A footballer goes down, apparently in some pain. The referee runs over, asks them whether they require medical attention, and waves the team’s physiotherapist on to the field.

But the player’s coach is not happy and instructs the physio not to go on, as the stricken defender is needed on the pitch and, under the rules of football, medical staff can only assess an injury on the field and must carry out treatment on the sidelines.

Once the physio enters the field, the player must go off. In the professional game, the player will not be allowed to return for 30 seconds, a rule introduced recently because so many footballers were pretending to be injured to waste time and slow the tempo of the game when their opponents were on top.

The physiotherapist is therefore caught in an ethical bind between their professional duty of care and their manager’s insistence that they do not step on to the field so that the team does not suffer a competitive disadvantage.

I witnessed this scenario multiple times over the past 17 years, when I was a referee in the professional football, including reffing many Premier League games.

Sadly, there were several occasions when the physio did as the manager demanded and ignored the referee’s signal. As refs, we raised this as a concern with our bosses and the competitions, because we had a player on the ground requesting treatment yet medical staff were blatantly being ordered not to come on.

While it is easy to criticise healthcare professionals in such circumstances, I understood that there are significant stakes in professional sport, with points, promotion, relegation and championships on the line – not forgetting the vast sums of money at the top of the game.

Eva Carneiro incident

There is also a precedent of medics losing their jobs in such instances. Many readers will be aware of a famous case in August 2015 involving of the world’s most successful and ruthless coaches, Jose Mourinho, when he was Chelsea’s manager.

As the BBC reported at the time, club doctor Eva Carneiro and physio Jon Fearn ran on to the pitch to tend to the club’s midfielder Eden Hazard, who therefore had to leave the field to receive treatment.

Already down to 10, Hazard’s removal left Chelsea with nine players for a time. It’s fair to say Mr Mourinho was not happy.

Afterwards, he publicly criticised the doctor and first team physio Jon Fearn for being ‘impulsive and naïve’. Dr Carneiro left Chelsea in September after being demoted, claimed constructive dismissal and almost a year later reached a settlement with the club.

The tension between the physio’s duty of care and the manager’s motivations is at its greatest when a player takes a blow to the head and there is a suspected concussion.

Especially if a team is already reduced in numbers, the temptation to insist that the player continues can be irresistible. The rules now allow teams to make an additional substitute in such circumstances, but their opponents are automatically given the same opportunity, which may not be in the manager’s interests.

Further, the player will have to follow a concussion protocol before playing again, which might mean they miss the team’s next match. Some footballers can be insistent that they continue, out of loyalty to the team or for fear of losing their place in the side.

Familiar dilemma facing top-level football physios

What’s a physio to do if their professional judgement says the player must come off in the interests of safety, but the player and his boss are determined that they carry on? In the abstract, the answer is easy, but less so in the heat of battle.

More recently, physios working in football have been presented with another ethical dilemma made possible by a loophole in the rules.

While out-field players must leave the field to receive treatment, goalkeepers are allowed to stay on the pitch. Some managers create the opportunity for a tactical time-out by flagrantly telling their goalie to sit down, claim they have a muscle strain and request treatment.

The physiotherapist duly trots on and spends a couple of minutes tending to the ‘keeper while the other 10 players congregate round the boss for some advice and a pep talk.

Occasionally, the goalkeeper may indeed be injured, but I have witnessed such unethical behaviour first hand and heard the conversations between managers, physiotherapists and players, who all know full well what they’re up to. It’s cheating.

What’s to be done? Changes to the rules are tricky, as teams always find ways round them.

Treatment could be allowed while play continues, but that would put medics at risk as the game follows unpredictable patterns. In any event, treatment would not be possible in the penalty areas as they can become too congested, so guess where the injured player would be found?

‘[An] independent medic would accompany them [the physio or doctor] on to the field to assist, maybe offer a second opinion and ensure there are no shenanigans. They would also have the final say on potential concussions’

Rolling substitutions would allow players to be treated while their team retained a full complement of players, but coaches would fabricate injuries so they could change the line-up of their teams depending on the match situation.

Managers could agree between them to play fair, but even as I write those words I am scoffing at my naivety.

Physios working for clubs could join forces to stop all this nonsense by insisting that they will not play along with faking treatment or failing to provide care to players in distress, but I appreciate that would be tricky. Such a group would only be as strong as its weakest link, which would likely break rather easily.

Suggested solution

So, how about this for a solution? A panel of independent physios with no professional obligation to either team, with one assigned to each match.

As now, each club’s physiotherapist would attend to injured players on the pitch, which I can see is necessary in part for continuity of care. But the independent medic would accompany them on to the field to assist, maybe offer a second opinion and ensure there are no shenanigans. They would also have the final say on potential concussions.

Unlike the NHS, there are no resource implications in the Premier League. Such a role would provide professional protection to club medical staff and might even prompt teams to stop bend the rules and allow the healthcare professionals to carry out their roles safely and ethically.

Twin careers

Graham enjoyed a parallel career as senior healthcare journalist during the early stages of his refereeing career.

As his LinkedIn profile states

‘Those two worlds may have little in common, but the lessons were the same:

• how to lead with clarity when the stakes are high
•  how to stay resilient when mistakes are inevitable
• how to earn trust and inspire confidence under intense scrutiny’

To read more of Graham’s columns, click

Graham’s goal is to explain how match officials in all sports – and football in particular – reach their decisions.

For more information on his activities and availability to speak at events, email: gdscott@refsplaining.com

Image: Shutterstock Graham is pictured during the 2018-19 Premier League game between Tottenham Hotspur and Watford at Wembley Stadium.