Pogba: It’s undoubtedly a Duck

Tuesday, October 22 2019

 

An insight into his rehab journey: Manchester → Dubai → Manchester

The Media Myth

There are several reports circulating that Paul Pogba has a “cracked toe”. Let’s put THIS speculative media claim to the test:

  1. If Pogba had a “cracked toe” then he certainly wouldn’t have a cast over his ankle and have nothing to protect his “cracked toe”.
  2. The fact that Pogba has heavy protection over his ankle would indicate that he does have an ankle injury.
  3. The fact that United themselves have stated that it is an ankle injury would lead to the conclusion that it is an ankle injury. Why would they lie? This would cause significant problems in the long run, and there is no advantage gained by disguising an ankle injury as a toe injury.

If it waddles like a duck

If it quacks like a duck

If it looks like a duck

Then its most probably a… *see blog title*


Weight-bearing Status

The current advice for injuries to the ankle is to weight-bear as tolerated (pain) as soon as possible to maintain strength and function of the foot and ankle as much as possible. It is only in very serious cases where the player would be advised to immobilise and rest the ankle completely (fracture-dislocation etc.)

Partial Weight Bearing

Pogba is currently “partial weight-bearing” which basically means that he is putting as much weight as he can tolerate through his ankle. As his pain levels decrease and his function and confidence in the ankle improve, he will quickly progress to full weight-bearing. It stands to reason and is common sense that he needs to be able to take all his body weight through this ankle before he can progress to more dynamic movements such as running, jumping, changing direction and kicking a ball (discussed later).


Off-Feet Conditioning Phase

Looking at Pogba’s Instagram posts, his rehab tasks have been focused around “off-feet conditioning”. This is where the player is carrying out his rehab in either a sitting or lying down or partial weight-bearing position so that he is not bearing the full weight of his body through his ankle. An in all fairness to Pogba he is maximising every opportunity during this phase to improve his aerobic fitness levels (general fitness - bike work), anaerobic fitness levels (ability to carry out multiple sprints during a game(rope work)) and power (medicine ball throwdowns). He is also most definitely working on his overall leg, core and upper body strength and power qualities during this phase too.

Warm weather conditioning

Why not? As long as the works gets nailed, then does it really matter where he does it?

Next stop: On-feet Conditioning

Once everything goes to plan, and he has no setbacks in his rehab journey then he can progress to activities which require him to weight-bear through his ankle, for example, lower limb gym strengthening exercises (squats/lunges/calf raises/jumping/hopping). If he does not react to these activities, then he can quickly progress to grass-based rehab. He will also most likely continue his off-feet conditioning to keep on improving his fitness levels.


Grass-based Rehab

This includes activities like jogging, running, sprinting, ball work etc. As a rule of thumb, two weeks is advised at the very least to cover this type of conditioning. Essentially, the team at United will be trying to gradually expose Pogba to running volumes, intensities, game-related activities and scenarios which he will be faced with when he returns to full squad training. Sometimes this period can take a little longer and occasionally the player will request to return to squad training earlier than advised. It’s a dark art rather than a fine science!!

Time to return to train

This is the period when Pogba will transition from 1 to 1 sessions with the fitness staff to training with the squad. Some managers like the player to be fed in gradually to the squad sessions while other managers prefer to wait until the player can participate fully - so this will come down to Ole’s preference here. Again, as a physio I always like to see players complete 2 weeks of full training before transitioning back to play, however, this is usually not dictated by the medical staff and is rather decided upon by the player and coaching staff following a risk analysis from the sports medicine team about the risks of re-injury when returning a player to competition. It’s important to recognise here that the risk of re-injury never goes away, it’s merely tempered through strategies which might help to reduce the ugly head of re-injury appearing again. It’s a very tough time for all involved, and no matter how long or rigorous the rehab is, there is always something lurking under the bed!! Proceed with caution.


Time to return to play

Given the above timeline, social media pictures, stage of his rehab, his weight-bearing status, it would be reasonable to suggest that Pogba is still several weeks away from playing for United again. However, rather than basing his return to play solely on time as the ultimate criterion, it will more likely be based on his ability to complete high-intensity football-specific tasks.

I hope this snapshot helps. 


Johnny

Fantasy Physio


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Five things we learned | Week Nine

Monday, October 21 2019

 

There are no goal scorers any more.

Only four of the 15 goals scored on Saturday were scored by recognised centre forwards. That is, number 9s. And out of the four – Jamie Vardy, Chris Wood, Raul Jimenez and Danny Ings (all do actually wear the No. 9 shirt, bizarrely) – Vardy is the only one you would hang your hat on to get near 20 goals this season.

Jimenez, for all his quality, spends most of his time outside the box. Wood has to share the role with two other players (see point 3) and Ings will have to work hard for chances this season. Although he has started well.

And it doesn’t help matters when Man City start Sergio Aguero on the bench. C’mon Pep, give FPL managers a break here!

 

We’ve seen the last of Otamendi and Stones lining up together for Man City.

Pep starting two central midfielders (Rodri and Fernandinho) ahead of Stones at Palace this weekend tells us one of two things: A, he was confident that City would dominate the ball and didn’t need a recognised centre back. Or B, he doesn’t fancy Stones. Because dealing with the ball at his feet is a problem for him.

The Norwich shambles was a match too far for the Otamendi-Stones partnership. And both are playing for their Man City futures until Aymeric Laporte comes back. Expect City to go big in January.

 

Burnley have a surplus of centre forwards. And decent ones too.

Picking a good value ‘second’ and perhaps even ‘third’ frontman is crucial. And Burnley used to be a ripe picking ground. You’ve got Chris Wood and Ashley Barnes – two solid, dependable double-figures per season men (ten and twelve respectively in 2018/19, and both on four this) who you know are going to start every week.

But adding Jay Rodriguez this season has potentially created a problem – which two do you pick from the three when Barnes returns from injury.

 

Marcos Alonso has woken up. At Last.

The beautifully coiffured Chelsea full-back has been an essential fixture for the last couple of seasons – and blitzed through the opening months in 2018/19, leaving the likes of Raheem Sterling and Mo Salah eating dust early on. But this season, not so much.

However, a goal and an assist in the last two suggest he is awaking from his slumber. Plus, Chelsea – sorry, Frank Lampard’s Chelsea – look a more solid proposition of late, with consecutive clean sheets at home. Okay, okay, it was only Brighton and Newcastle, but in a season where clean sheets are few and far between, Chelsea will rack up as many as anyone.

BD – It will be interesting to see how Lampard rotates around the Champions League when Emerson, who is very close to a return following a hamstring injury, is ready to play. The Italian defender has been the preferred option in the league – when fit – although the Blues have only won one of their five games he has started. In contrast, Chelsea have won all four with Alonso, scoring more (12v7) and conceding less (3v11).

 

In Tottenham, we don't trust. 

All is not well at Spurs. That’s obvious. Whether it is down to the alleged shenanigans with Mrs Eriksen – c’mon, we’ve all seen the Tweets. Or perhaps the ongoing speculation about Pochettino, it’s not a happy camp.

On the field, all three departments are struggling. Up top, Harry Kane is doing his bit, but Heung-Min Son doesn’t look the player of last season. The back four (sometimes five) has clocked up just one clean sheet, shipping nine goals in four away trips. And in between, it’s hard to name one certain starter from one game to the next.

Fact. They have only beaten Palace, Southampton and Villa in 12 matches this season.


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Nothing more than a charlatan

Thursday, October 3 2019

 

The “Expert” Football Physio / Sport Scientist:

 

I'm going to cut straight to the chase for this piece as I know we are all time-crunched these days: It is generally perceived that certain people are termed “experts” in professional football. Let me dispel some expert myths right now on the so-called expert physio/sport scientist/S&C.

 

You are not an expert just because:

YOU work in the Premier League

YOU have treated/ worked with a famous person

YOU have a big following on social media

YOU are published in a scientific journal

YOU are part of the “clique” “cool gang” or mafia as I like to call you. Needless to say, I have never been in the cool gang.

YOU are a social climber and will only talk to someone if you want something from them.

YOU always voice your opinion on social media as the only way to do something right

YOU are invited to speak at international conferences because YOU either:

  • Work in the Premier League
  • Treated a famous person
  • Published an article
  • Have a big social media following
  • Spoke at another conference etc. - you get my point right!!

 

First things first, if you are any of the above - get over yourself!!!

The above points might be very desirable to some people, but they are certainly not pre-requisites of what constitutes being assigned the “expert” tag.

 

You are only an expert if you work in the Premier League *emoji face* joke!

Let’s take working in the Premier League as an example. And let me be very, very clear here – it is the athlete who is the expert, not the support staff, be you a physio or sport scientist, no matter how good you might think you are - sorry to burst your bubble!! The recruitment process for a player (and associated pay package) couldn’t be any further from the recruitment of the support staff (and hence is reflected in their salary too).

 

Social Media Bullies:

I know plenty of physios/sport scientists/S&C’s who “piggyback” on the success of the athletes/club they work with and then become very vocal on social media because they assume that their opinion carries more weight because they hide behind a Premier League badge or superstar athlete. It’s as if the club or athlete owe all their success due to their “expert” practice. Complete and utter nonsense - again get over yourself.

 

I am a published author - seriously!!!

I know plenty of physios and sport scientists who have published articles in journals and thereafter assume that they are an authority in this field. For example, I know of a physio who considers himself an expert because he works in the Premier League and was part of a group who wrote a clinical piece on return to play decisions – thereafter he announced in his Twitter bio that he was an expert, again absolute poppycock. Furthermore, I read the piece and wasn’t all that overly impressed if I’m honest.

 

Expertism by Association:

There is a perception that the higher the status of the league or the more successful the athlete you work with is, then, the better a physio you are, and in some instances, I would imagine this to be true. However, this type of perception is more akin to “expertism by association” rather than a true measure of how efficacious that practitioner is. For example, a physio who works with Manchester United is assumed to be better than a physio who works for one of the lower league clubs such as Carlisle. Funny that because I know the physio at Carlisle and he is certainly without a shadow of a doubt one of the best in the business. However, this is a very shallow method for judging a person’s capability of how good they are as a physio/sport scientist /S&C. There are so many confounding factors, twists and turns in life, good and bad luck as well as timing which play a role where we all end up in our journey.

 

Learner or charlatan (expert) - Which one are you?

What makes someone an “expert” in their field? The quick answer is nothing. Nobody and I do mean nobody, is an expert in this field. How could they be? Seriously, how would you measure it? In my humble opinion, you have two types of people, those who think of themselves as lifelong learners and those who are delusional enough to believe they are experts in their field…. the charlatans!

 

Anyway, let’s get back to what the academics think constitutes expert practice.

 

A Reflective Practitioner:

This type of person according to Boud et al (1985) is able to reflect with purpose on their experiences, actions, emotions, feelings and responses in order to learn from them with the ultimate aim of challenging their understanding of themselves, their attitudes and behaviours to expose any biases they may have (Patterson & Chapman, 2013). The sequelae of such reflective practice may help improve patient care, bridge the theory-practice gap and fuel further critical thinking to promote ongoing changes in practice (Duffy, 2007).

 

Professional Craft Knowledge:

Benner (1984) argues that nothing trumps professional experience as the gold standard for “expert” practice - not even speaking at a conference or having thousands of followers on Twitter - imagine that?! Although she admits, it is very difficult to define what an expert is because this type of person operates on a deeper level. She believes that the expert clinician utilises evidence-based practice as merely another tool in the toolbox, a bit like k-tape, exercise or manual therapy or NICE guidelines for that matter. Again, I would argue against Benner’s choice of using the term “expert”, and this could be replaced with “learner”. Professional craft knowledge is reserved for those practitioners who are very experienced in their profession, who have seen the good, the bad and the ugly, and again who have reflected on and learned from all their experiences.

 

A novice practitioner, on the other hand, has “propositional knowledge” that is knowledge they have gained from books or courses but lack the real-life practical experience to inform their practice. They rely on and quote heavily, especially on social media platforms “scientific theoretic knowledge” because their personal practice is limited and inflexible. As their exposure to industry-specific scenarios increases (for example in professional football) as does their experiential practical knowledge (professional craft knowledge) and therefore they are able to lean on their propositional knowledge and anecdotal experience to make better decisions for the patient/athlete (Benner, 1984).

 

On the spot: Research action Research practitioner

The other defining aspect of an experienced practitioner is that they are able to reflect-in-practice, that is while the scenario is occurring which is in contrast to the novice practitioner who will be more likely to reflect-on-practice, i.e. reflecting on the event after it has occurred (Schon, 1983). This type of practitioner is able to carry out on the spot: research action research – they can generate a new understanding of the situation and change the situation there and then. They are able to consciously attend to the task in hand. In my humble opinion, the practitioner who is striving for best practice will be one who utilises both reflection in and on practice. The practitioners who view themselves as lifelong students, learners, reflectors, not those who think of themselves as experts just because of who they work for, what they have written or how many followers they have. But what do I know? I’m just a learner!

 

The Intuitive Practitioner:

This type of person uses intuition which is difficult to verbalise and has no rationale process – it’s simply a hunch!!! Again, you need quite a bit of experience to operate at this level. Your decision-making ability becomes fluid and effortless and not so cognitive anymore. Dreyfus & Dreyfus (1986) also refer to an “intuitive grasp” where the practitioner uses pattern recognition to inform their decision making. In essence, the practitioner compares their current experience with their past practice to make the right decision.

 

 

Metacognition:

This occurs when you are able to reflect on your reflection, be critical about your own thoughts. This type of clinician can act as their own supervisor and question whether they are dealing with the situation effectively (Rolfe, 2011).

 

Being a good listener:

My whole aim in life now is to be a better listener, did I really listen to the other person, did I understand their fears, expectations and aspirations. If I have listened well, I can put that person at the centre of the rehab journey and build from there.

 

Conclusion:

Is it correct to assume that someone is an “expert” in the field of sport and exercise medicine just because of who they work for, who they know or what they have written? In my opinion, this criteria defines what a “bureaucratic expert” is and nothing more than that. They hide behind smoke and mirrors, badges and athletes, journals and conferences.

If it's that important to you to be perceived as an “expert” in your field, then stop hiding, develop your own skillset as a practitioner and qualities as a good person. Listen more and stop telling people what to do on Twitter, realise that it is just your opinion that you are offering. Make your job your passion, reflect on your behaviour and become a nicer person. The more experience you have, the more you will realise that there are many occasions where current evidence does not advocate a particular practice. And, it is in these challenging situations of uncertainty – which you will constantly face within professional sport – that you, as a lifelong reflective learner, rather than who you work for, will help most.

 

Reference List:

Benner, P. (1984). From novice to expert. Reading MA: Addison-Wesley.

Boud, D., Keogh, R., & Walker, D (eds) (1985). Reflection: Turning experience into learning. London: Kogan Page.

Duffy, A. (2007). “A concept analysis of reflective practice: determining it’s value to nurses.” British Journal of Nursing, 16(22), 1400-1407.

Dreyfuss, H. & Dreyfuss S. (1986). Mind over machine. Oxford. Blackwell.

Higgs, J & Titchen, A. (2000). “Knowledge & Reasoning. Higgs & Jones (Eds.), Clinical reasoning in the health professions. Oxford: Butterworth Heinemann.

Jones, M. & Rivett, D (2004). Introduction to clinical reasoning. In M. Jones, & D. Rivett (Eds.), Clinical reasoning for manual therapists. London: Butterworth Heinemann.

Moon, J. (2004). “A handbook of reflective and experiential learning, theory & practice”. London: Routledge.

Paterson, C. & Chapman, J. (2013) “Enhancing skills of critical reflection to evidence learning in professional practice. Phys Ther in Sport. 133-138.

Rolfe, G. (2011). “Knowledge and practice. In G. Rolfe, M. Jasper & D. Freshwater (Eds.), Critical reflection in practice. Generating knowledge for care (pp.11-29) Palgrave MacMillan.

Schon, D. (1983). “The reflective practitioner: How professionals think in action. London: Temple Smith.

 

 

 


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The Late Fitness Test podcast | Episode Nine

Wednesday, October 2 2019

 

Getting down and dirty with all things injury-related. This weeks’ Late Fitness Test podcast covers a myriad of talking points… Johnny does his utmost to upset Frank Lampard while Stel pulls no punches as Manchester United’s on, and off-field, problems continue.

First up, we’re off to Stamford Bridge where the Chelsea boss is clearly unhappy following a recurrence of a hamstring injury which will rule Emerson out until after the international break.

 

(🎧 4:30m) The culture of blame

“Emerson is a similar injury to what he had, with a muscle. When you do that it means you’ve come back too soon. That’s not a slight on Emerson; everyone wants to play this game, fair play. Those things shouldn’t happen,” Lampard mused following the defeat to Liverpool.

“There is no blame when it comes to risk.” Practitioners need to delineate the risk of recurrence… to the player, to the manager to help make informed return to training, return to playing decisions… Research would postulate that your likelihood will lessen over time.

“You are not inoculated against the risk of injury…. What I find incredible is that he could give that type of answer, that type of answer might have held some water, let’s say 10-15 years ago, but not now. Everybody shares a responsible when returning players to training and playing.”

Physios reflect in practice, they’ll reflect during the event and use all their experience during that event and will be sympathetic to the fact that this hamstring may recur again. Lampard does not have that experience of returning a player to training and playing. He is reflecting on practice; he is reflecting on his decision after the event. This should not happen. He does not have the experience to reflect in practice.

 

(🎧 21:30m) Fitness, fitness, fitness

Fitness has always remained high on Ole Gunnar Solskjaer’s agenda since arriving at the club

Ahead of a warm-weather training camp to Dubai in January, Ole said. “We can get fitter, and we have to do that through the training sessions here. But Dubai is a good chance because now is the first time we get a week of work together.”

“Of course, we know our fitness is nowhere near good enough. I’ve said it before, I can’t wait to get a pre-season done,” he said following the 4-0 defeat to Everton in April.

While in pre-season, the United boss insisted “everyone should be as fit as they possibly could be” heading into the opening weekend. “It is not a case of breaking them down, it is not about proving a point; they are not fit enough. We are here to build them up.”

However, United's lethargy and growing number of injuries have called into question the squad, so much so, that the sports science department is said to be perturbed by the number of players breaking down so early in the season given that most of them are non-contact injuries.

“The easiest thing to blame, the easiest thing to change is the fitness of the players. However, you can’t hold onto that excuse 12 weeks later.”

 

(🎧 27:30m) Norwich injury record

The Canaries have suffered 18 reported injuries since the opening weekend, more than any other top-flight side. But how much is down to bad luck? And, how much is of their own doing?

"The first sessions and the first weeks have been good” Head of Sports Science Chris Domogalla told Norwich City TV in July. "I've heard that the guys are not used to double sessions, but they've done a really good job. We've increased the load softly in each session because we knew the background. We've pushed the guys to improve them. That's the way we want them to work."

“Did training have to get harder, or did you have to train smarter? How much reflection is going on in both those camps?”

 

(🎧 36:30m) Recruiting from within

“Sometimes I not sure whether the recruitment process on backroom staff, on players, is as robust as maybe how robust the conditioning of the players has been. So, maybe we’re just looking in the wrong direction here. They are still recruiting within…… I’m calling into question the recruitment process here. You’re at the best club in the world, but going to the best club in the world, have you got the best people giving you the best advice…?”

Meanwhile, Stel does not pull any punches.

“Marcus Rashford is bottler…. Things aren’t going his way, and I know in the past certain players, have refused to play because they feel that they are too injured even though they can. And, for me, this injury may be legitimate, but I just think that it’s convenient that he’s pulled up right about the time people are questioning his form, they’re questioning his ability….. It seems that a lot of players at this club are very quick to hide behind the managers failing, what’s happening off the pitch with Woodward. It’s like a shield, and it’s going to continue until the owners eventually sell up.”

 

(🎧 39:30m) Treating the person

In recent years the conversation has morphed from: “Shall I have an MRI?” On to.. “So, there’s nothing on the MRI? Well what do you think it is then? Stuff that players would’ve played with 10-15 years ago, they probably don’t play with it now.”

“It comes down to the person you’re dealing with. “You’re not treating a hamstring; you’re not treating an ankle, you’re not treating an ACL. You’re treating the person that’s in front of you and what are they bringing to you, and what type of behaviour, and what character, because their character will determine the outcome and the physiology.”

 

(🎧 40:00m) Evidence-based medicine

“You get all these practitioners, and they hide behind evidence-based medicine, you see them all on Twitter. They go and quote a paper on hamstring injuries; they go and quote a paper on ACL’s. This is called acquisitional knowledge. They’ve acquired this through reading, through books, through articles, they’re working in the Premier League and they don’t have the experience to go ‘matching my anecdotal experience over the last 10-12 years with the research I see…..”

 

(🎧 43:00m) Listener Question – Genetics.

“You’ve heard about people talking about the speed gene… There is no such thing as a particular strength gene, or a particular speed gene, or a particular performance gene…. Genes play a part, but the polarising notion that it’s nature – the way you were born – or nurture – your conditioning and training – well that’s archaic, and that’s proven not to be right.”

 

(🎧 46:00m) Andy Carroll comeback!

“Is he able to put back-to-back minutes together? No. Was this an emotional decision by Newcastle United? Absolutely, definitely!”

And on reports by the Telegraph that state the likelihood of Carroll starting a game in the short to medium term is extremely slim with his involvement almost certainly confined to cameo roles as a substitute.

“It’s a very, very, very graded return to play and not one I’ve been involved in that people have been afforded so much time to return. Because usually, a player is given restricted minutes for a couple of games, and then, if their status is high within the squad, then they’re back in.”

 

Have a listen; we would love to hear your thoughts!

 

🍏 Apple https://podcasts.apple.com/gb/podcast/the-late-fitness-test-season-2019-2020-episode-9/id633108165?i=1000451290091

 

🎙 Audioboom https://audioboom.com/posts/7379546-the-late-fitness-test-season-2019-2020-episode-9

 

🗣 Spotify https://open.spotify.com/episode/5v4tDd2Qd1JRcXT4PzZOtl

 


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Ben Dinnery

Ben Dinnery

@BenDinnery

Ben is football’s leading injury specialist. The ‘go-to’ guru for big hitters like Sky Sports, ESPN and NBC Sports when they need data. Or the BBC, talkSPORT and the broadsheets when a quote is required. His unique insight has helped provide a better understanding of what is really happening in the treatment rooms.


Johnny Wilson

Johnny Wilson

@johnny_wilson5

Johnny is a respected physiotherapist and sports scientist, specialising in football injuries and rehab. Johnny has headed up the medical departments at Chesterfield, Scunthorpe and Notts County. Overseeing everything from player-specific training loads to pre-signing medicals. He has a proven record working with elite athletes in Private Practice and is regularly called upon throughout Europe to deliver presentations on the latest rehab innovations.


Matt Nesbitt

Matt Nesbitt On TipTV

@MattNesbitt16

Matt's short, unremarkable football career was ended by his own bad driving. His long, distinguished career as a football tipster was ended by his own good advice. Because bookmakers don’t like a winner. First, they closed his accounts. Then his members’ accounts. Then his tipping service. And now they employ him as a consultant. Funny old game.


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