Lesson 6:-

Although the first thought in a football player with acute chest pain is usually towards cardiac causes, there are a number of life-threatening, non-cardiac, conditions that present with acute chest pain that need to be considered. It should be noted that football players with a potentially life-threatening cause of chest pain may appear initially relatively well, showing neither vital sign nor physical examination abnormalities. However, whatever the source of the chest pain may be, healthcare providers should always focus on the immediate detection of common life-threatening causes of chest pain and treat accordingly.

Primarily, “non-cardiac” causes of acute chest pain can to be differentiated by the origin of the pathology. Some of these non-traumatic, non-cardiac life-threatening medical emergencies are listed below and are included mainly for information and completeness.

Acute aortic dissection:-

The most critical cause of severe aortic-type chest pain is acute aortic dissection. In a football player, this would usually be due to congenital abnormalities, hypertension or connective tissue disease. One example would be a dissection which occurs in a player with Marfan syndrome. The event that may precede a fatal tear or dissection may be due to simple blunt trauma to the chest.

Acute pulmonary embolism:-

Although pulmonary embolism (PE) is thought to be a rare life-threatening field-of-play medical emergency, the exact incidence is unknown. However, its existence is always possible because of the frequent travel, that may increase the risk of PE above that of normal.

Exercise-induced bronchospasm:-

While shortness of breath and wheezing are more common symptoms associated with exercise-induced bronchospasm (EIB), players may also experience chest pain. This diagnosis is considered in more detail in the respiratory module.

Tension pneumothorax:-

A tension pneumothorax is a medical emergency. In a football setting, it is frequently associated with a rib fracture. The presentation and management of this condition is considered in more detail with “chest injuries” later in this module.

Inflammatory or infectious:-

Pleuritis, pneumonia, bronchitis and mediastinitis are rare on the field of play because signs and symptoms would have presented prior to the match or competition.

Treatment

Player should be removed from the field of play and advised against further physical exercise. They may require analgesia or antipyretic drug therapy. They should be treated symptomatically and transferred urgently to the nearest, most appropriate medical facility if clinically unstable.

Acute gastrointestinal conditions:-

As the cardiac system and the oesophagus share some common neurologic innervations, acute pathology in either system can present with classical symptoms of chest tightness, provocation by exercise and pain-release by rest or nitrates. 

As such, it may be difficult to distinguish clinically between cardiac chest pain and pain originating from the gastrointestinal system. Common, or more significant, gastrointestinal conditions include gastro-oesophageal reflux, oesophageal spasm, oesophagitis and spontaneous oesophageal rupture.

Symptoms and signs

Players with gastrointestinal conditions may experience chest pain, painful swallowing, tachypnoea or dyspnoea. Cyanosis, fever and shock may develop rapidly when there is a more significant problem.

Treatment

The player should be removed from the field of play and advised against further physical exercise. One should obtain intravenous access and administer fluids as required. The player should otherwise be treated symptomatically and, if clinically unstable, transferred urgently to the nearest, most appropriate medical facility.

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Blue Tigers defender Adil Khan feels Indian Football is moving forward and growing on “the right path” that corroborates its new motto – “Indian Football. Forward Together”.

“Indian Football is growing in a good way and through the correct path. I just wish (Indian football) keeps growing the way it has been and tries to maintain the quality,” the 32-year-old defender expressed during an AIFF TV interview, a year after he faced off with neighbours Bangladesh at the Salt Lake Stadium, Kolkata.

He praised the authorities for resuming football actions in the country in the aftermath of the Lockdown that was enforced owing to the COVID-19 pandemic.

“It is great! After more than seven months without any football activity, we’re back to the pitch once again. I followed the Hero I-League Qualifiers closely and have noticed the positive buzz around it – that’s fantastic. Kudos to the AIFF for bringing back sports, let alone football, move one step closer to normalcy.”

He further added, “It was difficult for everyone who is connected to football – supporters, owners, players and every single stakeholder. Our pre-season has also started. I am very excited and hopefully, everyone is.”

Following an aggravated injury that had halted his footballing career, Adil came back strongly to appear for the Blue Tigers after a seven-year hiatus. The sturdy central defender lauded the changes that have been brought into Indian Football to move things ahead, as players can now avail better infrastructure.”During my initial days, there was a dearth of quality grounds. Infrastructures, facilities have improved immensely since then. These things always help a player perform to their true potential. That has helped Indian players perform in a better way,” stated Adil.

“Earlier, teams used to depend heavily on foreigners to churn out results. But, the scenario has changed of late. Indians have been taking responsibilities and proving their worth. They are scoring goals, providing assists, taking guards in the defensive half, tackling with more conviction – only to take Indian Football forward,” the 32-year-old opined.

आप सभी मेरे साथ जुड़ सकते हैं नीचे दिए गए लिंक पर जाकर और अपने विचार रख सकते हैं। धन्यवाद 🙏

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अच्छा कोच या गुरु कैसा हो? ऐसा जोकि अपने विद्यार्थियों को प्यार दुलार से समझाए या ऐसा जोकि ज़रूरत पड़ने पर विद्यार्थियों और खिलाड़ियों पर लात घूँसे बरसाए, गालियाँ दे! आज की शिक्षा पद्वति के हिसाब से शिक्षक यदि किसी छात्र-छात्रा पर ज़रा हाथ उठा दे तो उसकी नौकरी ख़तरे में पड़ जाती है। इसी प्रकार यदि कोच अपने किसी खिलाड़ी को डाँट दे तो उसकी खैर नहीं। लेकिन भारतीय महिला हॉकी में एक ऐसा कोच हुआ है, जिसने पुरुष खिलाड़ियों के साथ साथ महिला खिलाड़ियों को भी जमकर पीटा, गालियाँ दीं और ज़रूरत पड़ने पर सरे राह उन पर हाकियाँ भी बरसाईं।

यह बदमिज़ाज और बदतमीज़ कोच बलदेव सिंह है, जिसने भारतीय महिला हॉकी को 80 के लगभग अंतरराष्ट्रीय खिलाड़ियों से सुसज्जित किया, जिनमें से सात ने भारत की कप्तानी की। वर्तमान कप्तान रानी रामपाल, नवजोत, नवनीत, मोनिका, रीथ, मनप्रीत आदि लड़कियाँ भी उसकी शिष्या हैं। ऐसे सिरफिरे कोच को जब 2009 में द्रोणाचार्य सम्मान मिला तो जलने वाले खूब जले। लेकिन ज़्यादातर ने कहा,”कोच हो तो बलदेव जैसा”।

हॉकी प्रेमी जानते हैं कि हॉकी जगत में नेहरू हॉकी टूर्नामेंट सोसाइटी का नाम बड़े आदर के साथ लिया जाता है। 1964 में पहले सीनियर नेहरू टूर्नामेंट की शुरुआत हुई थी लेकिन तीस साल बाद जब बालिकाओं के अंडर 17 टूर्नामेंट का बिगुल बजा तो इसे भारतीय महिला हॉकी में एक नई क्रांति की शुरुआत माना गया। जिस हरियाणा की लड़कियों को आज कुश्ती और मुक्केबाज़ी में अव्वल माना जाता है, उसकी लड़कियों ने मान सम्मान कमाने की दिशा में बड़ा कदम हॉकी खेल कर बहुत पहले उठा लिया था।

जहाँ तक हरियाणा में हॉकी क्रांति की बात है तो शुरुआत शाहबाद मार्कंडा के श्री गुरु नानक प्रीतम गर्ल्स स्कूल से हुई। साई कोच बलदेव सिंह ने गन्ना मजदूरों, रेहड़ी पटरी लगाने वालों, रिक्शा और ऑटो रिक्शा चलाने वालों की बेटियों को हॉकी सीखाने का जिम्मा उठाया। दो साल बाद जब 1994 में शाहबाद स्कूल की लड़कियाँ शिवाजी स्टेडियम में नेहरू बालिका टूर्नामेंट में खेलने उतरीं तो किसी ने सोचा नहीं था कि सिर पर चुनरी ओढ़ने वाली लड़कियाँ राँची, राउरकेला, दिल्ली, पंजाब, चंडीगढ़, लखनउ की टीमों को हराते हुए फाइनल में जा चढ़ेंगी।

अंततः ख़िताबी मुक़ाबले में राँची के स्कूल से हार कर उपविजेता बनीं। कोच बलदेव ने मीडिया के सामने अपनी टीम की लड़कियों को भद्दी गलियाँ दीं, जिन्हें सुनकर हॉकी प्रेमी हैरान थे। इतने से भी दिल नहीं भरा तो कोच ने तालकटोरा स्टेडियम से सटे पुलिस अधिकारी किरण बेदी के निवास के समीप अपनी कुछ लड़कियों की हॉकी स्टिक से पिटाई कर डाली। तमाशा देख रहे आम लोगों ने बलदेव को बुरा भला कहा। उन पर केस करने की भी बात चली।

बलदेव का यह रूप देख कर मीडिया भी हैरान था। नेहरू सोसाइटी के सचिव शिव कुमार वर्मा और डाक्टर केजी कक्कर से सवाल जवाब हुए लेकिन कोच ने माफी नहीं माँगी।
बलदेव के तेवर देख कर क्लीन बोल्ड का कौतूहल जाग गया, शाहबाद स्कूल स्थित साई अकादमी का दौरा तय हुआ। वहाँ जाकर देखा कि शाहबाद की लड़कियाँ लड़कों की टीम से मुकाबला कर रही थीं।

चूँकि मुकाबला बराबरी पर ख़त्म हुआ, इसलिए बलदेव अपनी लड़कियों को उनके माँ-बाप की मौजूदगी में हॉकी से पीट रहे थे। खूब गलियाँ भी दे रहे थे। लेकिन किसी को भी कोच के रवैये से एतराज नहीं था। कुछ ग़रीब अभिभावकों के अनुसार कोच साहब उनके परिवारों के लिए भगवान का अवतार बन कर आए थे। साई से सेवानिवृत होने के बाद वह फतेहगढ़ साहिब में खिलाड़ियों की फ़ौजें तैयार कर रहे हैं। शाहबाद के बाद अब उन्होने फ़तहगढ़ साहिब और अमृतसर को महिला हॉकी का गढ़ बना लिया है।

1997 में शाहबाद ने पहली बार नेहरू बालिका खिताब जीत कर अपने विजय यात्रा की शुरुआत की। 16 बार विजेता, चार बार उपविजेता, तीन बार ख़िताबी तिकड़ी बनाई। बलदेव को बार बार श्रेष्ठ कोच आँका गया। इसके साथ ही हरियाणा ने राष्ट्रीय हॉकी में भी मजबूत कदम रखा। सालों साल हरियाणा और रेलवे के बीच राष्ट्रीय हॉकी के फाइनल खेले गए। रेलवे का पलड़ा इसलिए भारी पड़ता क्योंकि बलदेव की शाहबाद अकादमी की तमाम खिलाड़ियों को रेलवे ने अपने बेड़े में शामिल कर लिया था। इतना सब होने के बावजूद भी उसने गाली देने और खिलाड़ियों को सरे आम पीटने का सिलसिला जारी रखा।

यह बलदेव की गालियों का ही चमत्कार है कि उनके द्वारा तैयार खिलाड़ी भारतीय रेलवे और अन्य विभागों में उच्च पदों पर हैं, हज़ारों लाखों कमा रही हैं, देश के बड़े से बड़े खेल सम्मान पा रही हैं और उनके माता पिता कहते हैं कि जो कुछ पाया, सर की गालियों से मिला है।जब वह गाली नहीं देते, बेटियों को हॉकी से नहीं पीटते, बहुत बुरा लगता है। ऐसा प्रतीत होता है जैसे हम से नाराज़ हों।

🗣️ आप सभी मेरे साथ जुड़ सकते हैं नीचे 
दिए गए लिंक पर जाकर और अपने विचार रख सकते हैं। धन्यवाद 🙏

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Lessons 4:-

Abdominal injuries in football are an uncommon event; however, they appear to be happening more frequently. Abdominal injuries do not present as obviously as many orthopaedic injuries, because of the internal and concealed locations of the intra-abdominal organs. A high index of suspicion and knowledge of the mechanism of injury may contribute to the earlier diagnosis of acute, serious abdominal injuries.

Blunt trauma to the abdomen may cause injury to the solid organs of the abdomen, namely the liver, spleen or possibly a kidney, resulting in intra-abdominal haemorrhaging.

 This can potentially be life threatening, depending on the extent of the haemorrhage. The injured player may present with relatively modest pain initially and over time develop hypovolaemic shock as the haemorrhage increases. The hollow organs (e.g. the jejunum colon and duodenum) can also be injured.

History:-

Pain may occur after an abdominal injury, but this does not always occur. Pain may not occur until signs of peritonitis develop hours after the injury.

Examination:-

The traditional examination of the abdomen, including inspection, palpation, percussion and auscultation, may reveal bruising, tenderness, guarding and loss of bowel sounds. The player should be assessed for evidence of shock, although signs can develop over time. This is especially common following the rupture of a hollow organ. Serial physical examinations have been shown to be a sensitive way to detect early intra-abdominal haemorrhage and are a practical way to assess these players.

Investigations:-

In general terms, any player who is suspected of having an injury to an intra-abdominal organ should have a CT scan. Ultrasound scans, including FAST scans, can be a helpful initial study. X-rays are not generally useful but may show pneumoperitoneum or obliteration of the psoas shadow (when there is a retroperitoneal haematoma). Baseline blood tests, including a cross match, should be taken. It is important to especially consider the patient’s haemoglobin.

A mid-stream urine test is also useful when an injury to the genitourinary tract is suspected.

Treatment:-

Injured players in hypovolaemic shock are managed like any other patient in shock with protection of the airway, supplemental oxygen administration, if present, intravenous access and limited crystalloid administration sufficient to maintain a blood pressure at 90mmHg and an appropriate diluted, titrated infusion of an intravenous analgesia with emergent transfer to hospital. Hypotensive resuscitation is preferred in such patients, because injudicious use of large quantities of intravenous crystalloids may result in increasing the blood pressure at the bleeding site and worsen the bleeding. Therefore, the sooner the player is transferred to hospital and under the care of a surgeon the better.

Once a diagnosis has been made, a decision must be made about whether the injury requires surgical management. In many cases, liver and spleen injuries can be managed non-surgically.

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Lesson 3:-

Severe anaphylaxis is an acute life-threatening allergic reaction. The risk of anaphylaxis in the football environment, both on and off the field of play, needs to be appreciated. Known trigger factors include food, medications, hymenoptera stings, fever and infections (such as upper respiratory tract infection). The risk of anaphylaxis may also be increased by “cofactors” that include non-steroidal anti-inflammatory medications (NSAIDS), exercise and alcohol. All of these precipitants may be relevant to the football environment. Travel into unfamiliar environments, particularly with regard to the consumption of food and drink, may increase the risk of severe allergic reactions.

The ability to recognise and manage anaphylaxis must be within the scope of team doctors and football stadium medical services.

History and examination

Prompt recognition and immediate treatment is essential in anaphylaxis. The following clinical criteria, adapted from the World Allergy Organisation Guidelines, are relevant within the football environment.^1-3

Anaphylaxis must be considered when any one of the following clinical criteria is present:

Acute onset of illness involving the skin, mucosal tissue or both (e.g. general urticaria, itching, redness, swollen lips, tongue or uvula)

AND

At leastoneof the following clinical syndromes:

• Respiratory – dyspnoea, wheezing, stridor, hypoxaemia
• Cardiovascular – reduced blood pressure, syncope, collapse

OR

Twoor more of the following syndromes that occur rapidly after known or possible exposure to a likely allergen:

• Acute onset of illness involving the skin, mucosal tissue or both (e.g. general urticaria, itching, redness, swollen lips, tongue or uvula)
• Respiratory – dyspnoea, wheezing, stridor, hypoxaemia
• Cardiovascular – reduced blood pressure, syncope, collapse
• Gastrointestinal – severe cramps, abdominal pain, vomiting

OR

Reduced blood pressure after known or possible exposure to a likely allergen:

• Children – low systolic blood pressure or greater than 30% decrease from normal for age.
• Adults – systolic blood pressure less than 90mmHg or greater than 30% decrease from normal for the person.

Treatment

The key to the successful treatment of severe anaphylaxis in the football environment is early identification, an appreciation of its life-threatening consequences and initiating immediate treatment with adrenaline/epinephrine.

In any situation where any of the above clinical signs or symptoms occur in the context of a possible allergic reaction to food, medications, hymenoptera stings (e.g. bees) or other chemicals, always consider the possibility of anaphylaxis immediately. It is always better to treat the player early rather than await clinical deterioration, as hesitation in the treatment of severe anaphylaxis can be fatal.

The mainstay of treatment of severe anaphylaxis is the administration of epinephrine (adrenaline) by intramuscular administration into the antero-lateral thigh (vastus lateralis).

Epinephrine (adrenaline):-

If an auto-injector (e.g. an EpiPen™) is available, it is used by thrusting the device appropriately against the antero-lateral thigh. This can be done through clothing if necessary. The pen should be held against the thigh for at least 10 seconds to allow full intramuscular injection of the intended epinephrine dose (0.3mg in an adult injector or 0.15mg in a child injector).

If epinephrine is only available in ampoule form as a 1:1000 (1mg/ml) concentration (or repeated doses of epinephrine are required without an additional auto-injector being available), administer 0.5mg (equal to 0.5ml of the 1:1000 epinephrine) intramuscularly (IM) into the antero-lateral thigh in an adult or 0.3mg in a child. Before injecting the epinephrine into the thigh muscle, withdraw the syringe plunger to ensure that the needle is not in a vein, as intravenous concentrated Epinephrine injection can have serious cardiac effects.

If severe symptoms continue after epinephrine IM injection, repeat the dose every five minutes. An ambulance should be called (if not already on site).

If, after epinephrine administration, the patient remains hypotensive (i.e. there is no radial pulse), position the patient supine and elevate the legs. Establish intravenous access as soon as practically possible and consider administering normal saline, or equivalent solution, in order to obtain a systolic blood pressure of 90mmHg minimum. Colloids may be considered, although there is no evidence to substantiate their use. Note that up to 50% of the intravascular volume can be lost within ten minutes in severe anaphylaxis, thus initially requiring potentially large volume replacement.

Beta-2 agonists:-

In the presence of anaphylactic-induced bronchospasm, in addition to epinephrine administration, consider the use of β2-agonist inhalation, either by an inhaler and spacer or via oxygen-powered nebulisation. This treatment can be repeated as often as necessary.

Antihistamines:-

There is no evidence that the administration of antihistamines in severe anaphylaxis has any beneficial effect in the initial management. As a result, it is not suggested as part of the immediate response. Once the patient has been transferred to the nearest, most appropriate emergency department, the use of an antihistamine can be considered after a full medical history and examination has been undertaken, possibly for the relief of urticaria and itching symptoms.

Glucocorticoids:-

There is no evidence that the administration of glucocorticoid medications in severe anaphylaxis has any beneficial effect in the initial management. As a result, it is not suggested as part of the immediate response. Its administration, once the patient has been transferred to the nearest, most appropriate emergency department, can be considered after a full medical history and examination has been undertaken.

The patient should be transferred to the nearest, most appropriate medical facility as soon as possible after the initial dose of epinephrine/adrenaline has been administered, so that further support may be administered by the emergency department, if and when necessary.

Follow-up

Discharge follow-up and educational strategies to prevent further occurrences and treat possible future events may be required from sports healthcare professionals overseeing the healthcare of the team member, where relevant.

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A total of 19 clubs have applied for National and AFC club licences for the 2020-21 season, out of which 8 are from I-League and 11 are from ISL. The result of National and AFC Club licensing applications for the 2020-21 season made by ISL clubs have been announced yesterday and they are as follows :

FC Goa, ATK Mohun Bagan FC, Bengaluru FC, Jamshedpur FC, Chennaiyin FC and Mumbai City FC have successfully secured the AFC and National licences for the 2020-21 season.

Odisha Football Club, NorthEast United Football Club, Kerala Blasters Football Club, Hyderabad Football Club and Sporting Club East Bengal have failed to secure the AFC and National licences for the 2020-21 season. These clubs can now either prefer an Appeal to the Club Licensing Appeals Body of AIFF against the decision of the Club Licensing Committee – First Instance Body’s decision within the stipulated time or can apply for an Exemption to the Club Licensing Committee – First Instance Body’s decision within the stipulated time to participate in National Club Competitions in the 2020-21 season.

Owing to the current situation, the Asian Football Confederation have been considerate enough to accommodate criteria exception and deadline extension requests made by AIFF throughout the licensing cycle of 2020-21 season. As a result of it, many criteria were exempted from fulfilment and the deadline too were extended multiple times, with the Final deadline being 9th November 2020 for all 19 licence applicants of the 2020-21 season.

Due to paucity of time along with the no. of licensing reports up for evaluation and owing to the league schedule of the ISL, the Club Licensing Committee – First Instance Body have delivered their decision for ISL clubs only for now. The decision on the club licensing application of 8 I-League clubs will be taken soon.

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Lesson 2:-

All football players with a suspected or clinically symptomatic spinal injury must be adequately and appropriately stabilised to prevent neurological injury to the spinal cord or further injury. This means that all healthcare staff on duty should be fully trained in the recognition, evaluation, treatment, stabilisation and transfer of the head and/or neck injured player. The correct equipment must also be available (rigid spinal board, scoop stretcher or Stokes-type basket stretcher or vacuum mattress).

Please note that use of the traditional “NATO”-type soft stretcher is no longer acceptable on the field of play. A hard cervical collar is also no longer recommended.

The basic principles of spinal column stabilisation comprise the following actions:

1. Carefully, gently and slowly, realign the head into the neutral position relative to the spine and maintain this position thereafter. If this slow, gentle realignment causes any neck or spinal pain, muscle spasm, abnormal neurological signs or symptoms, offers resistance or compromises the integrity of the airway, then immobilise the head in the position found and transfer as such to hospital on an appropriate stabilisation device at hand.
2. Once the head has been adequately realigned and stabilised, carefully, gently and slowly align the entire spinal column into the neutral position, following the same principles as stated above.
3. If the player is lying on their back (supine), the player needs to be stabilised on a long, rigid, spinal-type board (RSB). This may be undertaken by a careful, gentle and coordinated log-roll manoeuvre to turn the player onto their side, placing the RSB behind the player’s back and then performing a careful, gentle coordinated log-roll to move the player onto the RSB in the supine position for stabilisation. Alternatively, the player may carefully, gently and with coordination be lifted off the ground by a team straddling the player while an RSB is slipped under the player, who is then gently lowered onto the RSB.
4. All players strapped to a stabilisation device should be strapped sufficiently securely so that the device can be urgently turned into the lateral position if the player vomits, without creating excess movement of the spine as a result.
5. If the player is lying on their side (lateral), an RSB can be positioned behind the player’s back and the player is then carefully, gently log-rolled onto the RSB into the supine position for stabilisation.
6. If the player is lying face down (prone), a number of careful, gentle coordinated steps are required by the medical team to first realign the head into the neutral position, then log-roll the player onto his/her side, and finally log-roll the player onto a RSB into the supine position for stabilisation.
7. Once the player has been adequately and appropriately aligned in the supine position, anatomically neutral onto an stabilisation device, manual cervical spinal stabilisation should be converted into external stabilisation using external devices (e.g. foam-based head blocks).

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Lesson 1:

The management of significant trauma or medical conditions is complex and beyond the scope of this module. It is essential that a team doctor, stadium doctor or other clinicians working in football have a clear process for the assessment of medical and trauma emergencies. Having the appropriate equipment on site is also essential. The FIFA Medical Emergency Bag contains the equipment needed to manage the more common medical and trauma emergencies which might occur on the field of play.

It is always important to make sure that you have help. As soon as you suspect that you are dealing with a more significant problem, your first action should be to call for help. This usually means calling an ambulance if there are no other healthcare providers on site.

A basic approach involving a “primary survey” is outlined below. This involves treating the greatest threat to life first. The lack of a definitive diagnosis should not delay the treatment of life (or limb) threatening conditions.

Safety:-

An important part of the administration of any medical support is the safety of all people involved. The first active role of the clinician is to ensure their own safety and then the safety of the persons who require treatment. If the field is not safe to enter, for whatever reason, do not enter the field until it has been declared safe by the referee or local security personnel.

The risks on any football field are going to be reasonably well controlled. It is always worth taking a few seconds to make sure the area is safe and, if necessary, stop the match or training session while first aid treatment is carried out.

• Safety issues specific to a football pitch include:
• Other players – there may be arguments going on among opposing team players
• Spectators – pitch invasion by spectators, throwing of missiles onto the field of play
• Unsuitable pitch conditions – uneven or slippery surfaces
• Adverse weather conditions – e.g. lightning

It is also important to protect yourself from potentially contaminated body fluids. Use gloves and consider the use of eye protection and other protective clothing. The FIFA Medical Emergency Bag (FMEB) contains gloves and a pair of goggles.

Airway:-

The first stage of the assessment is to assess the player’s airway – with cervical spine protection. Look inside the player’s mouth to assess if anything is blocking their airway. Examples of items that may block a player’s airway on the field of play include the following:

• A loose and poor fitting mouthguard
• blood or vomit in the mouth
• broken and loose teeth
• mud (especially if the ground is wet and the player falls face down)

The airway can be opened by tilting the head backwards if there is no potential of a neck injury being present. If there is suspicion of a neck injury or trauma involved, then lift up the chin or do a jaw thrust. Any obvious obstructions should be removed if they are clearly visible and to the front of the mouth, use the Magill forceps from the FMEB. Do not place your fingers inside their mouth. If it is not possible to protect the airway using these simple manoeuvres, it may be necessary to insert an “airway adjunct” from the FMEB. If the player is on their side, you should leave them there until help arrives. If the player is prone, gently turn their head to the side enough to enable breathing. If the player is unconscious, they should be placed on their side (not their back).

The FIFA Emergency Medical Bag contains laryngeal masks, nasopharyngeal tubes and Guedel airways. There are also a ventilation bag and masks.

Breathing:-

Use a stethoscope to assess the player’s breathing. Remember that players who have suffered a sudden cardiac arrest may be breathing normally.

The aim of this assessment is to identify and manage six life-threatening thoracic conditions. These are: airway obstruction, tension pneumothorax, massive haemothorax, open pneumothorax, flail chest segment with pulmonary contusion and cardiac tamponade. Most of these conditions are rare in football.

If the player is breathing normally, continue with the assessment. If they are not breathing, CPR should be initiated.

Circulation:-

Look for and stop any external bleeding. Haemorrhage is the predominant cause of preventable post-injury deaths. If there is bleeding, applying direct pressure is the first response. Deep and firm direct pressure is applied to control the bleeding. Cover the area with your gloved hand and a (sterile) towel (if you have one).

One must also consider the possibility of internal bleeding. Tachycardia or reduced blood pressure may be the only sign of this.

The FIFA Medical Emergency Bag contains equipment to manage bleeding, including a variety of gauzes and tape for the compression of wounds. There is also a blood pressure cuff and stethoscope. An infusion set, tourniquet and IV lines are included and can be used to deliver IV fluids to support the player’s circulation.

Disability:-

A basic neurological assessment should be made, known by the mnemonic AVPU (alert, verbal stimuli response, painful stimuli response, or unresponsive). This is achieved by noting whether:

• the player is fully alert and responsive to you
• the player is not alert but is responsive to your voice
• the player is not alert but does respond to your touch or to a painful stimulus e.g. earlobe squeeze
• the player is totally unresponsive – does not respond to any of the above

Hypoglycaemia and drugs, including alcohol, may influence the level of consciousness. The FIFA Medical Emergency Bag includes a glucometer which can be used to assess blood glucose.

Exposure and examination:-

You cannot treat what you cannot see. You must be able to see the injury in order to be able to effectively treat it. Injuries may be hidden under the player’s clothing.

Expose the relevant injury by removing as much clothing as necessary to look for underlying injuries. You must also consider whether removing the players clothing is going to create more issues. For example, this may predispose them to becoming cold and developing hypothermia. It is also important to consider the player’s privacy.

Consider the player’s medical history that you are aware of so that you can pass this information on to the ambulance staff on arrival.

Once these steps have been completed, resuscitation efforts are underway and the player is stabilised (vital signs are normalising), a further evaluation (secondary survey) should be conducted. This involves a head-to-toe evaluation of the player, including a complete history and physical examination and a reassessment of all vital signs. In a football context, this can be done in the medical room or changing room before transfer to hospital. Each region of the body must be fully examined. During this phase, X-rays may be obtained. If at any time during the secondary survey the patient deteriorates, another ABCDE assessment must be carried out as a potential life threat may be present.

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A number of relatively minor complaints can have a surprisingly large impact on a player’s ability to perform to their maximum potential. Many of these complaints can be effectively prevented through education, training or with minor treatments. It is important to develop an approach to managing these issues if you are going to be involved with a football team and provide touchline medical care.

Ear, nose and eye problems can be significant and have an impact on a player both in the short, medium and long term. While a clinician should be prepared to manage the more minor conditions, it is essential that they are able to identify the more significant issues and to seek further review when needed.

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Lesson 9:-

There are a number of injuries that involve the ear that can occur during football. Some of these require prompt management to ensure that they do not cause ongoing deformity of dysfunction.

Cauliflower ear: This term refers to a haematoma between the skin and perichondrium (also known as traumatic auricular haematoma). If not treated appropriately, this type of injury can lead to lifelong deformity. The haematoma can become fibrotic within two weeks.

Initial treatment involves the use of ice and compression. Definitive treatment involves aspiration of the haematoma followed by direct compression with blue-tack/silicon or collodion-soaked gauze. To aspirate the haematoma, use a 20 gauge needle (or similar). After this has been done, the blue-tack should be used to attempt to preserve the normal shape of the ear. The player should then be examined daily to check their progress and to ensure that there has not been any recurrence. There is a small risk of infection with S.aureus or pseudomonas.

Otitis externa: This condition is common among those who swim or who train frequently in a pool. While it is generally caused by a bacterial infection, it can also be caused by a fungal infection. Players most commonly present with a painful and itchy ear. There may also be a discharge and in some cases impaired hearing.

On examination, the canal appears erythematous and a discharge may be observed. Tragal compression or tugging classically causes the player pain.

Treatment involves the player avoiding rubbing, scratching or Q-tips. Keeping the ear dry and the use of topical alcohol, oil or antibiotic drops are also generally useful strategies. Keeping one’s head above the water while in the pool is a good preventative strategy while topical alcohol applied after swimming, effectively dries the canal and prevents recurrence.

Tympanic membrane rupture: This typically happens after a direct blow to the ear or head. The player most commonly presents with pain, reduced hearing and sometimes bleeding. The player should be assessed with an otoscope to define and document the injury (and the size of the injury).

The majority heal with conservative management over two weeks. Treatment might involve the following:

• try to avoid any topical eardrops (due to risk of ototoxicity);
• keep ear dry (be especially careful with soapy water as it is more likely to enter the canal due to a reduced water tension);
• oral antibiotics might be used (amoxicillin is a good choice);
• consider an ENT review when the defect is large.

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Lesson 8:-

The nose is the most common facial bone to be fractured. The injury involves the nasal septum. This structure is composed of the vomer, the nasal bone and the cartilaginous quadrangular cartilage. A blow to the inferior nose is more likely to injure the cartilagenous septum. A lateral blow is more likely to injure the nasal bones (superior 1/3 of the nose).

Nose bleeding (or epistaxis) is a relatively common occurrence (and may be due to many different causes). The source of bleeding is rarely visible. This can be difficult to manage on the field of play. Direct compression, the application of Vaseline or packing the nose can all be good strategies. Topical decongestants (like Otrivine) can also be used to help reduce bleeding. Off-the-pitch cautery, using a silver nitrate stick, might be needed.

Examination: Ask the player and their friends whether they feel that their physical appearance has changed. Inspect the external nose and internal structure using a nasal speculum. Careful palpation of the bony structures about the face, an assessment of facial sensation and checking visual fields and eye movements are all important. Always remember to assess for associated injuries.

When inspecting the nose, it is especially important to look for a septal haematoma. Failure to identify these can lead to long-term deformity and morbidity. Haematomas can be confused with the inferior turbinate, especially when they are bilateral. When probed, a haematoma is soft as compared with the firm texture of the neighbouring nasal septum. Haematomas need drainage and packing by an ENT surgeon.

Investigations: In cases where a “simple” nasal fracture is suspected, no imaging is needed. Facial X-rays are generally not helpful as they have poor sensitivity and specificity and are frequently confusing. Facial CT is much more reliable when a more significant bony injury (i.e. a facial fracture) is suspected.

Treatment: It is almost always acceptable to treat the player with regular decongestants and review in two days. In the acute setting, where significant deformity exists, consider closed manipulation using a gloved hand. There is, however, no good evidence favouring early reduction of simple nasal fractures.

In most situations, it is usually preferable to allow several days for any swelling to improve. Reduction should be done within 5-10 days. This can be done by both open and closed methods.

Return to play following nasal fracture: Best practice in this area is somewhat debatable. In most cases, fracture healing occurs within three weeks. Ideally, the player should avoid contact during this time. Some athletes will, however, decide to accept the deformity and continue playing. Thermoplastic facemasks can be used to help protect the injury.

Any septal deviation can be treated as a delayed procedure. This may be required for cosmetic and functional reasons.

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Lesson 7:-

Injuries to the eye have not been considered elsewhere in this diploma course. Despite this, injuries to the eye are relatively common – and are largely preventable. It is important to have an awareness of common injuries and to have an approach to managing them. It is very important to be able to recognise indications for further evaluation.

Read more about how to approach an eye injury, or problem, in a football player.

History: The mechanism of injury can help to determine the probability of serious problems being present. High-velocity trauma (such as a punch or elbow to the eye) has the potential to cause a penetrating eye injury or orbit fracture (and should be taken very seriously). Dust from other foreign material falling, blowing or being rubbed into the eye will most likely result in a corneal abrasion. This is a common complaint in beach soccer (where sand frequently causes eye irritation). If there has been no associated trauma, consider possible infectious causes.

Examination: It is essential that the player’s visual acuity is adequately assessed (and documented). Normal acuity does not however exclude injury. The eye should be closely inspected, looking for changes in pupil shape, evidence of bleeding (including conjunctival haemorrhage or hyphaemia). Reactivity to light should also be observed. Eye movements should be checked and visual fields should also be assessed. There may be reduced upwards gaze (due to an entrapped inferior rectus following an orbital floor blowout fracture). Palpate for tenderness and assess facial sensation (a blowout fracture can also cause infra-orbital paraesthesia). The fundus should also be assessed with an ophthalmoscope, although this can be challenging in many football environments.

Treatment: Any player who is found to have reduced acuity, restricted eye movements, severe pain or persisting blurring should be referred for an assessment. Similarly, any player who has a hyphaemia, suspected penetrating injury, globe rupture or who is thought to have a retinal haemorrhage or detachment should be immediately referred for an assessment. More minor injuries, like a corneal abrasion, might be treated with lubricating eye drops, in some cases antibiotic eye drops or ointment or with padding of the eye.

Eye conditions are typically related to trauma, infection or allergic conditions. Dry eyes, especially following international travel, are a common complaint.

You should have equipment to assess and treat eye complaints in your medical bag (or stadium medical room). Suggested medications and equipment include:

• Ophthalmoscope
• Local anaesthetic eye drops (e.g. Minims amethocaine drops)
• Eye patches
• Cotton buds for everting the eyelid
• Chloramphenicol ointments and antibiotic eye-drops (e.g. tobramycin, gentamycin)
• Antihistamine eye-drops (e.g. emadastine difumarate, levocabastine, azelastine hydrochloride)
• Steroid drops (e.g. hydrocortisone, prednisolone, dexamethasone)
• Normal saline drops
• Tears Naturale eye drops

Common Injuries

Clinicians should be aware of the some of the more common eye injuries and have an approach to managing them. Learning the specific details of these injuries is beyond the scope of this course.

Click on the following tabs to read some further information about each of these conditions.

Corneal abrasion, Lacerations Sub-conjunctival haemorrhage, Hyphaemia, Retinal haemorrhage and detachment Penetrating eye injury Orbital injuries.

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Lesson 6:-

Some women have significant pain and morbidity associated with their menstrual cycle. This can have a significant effect on their ability to play and train. It is a very common complaint among female football players and is often not well managed.

Dysmenorrhea can be classified as either primary or secondary based on the absence or presence of an underlying cause. Secondary dysmenorrhea is dysmenorrhea that is associated with an existing condition. In younger players, painful periods often occur without an underlying problem. In older women, however, it is more often due to an underlying issue (such as uterine fibroids, adenomyosis or endometriosis). 

Further assessment or investigations are more likely to be needed in this group. The most common cause of secondary dysmenorrhea is endometriosis.

In most cases, the diagnosis of a dysmenorrhoea is based on a woman’s history and examination. In some cases, a pelvic ultrasound can also be helpful.

Learn more about the treatment of dysmenorrhea in football players.

Symptom: controlWhen faced with a player who has dysmenorrhoea, simple strategies can be used to try to manage their symptoms. NSAIDs are widely prescribed and can be used before training or matches. Heat (a hot water bottle for example) is another useful strategy – but is obviously not practical during training or matches.

Prevention: The oral contraceptive pill (OCP) can be used as a mean of trying to prevent menorrhagia. These treatments work by thinning the lining of the uterus, where prostaglandins are formed, which then reduces uterine contractions and bleeding. The OCP also gives the player the ability to control their menstruation and can also potentially improve the symptoms associated with their period. They may elect to skip the inactive pills if there is an important match or even which coincides with their period.

It is very important that the player’s suitability for the OCP be considered, that all possible side-effects are outlined prior to the medication being started, and that the contraceptive effects be clearly explained.

No negative effect on performance has been found from OCP use. ⁷ It is, however, important to realise that individuals respond to the OCP differently. As a result, the OCP use should not be started close to a major event.

Some players do not like taking the OCP, or do not have a satisfactory response from this treatment. Another option which might be considered is a Mirena intra-uterine device (IUD).

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Lesson 4:-

Bleeding wounds, from abrasions and lacerations, can occur during football matches. Skin wounds are the fourth most common injury in youth football. Scalp and facial lacerations can be particularly challenging as they frequently cause excessive bleeding.

The Laws of the Game: regulations for bleeding wounds

Any player bleeding from a wound must leave the field of play. They may not return until the referee is satisfied that the bleeding has stopped. A player is not permitted to wear any clothing with blood on it.

The vast majority of wounds seen on a football pitch are minor. Abrasions and small laceration are by far the most common of these injuries. Wounds

with capillary or venous bleeding are typically minor. Capillary bleeding is usually painful and the bleeding is slow but may be persistent. The amount of bleeding is directly proportional to the area of the skin involved. In football, these wounds are most commonly seen when playing on artificial turf.

Wounds with venous bleeding occur as a result of either lacerations or deep puncture wounds. The bleeding flow may be minor to major, depending on the size of the traumatised veins.

Wounds with arterial bleeding are a critical medical emergency and must be promptly recognised and managed. Bleeding is brisk, rapid and pulsatile. Once recognised, the bleeding must be immediately controlled by using whatever means are available. Direct pressure, elevation of the affected limb or wound closure can all be effective strategies. In some cases, an appropriate arterial tourniquet might be used.

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Lesson 3:-

While most players who complain of muscle cramps and muscle pain have a benign cause, these symptoms can be related to more significant medical conditions. These might include metabolic diseases or autoimmune conditions or be related to neurological conditions.

It is important to have an approach to assessing players who present with recurrent, or more significant, muscle pain. The following steps might help with this process.

History: It is important to make an assessment of the location of pain and any precipitating factors. It is also important to quantify the player’s overall loading (i.e. whether there have been any changes). Asking about any associated symptoms including weakness and myoglobinuria (coke-coloured urine) is important. When the pain occurs is also an important factor. Pain that occurs shortly after starting training may indicate McCardle disease, while pain that develops after about 30 minutes of training is more suggestive of carnatine palmitoyltransferase deficiency. Whether the symptoms also occur at rest is an important factor.

Enquiring about the player’s past medical history, family history and medication use is also important.

Examination: An examination of the neurological and musculoskeletal systems is needed. Palpate for tenderness and assess muscle strength. Proximal muscle weakness often reflects a metabolic myopathy.

Investigations: Baseline investigations should include the following laboratory tests:

• FBC
• Electrolytes
• CK
• TSH
• ESR/CRP
• Fasting glucose

In some situations, imaging studies can be helpful. Myositis can be demonstrated well on MRI. Neuropathic causes can also often be identified on MRI.

Treatment: In most cases, players with more significant muscle pain, or with more refractory symptoms, should be referred for further assessment. Referral to a neurologist is generally the best next step. This is particularly important when there is abnormal neurology or elevated CK at rest. Further evaluation may include EMG studies, a forearm ischaemic test or high-tech imaging.

Metabolic disease

Two of the more common metabolic causes of muscle pain are McArdle disease and carnatine palmitoyltransferase deficiency (CPT deficiency). These can be distinguished based on their history, examination and investigation findings. Review the following table to learn more about the presentation of these conditions.

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Lesson 2:-

Delayed onset muscle soreness (DOMS) is a term used to describe the muscle pain felt after a training session.  While this is a normal phenomenon, it can be quite significant and can limit a player’s ability to play or train. The pain typically starts 12 hours after exercise, peaks at 24-48 hours and is finished after about five days. It is generally associated with eccentric exercise or with unaccustomed exercise. Running downhill is a common cause.

Examination: Clinical signs might include finding painful and tender muscles, swelling and increased muscle girth, reduced passive stretch and reduced muscle strength. Exercise performance while suffering from DOMS may also be reduced.

Investigations: No investigations are typically required. Following exercise, especially eccentric exercise, there is an increase in creatine kinase (CK). This is normal. The magnitude of this increase is very variable and so the absolute total is not useful for predicting severity. The peak CK value occurs two days after activity and is gone after 5-7 days.

Treatment: Symptomatic treatment can help for acute episodes. Passive stretching, massage and other soft-tissue techniques can all provide symptom relief. Cold water immersion (ice baths) are also widely used – despite there being little evidence to support the efficacy of this practice. ⁴ Simple analgesia can also be used in some cases. Explaining that these symptoms are benign and outlining ways in which future episodes can be prevented is also important.

As with cramping, DOMS can also be prevented. The best strategy is training. If a player starts regularly participating in the type of exercise that has caused their symptoms, the probability of developing DOMS is dramatically reduced. Ensuring that the player warms up appropriately prior to training is also important.

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Lesson 1:-

Exercise-associated muscle cramps (EAMC) are among the most common problems encountered by a clinician looking after football players. This problem typically happens only during extreme exertion and is far more common during games than during training sessions. Some players frequently experience cramps while others do not. As a result, it seems likely that there is a genetic component to cramp (a predisposing gene has also been identified). 

 The fact that many players describe a family history of cramp also supports this hypothesis. Older players also seem to be at an increased risk of cramping. There is very little evidence to support the widely held belief that cramp is caused by either dehydration or electrolyte abnormalities. It appears to be a direct consequence of muscle fatigue. 

Cramp typically involves muscles which cross two joints (like the calf, hamstrings or quadriceps). There is often a prodromal – “cramp prone state” – when the muscle feels vulnerable which precedes the onset of symptoms. During this time, the player may have a sense of tightness or muscle pain or be apprehensive that cramp is imminent.

Investigations

No specific investigations are generally required. This is a clinical (rather than radiological or laboratory) diagnosis.

Treatment

The acute, on-field management of muscle cramps involves stretching the involved muscle with contraction of the antagonist. Once the player has developed cramp, however, it is very likely that they will be substituted.

Given that acute muscle cramping can be difficult to manage, it is important to try to prevent this from happening. The key strategy involves being adequately prepared and conditioned.

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There are a variety of relatively minor complaints that commonly occur on the touchline – or present in the dressing room – which are not considered in the other modules in this course. These conditions include the management of blisters, muscle cramps and minor bleeding. While quite minor, each of these problems can cause significant morbidity and prevent a player from reaching their potential or participating in the game they love.

Conditions involving the eye, ear and nose are also considered in this module. These injuries can be more significant and need specialist care. The definitive management of many of these conditions is beyond the scope of this course. It is, however, important to have an awareness of some of the potential complications associated with each and to be able to refer affected players for a further assessment.

In this module, we will consider how a range of more “minor” medical issues can be managed and consider how a clinician might be able to allow a player to continue to safely participate in football training and matches.

Touchline Care:

1. Muscle cramps
2.Delayed onset muscle soreness (DOMS)
3. Muscle pain
4. Bleeding
5. Blisters
6. Dysmenorrhoea
7. Eye injury
8. Nasal fracture
9.Ear injury
10. Summary

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