Frantically searching for WiFi on a cruise ship, having to be available 24/7, playing games with the waiting paparazzi and the pressure of potentially holding up a multi-million transfer.
Welcome to the world of a footballer’s medical examination.
“You are used to medical emergencies that are life and death, and somehow these things that are very much not life and death end up with a sense of urgency around them that really has you frantically on your phone, trying to multi-task and desperately chasing people — and you know the clock is ticking!” says Dr Sam Thistleton, a consultant in sports and exercise medicine.
The Manchester Institute of Health & Performance is often called upon to facilitate medicals for transfers involving clubs in the north west of England.
The battery of tests takes about eight hours and the institute could perform as many as six medicals per day as a transfer window draws to a close. Sometimes, clubs call the night before in hope of booking a slot, although in most cases staff do not receive the name of the player involved until the morning of a medical.
“Unless I am the one doing the medical, the secrets are very well kept,” Dr Thistleton says. “From a doctor’s point of view, confidentiality should be guaranteed. We should be a trustworthy part of the process.”
Someone is often tasked with keeping the potential new signings hidden from each other by moving them from room to room at specific times to ensure word does not get out. Players can be brought in through a separate entrance to the one used by the general public and kept in private waiting rooms.
On one occasion, there were so many photographers outside another clinic that one doctor jokingly left with a blanket over his head to act as a decoy.
“There was one case where a Premier League club wanted to unveil their player at half-time but they needed to have extra tests,” says Professor Aneil Malhotra, a cardiologist who has worked with clubs including Manchester City, Manchester United, Leeds United and Tottenham Hotspur, as well as Olympic athletes from Team GB.
“I was getting constant texts and calls, but I said to the club it will have to wait because we always put the patient or player first. That comes above any media circus or contract deadlines.”
And here’s something to remember ahead of deadline day on Tuesday — you don’t ever ‘pass’ or ‘fail’ a medical in these circumstances, you just complete one. What happens after that ultimately comes down to whether the buying club believes signing the player involved is worth the risk based on the information with which they are provided following all those tests.
So, what is it like to actually go through a footballer’s medical?
The Athletic visited the Manchester Institute of Health & Performance, which is where Manchester City’s Erling Haaland completed his medical last summer before joining them from Borussia Dortmund, to go through similar tests to those conducted on many Premier League players before a transfer.
The first task, once the necessary clinical paperwork has been completed, is for the player to have blood samples taken. Luckily, or perhaps unluckily as far as my bank balance is concerned, I am not on the cusp of a Premier League transfer, so my veins did not need to be probed on-site.
A special courier is arranged to transfer the blood to a private laboratory where it gets assessed before a report is sent back — usually within about four hours.
“Footballers are the worst for having their blood taken,” jokes nurse Sarah Grindrod. “There was one signing where the player went a bit faint, so I had to get the club doctor. I mentioned laying him flat and giving him some oxygen, but the club doctor said it’s fine and to carry on!”
Grindrod says some clubs want as many as eight separate vials of blood to be taken per player, so medical staff can check their blood count (the types and number of cells in the body), liver function, kidney function and bone profile. They also determine whether there are any blood-borne diseases the players may have.
Next, the player is sent to a cardiologist to have their heart examined.
After completing the paperwork, The Athletic was asked to strip down for an ECG test — an electrocardiogram to check the heart’s rhythm and activity. Unless the sun is beating down and there is a swimming pool to jump in, does anyone like being told to take off a T-shirt? Add an enclosed space, a clinical environment and an experienced professor to the mix and, well, you can imagine how it feels.
“This has stood the test of time in detecting heart conditions which may be inherited or structural and can manifest as an abnormal electrical heart tracing,” says Professor Malhotra.
“It involves 10 stickers on the chest and takes about five minutes. It is non-invasive and it gives us a very good impression of how the heart is behaving.”
The results are instant. A pink sheet shows the peaks and troughs of my heart rate, with Malhotra observing to ensure they are not longer or shorter than they should be. He is also looking for subtle patterns which could be suggestive of a heart muscle disorder.
“The pick-up rate from the ECG alone can be as high as 90 per cent for serious cardiac conditions,” he says. “It is the most sensitive test that we have that can detect cardiac conditions from an electrical or heart muscle perspective.”
In March 2012, Fabrice Muamba, then playing for Bolton Wanderers, suffered a cardiac arrest on the pitch during an FA Cup game against Tottenham Hotspur and saw his career cut short. At the European Championship in June 2021, Denmark’s Christian Eriksen collapsed mid-game and had to be resuscitated. Eriksen was cleared to continue playing, although rules in the Italian game (see below) meant he had to leave his club Inter Milan and he is now with Manchester United.
Earlier this month, NFL player Damar Hamlin suffered a cardiac arrest after making a tackle in a game and spent several days in intensive care before being allowed home.
These events make the next part of the medical, an echocardiogram — an ultrasound scan that looks at the heart in more detail — even more important, because it can help identify structural issues or underlying heart muscle disease.
“It visualises the heart muscle and the valves in real-time, so you see the heart beating away and the valves opening and closing,” Malhotra adds.
“The numbers that are read out (during the scan) relate to the various dimensions of the heart, so the cavity size, the wall thickness of the heart muscle, the speed at which the blood is flowing through the various valves, the size of the right heart as well as the left heart, the size of the vessels that come off of the heart.”
Players have a thin layer of cold gel applied to their chest and are then asked to turn onto their left side before the cardiologist examines the heart with a probe that is pressed to the skin. If something is discovered, it is usually followed by a delicate conversation.
Premier League footballer I am not, and after the coldness of the gel wears off you start to feel your leg going numb (mine did anyway — I’m sure Haaland was fine!) as you are lying in a bit of an awkward position.
“If it is a routine screening, the player may be completely asymptomatic and it comes as a bit of a shock to them (if anything shows up),” Malhotra adds. “But then we need to navigate our way carefully through that process and explain to the player what the condition is.”
Malhotra says in the UK and other parts of Europe — excluding Italy, where players with heart conditions are not allowed to play, following the death of Fiorentina’s Davide Astori in 2018 — a pragmatic approach is usually taken and the overall decision-making process is a shared one.
“We don’t want to curtail a potentially amazing, lucrative career, nor do we want to unnecessarily subject someone who is harbouring a condition to the risks associated with exercise,” says Malhotra.
A player’s age and ethnicity are also factors.
“Black athletes have more ECG changes than white athletes and the conditions we look for change over time,” the cardiologist adds. “Between 14 and 35 years old, inherited conditions or electrical conditions are the main problem which can be easily detected. After 35, coronary artery disease becomes the No 1 cause.”
Malhotra aims to have the results sent to the buying club before the player’s medical has concluded. If time is against them, however, sometimes a verbal report has to do. Highlighting the speed with which the results can be delivered, Malhotra had a file of my scans on his desk before I had left the room.
It is not his remit, he says, to determine whether a player should be signed or not based on the results of a medical. His job is to carry out the tests and then objectively present his findings to the potential buying team.
“There have been scenarios where a player may have developed a condition whilst at a club, but when they want to sign for a new club, that new club says they don’t want a player with a potential risk of something going wrong with their heart,” he says. “It is that club’s perspective, and how the club doctor presents that risk to the board. It is up to the club whether a player is signed or not.
“There have been a handful of transfers that have fallen through because of the medical from a heart perspective, but another club may have a different view because it is a really good player and they are willing to provide X, Y and Z and take that risk.”
If a player is joining temporarily, say on a half-season loan in January, clubs can be more relaxed about an underlying medical issue.
“Equally, if you are signing someone for huge money and giving them a five-year contract,” says Thistleton, “you might have a lower threshold for saying it makes it a poor or risky investment for the football club.
“But it is never black or white. You might be doing a medical with 30 days left of the transfer market, sometimes you might be doing it on deadline day with five hours left and you need to decide what is most important and where your risks lie.”
Rest of the body
Professor Waqar Bhatti’s first scan reading in sport was of Wayne Rooney’s infamous broken metatarsal (the group of long bones in your foot between the ankle and the toes) ahead of the 2006 World Cup.
Bhatti, a consultant musculoskeletal radiologist, informs clubs what the MRI (magnetic resonance imaging) scan — which uses strong magnetic fields and radio waves to produce detailed images of bones and other structures inside the body — reveals about their potential signing. His message is simple: “The scanner never lies!”
A full scan can take around 90 minutes but it’s usually closer to two hours. This includes the spine, pelvis, hamstrings, knees and ankles, which allows Bhatti to compile a detailed report on what the inside of a player’s body looks like.
When going into the MRI scanner, which is an enclosed and claustrophobic tube that contains powerful magnets, you are given sound-proofing headphones and have to lie on a bed.
“There are background changes you expect to see on any scan, and this is where it is an art when looking at a scan,” says Professor Bhatti. “You are like an experienced (property) surveyor and you know what is normal and what is normal for this house’s age. It is the same for footballers.
“Some clubs have very experienced doctors and they can just read the report. Other clubs have less experienced doctors and they will read the report before calling to ask you whether they can sign the player.
“The pressure is then put on the radiologist and it is not really for the radiologist to decide, but sometimes you have to guide them and say things look fine.”
Some players fall asleep while being scanned, with others asking for a break partway through so they can eat. There have also been occasions where a potential signing has flown to Manchester from Spain, been scanned at the institute, and then boarded a flight to the United States to join an MLS club.
The radiologist does not have to be present to read a scan and Bhatti admits to having to be on call to offer his expertise at all times, especially during transfer windows.
“Sometimes you can be on a cruise ship and a pre-signing medical is being done, so you are frantically searching for WiFi,” he says. “It is frantic.”
Bhatti says he has never seen a club fail to sign a player and thinks that if a manager has already made up their mind about a deal, it is unlikely it will be changed by anything he turns up in an MRI.
“Whatever the scan says, the player will get signed,” he adds. “(But) the insurers have to be happy, as they need to insure the player and that means their premiums may be slightly higher.”
It is not uncommon for players to try to hide any underlying issues they may have, given the mooted transfer might transform their career and future earnings.
“I have seen (club) physiotherapists really sweating and putting a player through their paces to see if something hurts and putting them through all kinds of stress,” says Bhatti. “They ask the player if it hurts and they often reply, with a straight face, saying no!”
There have been examples where scans show an abnormality but it has clearly had no impact on past performances. What can cause problems, though, is if a player is not upfront about a previous injury and the selling club are not willing to send over their medical records, which they are not obliged to do.
“We don’t have a magical way of knowing it (past injuries),” Thistleton says. “You rely on the player giving you an account of everything that has gone on.
“Sometimes you might find a news story, so you know what the player and club said at the time about an injury… or you try to find footage of the injury.”
At Premier League level, clubs are pulling out all of the stops to ensure they are on the right side of a risk-reward medical but lower down the divisions, the financial resources are not there to perform as many checks.
While a definitive price was not given, the consensus is that the cost of player medicals is going up, and the sums involved can vary depending on how far you want the doctors to go when looking for potential issues.
Asked if top-flight teams are taking more or fewer risks compared to past seasons, Thistleton says: “We are better informed. I don’t know if that is better-informed risks or better informed so you don’t take the risk.”
And has he ever been surprised to see a club sign a player despite the medical information suggesting the risk may not be worth it?
“You tend to understand the decision,” he says. “There are other factors in a decision and not all of them are in my area of expertise. I don’t know what the club’s budget was, or how weak they were in that area of the pitch.
“There are factors I wouldn’t appreciate, but whoever makes the decision has taken my bit of the equation into consideration and thrown it into the stuff I don’t know.”
Bhatti says players often appear relaxed throughout a medical, but senses they are tense beneath the surface — especially the ones flying in from abroad who don’t speak much English. Others, he admits, can be “quite arrogant”.
“You get all walks of life,” he adds.
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