Benchmarks the Practicalities of Football Medicine: A View from the Backroom

When then Chelsea boss Jose Mourinho became embroiled in an internal row with club doctor Eva Carneiro in the club’s first game of the 2015-16 season played out in front of millions of television viewers, it had repercussions for the whole football industry.

To recall, Carneiro, and head physiotherapist Jon Fearn, went onto the field to treat the injured Eden Hazard when twice summoned on by referee Michael Oliver. According to Mourinho, she rushed onto the pitch to attend to Eden Hazard when he felt the injury was not of a serious nature. He was later cleared at an FA hearing of being verbally abusive to her in his native Portugese language. The subsequent fallout from the incident, which made major headlines around the world, saw Carneiro leave her position shortly after the game. A constructive dismissal case heard in March 2016 was settled on confidential terms, although legal documents showed that Ms Carneiro had rejected a previous offer of £1.2m to settle the claim [1].

So where does this leave the traditional 'manager-physio' relationship, and how has that changed over the years as the game has become ever bigger? A quick scan of the official club website shows that Chelsea have a medical director, four fitness coaches and a personal trainer/nutritionist working with just the first team, although no club doctor or 'physio' is actually listed. This is very much against the tradition, certainly in English football, of the ‘Manager-Physio-Players’ model where good working relationships were traditionally built. A number of famous or long serving Physios have had their theories on the subject published either through books, written papers or interviews [2].

Fred Street was the England physio for 22 years, working with a succession of managers including Don Revie, Ron Greenwood, Sir Bobby Robson and Graham Taylor. Before that he served Stoke City and Arsenal, taking charge of medical matters in over 1,000 games in total. In an interview for the England vs Brazil Rous Cup matchday programme in 1987 he gave an insight into the England job, one which is at the top level of football [3] “The job is frequently as liaison between the doctors who are there for medical illness and the manager who selects and trains the team, he said. “I often think that Norman Medhurst (his assistant physio with England) and myself are like the civil service who carry on no matter whether the ministers, or in our case the managers, change, and we keep on rolling along regardless of who is in charge and that’s the way it should be.”

Fred gives a good example of how he had to use his judgement during a game between England and Yugoslavia when Steve Hodge and Glenn Hoddle clashed heads, with manager Bobby Robson trusting his judgement. He said: “We had already made a substitution but Hodge had to come off with his cut. Hoddle played on with padding over the wound and did very well, both from a footballing and bravery point of view. “You cannot make hard and fast rules about who can play with bad knocks in an emergency [4]. For example a sprained ankle for one player is the same injury for another but one will be able to carry on and the other will not. “Bryan Robson for instance is one who wants to carry on and play no matter what the injury is - Peter Storey used to be the same when he was playing for either Arsenal or England.

“It is important to let the manager have the facts as you see them, and not say what he would like to hear, and give your views as advice upon which he may act or not. “A manager may play a player that you feel is not quite right but that does not mean he is over ruling your view. “He has to make a decision based on advice from many sources against complex backgrounds.

“I remember a coach saying a particular player was worth having in his team even carrying a slight problem, and I understand what he meant- so it is not all black and white.” In 2014 Street was given a lifetime achievement by the Football Medical Association. As well as providing the accolades, chief executive and former Manchester City physio Eamonn Salmon had already gone on record to recall how the role of physio had changed over the years [5]. “Up until the early nineties, any problem at all, you had to deal with it,“ he said. “It really was an extended role - doctor, counsellor, you were the only person. There were very limited resources and you did seven days a week, 48 weeks a year.

Now, at the top clubs, the physio is likely to be part of a team of medics and scientists, although there is ‘massive disparity’ between Premier League clubs and those in the lower divisions where resources are still stretched.” Gary Lewin followed in Street’s footsteps as an Arsenal and then England physio.

He says: “Communication and trust is key to the partnership between a manager and physio, or the medical staff. Each manager will have his own way of working with players and staff and it is vital you work within this philosophy without ever forgetting or compromising your duty of care to your players. “The manager has to organise and captain an efficient ‘team behind the team’ that not only performs specific tasks but also has a role to play in creating the atmosphere around the team. “It is an important need to find the right balance between the medical and footballing standpoints [6].”

A famous incident occurred in 1989 when Michael Thomas injured his knee in the Wimbledon game ten days before Arsenal played Liverpool in the first division title decider at Anfield.

Gary takes up the story: “We had to win at Anfield by two clear goals to win the Football League Championship. “Michael had a fitness test the day before the match and although he was able to do everything, it was a high risk for him to play. “The discussion went along the lines of ‘He is fit to start but not confident he will finish and he may do further damage to his knee’. “This was discussed with the player and he wanted to play. It was also discussed with the manager and he wanted to take the risk. “The result was not only did he play, he scored the second goal in injury time for us to win the league by scoring more goals that season, so what do I know?” And again, Gary’s experience shows the difference between the decades in terms of staffing levels.

“When I started at Arsenal in 1986 the full-time staff was the manager George Graham, the assistant manager Theo Foley and the kit man Tony Donnelly as well as myself. “When I left in 2008 the full-time staff consisted of two physiotherapists, one doctor, two masseurs, one fitness coach, one osteopath, one travel and equipment manager and two kit men.

“Since then this has increased further with an extra coach, three more fitness coaches, two additional physiotherapists, an extra masseur, a nutritionist, two data analysts and a player liaison officer.

An article in 2012 by ‘The Secret Physio’, as part of the popular website and book by ‘The Secret Footballer’ said the working environment can be different depending on how high up the pyramid the club is [7] He said: “At smaller lower league clubs, there may be only one physio and they will have a very close working relationship with the manager. “When I was the sole first team physio and a new manager came in, I did feel uncertain about my future, it was up to me to prove to him I could provide an efficient medical service. “When the new man arrives you try to see what he requires from a medical department and adapt to him and his demands.

“At the larger clubs with a larger medical team, physios tend to be quite protected. There will be a head of department who will usually be either a doctor or physiotherapist and they will fall under the control of the board of directors.

“Many of the top premier league clubs now have four to five first team physios; even many championship clubs have two or three, each with their own specialties. “Their contracts don’t necessarily follow the managers and are organised separately. In fact they are relatively protected.

“Also these guys earn good wages and have close ties with the players as do most physios in a club - therefore changing them can be very disruptive and expensive.” He goes onto say not all managers are the same, they all have different approaches towards injured players and a medical team’s involvement in preventing those knocks. He adds: “I have worked with managers who see injured players as no more than malingerers and believe they are injured on purpose. “They want injured players in at 9am, well before the others and not to leave the training ground before 4pm to inconvenience them as much as possible. “There is only so much treatment you can provide for a player before you actually make things worse. “I have played cards with players until it’s 4pm just to fill the time - and usually lost!”

One example of a contrast to that scenario is former Liverpool, Aston Villa and now Hull City club doctor Mark Waller, who when he was offered the job by then manager found a condition attached. “The manager informed me I was not to attend the training ground when the players were in for training until after 2pm,” he said. “I respectfully asked why he had suggested such a stipulation for the post and his rather curt riposte was ‘because I don’t want any medical team stopping my players training or playing with minor problems. If it is bad enough they will wait for you, but most of them won’t.’ The manager and centre of excellence director’s opinion was eventually changed by the requests of players to be allowed to see Doctor Waller earlier if they needed to discuss a medical issue and a talk with him about preventative treatment -and so began a fruitful and amicable partnership with the management of the club.

Gavin Blackwell, an academy physio at Wolves is someone who has worked in football for over 30 years. He says: “Organising the backroom for the manager is no longer a one man band. “Today’s manager is the leading edge of a group of staff which frequently consists of assistant managers, coaches, goalkeeping coach, physio and a kit man as well as players and they are expected to build teams - in the pleural- rather than just a team. “Having built this, the manager is required to lubricate the machinery to ensure that it runs smoothly in all conditions. “An example of this is the performance decisions made by the support team need professional acceptance. Key decisions, such as when a player can return, should not be tainted by the opinion of the manager.” But the events involving Carneiro at Chelsea that day were an unwelcome distraction from the pivotal role that medical personnel play in football, as a paper from Teeside University stated in 2012 [8].

“The Premier League Doctors’ Group condemned Mourinho’s public criticism of Carneiro as “disproportionate”. “It led to the chairman of FIFA‘s medical committee, Michel D’Hooghe, setting up a sub-committee to draw up a new code of ethics for managers and team doctors. “They will work alongside managers and coaches across Europe to draw up the code. “On the one hand the team doctors have to abide by the Hippocratic Oath and intervene when a player is in medical need, but it also important to take account of the fact they work as part of a group under the coach,” it said. Mourinho later defended his position, saying: “Every week I face a decision about the bench. I have to choose. With the medical department, only two can go on the bench and we have more than a dozen.”

But what was most interesting again is the fact that Chelsea have so many medical staff when back in the late 70’s clubs only had one physio with the archetypal ‘magic sponge’ and a bucket of cold water. There is a definite increase in the importance of football medical staff.

For example Manchester United won the treble in 1999 and there were only three at the club. Now, as Gary Lewin illustrated, some clubs have more than 20 different full-time medical staff doing a range of different jobs. Joe Royle is one of the ‘old school’ managers, having took charge of four clubs, including Oldham twice, between 1982 and 2010. Ian Liversedge, who worked with Royle, said: “He always made me feel important. “In fact I have been fortunate to work with a number of good managers who make you feel part of the team. “It’s not just that you are the physio, you are part of the team, because a good team is in it together.”

In an article in Aspetar Sports Medicine Journal in August 2016, [9] Tottenham manager Mauricio Pochettino was asked: “As a coach how important to you is the medical team? He answered: “It is one of the most important parts of a football club. But I wouldn’t detach it from the other aspects of the game. It is just as important as the tactical, physical and psychological elements of football, but importantly, these all have to function correctly and together.”

The formation of the Football Medical Association in 2010 underlined the growth and importance of the medical support upon which clubs were becoming increasingly reliant. But whatever the arguments about the number of medical staff, their roles in the hierarchy at a football club and their relationship with the manager, swift treatment on the pitch is vital for the health and safety of the players themselves. In 2006 fans witnessed one of the worst injuries in football history during the Reading v Chelsea game at the Madjeski Stadium. Stephen Hunt of Reading was running into the box and as goalkeeper Petr Cech went down to collect the ball, Hunt’s leg collided with Cech’s head.

Cech was left severely concussed after being kneed in the head by the Irish midfielder and collapsed in the dressing room after being carried from the playing area. There were fears that he had suffered a blood clot and he was rushed straight to the hospital where he underwent emergency surgery for a depressed fracture of the skull. None other than Jose Mourhinho was the Chelsea boss that day and as well as blaming Hunt for causing the injury, he also criticised the ambulance crews and match referee Mike Riley for not acting quick enough. Cech has played ever since with a rugby-style head guard that protects the areas of his skull weakened by the collision.

Former Manchester City and England under 21 midfielder Paul Lake has experienced both sides of the coin. He saw his promising playing career effectively ended at the age of 21 by a ruptured anterior cruciate ligament, which would see him only play four further games. After training in matchday treatment at the Manchester City Academy he then went onto to become a physio for ten years for, amongst other clubs, Burnley, giving him an insight into the other side of the medical table. In his book ‘I’m not really here, a life of two halves,’ [10] he says: “The relationship between a football manager and his physiotherapist is a bit like a marriage, I suppose. “If it’s going to work it has to be based on the fundamentals of mutual trust, respect and understanding. “There are bound to be rifts along the way - one party standing their ground over a point of discipline, perhaps, or the other claiming they know how to handle the youngsters- but a sound partnership will help them to ride the storm. “Too many rocky patches, however - maybe due to personality clashes or differing opinions, and it just won’t last the distance. “The ideal gaffer, from a physio’s point of view is a model of patience and understanding. “Likely to be at the helm of a successful club with a large squad at his disposal, he’s less inclined to pressurise you to rush players back in unfeasible timescales.

“He’s someone who gives you and your medical team total responsibility, deferring to your scientific judgement and allowing players to return in the safest possible time without risking further injury.”

He contrasts that with the ‘boss from hell’ who treats the appliance of science with contempt and attempts to cheat nature by demanding that unfit players are returned in the shortest possible time, regardless of the ramifications. After a tempestuous year working at Burnley, Lake completed his Chartered Physiotherapy course at Salford University and went onto serve Altrincham, Oldham and Macclesfield Town.

One amusing tale from the book and again which illustrates the boundaries between manager and physio is when working for no-nonsense boss Stan Ternent at Burnley, who Ian Liversedge, mentioned earlier, also worked for. Lake faxed over a list of breakfast items for an overnight trip before playing Bournemouth, his first away game with the club. After taking advice from a number of physios, he kept the menu heavy with carbs and proteins, cereal, wholemeal toast and fresh fruit. Only to find on the morning of the game, a serving hatch full of bacon, sausages, fried eggs, black pudding, baked beans and mushrooms. He recounts: “I was just about to wipe the floor with the kitchen staff when I heard a familiar voice coming from the other side of the room. “There, sitting alone at a corner table was Stan, mopping up a pool of orange egg yolk with a slice of fried bread. “Let’s get one thing straight,’ he said, his voice laced with menace, ‘I choose the food at this club.” “I just burst out laughing, realising this was one battle I knew I wasn’t going to win.”

In many ways the physio’s room in a football club is its nerve centre. There is not a player who hasn't been in its inwards at one time or another, and some more than others.

For the physio it is important you sit in the middle between the manager and the players. You cannot afford to sit to close to one side of the fence. So you can give a valued judgement on all matters manager and player. Prior to Euro 96 EnglandPhysio Alan Smith who worked to get Alan Shearer fit highlighted the importance of the relationship following surgery to repair a hernia, both working seven days a week for six weeks to get him fit. And continuing his rehabilitation only playing 45 minutes prior to the opening game. Manager Terry Venables called his physio to his office as he had to submit the squad to UEFA. "Do I select Alan Shearer having not played ninety minutes yet? [11] he asked." Alan replied positively with a 'Yes he will be fit. 

Then training fully with the squad continuing his rehabilitation, this answer allowed him to be selected in the starting eleven for England’s opening group game against Switzerland. After the game, Shearer presented Smith with his shirt signed thanking him for getting him fit and the striker went on to become the tournament’s leading goal scorer winning the Golden Boot award. Alan Shearer was a player who always went out of his way to credit his medical men, referring to his club physio Derek Wright as “A brilliant man, someone you can trust, brilliant at his job and the most down to earth guy you will ever meet. He helped me enormously with my injuries. A rock.”[12].