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Former Manchester United Physio: Sir Alex Ferguson never picked players against my medical advice, but I’m not sure all other managers did the same

Treating client on pitch

By Rob Swire, former head physio at Manchester United.

In the highly competitive world of professional sport – and in particular Premier League football – there is huge pressure on results and winning, as at the end of the day that it is what it is all about.

Success defines a players’ career, and also that of managers. A failure to bring about results can see a manager quickly lose their job, and so therefore having their best players out on the field as often as possible is a major priority.

The relationship between a football club’s medical team and the coach or manager is therefore crucial.

The manager expects his head physio to ensure his players are kept fit, healthy, and ready to play as often as possible, therefore giving him the greatest chance of success on the field.

So, with so much at stake, who makes the final call on a player’s fitness when they’ve suffered an injury and are badly needed out on the field?

I was fortunate enough to work for a football manager for many years who trusted my experience and expertise and followed my advice on each and every occasion – no matter what the match or occasion, and its importance.

Sir Alex Ferguson was a manager under immense pressure to win major trophies each and every year at Manchester United, but in 15 years as the head physio at the club I can say that there was not a single occasion where he went against my advice over a player’s fitness and ability to play.

Even if a player came in at half-time and said he had suffered an injury that nobody had been aware of, and that I felt meant he really needed to be substituted, Sir Alex would not question it – no matter how important the player.

Sir Alex was a manager who trusted his staff to make decisions for the right reasons, and as a manager, he was always interested in protecting the player’s welfare long term. He was very good at that.

Obviously, I was at Manchester United for 23 years, spending 15 years as head physio, and in all but one final year under David Moyes, I worked for the same manager, so I can’t comment first-hand on what happened elsewhere.

Anecdotally, I heard  frequent talk amongst physios at other clubs, raising their concerns about managers who did not take the physios advice, encouraging players to return to action earlier than was suggested, or urging them to play on against medical advice.

In any walk of life, such as business, some people think they know better than everybody else in every aspect of the job. Football is certainly no different, and I would imagine it is the same across many other sports.

For me, that is never the way it should be, and as I say, I was very fortunate to work with Sir Alex.

No matter what the occasion, no matter which player, if I said he shouldn’t play, he didn’t.

Mistreatment of injuries can be devastating and career-ending

Since moving on from Manchester United in 2014, I have become more involved in providing expert opinions in legal cases where the medical treatment of players from many sports has come into question. Negligent treatment is a massive issue, and mistreatment can prove career ending.

There is a huge responsibility on medical professionals to get things right from the start, and in this modern age, very few injuries should bring about an early end to a sporting career.


Go back a few years however and an anterior cruciate ligament injury could often have proved career-threatening. Nowadays, with the right treatment and rehabilitation – including giving the player sufficient recovery time before returning to injury – a full recovery can more often than not be made.

I mention that full recovery time because again it comes down to making the right long-term decisions. Returning to action too early can cause an injury to reoccur, or lead to new, additional injuries being suffered. You have to take a long term view.Rob Swire

This was perhaps an area I was again fortunate in at Manchester United.

Being the head physio for so long, I got to know the players and their bodies, what pressures they were susceptible to and even at what periods in a season they may be more at risk of injury. This enabled me to bring in injury prevention measures with people like Ryan Giggs, a hugely talented international player and key squad member who I had worked with many years and knew very well.

At many clubs now, coaches and managers chop and change year to year, and at the very top level it can mean clubs change their entire medical team, as they travel with the specific manager.

They may be first-class medical teams, but they lose that historical knowledge and for me, would therefore lose some ability to reduce the threat of injury to some players.

Professional sportsmen and women understand the need to care for their bodies.

Perhaps many people will wonder what role a player has in making a decision as whether or not to play with an injury, or to perhaps declare themselves fit early in order to secure selection for a big game – a cup final perhaps.

Although we’d all perhaps find this understandable, I have found that, at the top level at least, players are understanding of the situation and rarely need convincing not to take a risk.

They know their bodies, know the potential consequences of playing with injury, and make the right decision.

Obviously, it is often also not a sudden occurrence.

As a physio, if I knew a player was unlikely to be fit to take part in a certain occasion, I’d be talking to them about it in the weeks prior, and helping them to understand and accept the situation they were in. It is all part of the job.

Role of medical teams and treatment is more important than ever

Having worked in top-level professional football for more than 20 years, what I can say, without any doubt, is that players’ bodies are being placed under increasing pressures year after year.

With each passing year they become fitter, faster and stronger. Strength and conditioning and fitness experts are used, and because levels are improving across the board, the physical demand on players’ bodies is increasing.

It is therefore paramount, in my opinion, that sportsmen and women are properly cared for, and that protecting their long-term careers is the priority.

As I said, that was something Sir Alex always had at the forefront of his mind, and as a manager under huge pressure, at the highest level of professional sport, it was a fine example to set.

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27/07/2017 No Comments

Head Injuries in Sport: Can More Be Done to Prevent Concussion?

Rugby players in scrum | Head Injuries and Concussion in Sport

Concussion has become a major talking point in the world of sport, largely due to the rollout of significant legislative changes in how head injuries are managed and assessed on and off the field of play. This is particularly true of rugby, whose governing body has recently introduced new directives for punishing high tackles — the leading cause of serious head injuries within the game.

The treatment of head injuries in sport has proved a sticking point for well over a decade. Despite new research highlighting the damaging long-term impact of successive blows to the head, sport governing bodies have been slow to act on the mounting evidence, perhaps through fear that major rule changes could dilute the enjoyment of the sport for players and fans.

But with young players like Welsh international forward Jonathan Thomas being forced to retire from the game with life-changing brain conditions, it’s clear that the management and assessment criteria of serious head injuries need to be addressed.

Here, we look at how different sports address the issue of head injuries, and comment on recent legislative changes which could prove invaluable in curbing instances of harmful concussion.


As one of the world’s most physically demanding sports, rugby has a high rate of head injury. Indeed, concussion represents almost half (47%) of all injuries sustained by a tackler, and 20% by the ball carrier. It’s believed that at least one concussion occurs in every professional rugby game, with one-third of all severe blows to the head occurring during the tackle.

Historically, World Rugby took a tough stance on concussion. Players were required to come off the pitch and not play for a week — previously three weeks. All that changed in 2012, however, when the Pitch Side Concussion Assessment (PSCA) was launched; a five-minute concussion test to check if players should be allowed to return to the field.

The PSCA has faced criticism since its launch, with ex-players and sports medical experts arguing that cases of concussion need to be addressed more thoroughly to prevent further brain trauma and cognitive impairment. Speaking to the Scotsman, former Ireland international player, Barry O’Driscoll, said that World Rugby was guilty of “trivialising concussion” and that “there is no test that you can do in five minutes that will show that a player is not concussed”.

Rugby players tackling | Head Injuries in Sport

On 3 January this year, World Rugby introduced a new zero-tolerance protocol on high tackles. Under the rules, the severity of punishment for reckless tackles has increased, with players now facing match bans for the worst offences. It’s hoped the legislation will give more protection to ball-carriers and tacklers, reducing the risk of serious head and neck injuries.

However, like the PSCA, World Rugby’s new high tackle protocol has received criticism, with the Guardian calling it “disingenuous” to refer to it as law change at all. It argues that high tackles have always been penalised, and that increasing sanctions for individual challenges doesn’t address the real issue of concussion within the sport.

Following World Rugby’s rollout of tougher high tackle penalties, Rugby Football Union’s chief medical officer, Dr Simon Kemp, predicted that further legislative change is likely in the professional game. He said that the new protocol doesn’t go far enough in addressing the tackle-to-concussion ratio, and that new initiatives were being considered which he hopes will address the head injury risk to the tackler, and not just the carrier.

With concussion now accounting for 25% of match injuries, more must be done to prevent serious head injuries which could prove debilitating for young players. In our view, World Rugby should change its stance on the PSCA protocol, and provide greater education on the long-term cognitive impact of concussion.


In late 2016, an in-game incident involving Manchester United’s Anthony Martial raised questions about the FA and Premier League’s approach to concussion and head injuries. During a match with Watford, Martial clashed heads with Daryl Janmaat, receiving extensive treatment before being cleared to play on. Minutes later, an error by Martial led to Watford’s opening goal, and the player was then substituted, clutching his head as he left the pitch.

Martial’s injury, and subsequent error, prompted much debate around the topic of concussion in football. Pundits and sports medical professionals alike have voiced concerns that the MUFC forward should have been substituted earlier, particularly if club doctors suspected that he had suffered a concussion.

Historically, the Premier League left it up to team managers to determine whether a player should be allowed back on to the field following a suspected head injury. Ahead of the 2014/15 season, however, the association introduced new rules on how clubs and match officials should deal with suspected concussion – passing the responsibility to club doctors rather than coaching staff.

Under current guidelines, medical staff enter the field of play to assess the injury, and determine whether there has been a loss of consciousness. If the player was knocked out, they’re removed from the pitch and not permitted to return.

Football player heading the ball | Head Injuries in Football and Sport

In cases where the injured player hasn’t lost consciousness, a brief assessment will take place to determine whether they have any symptoms of concussion. Medical staff can also review footage of the incident, to determine the order of events and impact of the injury.

As well as this, all players are now required to undergo a pre-season neurological assessment, making it easier for doctors to measure their recovery rate should they suffer a head injury.

While these measures appear comprehensive in safeguarding players against repeat concussion, the case of Anthony Martial does raise questions about the concussion assessment process, and the judgement of club medical staff.

Like the PSCA protocol used in rugby, the concussion assessment criteria used in football does have its critics. Luke Griggs of the Headway Brain Injury Association believes that the assessment doesn’t go far in enough in ascertaining whether a player has clear-cut signs of concussion, and has voiced concerns that too many professional players are allowed to play on after a serious blow to the head.

Speaking to Sky Sports, Griggs said: “We are concerned that the ‘if in doubt sit it out’ approach isn’t being adopted in all cases. If players continue after a concussion, a secondary knock can significantly exacerbate the damage to the brain and cause real problems.”

Given the serious impact concussion can have on cognitive performance, it’s vital that young players are protected from the life-changing effects of repeat concussions and head injuries. Team doctors should commit to a ‘safety first’ policy that puts the well-being of the player before the ambitions of the club.

Horse Racing and Show Jumping

It may not be a contact sport like rugby or football, but horse riding has more concussions than any other sport, with an average of 25 concussions in competitive show jumping events and 17 in flat terrain races (per 1,000 player hours).

So concerned is the British Horseracing Authority (BHA) by the number of concussions in equestrian events that it’s launched a new initiative aimed at preventing head injuries sustained by professional and amateur riders. This has been developed in conjunction with the Professional Jockeys Association, The Injured Jockeys Fund, and the Racecourse Association.

Under the new protocol, the BHA will introduce improvements to its current standards and procedures, with a special focus on enhanced education, regulation and research. It plans to replace the current annual cognitive screening with more rigorous Cogsport neuro-psychological testing, and introduce Scat5 testing to medical teams at the racetrack — bringing equestrian events in line with other professional sports.

Jockey falls off horse | Head injuries in Horseracing and Sports

In a bid to raise awareness of the widespread issue of concussion in equestrian sport, the BHA has also launched a hard-hitting poster campaign in conjunction with the Headway charity. The ‘If in doubt, sit it out’ campaign was developed to give jockeys help in spotting the warning signs of concussion, as well as practical guidance on what to do after suffering a serious head injury in a fall.

Dr Jerry Hill, chief medical officer of the BHA, was one of those behind the new head safety initiatives. Recognising concussion management as one of the biggest issues facing equestrian sport, Dr Hill and his team have begun work on a range of safety improvements, with a special onus on improving the education and awareness of concussion among jockeys.

Speaking to the Racing Post, Dr Hill said: “While British racing has for some time been a pioneer on this topic, I am determined that we remain at the forefront of scientific research, education and regulation when it comes to this crucial issue.”

Changes to baseline neurological testing represent a pioneering shift in the safety of equestrian sport. While the more rigorous testing process is expected to take longer, it should offer greater insight into the long and short term impact of concussion, and make it easier to track the rehabilitation process of individual jockeys.

It’s encouraging to hear the BHA’s commitment to improving research, education and regulation around concussion. We only hope that the recent protocol changes prove effective in reducing head injuries, particularly among young riders at the start of their career in the sport.


Despite the fierce nature of boxing, the sport takes a comprehensive and infallible approach to head injuries, ensuring that amateur and pro fighters aren’t unnecessarily exposed to the long-term impact of repeat concussion.

In the UK, boxers stopped in a bout are suspended for 28 days, rising to 45 if they’re physically knocked out or have suffered serious punishment to the head and upper body. After their suspension period is up, they must receive clearance to spar again from the British Boxing Board of Control (BBBofC). This rigorous concussion assessment is carried out by a BBBofC doctor, and can involve an MRI brain scan in extreme circumstances (alongside the routine annual brain scan required from all professional fighters).

Boxers sparring in ring Head Injuries and Concussion in Boxing

Unlike other contact sports, whose governing bodies have been slow to adopt a more rigorous approach to head injuries, British boxing has been at the forefront of concussion prevention for some time. One, two or even three doctors are ringside at every professional bout, with ambulance crews on standby in case of severe head trauma. Referees and fight officials are also extremely quick to react when a fighter is in obvious distress following a blow to the head, reducing the likelihood of a potentially life-changing secondary impact.

While boxing is an inherently dangerous sport, the safety regulations governing both pro and amateur fights mean that young boxers are less likely to suffer the consequences of repeat concussion than rugby players. With the help of leading neuro-surgeons like Peter Hamlyn, the BBBofC has developed a concussion assessment framework that other sporting bodies can learn from — and one that proves that erring on the side of safety can make all the difference in safeguarding the cognitive well-being of young sportsmen and women.

Through our work helping athletes to recover from a sports injury, we recognise the life-changing impact concussion and head injuries can have — both in the short and long-term. That’s why we take an active role in raising awareness of the dangers of head injuries sustained in sport. To find out more, visit our sports injury page or contact our team today.

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22/07/2017 No Comments

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