Organisation of a Professional Team’s Medical Staff and the Physician’s Role

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Physician’s Role

PIEROVOLPI

Introduction

As in many other top-level sports, in recent years, professional football has been building up a relationship between sport and medicine which has grown considerably in terms of organisation, regulations, and general care. During the 1980s and 1990s, Italian professional clubs began, both on their own account and to meet their legal obligations, to secure the occasional and even- tually continuous presence of a physician specialised in sports medicine to handle the medical side of their activities. Previously, it had in many cases been the club’s masseur who set out to advance from simply treating player’s muscles to caring for their health in general. Today’s staffs have gradually grown to include a psychologist, a physiotherapist, a chiropractor, and other practitioners, together with a clutch of consultants that can themselves be said to constitute a team in the wings rather than on the pitch.

A club’s chief physician is faced with many exacting tasks: organisation and supervision of the whole of its medical sector, assessment of the psychological and physical fitness of its players when they join the club and throughout the season, introduction of measures whereby illnesses and lesions can be prevented, and diagnosis and treatment of injured players, including their first-aid management. Furthermore, in conjunction with the trainer and the coach, the physician must monitor each player’s performance and elaborate the training programmes, supply diet charts and give advice on eating habits, oversee the use of drugs and integrators not prescribed and authorised by the physician, undertake health investigations required by sports regulations, and be present during anti-doping tests.

Organisation

The way in which a club’s medical sector is organised will be determined by its budget and the approach adopted by its directors. The model we have elab-

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orated and applied for a club with a high Italian and European standing (Fig.

1) provides for the establishment of a scientific reference and supervising committee for the sector as a whole.

This is comprised of a president and four members, all renowned aca- demics skilled in sports medicine: an internist, a haematologist, a cardiolo- gist, an expert in legal medicine, and a traumatologist. The physician in charge (1) is an expert in orthopaedics, traumatology, and sports medicine;

(2) runs the sector; (3) oversees its operations; (4) intervenes whenever sum- moned to deal with particularly serious and/or urgent questions. He and another sports medicine specialist are the official doctors of the club’s first team and take care of the health of a roster of 24–28 players per year.

A medical secretary handles the bookings and due dates for the special- ists’ examinations and liaises with the auxiliary medical facilities and consultants. A psychologist assists the staff for specific purposes. Two masseurs, three physiotherapists, and a chiropractor work every day under direct medical supervision. One of the two coaches on the staff is responsible for the recovery of players injured in the gymnasium and on the pitch. The training

MEDICAL SECTOR

SCIENTIFIC BOARD

• MASSEURS

• PHYSIOTHERAPISTS

• CHIROPRACTOR

• COACH (RECOVERY OF INJURED PLAYERS)

PHYSICIAN

MEDICAL SECRETARY

PSYCHOLOGIST

• AUXILIARY HEALTH FACILITIES

• CONSULTANTS

Fig. 1.Organisation of the medical sector

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grounds comprise playing fields, changing rooms, accommodation for players and staff, restaurant, bar, assembly rooms, and more, together with a practi- tioner’s surgery, a physical therapy room, and a gymnasium with the usual equipment.

The auxiliary facilities and consultants constitute a carefully chosen exter- nal service to which the club’s medical staff and its players can turn to at any time. The facilities comprise:

- A sports medicine institute concerned with the legally obligatory yearly match-fitness examinations;

- An orthopaedics institute that provides first-aid services, traumatological evaluation and care, a radiology and instrumental diagnostics service, and carries out laboratory examinations;

- A pluri-specialist hospital for internal medicine and neurosurgical con- sultations;

- A legal medicine institute handling insurance and doping issues;

- A rehabilitation and applied biomechanics centre for the evaluation of newly acquired players and the elaboration of re-education programmes;

- A dentist for evaluation and care as required. The second-tier consultants include a dietologist, an ear nose and throat (ENT) specialist, an oculist, a dermatologist and the like.

The Italian sports regulations require a first-team physician to be responsible for the health, organisation, and care of junior teams.

Evaluation

Compulsory Evaluation

As already mentioned, Italian law requires all professional footballers to under- go a yearly match-fitness examination at an authorised sports medicine centre, with updates at least every 6 months (Law No. 91 of 23 March 1981; Ministerial Order 13 March 1995). Compliance with this obligation is seen to by the team doctor’s duty. The examination consists of a general medical assessment, a car- diological evaluation including a resting and maximum-effort electrocardio- gram (ECG), an echocardiogram (every 2 years), a chest x-ray (first visit), a spirogram, vision and hearing evaluation, and blood and urine tests (every 6 months). Other specialist examinations are conducted if a clinical suspicion is aroused. All the documentation is collected by the physician in charge and stored in the club’s files. It is also summarised on the player’s health record, which shows that the examinations have been carried out and that the player is fit. It accompanies the player throughout his or her career.

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Recommended Evaluations

Further evaluations are undertaken to provide a fuller picture of a player’s physical condition and traumatological history. These include (especially when a player first joins a club):

- Orthopaedic assessment and traumatological examination;

- Instrumental examinations consisting of radiography, magnetic reso- nance imaging (MRI), ultrasound (US), and other instrumental examinations of areas considered at risk or indicated by the individual player;

- Postural and dental analysis is recommended for an overall evaluation;

- Biomechanical assessment of the lower limbs (isokinetic, explosive force, and coordination tests);

- Field tests arranged with the coach.

One of the hardest tasks for a team doctor is to assure the club’s directors and technical staff that a new player’s bones, muscles, tendons, and joints are in perfect shape. An orthopaedic examination cannot always determine total fitness, especially now that accidents are becoming more frequent, particularly among professional footballers. Take, for example, a player with a recon- structed anterior cruciate ligament. Functional efficiency will certainly have been restored, but the anatomy of the knee is no longer the same. Our work with an elite Italian club showed that the incidence of spondylolisthesis with spondylolysis in 80 new players from various parts of the world over the course of 5 years was about twice as high as in the normal population.

Furthermore, an echographic study of the patellar tendons of 12 of the club’s new players at the start of the 1999–2000 season showed that 5/24 tendons displayed evident but asymptomatic abnormalities. As it turned out, none of these players reported patellar tendon pain during the season. It is very diffi- cult, even for an expert traumatologist, to rule out the progression of such abnormalities on first inspection.

Prevention

Injury prevention is a sports doctor’s principal objective. A distinction can be drawn between general and specific prevention. General prevention involves keeping an eye on a player’s overall health through periodic, routine examinations; establishing work loads and training plans in conjunction with the trainer and the coach; elaborating individual prevention plans for players at risk for muscle, tendon, joint, and other types of injury; advising the use of protective devices such as taping, shin pads, and plantar arch supports; mon- itoring lifestyles (sleep, use of tobacco and alcohol, eating habits) and elabo-

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rating diet and supplemental regimens; checking hygiene and accident-prevention measures in changing rooms, gymnasia, with equipment, and the playing fields; and planning vaccinations (especially anti-influenza, anti- tetanus, anti-typhoid, and anti-hepatitis A and B) since athletes are exposed to a high risk of infection.

Specific prevention requires the prompt perception of any departure from a player’s optimum state of health so that appropriate treatment can be start- ed. In this respect, the doctor can be viewed as an integral part of the team and hence his or her assiduous presence is necessary during training ses- sions, matches, pre-match retreats, and pre-seasonal gatherings.

Care

If a player has an accident or becomes ill, the team doctor must take care of that player and set about the process of diagnosis and treatment, if necessary with the assistance of the auxiliary facilities and the consultants. The physician must also follow the course of the injury or disease and make sure that effective therapeutic measures are being applied. This is achieved through:

- Medical and instrumental diagnosis;

- Immediate and subsequent care;

- Non-operative, surgical, rehabilitative management;

- Active repose;

- Recovery;

- Resumption of sport.

In the case of bone and muscle injuries, the clinical cure achieved by surgery or rehabilitation procedures is not enough to ensure certain resumption of sport, and a functional cure must be sought. In other words, the healing processes must be adapted to the specific stresses each sport requires. A clinical cure and medical approval of resumption are thus the prelude to three periods: differentiated field work, field work with the rest of the team, return to competition.

Three aims are pursued in differentiated field work: complete athletic recovery and an increase in stamina, muscle power, coordination, and other capacities; adaptation to specific exercises with the ball; and psychological recovery. The amount of time required will obviously depend on both the subject and the type of injury. Field work with the rest of the team sets the seal on full recovery of function. Guided by the trainer, the player will take part in the team’s tactical exercises and become ready to play in minor matches and friendlies. Return to the field for a footballer corresponds to fully effi-

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cient participation in an official match. It is the moment when the player feels truly recovered and is once again on the football scene. The team doctor is also required to handle the medical and insurance paperwork until the player is completely cured.

Doping

In addition to being an ethical issue and a question of loyalty among sports persons, the fight against doping must be pursued to safeguard the health of footballers, as in any other sports sector. Soccer has unfortunately been involved in doping episodes in recent years despite the fact that it has always been regarded as a sport in which a player’s technical skills, dexterity, and a flair for tactics counted for more than physical constitution.

Now, however, winning is the be-all and end-all of every match and event, whether junior, amateur, or professional. In professional football, too, a calen- dar crowded with matches with a high economic value; the brief recovery times between one match and the next; and the excessive physical develop- ment required, as in all modern sports, are obvious risk factors. The constant drive for an ever better performance must be rationalised and perhaps chan- nelled into better planning of match calendars, the elaboration of new training methods, and the devising and application of innovative solutions in nutrition – not in the provision of pharmacological support.

The Italian Footballers Association (AIC) has long been engaged in pro- tecting the rights of footballers. It has discussed programmes, regulations, and questions of organisation in all the institutional forums but has concen- trated its efforts on instructing and informing players. It has striven for clear, correct, and direct information and advised greater vigilance and conscious- ness-raising with regards to doping by promoting educational programmes through dedicated meetings, articles, teaching material, assessment question- naires, and the like. After a congruous training period, the AIC has been pleased to find a greater awareness and understanding of health and doping among footballers. After much discussion of the scientific, legislative, and organisational sides of the question, blood and urine tests after Premier League and first-division matches came into force in Italy in 2003. The AIC approved this project, and its members readily and knowledgeably gave their consent. The constant increasing awareness of these topics on the part of players is probably the best foundation for future strategies.

We realise that future projects will seek closer co-ordination of anti-doping measures, at least in Europe, among the nations that take part in Continental soccer events. In addition to the European Cup series, therefore, there will be a better equilibrium in the number and means of testing in

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national matches. The other priority is agreement with the dictates of the World Anti-Doping Agency (WADA) through the national institutions – the Italian National Olympic Committee (CONI) and the Italian Football Federation (FIGC) – namely, that preference should be given to unannounced (surprise) testing in a non-competitive setting as opposed to the numerous expected checks carried out after matches.