Dr Carl Todd – Osteopathy in Football – Injury Rehab Network Event
The July event of the Injury Rehab Network from Sterosport and BASRaT on the evening of 7th July attracted over 100 sports rehabilitation professionals from the UK and around the world.
The expert guest speaker was Dr Carl Todd, who kindly shared his expertise and advice from over 20 years of working as an Osteopath in elite sports and professional football.
Dr Carl Todd – Consultant Osteopath in Sport & Exercise Medicine
Dr Carl Todd is a registered osteopath, lecturer, published author and certified strength and conditioning specialist. He has a PhD in orthopaedics and clinical science, a Master’s degree in sports injury medicine and an Honours degree in Osteopathy.
Carl’s professional memberships include the General Osteopathic Council, Institute of Osteopathy, Osteopathic Sports Care Association, British Association of Sport and Exercise Medicine, British Medical Acupuncture Society and the National Strength and Conditioning Association.
In 2005 Carl became the first Osteopath to be appointed by The Football Association and work with the England Football team. To date, he has provided osteopathic care for 200 international games and attended four FIFA World Cup tournaments, Germany 2006, South Africa 2010, Brazil 2014, and Russia 2018; three UEFA European Championships Poland & Ukraine 2012; France 2016; Euro 2020. Carl’s experience with England Football equates to over 2,500 hours of experience with the team.
Carl has been a consultant osteopath to Chelsea Football Club since 2008, working as part of the medical support for the first team players in all competitions. In 2019 Carl began providing osteopathic care in the sport of high-performance Athletics, specifically providing trackside support for Dina Asher-Smith.
Carl has previously carried out consultancy roles for the England Cricket Board, Team GB male and female Basketball at the London 2012 Olympics, British Athletics at the Tokyo 2020 Olympics and many other clubs, including Real Madrid, IFK Gothenburg, Manchester United FC, Manchester City FC, Liverpool FC, Tottenham Hotspur FC, Portsmouth FC, West Bromwich Albion FC, and Worcestershire County Cricket Club and from 2006-2008 as part of the medical team at Honda UK.
His unique areas of interest are the spine, hip, and groin rehabilitation pre and post-surgery and, specifically, injury prevention. Carl regularly lectures nationally and internationally at medical conferences on sports injury management and rehabilitation.
Osteopathy in Football
Carl’s presentation, “Osteopathy in football”, provided insight into osteopathic support for athletes as part of multi-disciplinary teams in professional football. He shared insights and learned from his own unique style of integrating Osteopathy and corrective exercise rehabilitation, encompassing bio-psychosocial, biomechanical, and functional rehabilitation for patient management, injury prevention and re-education.
The role of Osteopathy in the professional football environment
Dr Todd started the presentation by considering the role of Osteopathy in the football environment. Osteopathy plays a crucial role within the performance team, working closely with medicine and therapy professionals.
Carl described how multi-disciplinary teams (MDT) work to provide holistic athlete support with relationships and responsibilities between the MDT and coach. Communication and trust are essential with the aim to provide the best possible care and outcomes for athletes. Decisions are based on an informed process and the individual athlete’s performance goals.
Carl discussed the role of the Osteopath as part of an MDT, including:
- Support the performance team.
- Treatment of athletes prone/ known to have MSK issues/ niggles.
- Trauma management (acute and chronic).
- Osteopathic Practice Standards
Dr Todd discussed the priority during periods of competition where periodisation enables players to maintain function, resolve MSK issues and help prepare an athlete for performance. Carl described how this level of care is the real benefit of integrating Osteopathy into the performance team, where “Maximum availability creates winnability”.
He described the personal qualities of osteopaths and the range of professionals who work in the performance and medical teams in professional football. Osteopaths need to be able to work alone, be a team player, be humble, sincere, hardworking, honest, not phased by the ‘big hitters’ and have responsibility.
The Osteopathic Approach
Dr Todd considered the osteopathic approach, which is historically biomedical and biomechanical. Ascending patterns (foot up) focus on biomechanical issues such as leg length inequality. Descending patterns (head down) focus on a biomechanical approach where problems such as shoulder injuries can be associated with dysfunction of the upper cervical complex.
Carl described how pain is a major issue for many athletes, often leading to fear avoidance, catastrophising issues, and developing behaviours linked to pain and previous or past experiences. Osteopaths can offer reassurance and must use the correct terminology to address issues effectively.
Clinical reasoning skills are key to a bio-psychosocial approach. Dr Todd discussed the elements of clinical reasoning, including skill acquisition, clinical knowledge, and expertise. The talent or practitioners lies between art and science. Carl discussed how athletes are influenced in many ways, and practitioners should understand the whole athlete whilst recognising their ability to positively influence the athlete.
Dr Todd’s book “Managing the Spino-pelvic hip Complex” considers an integrated approach to Osteopath with a key concept of five ATEs, which Carl discussed in his Injury Rehab Network presentation:
Evaluate – Carl described the importance of evaluation ‘you can’t manage what you don’t measure’.
Educate – Osteopaths can educate athletes about symptom modification techniques and describe how these techniques may help with pain modulation to improve range of movement or function. Carl uses a test – modify – retest system to effectively apply symptom modification techniques.
Manipulate – Dr Todd showed a range of images of manual therapy techniques which can be used for acute and chronic injuries, both focused on a specific joint and through the kinetic chain.
Activate – Carl described the neurological effect of injuries and the need to activate neural drive throughout the activity. Osteopaths can work with athletes to give something back and wake up the neural system. The aim is to work on neuromuscular control and motor control.
Re-integrate – Dr Todd described the role of Osteopaths as athletes returning to sport from injury, aiming to improve range of movement and control through range. Carl discussed how functional exercise should combine dynamic stability with segmental control and joint dissociation. Athletes should be exposed to training stimuli to build capacity during this phase.
Carl considered some of the other aspects of the Osteopath role in professional football, where he provides pitch side assistance for both manual therapy and emergency care.
Dr Todd presented a case study of a football player with low back, hip and groin pain and discussed the Osteopathic treatment provided. The research article is available here. Symptoms increased with physical activity, and the player was unable to jog, strike a ball or sit for prolonged periods. The player had previously suffered from spondylolysis with treatment including an arthroscopy, labral reconstruction, and psoas release.
Assessment & examination – Carl used a range of quantitative and qualitative measures to assess the player, including visual analogue scale (VAS) for pain, a handheld dynamometer, and a pressure biofeedback unit. An examination of the pelvic hip was then completed, where Dr Todd identified areas of pain, movement, and strength issues. A spinopelvic examination was also completed.
Hypothesis – Following the assessments and examinations, Carl’s hypothesis was that the player had reduced segmental & hip joint motor control, intolerance to work capacity load and a breakdown of spinal and pelvic compensatory systems. This hypothesis was supported by research findings and applied knowledge of anatomy and physiology.
Management – The management of the players’ injuries included four treatment sessions focused on:
- Patient re-education and pain management
- Neuromuscular facilitation motor control techniques
- Work capacity tolerance loading
Conservative Management – Carl described how conservative management was used to treat the individual and the tissues. Conservative management should be sympathetic and realistic to their concerns, educate the patient and reduce fear, manage patients back to their valued activities and restore the balance between tissue load and work capacity.
Applying the ATEs for injury management – Carl discussed how the ATE principles were applied in the management of this injury, including education and advice, manipulation, activation using a wakening technique, and integration into a functional return to sport.
Osteopathy in practice – Dr Todd discussed the range of techniques used as part of a conservative intervention, promoting active care, motor control (functional and non-functional), motor control (dissociation and segmental), and work capacity (through the sagittal, frontal, and transverse planes, unstable surfaces.
Results and outcome – Carl showed how using the same assessment and evaluation methods, it was possible to re-evaluate the player, with results showing a significant improvement in strength and endurance. The outcome was that the player resumed modified training after ten days, played 45 minutes after two weeks and 90 minutes after three weeks. Thereafter they played 2 x weekly 90-minute games without reaction, and at the one-year follow up had played 44 games with continual self-preparation and recovery strategy. The approach from Dr Todd was to make a complex structure simple.
Limitations – As with any evidence-based approach, it’s important to consider limitations. Dr Todd discussed the limitations of this case study, including no quantitative measures or qualitative questionnaires apart from VAS. Carl also discussed how the hypothesis was based on clinical reasoning and that it could be argued that the patient may have improved by pure chance.
Return to training/ play – Carl discussed the phases to return the athlete to play as follows:
- Evaluate and manipulate with appropriate manual therapy.
- Motor control
- Muscle capacity
The presentation ended with the quote, “All are athletes, only some train.”
Dr Todd kindly answered several questions put forward by the practitioners who attended the session.
Q1. How would you approach a player with strong views regarding symmetry?
A1. Practitioners should look for an ‘in’ to help the patient to understand and change. Symmetry does not exist, but functional asymmetry does. Encourage the athlete to trust in the process and commit to the recommended rehab. Working with other professionals can also help to educate and build trust.
Q2. What is your advice for new players who will only play with ankle supports due to fear of injury?
A2. Do not make a fuss and educate the player regarding the importance of an effective warm-up. Taping and strapping have a role and can be used as part of treatment for injuries where appropriate.
Q3. Can different surfaces and ground reaction forces have an impact on injuries?
A3. Players get used to a consistent surface, so any variation can create an issue. Footwear can also be an issue.
Q4. What made you get into Osteopathy?
A4. After a career in the military, I retrained and worked with an excellent physiotherapist in private practice. I continued to learn and trained as an Osteopath. A patient was well connected in football and introduced me to Gary Lewin, which led me to work with England Football. Here I have worked with players to demonstrate the added value of Osteopathy in football. The best advice is to do your job properly.
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The next event of the Injury Rehab Network
The next Injury Rehab Network event is taking place on the 4th of August and features a presentation from expert guest speaker Fiona Rosamond (Podiatrist). To reserve a place, sign up with BASRaT – click here to register.
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