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Case Study: A Player, A Coach, And A Physical Therapist

“Discipline is choosing between what you want now and what you want most” — Augusta F. Kantra, co-founder and facilitator of CALM (Creating Awareness — Living Mindfully)

Photo Credit : Shutterstock

Dr Ved bhuller entered the nursing room of Purple Global School, a well-known sports institution. Inside, on one of the beds lay a young boy of maybe 13 or 14 being attended to by two teachers. The boy was groaning lightly and the two teachers were talking to him. The male, dressed in shorts and team T-shirt, was likely the sports teacher, going by his sweaty look. The lady stepped upfront and urgently greeted Bhuller. She was Radha Sen, the school’s Vice Principal. “You must forgive me for making you come here, whereas we should have typically brought our student to you. But Naitik here had a bad fall on the field and we did not want to make the mistake of making him even walk to the car park. He is our star player.... And Elmer, our coach, has been excessively worried that we may make a wrong move. Please do take a look, his parents should be arriving any minute.”

Naitik Carvalho was Purple Global’s most watched, most sought after soccer player and had been crucial to their wins at the state level. Bhuller looked at the boy to get a first hand feel of his pain. Naitik broke into a whistle, eyeing the doctor and carelessly dusting his shoulder, trimming a thread that had come off his T-shirt. Bhuller knew this symptom even better. He simply ruffled the boy’s hair and asked him how his game was. “Cool!” said Naitik, breaking into passionate explanation, but the edge of the pain as he spoke, could not be missed.

Bhuller: Tell me about your pain.

Naitik: Nothing serious, please. Just usual. Here in the outside of the foot and the ankle. But look, there is very little swelling, see? I am good to go back. Just give me some pain killers, doctor.

Bhuller looked at the sports coach, Elmer Nagendran. “Did he have a fall? Get hit?”

Elmer: The ball was lofted over the defenders to him … came from the far end of the field. He jumped up and lost balance just as he landed, fell and then had excruciating pain. Not sure if that is a swelling.

Bhuller touched the ankle and felt a mild shudder; Naitik winced oh-so slightly. He looked at Naitik who forced a smile, “I am good?” he asked cleverly. “We’ll see,” said Bhuller. His hands knew pain on touch and rarely needed the patient to confirm. The pain was on the outside, front and along the course of the peronei tendon that travel along the back and outside of the ankle and foot.

Bhuller: Now, my friend, the pain… and honestly this time. Is there pain when you move your ankle? Are you able to stand? Can we try?
naitik bravely swung his legs off the bed and before long his face tightened with pain but not a whimper left him.

Bhuller (to Elmer): Ok, that is a limp; (and now to Naitik) Can you walk to the end of the room?

Naitik braved it, as suppressed gasps of pain could be heard by the discerning Bhuller. The good doctor knew all this. Soccer and football were high contact games, where you don’t even realise that the player has hit the opponent and walked away. Hence, even if your body is prepared for the hit, it is going to lead to an injury, repeated ankle sprains, for instance. He had seen that. Then again, players don’t hit the ball from the ankle really, they hit from the foot but they have to plant their weight on one leg to hit with the other leg. “So, lots of them have repeated ankle sprains and they are constantly either taping it up or taking a pill to reduce the pain because they want to be back on the field, performing for the screaming spectators,” he said to Sen. Naitik clearly was on regular pain suppressants. Bhuller did not approve of it. Today, even young kids who want to be on a team, tried to copy (not emulate) star player styles.

Sen drew Bhuller to the outer office and looked up at the 6 foot, 8-inch tall Bhuller anxiously. “What are you thinking?” she asked. She was alarmed by Bhuller’s use of the term ‘pills to reduce pain’. “You are talking about pain killers or something else that is a booster?” she said carefully choosing her words, already agitated.

Bhuller: Lot of these kids in their teenage years, if they want to play at a competitive level either at school, state or even a league, they will take some kind of pain killer to suppress pain and the effects of injury. So, they will take over-the-counter pain killers and/or sometimes illegally obtained prescription meds. The use of these drugs and commonly used taping and/or strapping strategies give a false sense of support or wellbeing to these vulnerable joints that, in turn, lead to repeated ankle sprains and subsequent chronic ankle instability. I fear Naitik has an ongoing ankle condition or he has been hurt several times and not taken the right care.

What that basically means is that, the main ligaments supporting the ankle particularly the ones which are located on the outside of the ankle/foot what we call lateral ligaments get injured because most of the ankle sprains happen due to an inward force. So, these ligamental structures on the outside of the ankle, over a period of time, through repeated and continuous stretching, become weak and at one point snap leading to chronic ankle instability.

Now, you can either go for a surgical procedure or a long period of rehab. However, most often the ‘game’ takes precedence and a ‘pill’ is taken to subdue the pain and stay on the field. Which is what I think Naitik has been doing for a very long time.

Sen: So what should we be doing, are we missing something very critical? I am now worried. Look, usually our Principal Mr Tom Kurien looks after all this. He is away and I am not very involved with the sports area….

Bhuller: Simply, during training and during a tournament, you need professionals right on the field, who can determine if the injured player is fit to continue to play, and if not, he should be able to tell him/her, ‘you are out of the game’ and make the tough decision(s). But if the injured player is a star, making that decision can be very tough, both for the coach and the whole team.

Sen: Why should that be tough? If he is hurt, Naitik cannot play, that is clear. In any case, he has the Aryabhatta Math Competition coming up and tutorials to smarten up.

Just then, Elmer entered the nursing office, shutting the door behind him. He heard Sen’s verdict and paled. “Miss, he cannot not play. We are meeting Nunchuk Bulls coming weekend and those are semi finals, then we get to…” But Sen cut him short and said she would talk to him after she had made a decision and she did not want to be coerced. Then turning to Bhuller, she said, “This sports drive is driving me nuts! I would like to hear you out…”

Bhuller: This tussle between coach and fitness is a common struggle nowadays with millions of dollars at stake! Recently, the Chelsea coach had a big problem with the team physician because there was a disagreement on something similar and so, he threw her out! Probably because the team physician was taking a particular stand and the coach did not like it.

Sen: Are you saying he put this player back into the game?

Bhuller: That’s right, several times injured players go back into the play. Point is, the medical team has to make a call and that call can be overruled by the coach. That’s how it works — the final call is that of the coach.

Sen: Can be overruled by the coach? What is his medical expertise to overrule the medical professional? That does not even make sense.

Bhuller: Does not make sense but it certainly makes millions! One player out of the game means you are going to lose a lot of money! This is the hunger for competition today. Life is measured in wins.

Sen: So, a player is essentially just a thing...?

Bhuller: Yes, a commodity.

He is not a human being? He has no right to live injury-free? He only has a right to play and win for the team and make money?

Bhuller: Well…! Internationally and now nationally too, India included; because team franchises buy and sell players — be it football, cricket or kabaddi. How good does it feel when they bid Rs 10 crore for you? Here you can see your young star Naitik has all the makeup of a Chelsea or Manchester United player! I attend to many students like Naitik from different competitive sports. You can see that Naitik wants to be on the field more than anywhere else. The player himself says I need to be on the field. If I am not on the field, nobody is seeing me perform. So, there is this internal thing also, this desire to perform, to excel. This is critical for you as teacher to understand, Ms Sen.

I have a 17-year-old and I see that kids these days come with a drive to set the playfield on fire, make a name, a million.... Remember these kids are not getting up at 5 o’clock in the morning to run 10 laps because their parents told them to. It‘s their inner drive that makes them do it. They enjoy this thing. It is an inner calling. We live in a different era. We can be worried or we can work with it.

That means, we have to ensure they get proper guidance on the field. The therapist or the physician, whoever is out there, needs to evaluate the injury very quickly and very honestly: is it a bad sprain or a small one? Then, put them back into the game. But if they are undecided, then they should have the courage to send the player for a second opinion and if a long period of rehab is prescribed, then say, “Ok, you cannot go back to this season’s play.”

Bhuller had seen all this too often. He marvelled, he wondered and he also got annoyed with schools pushing for top-of-the-charts positions, urging kids that it was going to look great on their application to foreign universities. Bhuller did think this was dishonest and coercive. There were a few other school teams of different sports that sent their players to him for second opinion when there was a tussle between resting and playing a player. They would ask, “Can you tell us whether this kid has a simple or a complex injury? Does he need more rehab or can he go back to the game?” “These players come to us very reluctantly — very reluctantly,” Bhuller said to Sen.

For Bhuller, it was like being a forensic cop because these school players usually had a high tolerance for pain. “That makes it a challenge to
diagnose, because often pain is the indicator!” he said to Sen, laughing. “So, when you press down on a spot, or rotate an ankle or shoulder to elicit the pain, these guys are whistling!”

The other thing was the repetitive nature of the sport and its training. A classic example is Tennis, where the player, a young student player hits the ball thousands of times in a day causing repetitive torsional stress on the tendon and the bone. “At 13-14-15, the bone is not yet developed,” explained Bhuller. “As the junior competitive player ages, we see instances of joint (shoulder, elbow, wrist) problems. The game needs training of a specialised kind — the player needs fast reaction time and explosive ‘first step’ speeds. When we say more research-based training programmes need to be put in place, clubs and schools say, ‘Where are we trying to compete, at the Wimbledon?’ Nice. But the creation of sensible training programmes are aimed at not just improving performance, but also reducing the risk of injury. So, we do have injuries, which the student or the school does not find out before he graduates from high school! And once he has left the school gates, who owns that injury? Then, there is the whole business of diet. Muscle and ligaments need nutrition, not burgers and pizzas!”

Just then Naitik’s parents arrived and Sen, whose head was reeling with the understanding of what she was hearing, felt her mathematics contests were far better.

Seeing their son laid up at the nursing station, the Carvalhos were agitated. Of course, this was not the first time he was getting hurt, but this was too often. They began gently blaming the school for being aggressive. They had trusted the coach and the school but now watching the young boy in pain the father felt he had lost his ground for reason with the boy, who was now charged by the encouragement of his coach and his team (who were standing outside the medical room, their heads clearly visible through the glass panel) as they sent him text messages on their phones to urge him to “somehow get back to the game…”

Roma Carvalho, Naitik’s mother, was growing restless as Elmer tried to tell her what a great player Naitik was and the way he tackled this one or that kick…. But

Roma gently stopped

Elmer’s tirade. “You are a good man, but right now, I wish to keep my attention focused on what I need to do to give Naitik a better long term.”

Pradeep, Naitik’s father, stood arms folded, looking at a point behind Elmer’s head and said, “We are disturbed by conflicting information. You may say it is ok for him to play, but I keep hearing the doctor say it may not be wise. I wonder if you have availed of medical opinion on this in the past.” For Pradeep had just heard Bhuller talk about long bones, the epiphysis and that “the growth plates have not completely formed” and adding now for good measure, “So, one has to be very careful about the young teenage athlete.”

Roma: And he is just 14, barely a teenager! So, what happens if you start playing soccer at 13 or 14, very aggressively?

Bhuller: I am more concerned about the repetitive nature of the injury. The bone is being stressed repetitively, again and again. This is compounded by the fact that on several occasions, he will be hitting incorrectly, that happens in a fiercely competitive game — this causes another bio-mechanical stress, which increases the extent of the damage to the body structures. More than that, not just the bone but also the tendon is being stretched again and again and again.

See, muscle power is a function of not only the contractile element but the non-contractile element also, which in this case is the tendon. It’s like a rope and a spring. If the spring is affected, pulling at the rope leads to the rope getting strained too!

Pradeep: Amazing… does a player understand all this? Does he know?

Bhuller: He is 14, unlikely.

Elmer: Um... difficult to say.

Roma: Can you drive without a working knowledge of car parts and their needs? Likewise, when you start using your body to play a professional game, should you not be taught what the different joints are, what roles they are performing?

Bhullar: The neuromuscular

System is an unconscious memory system. It is not a conscious memory system where I say 2 times 2 is 4. Naitik has inner drive and desire to win, to play, to conquer. He needs to understand his body machinery, because he is not using it well enough to play!

The coach needs to have educated this child. (Then, turning to Sen and Elmer) If your team is into serious competitive sports, you need to look after the health of your players far, far better. You will then need to have a whole team working with them — a kinesiologist or a physiotherapist who is knowledgeable in biomechanics and kinesiology and also rehab. But it is the kinesiologist trainer who does their weight training, off-season training, their stretches, etc., in line with their sport needs.

Sen: That means we need a specialist for every field of sports? For tennis, for volleyball, for cricket…?

Bhuller: Each sport works a different muscle that is linked to performance. Their respective physiology, metabolism, biochemistry, and endocrinology, vary. If you take swimming, for example, height is a bias that determines success. In Olympic swimming, you will see that they are taller and heavier than others the same age as them. The amount of stretching and warm-up that all sports players need is so crucial to improve performance AND to prevent injuries. I do not know how much training is going into warm-up, here. If you are a tennis player your upper body needs to be built up or your core needs to be built up, all these things need work. That is how you play an efficient game AND reduce injuries. In many countries, they have begun to put them through yoga because that mental balance is also key to playing a good game. The mental aspect is a whole new area!

The Carvalhos felt Purple Global was peddling sports. Elmer felt he was doing a great job and now looking at Sen’s concern and annoyance, felt less appreciated. Sen was unnerved: if there was medical science to back what Bhuller was saying and Purple Global was not doing many of those, were they damaging the student players’ long term in the name of press visibility?

To be continued...

Read Analysis by Dr Raju K. Parasher
Read Analysis by Rahul S. Verghese

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(This story was published in BW | Businessworld Issue Dated 25-01-2016)

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