Interview With Alex Manos - Head Physio at Crystal Palace F.C

No prizes for guessing which one Alex is

A few weeks back, I met with Alex Manos, head physiotherapist at Crystal Palace F.C. Alex afforded me the pleasure of being my debutant interviewee at a secret location in South East London. He suggested we conduct the interview on a yes or no answer basis, which would have been great fun for us but not for you lovely readers, so we decided to go down the good old fashioned route of conversation. Thank you Alex for giving up 2 hours of your time!

Tell me about your education and work background?
I trained initially at King’s College, London, doing a degree in physiotherapy. My first job was at Crystal Palace, as the academy physio. I worked there for 3 years and then left for Australia to do my masters in sports and muscular-skeletal physiotherapy. I came back to London and worked in a sports medicine clinic in the City, treating Saturday and Sunday league footballers, weekend warriors, marathon runners, triathletes, swimmers - all sorts of sports participants.

Compared to professionals, do Sunday league/amateur footballers present different types of injury?
The injuries are normally the same but the recovery times are different - mostly because they don’t have the same intensive treatment schedule as professionals. Do you think lower league players pick up injuries more frequently? You’ll probably find that in the lower leagues injuries are less frequently documented. Players aren’t often aware they have an injury; some will plod along for a year with a sore hamstring, whereas at a higher level, the medical staff will pick it up straight away. Someone could come to me in a clinic and say, “I’ve got a groin strain”, I’ll ask how long they’ve been suffering and it could be 6 months! Often with amateurs, they will only seek advice when they have to stop playing because they can’t get beyond an injury.

Do playing surfaces and boot choices have an impact on frequency and types of injuries sustained?
There was a time when the school of thought was that blades might have caused more injuries and I can see the argument for that, although I’m not sure there is any hard evidence to support it. I think there has been a bit of a reversal to a more traditional type of boot - using smaller blades or studs. Theoretically if you have a big blade, this could get stuck in the grass and cause injury. It’s very much players personal choice, although I would prefer them to wear a more traditional type of boot.

When you’re in the dugout are you specifically tracking players who have just returned from the treatment room?
Yes, definitely. I tend to look at things close-up, so when someone jumps or lands or goes in for a tackle I’m watching how their body is working. If someone is sprinting for a ball, I’ll be looking how the body reacts, it’s a natural part of being a physio.

Is there ever any pressure on you to bring a player back from injury quickly?
Generally no. All of the managers I have worked with allow the medical staff to take full charge of a player’s recovery. A general assumption could be that as soon as a player is injured it is up to the medical staff to get him back on the field as quickly as possible. Years ago, somebody would pick up an injury and the expectation would be to get them back in action ASAP. Nowadays there is a much greater understanding of the treatment required. Of course there are times when you may have to try and speed up a player’s return to the field, say when the squad is depleted, it then becomes a risk analysis. Generally we try to minimise the risk of re-injury. For example, if somebody has potentially a 6 week injury, it’s much better to give them a 7 week recovery time to ensure optimum fitness.

What kind of work do you have to do with a player recovering from a virus?
The problem with illness is that a player is often completely incapacitated. With injury, conditioning and strength work can be continued. The general consensus is that after 2 weeks of inactivity a considerable degree of fitness is lost, then it goes down daily. The problem is when you’re ill, the body gets really tired and dehydrated. It’s really about monitoring their weight and hydration when they return. If it’s a case of 3 or 4 days, players will often get thrown straight back into training.
Some managers request players have the flu [vaccination] jabs, I’ve never had to deal with a player who had suffered with a long viral illness. I suppose when players have children they pick up more illnesses? Yes they do, they definitely do! Often it’s minor illnesses like vomiting and diarrhoea, which are easily spread throughout the squad. For the benefit of the team we’re pretty strict about players not coming in until they are completely symptom free.

Let’s talk about injuries that are more challenging to treat
Touch wood, I’ve had nothing on the pitch that required emergency medical skills to date, no terrible breaks or concussions that weren’t resolved quickly. I’ve had some long-term injuries that haven’t responded as well to treatment as I’d hoped but that’s the nature of medicine.
Cartilage damage can be one of the most challenging injuries to deal with. For example, it is well documented that Ledley King can’t do a lot of impact work which makes training so difficult. The treatment for cartilage injuries is not advanced enough to allow for a full recovery. The cartilage doesn’t regenerate and is difficult to treat because it is a part of the body that just doesn’t heal or repair to its original state. The surgical options are improving all the time and the possibility of gene therapy in the future may aid this process.

Do players with long term injuries often work with the club psychologist to aid recovery?
Some do, it depends on the assessment from the medical team. Potentially any long term injury, say over 6 months, may have an effect on the player. For instance, a cruciate ligament injury, which takes an average of 6-9 months can be a difficult time. Although we set milestones for recovery, you can run into difficulties and the injury may drag on longer than expected. At this stage we might introduce the psychotherapist. Long-term injury can be a very bad thing for a player to go through, it’s so hard for them to sit there, watch games, watch training, and be stuck in the gym all the time. Would you refer a player for therapy if he continuously picked up minor injuries? Sometimes, yes. The crucial thing to establish is why the injury keeps reccurring. It’s worth thinking about what you’re asking the body to do, day in, day out - the human body isn’t naturally designed to be a footballer! It could just be bad luck, picking up niggling injuries or it could be due to the training that they are doing. We aim to look at every aspect of their life, training, nutrition, rehab , recovery to try and identify what could be the problem.

Over the course of your career have you seen a change in the type of injuries presented?
I wouldn’t say the types of injuries sustained have changed over my 9 years on the job, but I’d say we see a greater variety of injuries because they are picked up earlier and we have a greater understanding of them. A typical example of this is with the groin; the pain you might suffer and think is a groin strain, might not necessarily be. Even as recently as 10 years ago, a lot of pain in that region would simply be labelled as a groin strain, be treated for a couple of weeks and then he’d be sent back into training and keep on breaking down. Now with more research and understanding, we look at other aspects of the body which may be contributory factors in groin problems. Typically in football you’ll always have your hamstrings, ankle sprains and cruciate ligaments though.

As elite fitness is achieved, does the incidence of injury increase?
Not really, it is often the opposite. However, as you become fitter you have more [fitness] to lose if you get injured. If a finely tuned athlete has a week or two off that will affect their health far greater than a semi-pro or part-time amateur.

Does having a nutritionist on hand help facilitate speedier recovery from injury? [Twitter tells us how much some players love going to Nando’s, all that salt can’t be good for them!] Do you try to keep them on the straight and narrow when it comes to nutrition?
Yes, definitely. We do as much as we can at the club, providing breakfast and lunch and giving them nutritional advice to use at home - although some of the younger players who live alone don’t follow it as well the older or married ones as they often can’t cook [won’t cook?] as well!

Do you hear of players having dental trouble from excessive consumption of energy drinks?
You see them on the telly endorsing these products but most choose water - we try and encourage water for hydration. Water is what you really need but a lot of players use sports drinks as well which is fine. Training sessions are quite short within season so as long as you stay hydrated that’s most important. A lot of clubs use hydration testing to analyse the players hydration levels. It is something that we are currently looking into and would think about in the future. It basically involves a player’s urine being analysed to score their hydration level and gives a good indication on how much fluid the player has taken on board. We believe that the risk of injury when you are dehydrated is much greater so any analysis available would help. It would also provide a good test to keep the players on their toes and disciplined with their fluid intake.

Are there any modern treatments or pieces of equipment you are particularly excited about?
I’m a bit of a traditionalist, there are all of these mod-cons and pieces of equipment but my training was very hands on. I think that your hands are your best tools. There are some pieces of electrical equipment we use, predominantly an ice compression machine, the Game Ready, where we pack different body components with ice and water and it flushes the ice for compression. [I find] electrical medical equipment is sometimes used just for the sake of exhibiting technology when hands on methods are far more effective. With a lot of these things there isn’t always hard evidence to say it will definitely work, a lot of it is harmless, but you don’t always know. Personally, I’m not a big machine fan. I would always look at traditional techniques, maybe use acupuncture to aid the healing process. The oxygen chamber is one you hear about, I haven’t used it this year but it is something I would consider. The rehab and ‘pre-hab’ are the most important things. We try to keep the players as occupied as possible for as long as possible, and being active is the best way rather than being stuck on a machine for hours.
I am a fan of using sand for rehab. It acts as a great medium between water and hard surface rehab training. [Buckets and spades at the ready boys]!

What are your thoughts on the congested English fixture schedule?
Fortunately, we haven’t been hit hard by injuries of late but I would prefer there to be a two week break around the Christmas period. Ideally we would have shorter breaks, more often - this would help reduce injury risk.

Finally, let’s warm down by talking stretches.
Stretching is still a slightly contentious issue in sport and football. Traditionally it used to be all static stretching however recent science would suggest that prolonged static stretching might decrease your power output. Although in football you aren't always working at your maximal output, we want to conserve muscular power for activities such as sprinting and jumping which have explosive elements. The mood has definitely turned towards dynamic stretching as opposed to prolonged stretching but it’s also very much players preferences. Some players like to do a static stretching workout before a game, if it’s part of their routine and they’ve been doing it for say 15 years, they aren’t likely to change that because of a scientific paper the physio has just read! It’s important to listen to the players and their individual routines as well as use scientific research and our input.