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No more poker face, it is time to finally lay our cards on the table

6 Mar, 17 | by BJSM

By Andy Rolls1, with contribution from Alan McCall

1 Arsenal Football Club, Research & Development Department, London, UK

LEARNING TO SHARE, SHARING TO LEARN

‘Learning to share, sharing to learn’ is a title I have borrowed from an article published in the teaching literature.[1] It is based on the premise that unless individuals disseminate or share what they have learned, insights gained from action and reflection are not fully realised at the higher level.[2]In it’s strongest form, dissemination is more than a one-way relay of information, it is an extension of the reflective process, moving reflection from the individual to the group level.[1] I propose that this concept is also true in elite sports where, in order for us as medical practitioners to continue to learn and optimise our practice, we need to start sharing our experiences, our mistakes and how we learned from these.

IS FEAR STOPPING US FROM SHARING?

Speaking from experience, I wonder why elite sport and in particular professional football is so secretive and adverse to sharing? And I fear this is stopping us from growing to the best we can. As outlined by Abraham Maslow,[3] regarding growth, every Human being has 2 sets of forces within – one set clings to safety and defensiveness out of fear, the other force impels him forward toward to the full functioning of all of his capacities. Perhaps it is a fear of being wrong, or a fear of being ridiculed that has been stopping us from sharing. Certainly, in the football industry, it has a reputation for being insular, secretive and protective, this may also be true for medical teams within the industry. It is my opinion that in any sporting environment, especially one that talks about the importance of gaining small margins and getting those extra inches and all such clichés, that we have actually become too insular in our quest to ‘show’ that we are better than others or at least market ourselves as being better/the best even if what we are doing is nothing special! Reputation is important, and of course everyone wants a good reputation for being world leading and good at what they do, however, often perception does not equal reality.[4] Perhaps, it is the fear of affecting our reputations that is stopping us from opening up and sharing with others and the safe option is remain behind our Wizard of Oz curtain. Such an insular and essentially selfish approach, may actually be halting us from making big strides in the care and management of our players.

RESEARCH CAN GUIDE US BUT IT IS ONLY PART OF THE PUZZLE

The role of sports medicine research is to help guide practitioners to implement evidence based strategies[5] and while we can and should learn from research to enhance our practice, this is only one piece of the puzzle. The reality is that in elite football, re-injuries are still an issue for teams and something we as individual medical teams are battling day in day out. Despite the exponential increase in published research, and the wide acceptance that previous injury is a major issue for not only a re-injury but also an unrelated injury,[6] we are still a long way off understanding what has actually changed due to previous injury that increases susceptibility for another. Indeed we are even a long way off knowing much about the entire return to play process.

In my experience the majority of us all want and appreciate advances in research that will and already do help us move our medical practice forward. However, research is not always cutting edge: it has been estimated that it can take up to 1 to 2 decades for original medical research to be translated into routine medical practice.[7] And creating confusion in the practitioners mind is that the results of these research can often be conflicting and riddled with biases. This is why we must use our practice-based experience and review current practice and intuition in combination with the best available research evidence to optimise what we actually do. A no secrets, no holds barred, open and honest approach of dialogue with our peers working at the coal face implementing both research and practice based evidence can only help us to advance. The key here is that this dialogue poses no risk of ridicule or humiliation. While this can help guide our immediate clinical practice, giving such a big voice to those operating at the coal face, we can guide researchers to do meaningful research that will actually be useful to us in practice.

Perhaps, as Prof Jan Ekstrand[8] has recommended it is time to start ‘thinking bigger and working together’. We need to begin sharing in order to learn, BUT first we need to learn to share.

To kick off (pun intended), this process I am going to lead the way and lay my cards on the table; In this blog you will find my global approach to a hamstring injury rehabilitation, no poker face, no small print, everything laid bare and I invite the world to analyse, critique, criticise and add their thoughts so that we can start learning from each other and finally make a meaningful impact based on our combined knowledge and experiences in the field.

EXAMPLE: AN ELITE FOOTBALLER WITH AN ACUTE HAMSTRING INJURY

To give us a starting point and context; A Player running at approximately ¾ pace in a competitive game pulls up suddenly holding the back of their leg, as the physiotherapist approaches the player says ‘he felt his hammy go’ he has to be helped from the field of play

As most of you reading this will relate to, the first question we get is “how long will I/he/she be”?

I have worked in professional football for a long time now and if I had £1 for every time I have heard that question above, I would have retired yesterday. Yet I fully understand that if certain individuals ask for a prognosis, we have to give them something. However I will stress as often as possible to as many people as possible that ‘you/he/she will be ready when specific pre-defined objective markers have been hit and the player can safely progress through the rehabilitation program’ in fact I used to say this so much that staff would finish the sentence for me.

I wholeheartedly believe that objective markers whatever they may be are essential for the successful rehabilitation of all injuries because without them how do we know when the player/athlete can run, when they can sprint, when they can decelerate, when they are strong enough, when they can kick etc. However what to use, when and for which injuries are the million dollar questions, because our knowledge of what we think is the best approach lags behind what may actually be the best, and we don’t know yet which markers are optimal or even appropriate for specific injuries and certain players but unless we try how will we get better? I do not currently know if such an approach to an objective marker led rehabilitation pathway leads to less reoccurrences. I would postulate currently not, but, I do feel that I return players back better using objective markers than when I never used this approach. Another advantage in my opinion is that if a setback occurs it is easier to look back and work out why. While I focus heavily on objective markers for the reasons highlighted above, I must mention that this goes hand in hand with subjective measures provided by the player. Involving the player in the process is critical to understanding better what these objective markers are actually telling us i.e. is a player coping or not, these are often critical in telling me can I progress or not, so when going from a double leg exercise to a single leg exercise I will use a RPE to compare the sides, also RPE will be used not for ever session (This piece is all about be honest!!) but I will use them if I am changing a rehabilitation emphasis or making a larger than normal step forward. When these are used especially to gauge outside work I think they are a big help in assessing is this player ready whether it be psychologically or physically.

So here goes, cards on the table. By following this link: https://andyrolls.footballmed.net/, you will be directed to a step by step rehabilitation program for a hamstring strain injury incurred by a professional football player (as in the example above). Please review step by step and I welcome and look forward to your feedback!

****************************

Corresponding author:

Andy Rolls, Arsenal Football Club,

Email: arolls@arsenal.co.uk

 

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