“What you are having to do is balance risk all the time,” explains Robin Chakraverty. “That’s the job.”

Chakraverty, the England men’s football team doctor between 2016 and 2020 and the former head of performance and medicine at Wolverhampton Wanderers, is discussing what he felt was the toughest part of working in a football club’s medical department.

Medics are seldom recognised or known by name even by the most fervent fan, yet they are among the most important people at a club — and the most under pressure. Their judgment calls can shape a player’s well-being, a manager’s future and a club’s season. They are bound by a duty of care to their patients, but are also conscious that every day a player spends away from the pitch is — from the club’s perspective — a day wasted.

Yet, for all the demands placed on them, it can also be an enriching and hugely rewarding line of work.

In the build-up to the congested Christmas period — one of their busiest times in the year — The Athletic spoke to a range of medical experts who either work in football, or used to, to learn about the highs, the lows, the stresses, the fun and the forever evolving nature of the industry.

Football has changed beyond all recognition in the last 25 years and medical departments are no different.

The Guardian reported that when Manchester United won the treble in 1999, they had just two physios and a masseur. Now, there might be as many as 25 people working in a medical department at a Premier League club. This includes doctors, physios, masseurs, strength and conditioning coaches, physical performance coaches, rehab fitness coaches and nutritionists.

“You’re not in this perfect world where everyone is able to play pain-free or without risk,” says Chakraverty, who also worked as the chief medical officer for British Athletics. “If your aim is purely not to get an injury, then that is almost an impossible job.

“No one likes to get injuries but when you’re part of a medical team, you live that injury with the player all the way through — it totally dominates the mind.”

He explains how, generally speaking, a medical department is judged on team availability, the number of injuries sustained throughout a season and return to play — whether it’s done speedily or slowly.

“Your hardest critic is always yourself,” Chakraverty adds. “No one wants to be responsible for an injury but also you don’t want to be the guy that’s pulling people from the team when there’s hardly anyone who is able to play or train.”

He says the ideal situation is for everyone at a club to be aligned, rather than pulling in different directions, and that clear communication is essential.

“Everyone wants the points,” Chakraverty continues. “What makes the job interesting is trying to marry up the often conflicting aims of getting a good performance for a player or the team against managing injury risk. That’s the challenge everybody has — which is enjoyable because it’s not easy.

“There will be situations where you know that if there’s going to be an injury, you are going to get blamed. You have to live with that a little bit. The key thing is presenting the information so decisions can be made.”

Andy Renshaw, who ran the first-team medical department at Liverpool from the summer of 2016 to November 2017 (a period that covered Jurgen Klopp’s first season in charge), agrees. He says the challenge is always trying to find the middle ground when there are conflicts of opinion.

“There’s a hefty amount of politics when you deal with a squad of 30 people,” he tells The Athletic. “If a player gets back quickly, the manager gets a player back quickly and the club get their asset back quickly. But certain people have their own preferences as to how they wish things to go in terms of their rehab and we have to manage expectations from that at times.

“The difficulty is finding a balance between the players and the staff, trying to manage personalities and keeping everybody happy. That can be very, very difficult at times. From my experience, I don’t ever remember feeling under any pressure from a manager to push a player back too soon. Jurgen wasn’t like that at all. It was a case of: ‘When he’s ready, he’s ready; you just tell me.’ There was never any pressure from that side.”

The Athletic has reported how the medical operation became complicated at Liverpool, with different departments clashing over the best approach and the methods of Andreas Kornmayer, the head of fitness and conditioning.

Andreas Kornmayer was an effective but divisive presence at Liverpool (John Powell/Liverpool FC via Getty Images)

In Renshaw’s time, however, he says he avoided too many awkward conversations with Klopp: Liverpool generally performed well in terms of injuries during that 2016-2017 season.

“Jurgen is a very strong character, he wasn’t afraid of coming forward with his opinion at times,” Renshaw explains. “He would always, if he felt it was justified, ask the question saying: ‘Why did you do it this way, or what about this?’ He had his own opinions on certain things, but we never had any arguments.”

Geoff Scott is another medic with vast experience working in the top flight of English football. He left Tottenham last summer after a 20-year stint in north London, where he climbed the ranks to become head of medical, and describes his role as “sitting in the crossroads between the player’s health and the needs of the team”.

He emphasises the need for joined-up thinking across the club. He explained how executives were always informed about player injuries in case they needed to look for cover or replacements in the transfer window.

“The manager has got more short-term pressure,” Scott adds. “From his side (of things), the next game is the most important one. Then you have the players — they want to play, but often they sustain injuries where it’s not a wise thing to play and one game can put them at considerable risk of more significant time out. So it’s about balance and those trade-offs between what different people want is always the most difficult thing.”

Medics are also expected to adapt when circumstances beyond their control change — most obviously the identity of the manager. A new presence in the dugout does not just often lead to an alteration in tactics or style but in training methods. With players having grown used to the rhythm and intensity of the previous coach, this can lead to a spike in injuries.

At Spurs, Scott remembered this being a particular challenge. “If you go from a style which is really high intensity from one that was low intensity, then that can lead to injuries quite quickly,” he says. “Certain managers at Tottenham have had styles that were more aggressive, like Mauricio Pochettino. We would adapt to that and would look at the attributes the players would need to be able to perform for that manager.”

On top of that, the job also comes with the added pressure to make the correct judgement call — often with a demanding manager in their ear.

“Having a conversation with a manager when a player pulls up with an injury during a session, or during the week, and then they are unavailable is just a horrible conversation to have,” says Luke Anthony, the former head of sports medicine at Reading. “Some managers can almost make it feel personal, like it’s your fault. It’s hard to feel like you’re not delivering bad news.

“And when you’ve got a run of injuries, it’s really tricky and those conversations can be hard because the manager is under pressure and stress as well.”

Luke Anthony: ‘Some managers can almost make it feel like it’s your fault’ (Lynne Cameron/EMPICS/Contributor)

Anthony explains how there was then a separate pressure that came with working an injured player back to full fitness. While some footballers are more risk-averse and reluctant to play if they feel any tightness or pain, others will push through a contact injury.

The medic has to find the right balance. “When players are coming back, you have to push them hard in their rehab,” Anthony says. “The problem with pushing them hard is that leaves you open to setting them back.

“Sometimes that will go for you, other times it goes against you. When the player will train or play when they’re not quite ready and they re-injure — and it doesn’t happen often, but when it does happen — that’s the worst sensation. You are always running that line between being too cautious and pushing players back too quickly.”

Steve Hard, the current head of medical at Portsmouth, explains how there are more layers to the job the higher a club rises through the leagues.

“Players are worth more money, there’s clubs playing bigger wages,” he explains. “When you go higher up, you will have more interaction with agents, because the player is an asset to them.”

One of the biggest changes is the advent of players having their own medical staff, who work with them on a specially-tailored programme away from their club. In June, The Athletic profiled Volt Sport Science, a firm that works with Arsenal defender Gabriel. But the Brazilian is far from alone, particularly among foreign players who may prefer to work with someone who speaks their native language, or who they have used previously in their career.

“I get that because it’s sometimes challenging: the communication,” Hard adds. “I’m never going to stop it. If the player wants to work with people they have used before, all you ask for is there is communication between the club and that person.”

Scott echoes those sentiments. “At the big clubs, you’ll get some that have their entourage,” he says. “It’s just making sure everyone’s singing off the same hymn sheet. It can work, but it can be difficult. But I think that’s the way it is going now. The club have their staff, players have their own staff as well.”

That level of trust between a player and the medic looking after them is vital but can lead to unexpected consequences.

In his first job at Millwall, Hard once had to rush out at 2am in the morning to rescue a player who had got himself into trouble at a nightclub. Hard, who had previously worked as a doorman, was able to defuse the situation by “pulling in a few favours” and bundling the player into his car.

“I said to the player, ‘Do not mention this to the manager — it didn’t happen,’” he recalls. “He owed me big time.”

Medics often act as carers, confidants and counsellors to the players in their charge.

Hard, who used to work at Bournemouth, twice had to inform Callum Wilson that he had ruptured his anterior cruciate ligament — examples of the tough conversations that medics often have to endure with players who have become more than just patients.

Callum Wilson ruptured his anterior cruciate ligament at Stoke in 2015 (Malcolm Couzens/Getty Images)

“I’ve had quite a few times where I’ve either telephoned the player or sat them down, and talked through results, and that’s quite hard because sometimes you’ve built that relationship,” he says. “They are like your kids. You love them like your family and you are telling them that they can’t do something that they love. That’s tough.”

All the medics The Athletic spoke to acknowledge that the job’s all-consuming nature is one of its greatest challenges. Christmas Day is just a normal working day, as it is for players and coaches, and juggling work and family commitments can be difficult.

“You can’t just turn your phone off,” Anthony explains. “A player could try and get hold of you on Saturday night or Sunday and you might need to then act on it. It’s that constant demand. You are on the whole time.

“I’ve been trying to organise a medical when I’m on holiday during the summer. It was a place with poor reception, I was having dinner with my wife and I had to leave to walk half a mile to find bars on my phone so I could organise a medical. You annoy a lot of people.

“You miss weddings and all sorts of things because they are on Saturdays during the season. It would be unthinkable to say you weren’t around. That’s the hard part from a personal point of view.”

Renshaw agrees. “It takes your life away, to be honest,” he says. “Even when you’re sat on a sunbed in June — the only two weeks you really get off — your phone will ring and you’ll be told that a new player needs a cardiac screening kit sorting, can you get to this area as he’s landing here, is that hospital available?

“For the staff, it is definitely intense.”

If this all makes working in a football club’s medical department sound like something to be endured, rather than enjoyed, that would be misleading.

There are plenty of moments of light amid the shade, not least seeing a player ascend to their previous heights of performance after a serious injury. For Scott, it is a reward for the “hundreds of hours (of rehabilitation) that go into a player across all the different specialities”.

It is also why Hard cites a turgid encounter between Bournemouth, his former employer, and Accrington Stanley, as his all-time favourite match.

“It was probably one of the s***tiest games I’ve ever seen,” he says. “I think we won 2-0. But the reason it was my favourite was because (defender) Shaun Cooper had been out for nine to 10 months with his hip. At the time, it was a big operation, and it wasn’t clear if he would be able to come back and play at that level. But he came back, played and kept a clean sheet. That was my favourite game, watching him play again, after what he had gone through.”

There are other perks, too, including the buzz that comes with being around a team environment.

“What I enjoyed was being part of a team, part of a group,” Anthony explains. “You are working towards a goal. And when you do that over the season and when you achieve something, there’s a tremendous sense of satisfaction.”

Scott was part of the Tottenham team that enjoyed a spectacular ride to the Champions League final in 2019 under Pochettino.

Tottenham players and staff celebrate reaching the 2019 Champions League final (Dan Mullan/Getty Images )

“Those victories over Manchester City (in the quarter-finals) and Ajax (semi-finals) were special,” he says. “That run and then seeing the players that Tottenham developed, like Dele and Harry Kane, that’s what really drives the staff to keep going.”

“I miss the people,” Renshaw adds. “It’s brilliant to challenge yourself from a professional standpoint.”

So how has the job evolved, and what does the future look like?

Hard says he witnessed big changes during his 15 years at Bournemouth, a stint that began in 2006.

“When I first joined, it was just me. I was the physio, I was doing the gym sessions, I was helping with nutrition,” he says. “It wasn’t until 2011 that I was able to employ someone to work with me full time in the medical department.

“We managed to bring someone in, in sports science, to do the on-field fitness stuff. That was when Ed (Eddie Howe) came in. Over time, the staff grew. When I left Bournemouth in 2021, including myself, there were five physios, five full-time sports scientists, a full-time doctor, three masseurs, we had people come in ad hoc, a chiropractor. It grew massively.”

Scott also saw a major overhaul of the department during his long association with Tottenham.

When he started, there were seven or eight people in the medical department for the first team. By the time he left, it had increased to 25 staff across all specialities — including sports science, doctors, physios and nutrition — all of whom were required to cope with the demands of a sport that continues to grow in terms of volume and intensity with each passing season.

“Ultimately, the Premier League gets faster each year; what’s expected physically from the players becomes more and more each year,” he explains.

There have also been changes brought about by technology — something that will continue to shape the industry in the years to come, especially with the advance of artificial intelligence.

At a football club, every training session and match is analysed — GPS packs, long since a standard-issue accessory at the elite level, measure everything a player does — but that creates a huge amount of data for a medical department to process. They will filter that down into what they think are the most relevant parts to dig into.

GPS packs help track players’ workloads (Benjamin Cremel/AFP via Getty Images)

However, AI could do that more efficiently, on a grander scale and help identify future injury risks. “It’s refining it (the GPS data) to get more accuracy,” Scott said. “That’s what AI can do because it’s got more brainpower and can do things a lot faster.”

Another area for development is with virtual reality (VR) headsets, which can be programmed to set players particular tasks to challenge different skills such as reaction times, cognitive training and hand-eye coordination.

To aid his Chelsea comeback, Romeo Lavia regularly wore a VR headset to help recreate moments for when he was back on the pitch. He used the device to prepare for positions his team-mates and opponents would take up.

Elsewhere, technology companies now offer specific services to clubs to help develop an array of physical attributes: from muscle strength to balance, jumping technique and how agile a player is in their movement.

“These are things that didn’t really exist even five years ago,” Scott says. “So it’s able to give us a way to measure players’ strengths in different positions. That’s really useful.”

It is a brave new world in many ways, and yet for all the progress in data and technological tools at a club’s disposal, medical care is still an essentially human process — requiring patience, empathy and cool judgment. All of which is likely to be put to the test ahead of the festive fixture rush.

(Top image: Sean O’Reilly for The Athletic, photos: Getty Images)