From The Physio – Gameweek 5

Fantasy Football Scout is delighted to welcome Facer as a new contributor to the site, to bring with him a new “From the Physio” regular. For those who don’t know, Facer is not only an excellent writer, he’s also a fully qualified Physio who has worked in many sports, including football. As a community member, he has recently contributed some superb analysis of injuries to both Wayne Rooney and Robin Van Persie. So good in fact, we took it upon ourselves to recruit him to lend him an official voice here on the Scout.

“From the Physio” will deliver a full report on new injuries, offering a remote assessment from the footage available with a prognosis on the player’s condition and, where possible, an estimate of the severity of the setback. The article will also focus on players currently under treatment, giving an idea of the process they are going through and the number of steps that remain before they can return to contention.

We’re certain the article will offer a unique insight into the injuries that are concerning Fantasy Football managers, although such a piece must come with a hefty disclaimer. We might be offering an expert’s view of such injuries but, as with just a remote assessment to go on, the views expressed here should not be taken as gospel or with any certainty. They are, however, hopefully of great interest and arm Fantasy managers with more information to help make their own judgements.

From next week, Facer will be posting his articles in person, but for this first week, I’ll hand you over to his debut “From the Physio” report.

New Arrivals

Nikica Jelavic
The initial injury to Nikica Jelavic occurred in the third minute against Newcastle, his trailing leg colliding with the post, at pace, as he attempted to score. The Croation forward’s right knee, specifically the Fibula head and the Tibial Tuberosity appear to take the full impact. This is a sensitive part of the knee as it serves as an attachment site for several muscles. More pertinently, it is also an attachment site for one of the main stabilising ligaments of the knee, the Fibular or Lateral Collateral Ligament (LCL). What is clear, at this point, is that the attachment site for the LCL took a crushing/compressive impact at some pace.

Immediately after the incident Jelavic can be seen clutching and rubbing his lower leg directly over the muscles of the Tibialis Anterior, Peroneus Longus and the Fibula Head. He is led from the pitch and Jelavic attempts to ‘run-off’ the soreness, but he is still struggling to put any meaningful weight on the knee. The striker returns to the fray at the end of the fourth minute with a pronounced limp still very evident. As the match time progresses he starts, progressively, to move with more freedom and less constraint and from the 17th minute he appears to be moving fluently. But, for me, he never quite regains full balance or mobility throughout the half.

In the 37th minute Jelavic is caught by a late challenge and can be clearly seen cupping the area perfectly over the region of the LCL. Two minutes later he appears to be running freely again and in the 40th and 41st minute executes two standing jumps, movements of impact that test the stability of the knee, and movements that would test the integrity of the LCL. Less than two minutes later he reaches down towards his LCL and appears unable to straighten his leg, he then collapses to the floor with no other player in the vicinity. At this point, again, he can be seen clutching his LCL (in fact, he cups the ligaments of the knee, as though offering additional external support). Tellingly, Jelavic now holds his knee at about a 40 degree angle, offering us a further diagnostic clue, as full extension of the knee stretches the LCL and would cause pain and discomfort, if injured. This is particularly true of the ‘closed-pack’ position of full extension at the knee joint, here joint stability is greatest and articulating bones have their maximum area of contact. Jelavic was helped from the pitch looking anxious and grimacing.

This whole scenario offers us several diagnostic clues. Two classic signs of a LCL sprain are immediate pain, but able to continue to play (if it were a muscle injury this would not be possible) and pain in the fully extended, closed pack position of the knee. Relative stability in the knee at this time would also differentiate this injury from a rupture. A further sign is “localised pain” as the ligaments of the knee do not refer pain and Jelavic can be seen clutching this area several times. Personally, I suspect knee ligament damage of minor to moderate severity and depending on the grade, Everton could find themselves without their star forward for anything from two to eight weeks, although current rumours on Twitter suggest it’s at the bottom end of that scale.

Benoit Assou-Ekotto
Reports emanating from White Hart Lane suggest that Benoit Assou-Ekotto may require surgery to alleviate a niggling knee complaint that has, apparently, been a source of discomfort for a number of weeks. The problem is reportedly a floating “foreign body” within the capsule of the knee joint, affectionately known in the trade as a “joint mouse”.

When this condition is suspected, conservative (non-operative) modalities are utilised initially to try to encourage macrophage activity to clear the problem. If unsuccessful then arthroscopic surgery (a type of ‘keyhole’ surgery) is required to remove the debris. In the case of Assou-Ekotto this procedure will be to alleviate pain rather than to correct knee instability. It’s a procedure that should only take about 30 minutes to perform and is minimally invasive, prompting shorter recovery times, but anticipate a minimum of three and more likely a four-week absence. If surgery is, indeed, required, expect it to have taken place this week. We’ve yet to have confirmation of that from Spurs.

Kyle Naughton slotted seamlessly into the left-back position at the weekend and looks the prime candidate to replace Assou-Ekotto were he to succumb to surgery, although Andre-Villas Boas also has the option of playing Jan Vertongen at left-back, a position he has played in several times for his country.

Fabio
A statement from Mark Hughes speculates that Fabio may be out of action for a number of weeks. If this is the case, we may infer that it is at least a grade 2 hamstring strain, indicating a best case scenario of just a few torn fibres with no disruption to the overlying muscle fascia. Observing him walk from the field, my first impressions are that it doesn’t look too serious.

Slight gait abnormalities were evident but his limp wasn’t overly pronounced. I’d anticipate only minor damage. It’s difficult to judge this one; modern footballers are usually more sensitive to injury pre-cursors (tightness, soreness) than the more traditional, so it may have been purely precautionary. It wouldn’t overly surprise me if he was fit for the weekend, which is slightly optimistic perhaps, but I suspect, barring tendon involvement, for him to be back within three to four weeks.

Carlos Cuellar
With the Carlos Cuellar conundrum we may offer a more upbeat assessment. During the first 15 minutes of the match against Liverpool, the Sunderland defender was not involved in any discernible impacts or incidents that would, from a physiotherapy perspective, raise alarm bells. He can be observed moving freely, without constraint, passing and performing several uni-lateral (one-legged) movements. Exhibiting perfect mechanical fluidity and fitness.

We can make further confident inferences based upon Cuellar’s resulting game incidents:

17:56 Minutes: A standing jump for a header, followed by a sharp turn with acceleration from a standing start.
22:25 Minutes: Here, you can witness Cuellar, with his shorts rolled up to resemble the ‘budgie smuggler’ model made famous by Speedo, practicing three or four ‘partial squats’. Now, I’m not sure what he was attempting to do but from a physiotherapy perspective it is quite enlightening, as the exercises were performed quickly and fluidly and at this point any hamstring problems would be quickly and painfully evident as the tissues become stretched with the movement.
23-25:00 Minutes: Still exhibiting perfect mechanical purity.
26:25 Minutes: Accelerating sprint, making an out-stretched sliding tackle, subsequent movements arouse no mechanical concerns.
35:00 Minutes: Standing maximal jump defending a corner.
40:00 Minutes: Turns and accelerates from a standing start.
41:34 Minutes: Freely moving, fluid and pure contractions evident. Balance and mobility appear normal.
43:56 Minutes: Long pass with limb extending fully, followed by acceleration
45:50 Minutes: Makes tackle.

The movements highlighted are important – broken down, they can form part of a battery of clearing tests to confirm a player match fit and are some of the most mechanically demanding match actions. Furthermore, Cuellar exhibits no sign of an antalgic gait (an abnormal form of gait where the stance phase is shortened relative to the swing phase and is a good indication of pain with weight-bearing). Hamstring muscles usually injure by either a forceful contraction or a direct blow and at no point in the half did I witness any incident that would raise a concern from a pitch-side physiotherapist perspective. Indeed, he shows no sign of any discomfort whatsoever throughout the half.

If any injuries were present the movements Cuellar performed would not be as pure or as fluid as he performed them. With this in mind we can only assume that Cuellar was subbed for tactical reasons or that the player reported some tightness or stiffness (injury pre-cursors) in the area. He does not appear injured and if not dropped, I’d personally expect him back this weekend.

Under Treatment

Wayne Rooney
On the September 14, Sir Alex Ferguson issued an update on the progress of Wayne Rooney, where he states that Rooney is progressing on course:

“He’s training very well but he’s not back in football training yet. All his work is being done with the physios at this point in time.”

From this we may infer that certain movements and impacts are still not permitted, twisting, turning and open-chain impact movements that put tremendous pressure on the knee joint are still off limits. This is important. The injury has not yet healed to a stage where intensive training can take place without risk of re-injury. It also suggests the new collagen (scar tissue) won’t have fully matured to its fullest strength and he still has “end-of-range” pain with passive over-pressure.

Reports today shine a further light, adding that Rooney started full-training on Tuesday and may be available for selection tonight for the Champions League tie. I personally doubt that he will be risked, having only just resumed full contact training, it’s always a gamble rushing someone back into action prematurely as it’s difficult to ensure that no subtle deficits persist that may lead to chronic injury.

Bearing in mind his genetic propensity towards endomorphism and the quicker than average fitness losses associated with that particular body and build, Rooney tends to need more matches than most to regain full-match sharpness. All things considered I’d wager that Rooney is still at least a couple of weeks away from full match fitness.