Although it only forms a small percentage of our working week, the thing most people associate with physio’s working in sport is the match day, and the infamous bucket and sponge! When we watch the TV at the weekends, this is the closest we ever get to seeing a physiotherapist working in professional sport. We don’t see all the early morning meetings, assessments, rehab programs, maintenance treatments etc.
I have to admit, rightly or wrongly, it is the least enjoyable bit of my job. I can’t remember the last time I enjoyed watching a game of sport whilst I was working. Wincing at every tackle, losing track of the score back in my rugby days because I’m too busy counting the players get up from a ruck and constantly running through scenarios and management in my head. However, it is the money end of the job. The games are all about why we do what we do.
I feel bad for physiotherapists trying to break into sport, I’ve been there and done it, working evenings and weekends covering training matches and weekend games and essentially not doing very many of the skills I’ve been taught at University or on the courses I’ve dished out money for. Essentially, you are a first aider. I try and make our part time work at the club as attractive as possible in other ways, with CPD, shadowing, training clinics etc because I know its not the glamour and jazz that people think when working for a pro club.
Like it or lump it, its a huge part of the job. So, what do we do when we run on mid game? Like all aspects of our job, there should be an element of clinical reasoning behind what we do. What are we actually asking? And why do we ask it?
For the sake of keeping the blog concise and not too heavy reading, I’m going to talk about your more routine injuries, which can sometimes create harder decisions. For the management of cardiac, spinal, airway stuff make sure you go onto a proper trauma course to get your qualifications!
Stop ball watching
The first habit I had to break when I got into sport was to leave the armchair fan mindset at home. I started off in rugby before moving to football and was lucky to have a brilliant mentor from the start, Clare Deary, who quickly taught me to look away from the ball. Instead your watching the knees and ankles of the forwards in a line out, or checking the prop gets up after the scrum has collapsed. One of the Maddox questions we ask when we check for head injury is “what is the score?” or “who scored last” – in my early days I was asking this without knowing the answer, so if they spoke coherently that was good enough for me.
It is a little bit easier in football because there are typically only two people involved in the tackle, but still don’t get caught up in the game. It important to watch the movement of players, those with known previous injuries or knocks sustained earlier in the game. Are they worsening or improving?
The run on
Ever consciously changed your walk or run because you think people are watching you and all of a sudden you lose all motor patterns and co-ordination? Well when the game stops for an injury, everyone is watching you. If the player is rolling around on the floor screaming in pain, you already know they are conscious and their airways are well maintained, so don’t worry about your 100m sprint time for these cases. Save that for the motionless players.
Approaching the player
The location of the injury will obviously affect your approach, head or spinal injuries aside, I always approach the feet first so the player can see me and I can continuously assess their level of pain, respiratory rate, shock etc. As well as asking “where does it hurt” always make sure you double check other structures, don’t be lured by the pain. Someone landing on their shoulder could always have a neck or head injury.
“You are not trying to diagnose the problem there and then”
When questioning the player, remember its not a consultation in the clinic. You are trying to determine “is it safe for the player to continue” and “will a labouring player cost the team tactically”. If they are missing tackles that they would usually make, or misplacing passes that they normally wouldn’t you firstly run the risk of putting them into scenarios that could cause another injury as well as potentially costing the team.
Try to determine the irritability of the pain early on. Has it changed since the game stopped to the point of you arriving at the player? If its worsened, despite not moving, that would suggest a rapid inflammatory problem. In which case you really want to be removing the player from the field of play to reduce the risk of secondary injury. If the pain has settled or gone in the time its taken you to consciously jog perfectly across the pitch without falling over, you can probably proceed with some more vigorous testing.
Providing you’ve excluded any fractures, check what the athlete can do with the injured structures ACTIVELY before you do any passive movements. If they are reluctant or guarded with any movements thats enough of an indication for me not to do any passive movements. Why force them through a range that they consciously don’t want to go through?
Walking the green mile
So you’ve establish that they are alive, there are no fractures, they can actively and passively cope with movement, by this point the referee is probably in your ear to make a call quickly. In football, if you have entered the field of play, the player is expected to leave before kindly being invited back on by the ref. This is a good time to continue your assessment as you the leave pitch.
Can the player get themselves up from the floor unaided? Can they weight bear? Can they walk? Does walking ease the pain or make it worse? If they can walk off, assess their ability to jump / hop / run / jog on the sideline.
By this point, you have to go with your gut instinct. If any of the assessment so far has thrown you into doubt, you probably have a good reason to remove that player from the pitch. Consider the structures involved, the presence of any swelling, the compensatory movement patterns that you may have noticed leaving the pitch. I usually ask myself what I would prefer to manage out of two scenarios:
1) Substituting a player that reports to clinic the next day with no signs or symptoms of injury, but is a little p*ssed off because you wouldn’t let them play (or a peeved coach because you’ve taken their best player off the pitch).
2) Allowing a player to go back on that has given you doubts and they break down in their next sprint / action on the pitch. They walk into clinic the next day and you have to tell them they are out for 6-8 weeks.. Your coach is definitely going to be more peeved today than they would have been pitch side, I can assure you.
This isn’t to say you remove every player from the pitch that has an injury. The mechanism of injury will have a big say in determining your thought process. For example you may be more lenient with an impact injury that is smarting a bit compared to a non-contact mechanism of injury.
So, chances are this has made things a lot less clear about pitch side assessment.. Unfortunately there is no algorithm to determine whether a player should continue or come off. Every individual player is different and every injury is just as individual.
- Is it safe for the player to continue – consider secondary injuries caused by swelling / decreased proprioception, as well as the initial insult worsening.
- Will a hampered player on the pitch cost the team tactically.
- Whats the worst that could happen if you remove them from the pitch. This can be made easier if you are working with younger ages that perhaps have a rolling sub system, giving you more time to assess. Also, consider the implication of the game / event. A once in a lifetime shot an olympic medal may be worth the risk of a secondary injury. A community level tournament in kids rugby might make you a bit more conservative.
- This is only discussing minor knocks and strains. If you are working pitch side and haven’t done or updated your trauma course, make sure you do! Don’t put others health at risk at the same time as your professional credentials. (lubas medical / AREA or RFU are good courses to check out)
I’d be really keen to hear peoples thoughts and experiences with this topic, I’m sure there will be some disagreement with my thinking and methods. Or perhaps people have seen some incidents of players returning to the field when they shouldn’t (I’m thinking the FIFA world cup 2014 with numerous head injuries, but concussion is a separate blog altogether I think).
As always, Yours in Sport
18 thoughts on “Pitch-side management in sport: a POV from a bucket & sponge man”
Great blog, i’m just about to venture into my first job working within football and this has been a good insight into the thought processes and the decision making involved within pitchside first aid. Will be keeping an eye out for any future blogs.
Reblogged this on Sports Therapy .
Great blog as always Sam.
I was interested to know you don’t passively move limbs if the players cannot actively move it. I understand your reasoning and will take it on board. I would value your opinion on my management of a player pitch side who presented with lateral thigh pain following a knock during a game. This young player had a mild impact injury to the lateral thigh presenting like a ‘dead leg’ and clearly in pain. The player in this case was very reluctant to actively move due to pain. I cleared significant trauma and passively moved the limb. The player felt better with the movement and was able to continue in the game. On reflection I may have reduced the threat value of pain and movement by showing the player he could move the limb. Or maybe the initial nociceptive input wore off naturally I am unsure. Would you consider the use of passive movement inappropriate in all cases of a player unable to actively move their leg?
Once again, great blogs.
I just think that if there is a disruption to soft tissue, in this case a potential contusion (which is still a tear, despite mechanism) then passive movement may in fact cause greater disruption to those fibres. Especially given how acute we get to assess them.
I guess part of your reasoning would be around fear avoidance or true nocioceptive restrictions. Depends on how well you know the player, how well they know their own body and whether they have experience similar injuries.
Cheers for your comments Olly. Great discussion point.
I found this to be an extremely useful blog! Having just qualified as a sports therapist and working alongside a rugby team at national 2 level I have always found it a little daunting when telling a player they are off due to an injury. In some cases I have been overruled by management (possibly due to being a ‘newbie’) but reading this blog has actually given me a little boost of confidence! And I’m very glad that I have finally found something to read that is easily understandable and very relatable! So thank you very much for taking the time to write this – I will be sharing the link 🙂
Very kind Grace, glad you found it useful! Very easy to get wrapped up in the game and forget the bigger picture, but keep it simple and stick with your instincts. I don’t talk tactics with coaches so appreciate it when they don’t talk injury management to me 🙂
Apologies – seemed to have repeated the message below! But thank you for the advice and I shall be a little more confident when addressing the management!
Finally someone who has written a clear and understanding blog! Being a newly qualified sports therapist I have often found it difficult to decide what to do with players when injured during a game (currently working alongside a national 2 level rugby team). Sometimes I am overruled by the management side – which I’ve put down to being a ‘newbie’ – but this blog has given me more confidence to deal with these situations (and I actually follow many of your guidelines and tips). I will definately be using this again and forwarding it on to others. Thank you!
Really well written, concise blog Sam. I’m so happy you mentioned not performing passive movements if they struggle performing an active movement. I recent witnessed a physio perform an Anterior Drawer on somebody who had gone down holding their knee c/o a ‘popping sensation’!!! If his ACL wasn’t torn, then the risk of an iatrogenic injury causing an actual tear in that scenario is huge and it drives me insane seeing pitch side assessment involving ligament stress tests! I try and get as much subjective as possible and then active testing only before RTP at pitch side!
Look forward to your future blogs!
Absolutely Tony!! What are you going to learn at that acute stage? What is the reasoning behind doing them? If their knee hurts and they don’t have active range, they can’t play. So what about anterior draw?! Are you going to operate there and then? No. And if ACL is gone, partial or complete, then you wait for pain and swelling to reduce before any further intervention. Ligament stress tests on the pitch baffle me. Great point, well raised.
Excellent blog, I am currently working as a pitch side first aider in football for a non league team and I found this very reassuring that there is no algorithm in this case. Is there any advice regarding head injuries you would share as this is the one area which worries me should the worst happen
[…] while back, we wrote a blog about pitchside management (here) and I was very careful not to discuss concussion at the time as its potentially a topic that […]
[…] mechanism, the severity, even the initial management. We have discussed pitched management before (here) but what about the day, or days, following? Are we doing enough to aid the healing processes in […]
[…] Hopefully the lengthly timeline of this case study demonstrates the importance of giving each individual injury the respect it deserves. While I hope the management is interesting, the key discussion point is how do we approach “dead legs”? Should there be better education to athletes and coaches about the magnitude of injury? Essentially given the tissue damage, are they a tear? If an A4 piece of paper represented a muscle, and we tear down the middle (strain) or poke a hole through the centre of the page (blunt force trauma), that page is still affected and unable to serve as an A4 piece of paper. Why does the mechanism of damage change the management of injury? Given any loss of range or function following a blunt force trauma, always consider the magnitude of potential damage; monitor swelling, bruising and pain and have adequate timelines in the back of your mind – don’t rush to a diagnosis / prognosis on day 1. There will be times where there is impact and initial pain but full range and full strength – this is where our pitchside assessment and reasoning comes in (here). […]
This is awesome! Well said Sam, kudos to you, your team and people behind the sceen. Great job
I agree with what was said
this is educative
A lot of good information here.