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48 Br J Sports Med 2001;35:4853

Methods of appointment and qualifications of


club doctors and physiotherapists in English
professional football: some problems and issues
I Waddington, M Roderick, R Naik

Abstract priate specialist qualifications, and Dodds,9


ObjectiveTo examine the methods of writing from the perspective of a medically
appointment, experience, and qualifica- qualified international hockey player, has
tions of club doctors and physiotherapists sought to define what a team expects from its
in professional football. doctor. In describing the role of the club or
MethodsSemistructured tape recorded team physician, several authors have drawn
interviews with 12 club doctors, 10 club attention to the possible conflict of interests
physiotherapists, and 27 current and between the doctors responsibilities to the
former players. A questionnaire was also individual player as patient and to the team or
sent to 90 club doctors; 58 were returned. club,4 10 while Macauley11 has recently sug-
ResultsIn almost all clubs, methods of gested that the increasing commercialisation of
appointment of doctors are informal and sport may result in increasing pressure on doc-
reflect poor employment practice: posts tors to treat or rehabilitate players in a manner
are rarely advertised and many doctors that they find unacceptable, or to allow a player
are appointed on the basis of personal to return to play sooner than the doctor may
contacts and without interview. Few club wish. A related problem, which has been
doctors had prior experience or qualifica- considered by several writers, is that of the
tions in sports medicine and very few have degree to which, within the context of club
a written job description. The club doctor medical practice, information should remain
is often not consulted about the appoint- confidential to the doctor-patient relation-
ment of the physiotherapist; physiothera- ship.2 4 12
pists are usually appointed informally, Useful though this literature is, most of it is
often without interview, and often by the prescriptive: it describes not how club doctors
manager without involving anyone who is actually behave in the real world but how, in an
qualified in medicine or physiotherapy. ideal world, they ought to behave, and, in this
Half of all clubs do not have a qualified respect, most of the literature is not empirically
(chartered) physiotherapist; such un- grounded. Moreover, insofar as this literature is
qualified physiotherapists are in a weak empirically grounded, it tends to be based on
position to resist threats to their clinical personal experiences of individual club doc-
autonomy, particularly those arising from tors, rather than on the systematic collection of
managers attempts to influence clinical data from a more representative sample.
decisions. The data reported here formed part of a
ConclusionsAlmost all aspects of the larger study designed to help fill this gap and to
appointment of club doctors and physio- provide a basis for appropriate recommenda-
therapists need careful re-examination. tions designed to improve the quality of care in
(Br J Sports Med 2001;35:4853) professional football clubs in England. That
broader study investigated a number of aspects
Keywords: football clubs; doctors; physiotherapists; of the work of club doctors and physiothera-
qualifications pists, including the ways in which they dealt, on
a day to day basis, with the potential conflicts of
interest and confidentiality issues outlined
Although there is a very substantial literature above.13 14 The central focus of this paper is the
on the clinical management of sports related qualifications, experience, and methods of
injuries, literature on the role of the club or appointment of club doctors and physiothera-
Centre for Research team doctor is rather more limited, although it pists, an area not previously systematically
into Sport and Society, has begun to grow significantly in the last dec-
University of Leicester,
investigated.
ade or so. In 1991, the American College of
Leicester, UK
I Waddington Sports Medicine published its Guidelines for the
M Roderick Team Physician,1 while Mellion and Walsh2 have Methods
provided a useful general description of the The research reported here was undertaken on
SheYeld Wednesday role of the team doctor. In relation to specific behalf of the Professional Footballers Associ-
Football Club sports, Lynch and Carcasona3 and Crane4 have ation (PFA) and involved semistructured tape
R Naik
outlined the role of the club doctor in football recorded interviews of between 30 minutes and
Correspondence to: (soccer), while Macleod,5 Kennedy6 and Dav- one hour with 12 club doctors and 10 club
Dr I Waddington, Centre for ies7 have described the role of the club doctor physiotherapists. A total of 19 current and
Research into Sport and in rugby union. Smith8 has drawn attention to eight former players were also interviewed
Society, 14 Salisbury Road,
Leicester LE1 7QR, UK the importance of team doctors and crowd about their experiences of injury and rehabili-
iw11@leicester.ac.uk doctors in professional football having appro- tation. Interviews were carried out in the

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Club doctors and physiotherapists in professional football 49

second half of the 19971998 season and the club doctors is associated with the fact that
first half of the 19981999 season. Interview- they are not just football fans but, in many
ees were given a guarantee that neither they nor cases, fans of the particular club for which they
their clubs would be identified. work; indeed, this is one of the reasons why
Doctors in the Premier League were more most are prepared to work for such modest
amenable to being interviewed, which probably rates of pay.
reflected their generally greater involvement in Securing an appointment as club doctor is
their clubs. However, this did mean that the dependent, in the vast majority of cases, on
sample of doctors interviewed was biased personal contacts. Appointments are hardly
towards those in the Premiership. Of the 12 ever publicly advertised; of the 55 posts on
doctors interviewed, seven were at Premier which we have information from the question-
League clubs, two were with clubs in the First naire (there were three non-replies to this
Division of the Nationwide League, two with question), only four were publicly advertised,
Second Division clubs, and one with a Third and only one was advertised in a medical jour-
Division club; one Premier club doctor had nal. Most doctors (35 out of 55) obtained their
previously worked in a Second Division club. positions through personal contact with the
In addition to the interviews, a postal
previous club doctor; most often, the previous
questionnaire was sent to 90 club doctors who
club doctor had been the senior partner in the
were not interviewed; 58 questionnaires were
general practice in which they worked and,
returned. The bias towards Premier League
when he retired, the post was passed on to a
club doctors in the interview data was oVset by
the questionnaire data. Replies were received junior partner. Several club doctors inherited
from 13 Premier League club doctors, 13 First the post from a family member, or obtained the
Division club doctors, 15 Second Division club post as a result of personal friendship with the
doctors, and 16 doctors at Third Division club chairman or a club director or someone
clubs; one doctor did not indicate the division else connected with the club. The personal
in which his club played. friendship, family, and professional ties were
Of the physiotherapists who were inter- sometimes closely interwoven, as in the follow-
viewed, three work in Premier League clubs, ing case:
two in clubs in the First Division of the Dads senior partner was the club doctor
Nationwide League, two in Second Division when Dad joined the practice and he being
clubs, and two in Third Division clubs; in very interested in football, went along with the
addition, one physiotherapist had worked in senior partner and sort of acted like a reserve
doctor . . . when that chap retired he [Dad]
two football clubs (one Third Division club,
took over and one of his friends became the
one Premier League club) but now worked in reserve doctor and then when I qualified I took
another sport. over as reserve doctor and then took over [from
Dad] as first team doctor.
Results Another doctor described how he had
CLUB DOCTORS obtained the post as a result of his friendship
The conditions of employment of club doctors with the previous club doctor, who had himself
vary greatly from one club to another, but a few inherited the post from his uncle. One doctor
generalisations can be made. Firstly, almost all recognised that the process by which most club
club doctors are appointed on a part time basis; doctors are appointed would not generally be
there are only half a dozen or so full time club regarded as good employment practice:
doctors in England. Secondly, the primary I . . . am in practice in this area, where the two
employment of most club doctors is in general senior partners had been attached to [the club]
practice; of the 56 doctors who answered the since the late 1960s, so its nepotism. Dead
relevant question on our questionnaire (there mans shoes.
were two non-replies to this question), 42 indi- Although personal ties, professional ties, and
cated that general practice is their primary family ties were often closely interwoven, occa-
employment. Thirdly, there are substantial sionally the interpersonal ties were more tenu-
variations in the income that doctors receive for ous, as in the following example, in which a
their services. Doctors in the higher divisions doctor explained how he was appointed at a
are normally paid, although the pay is modest. Premier League club:
One doctor explained that he received 5200 a Interviewer: Could you tell me how you got
year from the club but that, applying the Brit- the appointment?
ish Medical Associations recommended scale Doctor: I was phoned up by [the previous
of charges to the number of hours he worked, club doctor]. He just said . . . he wanted to
he should have been receiving 25 000. retire and was looking for a successor and
Clearly, most football clubs are dependent on would I mind coming along and watching a few
the goodwill of their doctors and do not oVer matches with him as he got to know me.
the rates of pay that doctors would normally Interviewer: And you knew him profession-
expect for their professional services. Doctors ally?
Doctor: No. I didnt know him at all.
at lower division clubs may not receive any
Interviewer: So why did he contact you?
payment; the doctor of a Third Division club Doctor: I dont know. I think I met his brother
explained that he actually subsidised the club at a conference and I think his brother must
by providing some medicines and items of have spoken to him.
equipment from his own general practice Interviewer: So you hadnt been involved in
surgery. It might also be noted that an sports medicine before?
important part of the job satisfaction for many Doctor: No, I hadnt.

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50 Waddington, Roderick, Naik

The arrangements under which club doctors questionnaire have a specialist qualification in
were appointed were, as in the above case, often sports medicine; only two indicated that their
extremely informal. One doctor, a long stand- primary employment is in sports medicine; and
ing fan of his local club, explained how he was only six were members of the sports medicine
appointed: section of the Royal Society of Medicine.
The existing club doctor at the time phoned
up and said that he didnt think he could make PHYSIOTHERAPISTS
it to this afternoons match and asked me if I The position of club physiotherapist, like that
was going to be there, to which I said Yes, and of club doctor, is rarely advertised and many
he asked if I wanted to be the oYcial match appointments are secured on the basis of
doctor. personal contacts. Of the posts held by the ten
He added that he had not been formally
club physiotherapists who were interviewed,
interviewed and had not even formally applied
only one was advertised (in this case, in a
for the post: There hasnt been an oYcial
national physiotherapy journal). There were
appointmentthere is no correspondence to
considerable variations in the ways in which the
quote.
physiotherapists were appointed. In three
This club doctors experience was not atypi-
cases, club managers had asked the FA
cal. Of the 58 club doctors who returned the
Medical Education Centre at Lilleshall to rec-
questionnaire, only half (29) had been formally ommend a physiotherapist. One respondent
interviewed. Only three were interviewed by a obtained his post by sending his CV to a club
panel that included a doctor, in each case this after hearing on the grapevine that they
being the previous club doctor. There can be needed a physiotherapist. In two cases, physi-
few other situations within medicine in which otherapists were poached from smaller clubs
an applicant for a medical post would be inter- by larger clubs; one respondent, describing
viewed by a panel that did not include a medi- how he moved from a Third Division club to a
cally qualified person; this cannot be regarded Premier League club, explained that after one
as good practice. Those who were interviewed year at the smaller club he had one of the
were typically interviewed by the manager, classic phone calls that you get in professional
chairman, director, or club secretary. Not sur- football, which was: We have not had this con-
prisingly, the interview did not, indeed could versation, but if our physiotherapist leaves at
not, take the form of a searching examination the end of this season, would you be interested
of the applicants clinical knowledge. One club in working for us? . Another physiotherapist
doctor described his interview with the chair- explained how he moved from a Third Division
man and manager as very gentle, while to a First Division club:
another said that for most of his interview he The manager of [the First Division club] just
simply sat and listened to the chairmans plans rang me and said I fancy a change [of physio-
for the development of the club! This informal- therapist] . . . it was totally illegal . . . hed got
ity is also reflected in the fact that only six of rid of his physio, had left for whatever reason. It
the 58 doctors surveyed had a written job was a female actually. I think pressure from the
description. The absence of proper procedures Board. I know its sexist, but pressure from the
for appointing club doctors is a cause for con- Board . . . He spoke to various people and I
cern. think I was doing a decent job at [my previous
club] . . . I think he probably said I am looking
The fact that most club doctors are involved for a physio and someone said have you heard
more or less full time in general practice limits about the chap at [my previous club]? .
their experience of, involvement in, and This is a good example of what one
commitment to sports medicine as a specialist physiotherapist described as getting a job
area of practice. As noted above, most doctors through the old boy network of I know some-
became involved in their local club when the body who, etc. .
previous club doctoroften a friend or This old boy network is associated with a
relativeretired or died, and they were oVered second characteristic of the appointment proc-
the post. Most had no previous experience in ess, which is that the job of club physiotherapist
sports medicine, and, for most club doctors, is often in the gift of the manager. One example
this is their one and only involvement in sports was provided by a physiotherapist (an ex-
medicine. Of the 58 doctors who completed player) who explained that, after working
the questionnaire, only eight had ever worked abroad for some time, he returned to England
in a sport other than football and only two had and a former playing colleague who was now a
ever worked at another football club. Typically, manager heard that he was back in the country,
therefore, the club doctor has a very limited phoned him, and oVered him the job as club
experience of sports medicine; he (almost all physiotherapist. There was no formal job
club doctors are male) is a one sport, one club application and no interview; the job was
doctor. His commitment is typically not to oVered and accepted over the phone. After this
sports medicine in general but to his local club, interview, the interviewer had a brief conversa-
and several doctors indicated that if, for any tion with the club groundsman, who had been
reason, their contract with their local club were formally intervieweda jacket and tie job, as
to be terminated, they would not seek employ- he put itby the club chairman. It is disturbing
ment in another club but would simply return that the person who looked after the pitch was
full time to general practice. The absence of a interviewed, while the person who treated the
commitment to sports medicine as a career is players injuries was not.
also evident in some of our other findings: only It is not unusual for managers, when chang-
nine of the 58 doctors who completed the ing clubs, to take some of their previous back-

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Club doctors and physiotherapists in professional football 51

room staV, including the physiotherapist, to the appointment is usually made informally,
their new club. This is sometimes a cause for often without interview, and often by the man-
concern. Two doctors indicated that problems ager without involving anyone who is qualified
had arisen as a result of a new manager bring- in medicine or physiotherapy; this cannot be
ing in a non-chartered physiotherapist from his regarded as good practice.
former club. In one of these cases, the physio- The questionnaire sent to club doctors
therapist had only a much lower level qualifica- included a question about the qualifications of
tion in sports therapy. The doctor explained: the senior physiotherapist at the club; of 53
I wasnt involved in choosing him and I wasnt physiotherapists on whom we have information
desperately happy with that situation . . . I sup- (five doctors did not answer this question), 27
pose I had hoped that having been here for a were chartered physiotherapists, while 26 were
while they might consult me . . . it just not chartered, the most common qualification
happened very, very quickly and so it was diY- held by non-chartered physiotherapists being
cult because when the manager suggested this the FA diploma (held by 23 of the 26
guy who hed actually worked with before non-chartered physiotherapists). Chartered
that was the connectionI said, Thats fine.
He said, Its this great physio. He works really physiotherapists are more likely to be found in
hard and hell be fantastic. I never thought to clubs in the Premier League and First Division
question when somebody said the physio of the Nationwide League; of the 13 Premier
was . . . very, very good and very experienced, League club physiotherapists on whom we have
that he wasnt chartered. Which was my data, 11 are chartered. In the First Division of
mistake. By the time I met him and said, the Nationwide League, six out of 11 are
Where did you train? and he said hed done chartered, in the Second Division, five out of 15,
the Sports Therapy Course, hed already sold and in the Third Division, five out of 14. Over-
his house . . . and arranged to move . . . he knew all, in half of the professional football clubs in
I wasnt comfortable with him but, at the same England, the day to day management of injuries
time, the appointment had been made.
is in the hands of people who are not qualified to
In another club, the doctor explained that in
work as physiotherapists within the NHS. This
recent years, the clubs physiotherapists had all
raises serious questions about the quality of care.
been chartered, with just one exception. The
exception was a non-chartered physiotherapist
Discussion
brought in by a new manager:
Almost all aspects of the processes of appoint-
Weve always had chartered physios. It was
only that one . . . because the manager came in ing and remunerating club doctors and physi-
and insisted on bringing his physio from this otherapists need careful re-examination; cur-
other club . . . I said at the time I would rather rently, these processes constitute a catalogue of
have a chartered physio . . . the manager got his poor employment practice. The limited qualifi-
way but that appointment was not successful cations and experience of many club doctors
. . . and from that came the fact that I would sit are also matters of concern. Paying a very
on the interview committee and then interview modest fee to a local general practitioner, who
any new physios and have a say in who was has no experience of sports medicine but who
appointed, which I find more satisfactory. happens to be a fan of the club and who is
The club now had a chartered physiothera-
recruited on the basis of personal or family
pist once again; the doctor explained how this
contact, may be a cheap and easy way of
had aVected the pattern of medical work at the
appointing a club doctor but it has little else to
club:
commend it and it is unlikely to be in the best
In the past, players have come to me without
going through the physio if they havent been long term interests of the club or the players.
happy with the physio . . . that has happened, A number of questions are also raised about
but this physio isnt that sort of problem . . . At the qualifications and experience of physio-
the moment, I just see the players he wants me therapists. Most of the physiotherapists who
to look at. Hes only been appointed this season hold the FA diploma are ex-players, and many
and up until this season I would always have spent the whole of their working lives
religiously go in every week and see everybody within the world of professional football. This
who was injured, but that was a diVerent physio is claimed by some people within football as an
and he wasnt as well qualified so I was happier advantage; one non-chartered physiotherapist
seeing absolutely everybody and making sure argued that chartered physiotherapists have
everything was going along. This physios far
more confident and better qualified so he will - never played the game . . . they dont know
like this week - its all quiet so he says at the what its like, they dont know what the players
moment theres no need for me to go in so I are going through . . . I feel that I have a little
wont even go in this week. advantage over the chartered people in as much
It may be significant that both doctors were as I have played the game. However, whatever
relatively young, and one was one of the advantages the ex-player with an FA diploma
relatively few club doctors with a specialist may have over his chartered counterpart, these
qualification in sports medicine; it may be that are more than oVset by several important
younger and better qualified doctors are disadvantages in terms of the quality of care
becoming more demanding about issues con- that he is likely to be able to oVer.
cerning the quality of care in football clubs. The problems here relate not just to the fact
Nevertheless, these two cases do highlight a that non-chartered physiotherapists have a
problem concerning the appointment of club much lower level qualification than chartered
physiotherapists, namely that it is not normal physiotherapists, although this is itself a matter
practice for the club doctor to be consulted of concern. There are also other problems.
about the appointment of the physiotherapist; Firstly, in the course of the research, it became

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52 Waddington, Roderick, Naik

clear that many playersprobably a majority pists to the generally higher standards of clinical
are not registered with a general practitioner and ethical care expected of those who work
outside the club or, if they are, they rarely use within the NHS, and they have no knowledge of
him/her; indeed, in one club with a small play- standards of care other than those that apply
ing staV, players were actively discouraged within football. In this context it was noticeable
from using a general practitioner outside the that, although the sample of physiotherapists
club because it was feared that an outside gen- interviewed was quite small (of the ten
eral practitioner may too easily agree to their physiotherapists, six were chartered and four
having time oV when sick, thus depleting the not chartered), there did appear to be an appre-
clubs limited squad of players. This is, in itself, ciable tendency for chartered physiotherapists
a matter of concern; it is important that players to be more critical of the quality of care oVered
should have routine access to medical advice within professional football.
that is independent of that provided by their There is a further related problem in
employer. The research also indicated that relation to non-chartered physiotherapists. As
many players use the club doctor and, particu- the report prepared for the PFA clearly docu-
larly in lower division clubs where the club ments,13 playing with pain, or when injured, is
doctor may not come in regularly during the a central part of the culture of professional
week, also the club physiotherapist as, in eVect, football.15 Managers look for players who have
primary care practitioners to whom they bring what, in professional football, is regarded as a
problems relating not only to injury but also to good attitude, and one way that players can
illness. In such situations, the very limited show that they have such an attitude is by
knowledge that FA trained physiotherapists being prepared to play when injured. If the
have about more general health matters is a risks of playing while injured, or with pain kill-
cause for concern. One doctor expressed this ing injections, are fully explained to players
concern thus: and if, after being given this information, they
choose to play, then this does not of itself raise
Footballers, however often you tell them,
especially younger footballers, dont register any ethical problems. However, diVerent
with other GPs. They dont have any other problems arise when coaches/managers insist
access to health care, they tend to go straight to on becoming involved in the treatment proc-
the physio with anything . . . my worry would be ess. Such situations were described by several
that if an 18 year old lad comes in and says Ive club physiotherapists (and doctors) all of
got a dreadful headache . . . theyre sent home whom indicated that such managerial inter-
with a couple of paracetamol and really theyve ventions are, almost invariably, unhelpful. In
got meningitis. I think a broader range of extreme situations, the clinical autonomy of
experience is quite important for the physio. physiotherapists and doctors may be under-
This broader range of experience of the char- mined; they may find themselves marginalised
tered physiotherapist is also important for other and their advice ignored, while players are
reasons. Leaving aside the diVerent levels of regularly returned to play before they are
qualification, perhaps the most important medically fit to do so, only to break down
diVerence between non-chartered and char- almost immediately. Physiotherapists who are
tered physiotherapists is that the latter will have not chartered, who are not familiar with
carried out part of their training, and will prob- standards of practice outside of football, and
ably have spent some of their professional lives, who, most importantly, are not qualified to
within the NHS and perhaps also in private work outside of football are in a weak position
practice. In these contexts, they will have to resist such threats to their clinical au-
absorbed the culture of a health care system in tonomy. Chartered physiotherapists, by con-
which their work will have been subject to the trast, are not only more likely to have a clearer
scrutiny of their seniors and their peers, and in idea of what constitutes a satisfactory standard
which there are relatively well established crite- of professional care but they are in a better
ria of what constitutes good quality care, both in position to resist threats to their autonomy, not
terms of technical and ethical considerations. least because they can find alternative employ-
By contrast, ex-players who have taken the FA ment outside of football.
diploma are likely to have spent much, or even In the light of our findings we recommend
all, their working lives within football and will the following.
have absorbed the culture, not of the health care (1) All vacancies for club doctors and physio-
system, but of professional football. The stand- therapists should be publicly advertised in
ards of care with which they will be familiar will appropriate professional journals.
not be the clinical and ethical standards that (2) Applicants should be provided with a clear
apply within the health service, but those that written job description and a personnel
derive from the culture of professional football, specification listing essential and desirable
some aspects of which, notably the strong con- candidate attributes.
straints on players to play hurtthat is, to (3) All short listed candidates should be
continue to play with injury and pain, if neces- formally interviewed.
sary with the help of pain killing injections and (4) Possession of a specialist qualification in
even if this risks further damageare not sports medicine (or the willingness to
conducive to good clinical practice. It is not undertake a course of study leading to a
suggested that ex-players who have become specialist qualification) should be specified
physiotherapists knowingly cut corners in terms as a desirable (although not, in the short
of quality of care; however, they have not had term, essential) attribute of candidates for
the same exposure as chartered physiothera- the post of club doctor.

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Club doctors and physiotherapists in professional football 53

(4) At least one independent medical research was also part funded by the Social Sciences Research
Committee at Leicester University.
practitionerthat is, one having no con-
nection with the clubwith expertise in
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Belfus, 1994:14.
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(soccer). Oxford: Blackwell Scientific Publications, 1994:
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SDW, ed. Medicine, sport and the law. Oxford: Blackwell Sci-
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Take home message


Almost all aspects of the processes of appointing and remunerating club doctors and
physiotherapists need careful re-examination; currently, these processes constitute a catalogue
of poor employment practice. The limited qualifications and experience of many club doctors
and physiotherapists are also matters of concern.

Commentary
This paper highlights several areas of concern about the appointment of doctors and
physiotherapists to professional football clubs. As this research was part funded by the
Professional Footballers Association, it seems that this body shares these concerns.
Professional football is a multimillion pound industry, with players often being transferred
between clubs for many millions of pounds, and top players earning vast sums of money on a
weekly basis. That the medical care of these players is often handed down between generations or
through the old boy network is a matter of concern. Appointment of club doctors should be
made on a competitive basis using the same strict guidelines that apply to doctors employed
within the NHS and industry. A relevant postgraduate qualification should be an essential
prerequisite.
It is a fallacy to believe that you have to have played the game to make a good football physio-
therapist. Experience is vital in all areas of employment, but bad habits can easily become
ingrained in an environment like soccer, where it is the macho thing to play through an injury.
Surely in an age when many top clubs are quoted on the Stock Exchange, it should not be long
before the money men wake up to the fact that they may not be properly guarding their most
valuable assets, the players.
MICHAEL CULLEN

www.bjsportmed.com
Downloaded from http://bjsm.bmj.com/ on August 12, 2017 - Published by group.bmj.com

Methods of appointment and qualifications of


club doctors and physiotherapists in English
professional football: some problems and
issues
I Waddington, M Roderick and R Naik

Br J Sports Med 2001 35: 48-53


doi: 10.1136/bjsm.35.1.48

Updated information and services can be found at:


http://bjsm.bmj.com/content/35/1/48

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References This article cites 3 articles, 2 of which you can access for free at:
http://bjsm.bmj.com/content/35/1/48#BIBL

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Topic Articles on similar topics can be found in the following collections


Collections Physiotherapy (188)
Physiotherapy (245)

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