To inject or not to inject? That is the question for Gerrard and McClaren

England's qualification for Euro 2008 could depend on a cortisone injection. Which makes the issue a complex one, writes Sam Wallace

There is a story about Allan McGraw, one of the great legends of Scottish football, that the Greenock Morton striker had 25 injections in his knees in one season alone in the 1960s. It never occurred to him at the time why his club took him to a different doctor in Glasgow for each one but now that he walks with a stick it is obvious. No doctor would have permitted one man to have so many cortisone jabs.

To inject or not to inject? Steven Gerrard will know the story of Tommy Smith, another Liverpool midfielder who, in a less cautious era, had so many injections in his knee that he needed operations – paid for by the Professional Footballers' Association – when he finished playing. In fact, his plight became the rallying call for the PFA chief executive Gordon Taylor when his union threatened strike action six years ago over their share of television revenue. Smith's knees were symbolic, in a surreal sort of way, of how a player can give up his long-term health for the short-term good of his team.

Given the modern-day understanding of footballers' health and developments in sports science, no one would suggest that Gerrard is putting himself at quite the same risk as McGraw or Smith if he decides that he would be most effective against Israel on Saturday with a jab in his right foot. The components and regularity of painkilling injections have changed but modern medicine still agrees that they are not to be taken lightly.

The debate goes thus: what would a player be prepared to sacrifice now for then? Gerrard is one of the greatest players in the modern game, in his prime at 27 and poised to ride to the rescue of England's Euro 2008 qualifying campaign. The temptation to play must be strong. So what if the knees are a little creaky come 40 years old, the argument goes, the medals and the memories will make it all worthwhile.

For those who have finished playing that is a compelling argument – Tim Sherwood, a former England international who captained Blackburn Rovers to the Premier League title in 1995 during his 18-year career said he does not regret the many painkilling injections that helped him play. "I'm pleased I had them," he said. "I feel sorry for the players who were older than me who didn't have the right advice and had to have hip and knee replacements, but injections allowed me to get through games."

It was the standard of the medical care that alarmed Sherwood during his playing days, even when it came to the administering of injections which would occasionally be done by the opposing team's doctor if no-one else was available. "I remember playing in London once for Blackburn and doing a loosener on the morning of the game with the boys in Hyde Park," Sherwood said. "My knee was so painful I couldn't run on it. An injection was suggested and we left it as late as possible before the start.

"One of our medical staff put a cross with a marker pen on my knee where they wanted the injection but for some reason the opposition team's doctor had to give me the jab. I don't like needles and would have usually looked away but it was a good job I didn't. When I looked he was just about to put the needle in my other knee. It was a mistake, but I did shout at him that it was the big black cross that he should be aiming for."

The pain, according to Sherwood, would return immediately after the injection wore off to the extent that he could not even climb the stairs afterwards. His attitude was then that he did not care, just as long as he could play. The former Sheffield United manager Neil Warnock said he would only allow a player to have an injection if the consensus was that it would not cause lasting damage. "Most players say they want to play through the pain," he said, "and then when it starts to hurt they ask for a jab."

The question of injections and the short-term fix in football relates directly to the standard of care that clubs provide. Many top Premiership clubs, like Chelsea, have invested in getting the best medical staff on the basis that if you are prepared to pay as much as £31m for a footballer then you should also be prepared to invest in the best possible care. It is not a logic that has always prevailed at football clubs where, traditionally, physiotherapists have been low-paid and over-worked, often having to care for academy players as well.

Many of them have moved around from club-to-club to raise their salaries. The players themselves have often sought private treatment away from their clubs like the renowned physiotherapist Kevin Lidlow who works at the Third Space clinic in London and whose reputation has grown by word of mouth. There has also been a cultural change towards injections brought in by foreign players.

"If we [British] players had a little niggle or a twist we would have a painkilling injection and strap it up," Sherwood said. "The foreign lads wouldn't entertain the idea of having an injection." The top sports injury specialist Professor Angus Wallace, who was brought in to adjudicate on Wayne Rooney's fitness at the last World Cup finals, said that painkilling injections were still used a lot in professional football.

"In my own practice I usually only offer three steroid injections [combined with local anaesthetic] in one year," he said. "But there's a lot of pressure on team doctors to get sportsmen playing again."

The brutal truth for Gerrard and footballers at any level is that it will be the knocks, niggles and strains that catch up with them in the end. Sherwood's career was effectively brought to a close when he broke his leg on Boxing Day 2003 playing for Portsmouth.

Although he later signed for Coventry he was taking 1600 milligrams of painkillers daily just to train and decided to quit on the day he tried to play without the jab. "I found I just could. I thought 'there's life after football'. I was making myself ill."

Cortisone much safer these days, says doctor

Steven Gerrard should suffer no ill-effects from an injection to allow him to play for England this weekend, and Liverpool's concerns are unlikely to be drug-related, according to a leading sports doctor. Gerrard could receive a jab containing cortisone and anaesthetic to overcome the paid of a broken toe. "Cortisone is a glucocorticoid steroid which acts on the nucleus of cells to reduce inflammatory response to injury or infection," said Dr Craig Panther, a specialist at the London clinic, Pure Sports Medicine.

"I'd guess it's not for the injury itself [which is a fracture] but perhaps for an inflamed joint nearby. Cortisone has no anaesthetic properties as such, but it does need to be diluted in something, so it makes sense to dilute it in anaesthetic, which treats the pain."

Dr Panther said "anecdotal, apocryphal stories" of cortisone ruining careers were history. "It's safe in small doses, which is how it is given these days. Large doses over a long period, especially in the same area, may have led to softening of cartilage and bone and chronic problems in the past. But a one-off jab is safe." Dr Panther says Liverpool's objection is probably down to Gerrard playing at all. "His injury has a healing time-frame, and they perhaps feel this match is inside that time frame." In other words, Gerrard faces a risk, however small, of making his toe worse through playing, but not through medication.

Nick Harris

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