The final decision on player fitness: who's job is it?

For me, two images of this past weekend's sport stand out.

 One of the NFL's brightest (and therefore most expensive) stars, playing with a 4 week old lateral collateral ligament injury and wearing a heavy duty knee brace, in arguably the biggest game of his career, biggest game of the team's season, until he broke.  Should he ever have been put in that situation?

Now, if you haven't kept abreast of the details of this story, it's quite convoluted and full of "he said/she said".  These articles may help:

http://www.sfgate.com/sports/article/Did-Shanahan-lie-about-RGIII-s-injury-4171624.php
http://www.washingtonpost.com/blogs/early-lead/wp/2013/01/07/rgiii-injury-a-guide-to-the-qbs-knee-and-the-shanahan-criticism/
http://www.washingtonpost.com/blogs/football-insider/wp/2013/01/06/nfl-playoffs-seahawks-vs-redskins/#10550

A lot of the criticism has been leveled at Mike Shanahan (Head Coach) and at Robert Griffin III (RGIII - player), but for me there has been a lack of focus on the medical decisions made by the Redskin's medical staff on Sunday and in the lead up to the game.

First of all, we'll rule out RGIII from this.  It's his body, but it's not his decision.  "Players often have to be protected from themselves and Griffin, Andrews said, is “a competitor. He didn’t want to let his team down.”"  A quote from the article by Cindy Boren.  Absolutely right.  This was 100% my mentality as a rugby player - I was there to compete, to put my body on the line for my brothers left and right of me.  You sacrifice your own health and well-being for the cause and if you don't take that attitude into a game, you'll come off second best.  It's why the top players are the top players, complete disregard for their own body for the good of the whole (see Jonny Wilkinson, 2003 WC final, smashing the Australian number eight 30 seconds after picking himself off the deck with a neck injury that would eventually require spinal surgery to decompress a nerve).  Of course he's going to want to play.  Of course he'll say he's "hurt, not injured".  I haven't yet met an elite sports man or woman who doesn't share the same point of view.

So, Mike Shanahan, the coach.  I'm not sure if he has any kind of medical degree.  I'm assuming not.  He's the coach.  His job is to win.  RGIII is his number one superstar, the rookie who's been leading his team, the rookie that is his captain (chosen by the rest of the team as the man to lead them), the rookie who has been winning.  Why would his mindset change in this, the biggest of games?  So often coaches will risk it all to win, the poker mentality, putting the tick in the W column as a higher priority to athlete's health.  Players get injured, right?  That's just normal?  The only decision Shanahan should have made on RGIII is whether to pull him when it was obvious he wasn't right and his play was damaging the team's chances of winning.

In the lead up to the game, Shanahan (and the player, to an extent) should have been led by constructive and reasoned information from the medical team.  The medical team MUST have overriding control of ALL medical matters.  It's not their job to call the next play, as per it's not the coach's job to make medical decisions.  So when you hear Dr. James Andrews (the Redskins sideline Doctor, a knee specialist no less) saying that he was "still worried" about Griffin's knee and that watching RGIII being sent back out to play "scared the hell out of me"; frankly that makes me feel a little uneasy about the whole situation.  This is a quote regarding the initial injury when RGIII was sent back on for 4 plays after a sickening looking knock to his knee:

“[Shanahan] didn’t even let us look at him,” Andrews told Robert Klemko. “He came off the field, walked through the sidelines, circled back through the players, and took off back to the field. It wasn’t our opinion. We didn’t even get to touch him or talk to him. Scared the hell out of me.”

As a medical team it is your job to be proactive - would you wait for the coach to give you the go-ahead to administer care after seeing a bad head injury on the pitch?  We know that the coach wants him to play, and you can be sure the player wants to play, the voice of reason must ALWAYS be the medical team.  Take your time, assess, make a reasoned clinical decision, present this information to the coaching staff/player, and act upon it.  In this instance, seeing the player go down injured, the medical team should have been on hand to greet RGIII as he came off the pitch, walked him to a quiet corner, and assessed the injury.  Essentially, putting their foot down.  I couldn't care less if the coach wants his player back on there and then.  There's been an injury, it needs assessing, regardless of who the player is.

Regarding the game on Sunday, I do have some sympathy with the medical staff.  It's been reported that RGIII passed all the functional tests etc that were prescribed.  If this includes game specific work including collision work, then fine.  If it doesn't, I once again question the medical staff.  In an intentional collision sport, a player can't be cleared to play unless they can get through a collision session without symptoms during, post and the day after.  If they can't, it's like putting a footballer back on the field who can't kick a ball.  They will be re-injured, because of the nature of the situation you're putting them back into.  RGIII has also got history of working above and beyond during the rehab process.  After ACL reconstruction in the same knee whilst at Baylor in 2009, his surgeon Mark Adickes stated "all efforts post-operatively were spent trying to slow him down".  However, during the game, when it was obvious that he wasn't right, why wasn't he assessed?  After he was tackled during the 1st half when he was off-balance on his injured leg mid-pass and hobbled around the next two plays, why wasn't he assessed when he came off the field?

As a medical staff we, you, have a duty of care to all our athletes.  That duty of care extends far beyond the wishes of the coaching staff.  Regardless of whether this player is at the beginning or the end of his career, that duty of care still applies.  If this situation shows us anything, it's that we must be proactive in finding the information, and firmly fight our cause with a well informed and reasoned argument outlining not just the immediate outcomes but the long term implications of any decisions. 

Even if the Redskins had won, would RGIII have been able to play next week?

Medical vs Strength & Conditioning

Given current trends of professional integration, this blog post is probably out of date with most people.  If you're the kind of medical professional or S&C coach who works with with the other profession towards common movement and performance goals (population A), don't worry about reading on.  Or read on and comment on how correct I am.....

If you don't already work with the "opposing" profession (population B), why?!

I'm a Sports Therapist.  Clinical staff.  I'm also an ex "lift as much weight as you can"/"be powerful and massive" rugby player.  I've also worked an internship as a strength coach in alliance with some study in S&C.  So I'm somewhat biased towards the integration of medical and S&C towards common goals.

If you're a clinician like me, you spend your whole life sat in your little clinic room, running away from any hint of sunlight as you recoil back into your cave with your next "victim".  The notion that people run around and bump into each other outside of that sterile and contained world is a scary prospect.  However, people do, athletes do, and without embracing this, how can you offer a complete service?  I will point out that you don't need to become an S&C coach (or vice versa), but understanding what the other world does is as important as understanding the different rehab demands of a hamstring or patella tendon ACL reconstruction.

This is how I spent my Wednesday lunchtime.  The big tall people doing exercise type things are Surrey Heat basketball players.  The people in black are the S&C team.  I'm there to observe movement.  Whilst I'm interested in the weight they're moving/height they're jumping, because decreasing performance figures can point towards movement issues, in this setting I care about the way that they move.  Luckily this was a conditioning circuit, which gave me further insight into how they move under fatigue.  Seeing a player continually cramp in his hamstring doing glute bridges under fatigue points towards a lack of activation endurance in his gluteals and a "mis-firing" posterior chain.  You're right in thinking that I could highlight this in clinic and as part of the screening process this would be picked up (the player in question is yet to be screened).  However, in picking this up during a gym session, we've avoided taking up any more of his time and instantly corrected the prehab programme with the S&C team.  Which brings me to the working relationship between the 2 professions.

Tom is my friend.  He's also an S&C coach.  As well as being mind blowing using excel.  He also has a fascination that his injuries only occur due to his "massive lats".  Including his recent traumatic MCL sprain.  Don't ask.  He's the man looking at his watch in the picture.  He runs the S&C programming for the Surrey Heat.  A few months ago, he came straight to me and asked me to screen all of the Heat players and write bespoke prehab sessions for them.  This in itself is not strange.  Every athlete should be screened at the start of and throughout the season so that bespoke and constantly updating injury prevention programmes can be added into their general programming.  However it came with the statement "because I want to make sure all these guys can move correctly before we start loading them up".  No "get massive because it's better" philosophy there.  Everything the players do is about movement: full range and with good consistent quality.  And I'm yet to see any of them for anything more than niggles that they arrived to us with (which are all managed with their prehab and self massage/mobility sessions).  Movement quality and efficiency is improved on court, and the players are fresher come the end of games.  As a team of coaches, the S&C team has brought into the fundamentals of correct functional movement and as such embrace and push the prehab programmes for the players.

Similarly, there has to be understanding from my end as a clinician.  If I don't understand the mechanics of a squat/clean/jerk/deadlift/etc, I can't make comment on the way an athlete moves in the weights room and therefore it's transfer to the way they move on court/on pitch and their subsequent injury predisposition.  As a medical profession we need to wholeheartedly buy into the need for load in the athletic population.  Load is good if administered correctly, because without overloading athletes, they won't ever progress, no matter how well they move.  For me, it's this lack of understanding of loading that creates the friction between the two camps - people are too quick to dismiss load as all being bad and unsafe.  Some examples:

• I just recently heard someone being told by a physiotherapist that they shouldn't stretch when they have DOMS as it's the bodies way of telling us it's damaged and stretching will damage it further.  Aside from the fact that we still don't know definitively the cause of DOMS, if this was the case, no athlete would ever do anything the day after a training session.  How do expect to create overload if the athlete never trains?!
• "Snatches are unsafe because the bar is unstable overhead", I was once told.  True.  But you think that 30 blokes running into each for 80 minutes is safer?  A well coached lift is much safer than the non-sterile environment of a game of rugby.

A blog lacking on "science" and high on philosophy, but I think an important point for consideration and discussion.  If you've made it this far, I guess you're in population B.  Or just interested.  Either way, hope there's some fresh debate/discussion arising.....

Initial thoughts.

"I have found that among its other benefits, giving liberates the soul of the giver."
May Angelou

.....pretty much sums up why I now have a blogging identity.  I am now 5 years after graduating and feel that I'm in a position to start voicing my opinions and philosophies on all things movement to an audience wider than friends, family, patients, co-workers, people that I force to listen.  I'll point out from the outset however:

I AM NOT AND DO NOT BELIEVE MYSELF TO BE THE ORACLE ON THIS.

Without reasoned debate and discussion, we cannot progress as individuals or as a population.  I fully expect some people to share the same philosophies as me, and others to question what I say.  I welcome the questions; this is as much a way of improving myself as it is helping others (see the quote at the top.....).

Also, please do not expect my blog posts to be written as a journal article.  I'm not writing journal articles at present, nor aiming to do so in the near future.  I will however try to include as much accessible literature as possible, however I'm not expecting all readers to have access to journal resources.  

A Parting Gift

Whilst not strictly movement analysis/patterning, I want to give an example as to why I'm so passionate about the functionality and, more importantly, dynamic correspondence (more to come on that) of the exercises that we as clinicians prescribe.  This YouTube video is from an ESPN series called "Gruden's QB Camps".  Jon Gruden is a proper work-a-holic style NFL coach turn analyst who takes the top college QB prospects and breaks down how they view the game during on field/off field play by play analysis (completely fascinating if you're a sports geek like me), as well as running them through a few QB specific drills.  The part I'd suggest watching is from 21'51".  The QB under the spotlight is Robert Griffin III (or RGIII).  This short QB drill segment is a perfect pre-analysis snapshot of why movement, and in particular co-ordination of movement, matters so much to me.  Everything from the speed of feet to the rotation of the torso to the snap of the wrist on the ball, all in one fluid motion with absolute speed, fluidity, and accuracy.