or signs at the firstopportunity. It is prudent for everyplayer, particularly youth players, to have a six-monthly foot exami-nation. A proactive, pre-seasonpresentation from a podiatrist orphysiotherapist may have consider-able benefits for the football club’splaying personnel and those whowould ultimately have to manageany foot problems.

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CARING ABOUTFOOTBALL PLAYERSBY ALAN HODSON, MA, HEAD OF THE FOOTBALL ASSOCIATION’SMEDICINE & EXERCISE SCIENCE DEPARTMENT

As Dr Urs Vogel, chairman of UEFA’s Medical Committee, mentions in his editorial, medical care is not just about the high-profile cases at the peak of the footballing pyramid. Alan Hodson, one of his colleagues on the committee, presents a case history based on the structures he has helped to build in English football.

The Level 1 course is a one-even-ing session for a group of 10-12 students with the emphasis fair andsquare on resuscitation and life-saving skills.

The Level 2 course is specifically designed to meet the needs of afirst-aider working in football, nomatter whether they are classed as ‘manager’, ‘coach’, ’trainer’ or‘therapist’ at amateur or youthclubs. Participants gain knowledgeand skills in basic anatomy, trau-matic injuries that require first aid,injury identification and medicalconditions that can affect players.There is a minimum of 14 hours of teacher-pupil contact plus a minimum of seven hours of guidedlearning/home study.

The Level 3 course is designed for thesame sort of target group with addi-tional emphasis on the reaction toand repair of injury, signs and symp-toms of commonly-found injuries, injury prevention, plus basic treat-ment skills and management advicefor the injured player. It involves a minimum of 20 contact hours plusa recommended 30 hours of pre-course and in-course home study.

Level 4 is for students who wish to build on the foundations of oneof the more basic courses. It offersfurther training related to specificupper- and lower-limb injuries,recognition and assessment of in-juries, plus treatment and manage-

As long ago as 1990, The FootballAssociation recognised the need to devise and launch a specific edu-cational training programme at all levels of the game in order to enhance and safeguard the medicalwelfare of all affiliated players,ranging from amateur to profes-sional levels and age groups fromthe youngest to the veterans.

It was easier said than done in afootballing nation of over 43,000affiliated clubs, over 70,000 teamsand some 2,500,000 registeredplayers.

Medical education structures there-fore had to mirror the wide-rang-

ing nature of the footballing ‘workforce’. Educational trainingcourses were therefore divided into three broad categories:

■ Emergency and first aid courses■ Treatment and injury manage-

ment courses■ Exercise science courses

The leitmotiv of the courses is totrain medical and exercise supportstaff ranging from emergency andfirst aiders through to therapistsand exercise scientists to fitnesstrainers fully equipped to operateat the top levels of the professionalgame. Medical education coursesare structured on five levels:

LEVEL COURSE CHARACTERISTICS

1 Emergency Aid Three-hour basic course

2 First Aid for Sport Minimum duration of 14 hours

3 Level 2 Certificate: Minimum duration of 21 hours;Treatment & Management syllabus and assessmentof Injury in Football procedures designed to maximise

student learning

4 Level 3 Certificate: Minimum duration of 36 hours;Treatment & Management syllabus and assessmentof Injury in Football procedures designed to maximise

student learning

5 Diploma: Two-year course with increasedTreatment & Management contact hours in residential modulesof Injury in Football and additional in-course projects

MEDICINE MATTERS/15

EDITORIAL GROUPAndy RoxburghGraham TurnerFrits Ahlstrøm

PRODUCTIONAndré VieliDominique MaurerAtema Communication SA –Gland, SwitzerlandPrinted by Cavin SA – Grandson, Switzerland

ADMINISTRATIONFrank LudolphEvelyn TernesUEFA Language Services

IMPRESSUM

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ment of injured players, includingexercise therapy, foot care, treat-ment modalities, injury manage-ment advice, and fitness trainingprinciples. The parameters here are36 contact hours plus 20-30 hoursof pre-course and in-course study.

Level 5 is an advanced course designed to build even further onprevious courses. The additional elements include fitness training,fitness assessment, physiology of exercise, plus the pathology and assessment of a wide range of foot-ball injuries. The two-year course is divided into two parts, with 120 contact hours in each plus tasksand assignments during residentialmodules and comprehensive dis-tance learning. The resulting FAdiploma is a recognised requisite for those aiming to work in profes-sional football.

When the FA’s Medical EducationCentre became the FA Medical and Exercise Science Department in 1999, three additional courseswere added to the ‘menu’ with a view to equipping amateur andprofessional club personnel withspecific skills in fitness and condi-tioning training:

■ Physiology for football■ Weight resistance training course■ Fitness trainer’s award

The physiology course focuses onrelevant exercise physiology, bodilyresponses to exercise and the demands of football. Specific atten-tion is paid to the application of basic training principles and practi-

cal strategies for preparation andrecovery. The course also focuses onthe conditioning needs of childrenand adolescents, along with the nutritional requirements of all play-ers. The syllabus therefore includestopics such as physiological responsesto warm-up and cool-down ses-sions and physical strategies to as-sist performance and delay fatigue.

The weight resistance course aims toprovide students with an understand-ing of strength-training theory, in-cluding the musculo-skeletal adapta-tions that occur in response to weighttraining. Emphasis is placed on gain-ing knowledge of how to plan, con-duct and evaluate weight-trainingsessions for the development ofmuscular strength and endurance.

The Fitness trainer’s course spans a two-year period and entails about650 hours, 130 of which are dedi-cated to practical work and 120 ayear to distance-learning. Residen-tial modules account for 80 hours ayear. In addition, students under-take on a specific project assign-

ment during their first year. Studentsmust have a sports degree and musthave the Treatment & Management ofInjury diploma. The syllabus includeselements such as motor control, kine-siology and biomechanics, growthand development, the demands ofthe game, application of power/plyo-metrics to football, and injury pre-vention, along with specific compo-nents dedicated to women’s football,legal and safety issues, and psycho-logical aspects such as motivation andtarget-setting. In 2005, over 41,000people attended the FA’s medical and exercise science courses. This evi-dently requires a substantial infra-structure, so The FA recruits and trainstutors and assessors – over 1,000 ofthem. To support the courses, The FAstages three annual medical confer-ences at different levels, for ortho-paedic surgeons, haematologists,sport medicine doctors, club doctors,chartered physiotherapists and thera-pists/first-aiders working in amateurand professional football. Two otherannual conferences are organised for exercise scientists, fitness trainersand coaches attached to professionaland amateur clubs. Each year, theconferences are attended by over1,000 people.

The initial ‘mission aim’ of this edu-cational structure was “to devise andimplement a comprehensive medicaland exercise science educational programme aimed at protecting and enhancing the medical welfare ofplayers of all ages and ability, forable-bodied and disabled players ofboth sexes”. The success of The FAcourses demonstrates that the mis-sion is being effectively completed.

First aid is the subject of the Level 2 course.

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