Bleeding gums and ‘frightening’ stress: Why football management is bad for your health

The season is rapidly approaching its conclusion and the pressure is cranking up.

At the top of the Premier League, Pep Guardiola’s Manchester City and Mikel Arteta’s Arsenal are locked in a gripping title race; at the other end of the table, Rob Edwards is desperate to prolong Luton Town’s top-flight fairytale at the expense of Nuno Espirito Santo and Nottingham Forest. And in the English Football League (EFL), play-off season is in full swing, complete with all its usual emotional ebbs and flows.

These are the days when reputations are forged or shattered and, while it is enthralling for fans, managers would be forgiven for regarding the whole thing with dread.

Jurgen Klopp’s announcement in January that he would be leaving Liverpool at the end of this season was proof of how draining the job can be. “I cannot do it again and again and again and again,” said Klopp, who turns 57 next month.

In February, Roy Hodgson left Crystal Palace shortly after collapsing at their training ground. Although the 76-year-old’s health was not a factor in the club’s decision to end his contract three months early just a few days later, it caused understandable concern among players and staff.

It is not just in the Premier League, either.

Emma Hayes, who is leaving Chelsea Women at the end of the season to take over the United States women’s national team and is involved in a title battle with Manchester City, deleted her social media accounts last week, and called the expectations around her profession “ridiculous”. Media demands have, in her view, effectively turned managers into “pieces of meat”.

In the same month that Klopp made his announcement, Xavi also said he would finish as Barcelona’s head coach at the end of this season, calling the job “cruel”. “It wears you down,” he said. “In Barcelona, you always feel like you’re not valued, you’re mistreated — that’s how the club works. From a mental health level, it’s tough too.”

Xavi sounded broken then; three months and one surprise U-turn later, however, he has decided to stay on.

Management may be bad for your health, but it is also hard to give up.

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If you ever needed proof of the effects of working as a football manager, just compare pictures of them from their first day in the role — the posed photos on the pitch holding the shirt they will never actually wear, the cheery introductory press conference — to ones from their last. The ageing process plays a part, but the changes in appearance very often outweigh the number of years that have passed.

“I know it sounds mad, but I can’t grow a beard anymore,” Richie Wellens, whose Leyton Orient side finished mid-table in League One, English football’s third tier, this season tells The Athletic. “I only get stubble around my mouth, like a goatee. It doesn’t grow on my cheeks anymore. And that’s been in the last four years.

“I’m also losing hair on top and I’ve put a bit of weight on, eating at motorway services all the time. I’m always on the move, going to training, watching games in the evening — very rarely do I sit down and have a proper cooked meal.”

Wellens was 37 when his managerial career started, somewhat unexpectedly, in September 2017. He had been working as a first-team coach at Oldham Athletic, then in League One, when manager John Sheridan suddenly departed by mutual consent, leaving Wellens, who had ended an 18-year playing career only weeks earlier, to take caretaker charge. After leading the team on a five-match unbeaten run, he was given the job on a permanent basis.

Now 44 and in his fifth managerial role (he was dismissed by Oldham after their relegation at the end of that 2017-18 season and has since had stints at Swindon Town, Salford City and Doncaster Rovers before being appointed at then-fourth-tier Orient in March 2022), Wellens is aware that the stress of the job is affecting him physically — and not just because of what he sees in the mirror.

“I clench my jaw a lot at night,” he says. “And sometimes I wake up in the morning with bleeding gums. I think that’s down to stress.

“I’ve learnt to deal with a lot of issues as I’ve got more experience and realise there are certain red flags. You ask any manager, at certain points they’ll have the brain fog — they’ll have the parts where they’re looking at a computer screen, watching the opposition or whatever, and they aren’t taking any of the information on. Or they might be at the family meal table and they’re present, but they’re not really there.”

Wellens is renowned for his energy on the touchline. At a recent match, one observer in the crowd could be overheard joking, “That Richie Wellens, he’s gonna have a f***ing heart attack.”

It’s less funny when you consider that in June 2019, Orient’s then-manager Justin Edinburgh suffered a cardiac arrest while training in the gym. Six days later, he passed away. Edinburgh was 49.

His death came a month after Edinburgh had guided the east London club back into the EFL as National League champions.

Orient now carry out cardiac screenings at the start of every season for players and management staff. Wellens also has access to regular health screenings offered by the League Managers’ Association (LMA) but admits he didn’t have his last year. ”I will be doing it this summer,” he promises.

The LMA, the managers’ trade union, led by research that has repeatedly demonstrated that elite-level coaching offers perfect conditions for stress, anxiety and burnout to develop, started offering regular health checks for managers more than 15 years ago. It enlisted the help of renowned cardiovascular expert Dr Dorian Dugmore to help design and run the Fit To Manage scheme, which has developed into a comprehensive testing programme. Managers are now given a physical examination and blood screening, age and gender-related specific tests and a consultation with a private GP.

For Dr Dugmore, the seriousness of the situation was laid bare in December 2001, when he conducted an experiment on then-Bolton Wanderers manager Sam Allardyce and his Leicester City counterpart Dave Bassett. The pair were wired up to electrocardiograms and wore blood-pressure cuffs for a match between their two teams, and the results left Dugmore shocked.

“We took their bloods before the game, at half-time and full time, and we found that the physiological demands of watching the game were higher than being pushed to exhaustion in a clinical setting 10 days earlier,” he says. “It was quite a shock to see the rhythm changes in their electrocardiograms during the game. They were frightening.

“I’m a PhD in cardiovascular medicine and had spent previous years running the biggest centre in the world for cardiac rehabilitation in Toronto. I’d been dealing with high-risk patients every day of the week and I was quite shocked at the whole scenario.”

A chaotic 2-2 draw, featuring three red cards and a 93rd-minute equaliser for Bolton, was the perfect storm for the managers. At one point, Allardyce’s heart rate reached 160 beats per minute (bpm) — four times his normal resting rate. Bassett’s pulse topped out at 120bpm while his blood pressure peaked at 190 (ideal blood pressure is usually considered to be between 90 and 120) and he developed an irregular heartbeat as the game came to a close.

Reflecting on the experiment now, 79-year-old Bassett says that while there was stress involved in football, it’s far higher in other jobs. “The occupations I’ve been told that’s the hardest is North Sea fishermen and firefighters,” he says. “You don’t suffer that stress as a manager.”

For Bassett, it was often things away from the pitch that impacted him most. “One of the biggest problems is the media. They talk about sacking managers or, ‘You’ve only got another game.’ They don’t care about the stress that they’re putting on the manager and his family and friends. They make it a life-and-death game.

“When I was having a bad time at Watford (in the 1987-88 season), getting slaughtered every week, you find it hard to go to work. But if you can’t deal with it, you can’t be a manager.”

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Each individual will have their own way of dealing with it all — some of them healthier than others.

“All the guns and all the arrows are pointed at you,” says Tony Pulis, who managed Stoke City, West Bromwich Albion, Middlesbrough and many more over 30 years before he retired in 2023, aged 65. “And if you lose, then you feel responsible for everything. It’s a hell of a responsibility.”

Throughout his career, Pulis was renowned for being one of the first to arrive at the training ground each day — not to sit at a desk and get going on the various tasks on his to-do list, but to get into the gym and exercise before the real work even started. Even on a matchday, he would often go in early to run or cycle, to try to “get all the stress and tension out” before kick-off.

“I felt that, by maintaining a certain level of fitness and being strong, I could cope with all that stress,” Pulis says. “It took a lot of the after-effects of stress away.”

Pulis, who still has his annual health check with the LMA even now he has retired, also points to the fact that wherever he managed, he always had more experienced assistants alongside him: “People like Lindsay Parsons, Gerry Francis and David Kemp, who were all between six and 10 years older than me. So I could sit and talk to them and they’d been through my experience before.”

Brentford head coach Thomas Frank regularly goes for walks around the Premier League’s training ground with sports psychologist Michael Caulfield and the latter’s greyhound, Paisley. Instead of Frank having meetings in an office with his boss — the club’s director of football, Phil Giles — they catch up over a coffee.

When Brentford’s training ground was upgraded in 2022, padel courts were installed and the coaching staff regularly compete against each other in that racket sport — as do their counterparts at Liverpool.

Frank will celebrate his sixth anniversary in charge this year, assuming he is still in the job in October, and in that time, he has faced scrutiny.

He lost eight of his first 10 games after being promoted from an assistant role in October 2018 and Brentford went nine without a win from February to April of this season, heightening relegation fears. Going for a run or watching a new television series with his wife, Nanna, are two ways the Dane copes with the intensity.

“It’s about being consistent every day,” Frank says. “I have my routines, and when I go home I need to get my exercise and switch off. There are things out there that are way more important than football, so I try to give that perspective to myself. The issue is sometimes you are dragged into the hamster wheel and your thoughts are only about selection, injuries, preparing — but you need to take yourself out of that.”

Brentford lost the 2020 Championship play-off final to Fulham and returned to Wembley a year later to defeat Swansea City in the same fixture. Managing in the play-offs brings unique challenges. “That is by far the worst,” Frank says. “Your body is tense for 24 hours, even when you are asleep, because there is so much at stake.”

According to the 50-year-old, going on holiday is “key” to feeling refreshed. He owns a property on the south coast of Spain, which he visits with Nanna and their children during international breaks.

“I learnt over time that those weeks where you can switch off are absolutely crucial,” he says. “There are not any transfers. There are very few players. My coaches are highly qualified and there isn’t anything they shouldn’t be able to handle. No one can really disturb you — unless the training ground is on fire.”

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The physical and mental effects of stress are inextricably linked, but psychotherapist Gary Bloom believes that needs to be more attention paid to the latter.

“The first-team manager normally has an inordinate amount of power and sway in the club, in a way that the head of a corporate organisation wouldn’t have,” says Bloom, who spent five years working as the sports performance psychotherapist at EFL side Oxford United. “So the actual organisational psychology bit is dysfunctional.

“If a CEO wanted to make significant changes, he’d be going through a whole raft of people who’d be implementing them. At a football club, the manager is having meetings with all sorts of people, deciding on policy, transfers, recruitment, staff. And the lower down you go (down the divisions), the harder it is for football managers, because they haven’t got the money or resources to hire people who can help them.”

At the top level in the game, backroom staff numbers seem larger than ever, but that is only helpful if the manager places enough trust in them to delegate some decisions.

Part of the problem, says Bloom, is a lack of clarity over the role of football manager/head coach: “You know where the boundaries are of your job — how many days, roughly how many hours you work. That doesn’t exist in football. The job is as deep as anybody wants to go with it. That’s dangerous. Because you could work 24/7 if you wanted to.”

Wellens says that after his first job at Oldham ended he realised “how big the mental side of the game was”, and hired a psychologist. Not only to support his players but also to support himself and act as a “sounding board”.

Since 2019, the LMA has added mental health provisions to its support offerings for managers. As well as issues relating to stress, anxiety and burnout, the body sees an ongoing range of other even more serious mental health conditions, often linked to employment termination.

Bloom says there are still challenges in getting managers to recognise and accept that they need help.

“Some of the younger managers coming through — guys in their late thirties — might have done a bit of psychology at university or as part of their badge (coaching qualifications). So then they think, ‘I don’t need that support’, and ignore that element of it.

“I would urge more football managers to look at psychotherapeutic support for themselves. It is offered through the LMA, but the take-up is very low. I would be amazed if five per cent of football managers worked with individual psychotherapists or psychologists.”

Social media and 24-hour rolling news channels, together with the ever-increasing financial stakes, make it feels like football managers have never been under more scrutiny. Yet those of previous generations are unconvinced that life is harder for their successors.

“When I was managing, I did everything,” said Bassett, who last worked as a manager in 2005. “Now they have a staff of 30 people — set-play coaches, people that do the fitness and everything else. In the early days, you had a manager, an assistant manager, a physio and a kit man. And that was it.

“And there weren’t all these games you can now get on video and everything else. I’m not saying they don’t work hard but you don’t see managers going off and watching games (around the country and even further afield in person). They can get it on telly.”

Both Bassett and Wellens agree that the media demands on managers today are greater than ever, especially in the social media age, but the Orient manager also believes that expectation levels have changed. “It doesn’t matter what club you manage now, everybody’s expected to have success, even though, financially, you can’t compete with some clubs,” he says.

Dr Sally Harris, general practitioner (GP) at HCA UK at The Wilmslow Hospital, near Manchester, has been working with managers via the LMA for the past six years.

She has seen first-hand the effects of stress on her managers — whether it was seeing one of them confronted by a fellow restaurant-goer in Manchester as he tried to eat a pizza, or watching them ride the wave of emotion on the touchline on television.

“When I watch the highlights on TV, it’s like watching stress evolving in front of me,” Dr Harris says. “It’s one of the few businesses where you can have prepared everything absolutely right but then something happens on the pitch and all that work is out of the window. And then, of course, your work is more stressful.

“You work longer hours, so you don’t do your exercise. You don’t eat as well, because you’re travelling home late. You might drink more coffee because you’re feeling tired in the morning after not sleeping. Might have an extra glass of wine at night because you think, ‘Well, that’s the only good thing I’ve had’. And it just becomes this rapid cycling of stress in a very short period of time.

“It can also depend on your (club’s) owners and the support you get from within your club. But you don’t know any of that until you start the job.

“If you think about people who are running big businesses, they’ve had management training. These guys (football managers) are incredible people with incredible resistance, but it’s just a really stressful job.”

Equally, it can be a really enjoyable one. And doing a job you love can be a “protective factor”, says Dr Harris.

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Wellens could have many years of management still ahead of him.

Since he left school at 16, football is all he’s known. He’s been out of the game for a grand total of three months in 27 years. When he looks ahead, he sees himself doing the job for decades yet.

Does he worry about how it might impact his health?

“Everybody in life has concerns,” Wellens says. “I’m also very fortunate that the majority of my day is spent outdoors with young people who want to improve and we do something that we love. At the weekends, I get to enjoy being in front of big crowds, trying to entertain a supporter base and give them the highlight of their week. And we’re very well paid for it.

“We have to understand that, in every job, there can be stresses and complications in your health long term if you don’t enjoy it.”

With the LMA’s health screenings in place and experts on hand, there is more support available than ever before for managers. But, as Dr Harris points out, it is vital that minds are open and people are willing to access it: “When you’re stressed, sometimes you feel too vulnerable to access things that are in place. It doesn’t matter whether you’re a lawyer or a teacher or whatever — you get into this mindset that we have to be able to do it all. And nobody can do it all.”

Not even Klopp. “I am, how can I say it, running out of energy,” he admitted in January in explaining the decision to leave Liverpool this summer.

Brave? Maybe. Admirably honest? Certainly. And hopefully, it makes it a little easier for others who might feel the same way to follow his example and step away if and when they need to.

(Top photos, from left: Jurgen Klopp, Thomas Frank, Emma Hayes; Getty Images)