Bloodgate physio wins high court appeal

Posted by Nell Mead at 16:00 on 3 Feb 2011

Moving back to the theme of HPC sanctions, do you remember Bloodgate?

On 12 April 2009, Harlequins rugby player Tom Williams was taken off the pitch by the team physiotherapist, Steph Brennan, with blood pouring from his mouth.  As he approached the Harlequins' bench, Williams grinned at his teammates, arousing such suspicion in Quins' Heineken Cup opponents, Leinster, that the Leinster team doctor requested to see the injury at the end of the match.

The problem was that there was no injury: Brennan had carried a fake blood capsule onto the pitch and Williams had bitten it in order to fake an injury which would allow him to be benched in favour of another key player.  In a panic, Williams approached the Harlequins' team doctor, Wendy Chapman, and asked her to cut his lip, so that he would have an injury to show the Leinster doctor.  Initially, she turned down his request but eventually gave in to the pressure and made a cut with a scalpel, as requested.

Following an investigation, the Rugby Football Union discovered that there had been four other incidents in which Brennan had facilitated the fake blood injuries.  He was banned from working in rugby for two years, while the chairman Dean Richards was banned for three years and the player, Tom Williams, for 12 months, reduced to four on appeal.  

Chapman, the doctor who had deliberately cut her patient, was initially suspended by the General Medical Council (GMC) but the suspension was lifted in August 2010 when the GMC decided that her fitness to practise was not impaired.

In contrast, Brennan, the physiotherapist who had facilitated cheating but who had not injured a patient and whose physiotherapy expertise was not in doubt (at the time of the scandal, he had been about to take up a post with the England rugby team) was struck off by the Health Professions Council (HPC), meaning that he could no longer work as a physiotherapist. 

As I'm sure you can imagine, this was pretty controversial, certainly within the physiotherapy community - a super-hot topic of debate on online physiotherapy forums.  Some felt that striking off served him right for cheating; more felt that the rugby ban was enough of a punishment in itself and an online petition asking the HPC to reconsider has so far gained 1175 signatures.

I think I agree with the petitioners.  Steph Brennan was clearly wrong to provide Tom Williams with a blood capsule, so the ban from rugby is fair; but his actions were not in any way dangerous.  The HPC's own Indicative Sanctions Policy states that a sanction such as striking-off is not to be used to punish wrongdoing, but to protect the public.  I'm not sure how striking off an experienced and well-regarded - albeit misguided in this instance - physiotherapist who has done no harm, is a move towards public protection.

Last week, Steph Brennan's lawyers successfully argued that his actions had not merited a sanction of such "gross severity" and Mr Justice Ouseley at the High Court ordered the HPC's Conduct and Competence Committee to reconsider the case.

Currently, the HPC are refusing to do so, saying that the striking-off order is not open to legal challenge.

So, should Brennan have been banned altogether from practising his profession - or just banned from rugby?  It's an interesting debate - what do you think? 

Shoulder pain - an underdiagnosed dysfunction

Posted by Nell Mead at 14:00 on 18 Feb 2011

This post is triggered by Dave Thomas of The Foundry, who commented yesterday on Facebook following a therapy session with me that “if you haven’t had your subscapularis walked on before, it’s a treat!” It seems to be a relatively unusual technique, but one of my favourites, and this is why.

The subscapularis (aka subscap, to rhyme with hubcap) is a triangular muscle which sits between the ribs and the shoulderblade (scapula) – its name meaning literally “below the scapula”. With its base covering the entire of the inside edge of the scapula, it narrows to a tendon which attaches to the inner part of the humerus (upper arm bone) and the shoulder joint capsule. Its role is to twist the arm inwards (place your hand on your stomach and try to push through to your spine: you’re using your subscap) and to pull the humerus forward and down when your arm is raised, thus preventing your shoulder from dislocating.

It’s one of the four muscles that make up the rotator cuff, (the others being supraspinatus, infraspinatus and teres minor, if you’re interested!) but far less frequently torn than the more vulnerable supraspinatus and infraspinatus. Probably because of this, it’s a muscle that’s often ignored by therapists when treating sore necks and shoulders, but in my view that’s a mistake. Good subscap function is essential to good neck and shoulder function, and I have a few theories as to why this is the case.

One theory is the effect that subscap has on the ribs. As I’ve mentioned, subscap sits between the ribs and the scapula. Normal shoulder movement depends on the scapula being able to glide freely over the ribs. When muscles are sore, they tend to tighten up and develop trigger points – isolated areas of muscle spasm; and subscap is no exception. It’s my belief that tightness and/or trigger points in subscap can be partly responsible for dysfunctional movement of the scapula over the ribs. This in turn places excessive strain on the rib and shoulder joints, leading to pain in the upper back, neck and/or shoulder.

I believe that another problem with subscap trigger points is the effect these have on blood flow and nerves. I suspect that when a muscle is tight, its spasmed fibres affect not only each other, but also other local structures such as blood vessels and nerves. In the case of subscap, this could – theoretically - affect the axillary (armpit) artery and the ulnar branch of the brachial plexus – the nerve that goes down to the inside of the elbow and the ring and little fingers. It’s certainly noticeable that patients often comment that they feel odd sensations in these areas, as I release their tight subscaps; or that once I’ve finished, they feel a rush of heat to the area (increased blood flow?)

Releasing the subscap is pretty tricky to do on your own. I often use my heels to release subscap in my patients – most therapists use their fists or fingers, but it’s hard to do that without jabbing your patient and causing more discomfort than necessary. If I have to release your subscap, I’ll ask you to lie on your back with your hand behind your head. This brings the edge of your scapula out to the side of your body, and I can then fit my heel between the edge of your scapula and your ribs, and use my bodyweight to stretch and massage the subscap, gently and rhythmically until the spasm subsides.

Not only does this tend to release the subscap spasm, it also frequently seems to relieve neck pain and increase in rotation at the neck, which is a great side effect. I’m not sure whether this is also due to better rib mobility, or whether there is some sort of chain reaction going on whereby the subscap release causes a release in the levator scapulae – any bright ideas gratefully accepted!

After I’ve released your subscap, I’ll show you how to stretch it yourself, using a chair, Swiss ball or yoga brick, so that you can maintain the improvement at home. 

If you're having problems with a shoulder, please e-mail me for advice or for an appointment.