Weekly video podcast with Sarah Flotel. Blog articles with a focus on football injuries and development.
Friday, 27 January 2012
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
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
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
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
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
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
What kind of work do you have to do with a player recovering from
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
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
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
As elite fitness is achieved, does the incidence of injury
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
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
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
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.