By Terence J Babwah, Team Doctor, Trinidad & Tobago Football Team

In response to “The use of medications and nutritional supplements during FIFA World Cups 2002 and 2006″ it must be stated that elite footballers suffer from playing too many games during a season. In elite Europeans leagues, it is not uncommon for some footballers to be eligible to play 70-75 games in a season which includes league and knockout games together with Confederation Competitions and
International matches. Even in some smaller leagues like in the Caribbean, some players may partake in 50 odd games during one season and even at the youth level some players play 3 full games per week. The end result is that players get tired and eventually get injured. Footballers suffer medical problems similar to the general population and most injuries are mild and soft tissue in
nature.(1)

As a Team Physician, there are some injuries that players have which would not prevent them from training or playing especially low grade tendinopathies and entheses. These injuries are not usually
recorded in epidemiological studies as the players do not usually miss training or playing as defined in some studies and so are under-represented in such studies.(2)Players soon learn that they can
get relief with painkillers and be allowed to play with minimal discomfort. They take painkillers and play and this cycle continues until the injuries worsen and they now have to get more formal treatment. An injury may result in the first full break that a player has for years. There is rarely any time for full rehabilitation and having a reduction of pain to an acceptable level to play is usually the
prerequisite to return to play.

Team Physicians are under tremendous pressure to return players to play that there has been a shift to alternative techniques like mesotherapy, biopuncture, injections of haemolysed calf blood and widespread use of steroidal (anti-flammatory) injections all in an attempt to hasten recovery of players.

Players get tired and may take supplements in an attempt to improve performance, reduce fatigue and may feel that they have to take supplements in an attempt to keep up with the competition. Coaches were rightly identified as being influential in footballers taking supplements. Most players do not take supplements on the recommendation of the doctor.

If there is to be a reduction of pain medications and supplements taken by players then there must be a reduction in the number of games that a player plays per season. This may mean a reduction of
competitions within an individual league.It may mean expanding squads to play players in a rotation scheme. This needs urgent looking into. Secondly evidence based injury prevention programs need to be implemented at all levels of football to reduce injuries.

References:
1.Babwah TJR,Rogers R. The team physician in football:What skills are important? International SportMed Journal 2008;9(3):108-115 (available at http://www.ismj.com)

2.Ekstrand J, Walden M, Hagglund M. Risk for injury when playing in a national football team. Scand J Med Sci Sports 2004;14:34-38

Sometimes readers are looking to combine science with exotic travel, the 2009 Arctic Conference next June, will be hard to beat. Up close and personal with Paul Hodges and LJ Lee not to mention penguins, polar bears and giant Aleutian seals.

It will be a great trip and a great blend of the latest science and clinical application for lumbopelvic-pain and postpartum health. The conference program is listed on the website and it is for both physicians and physiotherapists.

BJSM eLetter from Henare R Broughton of Auckland Rugby referees’ Association.

The study presented by Hamish Kerr et al., Collegiate rugby union injury patterns in New England: A prospective cohort study, deserves comment. In a general sense the injury pattern may be attributed to the confrontational type of game that the players had been taught. The tackle features as the event with more injuries occurring as illustrated in the study. In this type of game the fact that T-boning occurs, that is, where the ball carrier runs directly towards an oncoming defender(s) the tackler(s) creates an opportunity for a front-on tackle where head/neck and shoulder injuries are a commonality for the tackler and lower limb injuries for the ball carrier.

Reference is made to ‘ball in play’ time of 42 percent in 2003 Rugby World Cup but at the Under 21 Rugby World Cup in 2006 this was 40 percent with an average of 134 rucks/game. These figures may suggest that most of the time more infringements were occurring and that there were more interaction instances between the ball carrier and the defenders. The authors however, suggest that U.S collegiate games may have lower ‘ball in play’ time and fewer rucks (Law 16) and tackles (Law 15) per game. Does less ‘ball in play’ time mean that there were more stoppages? More infringements occurring?

Nevertheless, the authors’ observations where there were fewer rucks in a game suggests that there may have been fewer tackles and a more open type of game was being played. Less tackle injuries could be expected if that were the case. The results from the data could have benefited from categorizing the injury data as relating to the defense injury pattern and the offensive injury pattern. Such an account would enhance the interpretations to be made of the data. This study provides an opportunity for relating injuries to how the game is played.A comparison with an open type of game may be worth an analysis.

Reference: The International Rugby Board. (2007). Laws of the game. Dublin: The International Rugby Board.

The full article can be found here.

Another excellent patient information to download!

Patient Information Sheet 17 - Lateral hip pain

More patient information sheets can be found here.

The WarmUp which summarizes some key issues in 800 words is available free at the site and you can click on it here or view it as a PDF.

The ‘editor’s choice’ which is available for free is the meta-analysis of walking. This simple daily task has many benefits and the dose-response relationship is explored by Hamer and Chida. There appears to be about a 30% reduction in both cardiovascular risk and all-cause mortality with a casual walking dose of about 3 hours per week. Walking pace was a stronger independent predictor of overall risk compared with walking volume (48% versus 26% risk reductions, respectively). Next month there are several other papers highlighting the benefits of walking (see Online First) so this simple physical activity may be more powerful than is often appreciated. A case of ‘a kilometer a day keeps the doctor away’?

I connected with ACSM president Bob Sallis today - he is heading up the ‘Exercise Is Medicine’ initiative through ACSM.

Bob, a family doctor in California, shared his frustration with mainstream medicine overlooking physical activity as the most powerful therapy available to physicians. The Exercise is Medicine initiative aims to have every family doctor assessing current level of physical activity by a simple questionnaire at every consultation. This question would be asked by the office assistant so that the doctor, of course 100% reliable, would not need to take up time to do that.

Patients who are doing less than 150 minutes of physical activity per week could then be readily flagged for interventions. And that is a whole new ball of wax as they say! But there is hope - more and more interventions are proving successful so combining the best of research from psychology, exercise physiology, engineering and electronics should allow us to make a difference. As Bob says, ‘we can convince patients to have their stomach stapled and take medications that sometimes make them feel awful, so promoting physical activity shouldn’t be that difficult!’.

The Exercise is Medicine initiative aims to have every family doctor assessing current level of physical activity by a simple questionnaire at every consultation. This question would be asked by the office assistant so that the doctor, of course 100% reliable, would not need to take up time to do that.

Do you have a successful way of promoting physical activity in the office? And please remember the BJSM special issue for 2009 - Integrating Physical Activity into Clinical Practice.

The April issue of BJSM has 4 papers related to physical activity and health:
check them out online first!

An active school model to promote physical activity in elementary schools: Action Schools! BC
Patti-Jean Naylor, Heather M Macdonald, Darren E. R. Warburton, Katherine E Reed, and Heather A McKay

Walking or vitamin B for cognition in older adults with mild cognitive impairment? A randomized controlled trial
Jannique G.Z. van Uffelen, Marijke J.M. Chinapaw, Willem van Mechelen, and Marijke Hopman-Rock

Effect of commercial airline travel on oxygen saturation in athletes
Celeste Geertsema, Anthony B Williams, Peter Dzendrowskyj, and Chris Hanna

Best The Practice of Primary Care Sports Medicine in the United States
Jason J Diehl, Jason J Pirozzolo, and Thomas M

Submitted by editorial board member Dr Gavin Davis

As clinicians, we often wish we had expert guidance at hand. There are some list-serves that provide this function and we hope that this blog might do the same thing. Feel free to submit difficult cases, and invite submissions from the readership to assist with patient management.

As a starter example, consider the case of a patient presenting to a sports medicine office with a past history of craniotomy for tumour, and insertion ventriculo-peritoneal shunt. She wants medical clearance to be able to play women’s rugby.

What are your thoughts on this case?