F-MARC - Football for Health 20 years of F-MARC Research and Education 1994 - 2014
Editors: )HŔ´#UNŔ¨J Astrid Junge TABLE OF CONTENTS | FOOTBALL MEDICINE PROJECTS
Table of Contents
Preface
1 Executive Summary 2
2 Epidemiology of Football Injury 4
2.1 Review of Literature 4 2.1.1 Football Injuries before 2000 4 2.1.2 Football Injuries in Children and Adolescent Players 6
2.2 Definitions of Injuries and Assessment Methods 8 2.2.1 Influence of Definition and Data Collection on Injury Incidence 8 2.2.2 Consensus on the Injury Definition and Data Collection Procedures 10 2.2.3 Injury Surveillance in Multi-Sport Events 12
2.3 Injuries during the Football Season 14 2.3.1 Injuries of Male Players of Different Age and Skill Level 14 2.3.2 Severe Injuries of Male Players 16 2.3.3 Injuries of Female Players of the German National League 18 2.3.4 Injuries in the Tunisian Professional Leagues 20 2.3.5 Injuries in the Congo National Football League 22
2.4 Injuries during Football Competitions 24 2.4.1 Injuries during FIFA Competitions 1998 - 2001 24 2.4.2 Injuries during the 2002 FIFA World Cup Korea/Japan™ 26 2.4.3 Injuries during the 2006 FIFA World Cup Germany™ 28 2.4.4 Injuries of Female Players in Top-Level International Competitions 30 2.4.5 Injuries during the FIFA Futsal World Cups 2004 and 2008 32 2.4.6 Injuries and Illnesses at the 2010 FIFA World Cup South Africa™ 34 2.4.7 Injury Surveillance in World Football Tournaments 1998-2012 36
2.5 Risk Factors and Injury Causation 38 2.5.1 Risk Factors of Injuries in Different Ages and Skill Level 38 2.5.2 Risk Factors for Injuries in Elite Female Football Players 40 2.5.3 Tackling Situations of Male Players during FIFA Competitions 42 2.5.4 Video Analysis of Ankle Injuries 44 2.5.5 Causation of Injuries in Elite Female Players 46 2.5.6 Tackling Situations of Female Players in Top-Level Competitions 48 2.5.7 Refereeing in Injury Situations 50 2.5.8 Risk of Injury on Artificial Turf 52 2.5.9 Influence of Match Events on Injury Incidence during FIFA World Cups™ 54
2.6 Head Injuries 56 2.6.1 Head and Neck Injuries during FIFA Competitions 56 2.6.2 Biomechanical Aspects of Head Injuries 58 2.6.3 Biomechanical Analysis of Head Impacts 60 2.6.4 Biomechanical Analysis of Ball Properties 62 2.6.5 Biomechanical Analysis of Headgear 64 FOOTBALL MEDICINE PROJECTS | TABLE OF CONTENTS
2.6.6 S-100 Beta Serum Levels after Controlled Heading 66 2.6.7 Serum Levels of S-100 Beta after Minor Head Trauma 68 2.6.8 The Value of Neuropsychological Testing after Head Injuries 70 2.6.9 Effects of Heading Exposure and Previous Concussions 72 2.6.10 Do Minor Head Impacts in Football Cause Concussive Injury? 74
2.7 Injuries of Referees and Assistant Referees 76 2.7.1 Injuries in FIFA Competitions 76 2.7.2 Injuries of Referees at All Levels of Play in Switzerland 78
2.8 Injuries in Other Sports 80 2.8.1 Comparison of Injuries in Football and in Rugby 80 2.8.2 Injuries during the Olympic Games in Athens 2004 82 2.8.3 Handball Injuries during Major International Competitions 84 2.8.4 Sports Injury during the 11th IAAF World Championships 86 2.8.5 Injuries during the 2008 Olympic Games in Beijing 88 2.8.6 Sports Injuries and Illnesses during the 2009 FINA World Championships 90 2.8.7 Sports Injuries and Illnesses during the 2010 Winter Olympic Games 92 2.8.8 Sports Injuries and Illnesses during the 2012 Summer Olympic Games in London 94 2.8.9 Injuries in 13 International Athletics Championships 96
3 Prevention of Football Injury 98
3.1 Review of Literature 98
3.2 Development of Prevention Programmes 100 3.2.1 “The 11” – A Prevention Programme for Amateur Players 100 3.2.2 “FIFA 11+” A Complete Warm-Up Programme 102 3.2.3 “FIFA 11+ for Referees” 104 3.2.4 “FIFA 11+ Kids” 106 3.2.5 Enforcement of the Laws of the Game 108
3.3 Evaluation of the Effects of Prevention Programmes 110 3.3.1 Prevention of Injuries in Male Youth Amateur Players 110 3.3.2 Prevention of ACL Ruptures in Female Players 112 3.3.3 Prevention of Injuries in Female Adolescent Amateur Players 114 3.3.4 Importance of Compliance with Preventive Programmes 116 3.3.5 Effects of Different Implementations Strategies and Compliance with “FIFA 11+” 118 3.3.6 Benefits of High Adherence with regard to Performance and Injury Risk 120 3.3.7 Physiological and Performance Effects of “FIFA 11+” 122 3.3.8 Prevention of Injuries in Male Amateur Players 124
3.4 Implementation of Prevention Programmes 126 3.4.1 Country-wide Campaign to Prevent Football Injuries in Switzerland 126 3.4.2 Country-wide Campaign to Prevent Football Injuries in New Zealand 128 3.4.3 From Development to Worldwide Dissemination 130 TABLE OF CONTENTS | FOOTBALL MEDICINE PROJECTS
Table of Contents
4 Prevention of Sudden Cardiac Death 132
4.1 Pre-Competition Medical Assessment (PCMA) 132 4.1.1 PCMA at the 2006 FIFA World Cup™ 132 4.1.2 PCMA at the 8th African U-17 Championships 134 4.1.3 PCMA in International Football – Feasibility and Considerations 136 4.1.4 PCMA of Referees and Assistant Referees 138
4.2 Risk Factors and Management of Sudden Cardiac Arrest 140 4.2.1 Statement on Sudden Cardiac Death 140 4.2.2 Practical Management of Sudden Cardiac Arrest on the Field of Play 142 4.2.3 FIFA 11 Steps to Prevent Sudden Cardiac Death and the FIFA Medical Emergency Bag 144 4.2.4 Cardiac Findings and the Athlete’s Heart in African Adolescent Players 146
5 Other Recognised Matters 148
5.1 Assessment of Player Characteristics 148 5.1.1 Medical History and Physical Examination 148 5.1.2 Psychological Characteristics 150 5.1.3 Assessment of Performance 152
5.2 Ramadan and Football 154 5.2.1 Influence of Ramadan on Performance 154 5.2.2 Influence of Ramadan on Physiological and Performance Variables 156 5.2.3 Ramadan and Sports Performance 158
5.3 Use of Medication and Nutritional Supplements in FIFA Competitions 160
5.4 Age Determination using MRI 162 5.4.1 Developing a Methodology and Application in FIFA U-17 Competitions 162 5.4.2 Age Determination in U-20 Players 164
5.5. Cartilage Injury in the Football Player 166
6. Improving Standards of Care 168
6.1 Football Medicine Manual and Website 168 6.1.1 Football Medicine Manual 168 6.1.2 Emergency Medicine Manual 170 6.1.3 First Aid Manual 172
6.2 Consensus Statements and Recommendations 174 6.2.1 Recommendations for Diagnosis and Treatment of Concussion in Sport 174 6.2.2 Nutrition for Football 176 6.2.3 Medical Issues of the Female Football Player 178 6.2.4 Playing Football at Different High Altitudes 180 6.2.5 Playing Football in Hot Environments 182 FOOTBALL MEDICINE PROJECTS | TABLE OF CONTENTS
6.3 FIFA Regulations 184 6.3.1 Gender Verification Regulations 184
6.4 FIFA Medical Centres of Excellence 186
7 The Fight against Doping in Football 188
7.1 FIFA’s Approach to the Fight against Doping in Football 188
7.2 Comprehensive Information for Laymen 192
7.3 Research Projects 194 7.3.1 Nandrolone Excretion after Exercise 194 7.3.2 Testosterone Variability – the Influence of Ethnicity on Steroid Profiles of Football Players 196 7.3.3 Quantification of Clenbuterol at Trace Level in Human Urine 198 7.3.4 Profiling of Steroid Metabolites after Transdermal and Oral Administration of Testosterone 200 7.3.5 Influence of Multiple Injections of Human Chorionic Gonadotropin (hCG) on Urine and Serum Endogenous Steroids Concentrations 204
8 Football for Health 208
8.1 Prevention of Non-Communicable Diseases 208 8.1.1 Prevention of Risk Factors for Non-Communicable Diseases 208 8.1.2 Prevention and Treatment of Non-Communicable Diseases across the Lifespan 210
8.2 ”FIFA 11 for Health” 212 8.2.1 Development and Evaluation in Different Settings 212 8.2.2 Planning a Nationwide Implementation 214 8.2.3 Implementation in Five African Countries 216 8.2.4 FIFA in the Fight against Ebola 218
9 Bibliography 220
10 Supplements 236
10.1 Twenty years of the FIFA Medical and Research Centre (F-MARC): From “Medicine for Football” to “Football for Health” 244
11 Acknowledgement 246
FOOTBALL MEDICINE PROJECTS | PREFACE
Preface
Joseph S. Blatter Dr Michel D’Hooghe FIFA President Member of the FIFA Executive Committee
Since 20 years the FIFA Medical Assessment and In my capacity as chairman of the FIFA Medical Com- Research Centre (F-MARC) has focussed on the most mittee, and together with members of our Medical important thing in sport and indeed in society – health. Committee, I wholeheartedly congratulate to F-MARC, Prof Jiří Dvořák (Chairman) and Prof Astrid Junge The presented publication recognise the achievements of (Head of Research) for presenting the update of all 369 the F-MARC since its establishment in 1994. Under the scientific publications related to football. This publica- leadership of chairman Professor Jiří Dvořák and head tion gives an unique opportunity to further develop the of research Professor Astrid Junge, F-MARC has con- spectacular evolution in the world of our sport for the ducted rigorous research studies that have benefited the good of more than 300 million football players. development of our beautiful game. The results of sci- entific studies documented in 369 original publications This evolution started with our ambition to bring medi- by F-MARC offer many constructive answers to my cine into football, putting the various medical disciplines original questions 20 years ago: what can medicine and at the service of the health and the physical condition science offer to improve the game of football and how of our athletes. This led to the introduction of the Pre- can the frequency of football-related injuries be reduced Competition Medical Assessment as well as to various at all levels of the game? It has been proven that injuries changes and amendments to the Law of the Game and in football can be reduced by up to 50% if the complete the regulations of our competitions. We also introduced warm-up programme “FIFA 11+” is practised on a regu- the “FIFA 11+” warm-up programme with the success- lar basis. Research has also shown that playing football ful intention of drastically reducing the number of non- twice a week for 45 minutes is the best prevention tool contact injuries. for diseases such as high blood pressure, diabetes, obesity and others. Furthermore, we tackled the problem of sudden car- diac arrest on the pitch, introduced new regulations for The power and popularity of football worldwide can be cases of concussion, and proposed drinking and cool- used to contribute to the improvement of public health, ing breaks at matches played in high temperatures. We which has once again been well documented in stud- have already done so much, but we can still do even ies connected to the “FIFA 11 for Health” programme, more. Indeed, we have seen that football itself can be a which has already been implemented in 20 countries fantastic tool for improving health, and that is why, in and becoming a global health initiative of FIFA. our mind, “medicine for football” progressively became “Football for Health”. Now is the time for this research to be integrated into the daily lives of those in the football community Football, at all ages, can play a major role in the preven- and for us to fully benefit from the achievements of tion and treatment of many illnesses, such as diabetes, F-MARC within the 209 Member Associations of FIFA. hypertension, hypercholesterolemia, and others. With our “FIFA 11 for Health” programme, we have even There can be no compromise in our focus on player’s gone a step further, giving advice to millions of children health. I have no doubt that by combining our efforts, and youngsters, in more and more countries, to prevent we can make an important contribution towards better illnesses and improve people’s general wellbeing. health in football and society in general.
Joseph S. Blatter Dr Michel D’Hooghe FIFA President Chairman, FIFA Medical Committee 2 EXECUTIVE SUMMARY | FOOTBALL MEDICINE PROJECTS
1 Executive Summary
Prof )HŪ´#UNŪ¨J Prof Astrid Junge FIFA Chief Medical Officer Head of Research F-MARC
Football is the most popular sport worldwide with cur- been tested in prospective controlled studies on female rently approximately 300 million players in 209 Mem- players in Norway, and on male players in California ber Associations. The Fédération Internationale de and Nigeria. All came to the same conclusion: if the pro- Football Association (FIFA) has, as the world football gramme is performed on a regular basis, injuries can be governing body, the responsibility to ensure the smooth reduced by 30% while severe injuries can be reduced by running of its various competitions, and the develop- 50%. Higher compliance with the programme results in ment of the game for all age groups, at all levels of play, less injuries. The simple conclusion is that injury preven- both sexes and all in the spirit of fair play. tion works but only if performed regularly. Mindful that it also has the responsibility towards the FIFA´s Member Associations have understood the pow- players´ health, FIFA decided to play an active role in er of the injury prevention programme, and many have developing and supporting research on football medi- implemented the programme to all clubs within their cine. In 1994 and upon the initiative of the current countries - to name but a few – Germany, Japan, Iran, FIFA President, Joseph S. Blatter, the FIFA Medical Spain, Italy and others. The programme has since been Assessment and Research Centre (F-MARC) was estab- introduced to more than 90 Member Associations, and lished to reduce football injuries, and to promote foot- the FIFA 11+ programme become an integrated part of ball as a health enhancing leisure activity. all FIFA development courses. The programme has been also adapted for children and referees. In 1994, epidemiological data related to football injury were sparse. Thus, F-MARC established an injury sur- veillance system at the 1998 FIFA World Cup France, 11 steps to prevent sudden cardiac death which is now routinely implemented at all subsequent FIFA and Confederations competitions. At the same Following the tragic death of Marc Vivien Foé dur- time epidemiological data for recreational football play- ing the FIFA Confederations Cup 2003 France, FIFA ers was obtained in studies performed in the Czech has been fully committed to a programme of research, Republic and Germany. The data revealed that each education and practical implementation to prevent and football player sustained on average 2.1 injuries per manage emergency cardiac arrest on the football field. year, unrelated to the level of skills. Taking into account The pre-competition medical assessment has been rou- 300 million footballers worldwide, it was obvious to tinely implemented for all FIFA competitions. It has also F-MARC that prevention is the way to go, however not been adapted for the routine examination within the only limited to the prevention of injuries but to all nega- Member Associations in accordance with the interna- tive aspects occurring in relation to the game of football. tional accepted guidelines and recommendations. A clear “11” was used as synonym for prevention in football. protocol has been developed and applied for field of play for the recognition, response, resuscitation and the removal of the player under sudden cardiac arrest. FIFA FIFA 11+ to prevent injuries has introduced and distributed the FIFA Medical Emer- gency Bag, including an automated electric defibrillator, The first injury prevention programme we developed to all 209 Member Associations. It has been reported consisted of ten evidence based and/or best practice exer- that lives have been saved by using this equipment or as cises enhanced by the promotion of fair play. Thus, we a result of educational courses provided by FIFA and/or called the programme the “FIFA 11”. the Member Associations. The programme was subsequently further developed to be a complete warm-up programme focusing on the prevention of injuries: “FIFA 11+”. The programme has FOOTBALL MEDICINE PROJECTS | EXECUTIVE SUMMARY 3
11 rules to prevent doping tries taking into consideration the social economic envi- ronment and the risk factors for diseases. It is intended Since the last prominent doping case, involving the most that FIFA will introduce the programme to 100 Mem- celebrated player Diego Maradona who tested positive ber Associations by 2019. for a prohibited substance during the 1994 FIFA World Cup, a stringent strategy has been developed and imple- mented by FIFA to prevent doping in football. FIFA Medical Centres of Excellence This includes in and out-of-competition doping con- trols at the level of FIFA, Confederations and National As part of the sustainable development of football medi- Leagues as well as educational programmes for play- cine, 42 FIFA Medical Centres of Excellence for foot- ers, coaches, doctors and para-medical staff. FIFA sup- ball players have been accredited around the world since ports and is compliant with the World Anti-Doping 2005. The FIFA Medical Centres of Excellence, serv- code improving the protocol of controls by develop- ing the needs of footballers at all levels of play, offering ing the biological profile for individual football players. independent assessments including state-of-the-art treat- On average, approximately 30’000 doping controls are ment. Moreover, the centres have become an important performed annually in football, revealing 0.4% positive part of the worldwide network for medical football doc- findings (majority are so-called recreational drugs such tors, physiotherapists and paramedical staff who deal as marijuana and cocaine) including 0.03% for perfor- with problems on a day-to-day basis with clubs and indi- mance enhancing substances such an anabolic steroids. vidual players. Although positive findings are rare, FIFA continues the fight against doping in football and sports in general, while being the first International Federation to imple- Translation of Research into Education ment the biological profile, by collecting blood and urine samples at the same time prior to and during the While F-MARC has so far issued 369 original scientif- 2014 FIFA World Cup Brazil. ic publications in peer-reviewed journals, an additional future activities will be the education of medical person- nel who cater for football players all around the world. A FIFA 11 for Health free E-learning platform will be launched on the 1 Janu- ary 2016 offering information on all aspects of football Under the umbrella “Football for Health” the effects of medicine. The E-learning programme can be completed recreational football for the prevention and the treat- by passing the examination process or assessment tool, ment of non-communicable diseases has been extensively finally leading to a “FIFA Diploma in Football Medi- studied involving children, mature women and ageing cine”. This way F-MARC´s concept of prevention will men. It revealed that playing football on a regular basis be disseminated around the world and support FIFA´s twice a week for 45 minutes has a positive impact on the mission: `Develop the game, touch the world, built a health status, and could even be prescribed as a thera- better future.´ peutic procedure for a number of diseases such as high blood pressure, diabetes, child obesity and others. The We sincerely thank FIFA and President J.S. Blatter for results are based upon more than ten years of research the unconditional support of our work, and the many work, including a collective effort of more than 150 engaged people who contributed to make F-MARC´s researchers. projects successful.
The “FIFA 11 for Health” programme is a football- Prof Jiří Dvořák Prof Astrid Junge based health-educational programme for school chil- FIFA Chief Medical Officer Head of Research dren. The programme is being promoted by prominent Chairman F-MARC F-MARC football players and has been successfully implemented in 20 countries. The programme is continuously being developed and is adapted towards the needs of the coun- 4 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2 Epidemiology of Football Injury
2.1 Review of Literature
2.1.1 Football Injuries before 2000 or emergency department records) or overestimates (e.g. a player complaint) of the actual rate of injury meaning injury incidence statistics can be quite variable and dif- What was known on football injuries ficult to compare between sports, between projects, even within a particular sport as different authors use different The ever-increasing number of active players, leading in definitions of an injury. turn to an increasing frequency of injury with the result- ing cost for treatment and loss of playing time, made the need for an injury prevention programme evident. Defining an injury The Fédération Internationale de Football Associa- tion (FIFA), as the governing body of football, realised Most definitions of injury have three criteria in com- this need and decided to play an active role in develop- mon: missed training sessions or matches; an anatomic ing and supporting research on football injuries. When location of tissue damage and the need for medical treat- F-MARC decided to approach this problem, it soon ment. Thus, a thigh contusion (location and diagnosis became obvious that the epidemiologic information of tissue damage) that receives an ice application (treat- regarding football injuries was inconsistent and far from ment), but does not lead to any training or match missed complete because of the employment of heterogene- would not be classified as “an injury” because the player ous methods, various definitions of injury, and differ- missed no time. Despite this sounding fairly objective, ent characteristics of the teams assessed by investigators. there is much subjectivity for each of the criteria, espe- Therefore, it was crucial for F-MARC to first establish cially time missed. Apart from different definitions, the what exactly was known and then define our future epidemiologic information showed inconsistencies in strategy based on that. methods, definitions, player/team characteristics and environmental factors. To make it even more complicat- ed, there are also many pitfalls and biases in the rational Aims of the review estimation of the degree of severity of an injury.
UÊ>ÞÃiÊÌ iÊÌiÀ>ÌÕÀiÊÊÌ iÊV`iViÊvÊÕÀiÃÊ>`Ê symptoms in football players Incidence of football injuries UÊ`iÌvÞÊÀÃÊv>VÌÀÃÊvÀÊÕÀÞÊ>`Ê`iÃÌÀ>ÌiÊ«Ã- sibilities for injury prevention Injury incidence is mostly defined as the number of inju- UÊÃÃiÃÃÊÌ iÊÜi`}iÊÊÌ iÊÀi>Ìà «ÊLiÌÜiiÊ«ÃÞ- ries occurring during a time period when there was a risk chological factors and sports injuries of injury. Consequently, the incidence of football inju- ries has most frequently been calculated based on hours played during games and training. However, because of What did the medical literature tell us about the above-mentioned problems, the injury rates reported injuries? in the literature result in an incidence ranging from 0.5 to 45 injuries per 1,000 hours of practice and games. The first place to search for and to better understand Furthermore, incidence also varies between match play the nature of injury in a sport is the available medical and training, gender, age and indoor and outdoor play. literature. The problem is that research studies differ on Obviously, the majority of injuries occur to the lower their basic definition of injury. Defining an injury can extremities, mainly in the knees and ankles. be quite difficult. Does it mean a player down on the field? Any medical treatment on or off the field? Being removed from play? For how long – minutes, hours, Psychology and football injury days, weeks, months? Meeting an arbitrary minimum diagnosis? Only injuries that were submitted for insur- As opposed to external influences, the primary player- ance reimbursement? Those that required a visit to an related risk factors in risk assessment are psychologi- emergency department? Any physical complaint by a cal components. It had been shown that they not only player? Unfortunately, there was no universally accepted affected the overall performance of a player, but also definition of a sports injury in the literature. As such, their injury risk. Most investigations in this regard were reports of injury could be underestimates (e.g. insurance based on either a stress theory or a personality-profile FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 5
Country Level of play Injuries per 1000 game hours Injuries per 1000 training hours MALES Iceland National elite, first league 24.6 2.1 Sweden Sr. National team 30.3 6.5 Sweden National top division 25.9 5.2 US MLS professionals 35.5 2.9 UK Premier League, 1st and 2nd division 25.9 3.4 Finland Highest national league 25.9 3.4 Sweden 1st division 21.8 4.6 2nd division 18.7 5.1 3rd division 16.9 7.6 6th division 14.6 7.5 Denmark 2nd division (high) 18.5 2.3 Series (low) 11.9 5.6 FEMALES Sweden Senior players, various skill levels 14.3 3.7 Sweden Premier, 2nd division 24 7 YOUTH (<18y) New Zealand Schoolboy 16.2 3.7 Switzerland High level males 18.7 4.1 Low level males 21.7 8.2 Denmark Male youth 14.4 3.6
Tab. 2.1.1.1 Incidence of football injuries in different studies approach. Although the majority of these studies had What we learned from the reviews employed different methods, the results were in gener- al agreement that “life events” could influence the risk The frequency of football injuries reported in the sci- of injury in athletes. Life events are important circum- entific literature is estimated to be approximately ten to stances in one’s recent history such as death of a parent 35 per 1,000 playing hours (Tab. 2.1.1.1). Reviewing or spouse, birth of a child, divorce, change in job, resi- the literature is an important first phase of any research dential move, personal illness, and many more. In most programme. This review showed us some of the chal- cases, some major life event preceded an injury or was lenges of research into the frequency and characteristics related to the severity of injury. In this context, social of injury. The information regarding the sports medi- support appeared to have a buffering effect, but the cine aspects of football injuries presented itself as incon- influence of stress-coping strategies was somewhat ques- sistent. More research was needed to identify high-risk tionable. groups and variables that may predict injuries within these subgroups. A uniform definition of injury based on sound epidemiologic and methodological principles was Are some players just injury-prone? urgently needed.
Some coaches and players might say that a particular With regard to psychological factors, situation-related player is “injury-prone” because of their personality. Per- emotional states and coping resources may represent sonality traits are situation-independent and characterise important avenues for intervention. Therefore, we a person. However, according to the scientific literature, decided to further investigate these factors be investigat- personality traits seemed to have no influence on the risk ed with respect to injury prevention and improvements of injury and there was no typical personality profile for in performance. an injury-prone player. Nevertheless, several studies have shown that a certain readiness to take risks manifested Duration: 1996 - 1998 by personality traits such as lack of caution, tough-mind- Countries: International edness or an enterprising or adventurous spirit might be References: a factor related to injury. We might think that anxiety Dvořák J, Junge A (2000). Football injuries and physical symp- might be a factor in injury. In this regard it is important toms – review of the literature. American Journal of Sports to distinguish between general anxiety as a personality Medicine 28 (5 Suppl): S 3-S9 trait and situational anxiety in relation to competition. Junge A (2000). The influence of psychological factors on There was no data showing that general anxiety had any sports injury – a review of the literature. Am J Sports Med 28 (5 role in injury. However, competitive anxiety has been Suppl): S 10-S15 shown to be of utmost importance in injury occurrence. 6 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.1.2 Football Injuries in Children and broader perspective on the injury problem in children Adolescent Players and youth football.
What was already known about football injuries What did the literature tell us about injuries among children and adolescent players? among children and adolescent players?
Football is the world’s most popular sport with both UÊIncidence of injury active players and spectators, and people all over the The overall injury incidence varied mostly between world are enthralled by the power of the beautiful game. two and seven injuries per 1,000 hours of football However, it is still the smallest fraction of the playing for players aged 13-19. The review showed that the population, made up of adult male professionals, which incidence of injury in children’s and youth football attracts most of our attention while by far the highest increases with age. Thus, incidence values observed proportion of participants (22 million of the 38 million in players of both sexes aged 17-19 approached the officially registered players) are actually under the age of values observed in adult players. It was furthermore 18 years. Previous research has shown that football may revealed that growth-related conditions may have have beneficial health effects on players of all ages but an impact on the vulnerability of adolescent players, that there is also a high risk of injury. Epidemiological and that the potentially fluctuating maturation status data were collected on the incidence and characteristics among peers should be considered when comparing of football injuries, and a consensus regarding the meth- players of the same age group. Match injury was found odological standards for epidemiological studies was to increase with age, whereas training injury remained published. With regard to children and young players, rather stable. No relevant difference in injury inci- however, comprehensive and comparable data on the dence of boys and girls was apparent, and a compari- frequency and characteristics of football injuries have son between the injury incidence in elite youth players largely been missing. and sub-elite players suggested that the two groups have a similar injury risk.
Aims of the review UÊMechanisms of injury About 40 to 60% of all injuries were due to contact To analyse and summarise previously published epide- with another player or an object. Contact injuries miological data on football injuries in children and ado- were dominant during match play while noncontact lescent players in order to arrive at comprehensive con- injuries more frequently occurred during practice ses- clusions and valid considerations for the development sions. of future studies and injury-prevention programmes in children’s and youth football. UÊLocation and type of injury Most injuries (60 to 90%) were located at the lower extremities with the ankle, knee, and thigh being How we conducted the survey mostly affected. This said, it should be noted that the proportion of injuries in these locations varied consid- A literature search was conducted using the Medline erably between studies, possibly due to inconsistencies database PubMed up to November 2012. Studies were in definition and documentation as well as low sample included in the analysis if they were published in an size. The most common injury types were strains, international peer-reviewed journal and if injury inci- sprains, and contusions. dence was reported relative to the hours of football expo- sure. Studies using retrospective questionnaire analysis UÊSeverity of injury and return to play were excluded in the analysis in order to avoid retrospec- Using the established consensus, injury severity was tion bias. Ultimately, 32 titles fulfilled the given research measured using the categories mild, moderate, and criteria, thus establishing the base for this review. Addi- severe injury, where mild is defined as an absence due tional information from the remaining 21 retrospective to injury of between one and seven or eight days; studies was considered where appropriate to obtain a moderate as an absence of between seven or eight and 28-30 days, and severe as an absence of more than 28 FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 7
or 30 days. It was shown that about half of all time- loss injuries led to an absence of less than one week whereas one third resulted in an absence of between one and four weeks and 10-15% of all injuries were severe. The average duration of absence from training or match play due to an injury was 15 days.
What we learned from the review
A coherent application of terms and definitions as defined in relevant consensus statements is crucial when it comes to warranting the validity and comparability of research findings. There is a remarkable lack of informa- tion on football injuries and their prevention for play- ers younger than 13 years. This review suggests three key issues that should be addressed in future injury-preven- tion research among young football players: the num- ber of severe contact injuries occurring during match play; a strict application of the laws of fair play – both in training and matches; and a continuing development of specific injury prevention tools for young players of football so that the children and youth players of today can become the responsible, successful and healthy adult footballers of tomorrow.
Duration: 2012 - 2013 Country: Switzerland Cooperation: Department of Sport, Exercise and Health, University of Basel References: Faude O, Rößler R, Junge A (2013). Football Injuries in Children and Adolescent Players: Are there Clues for Prevention? Sports Med 43(9):819-837 8 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.2 Definitions of Injuries and Assessment Methods
2.2.1 Influence of Definition and Data all injuries are easily seen on videotape. For example, it Collection on Injury Incidence is very difficult to tell exactly when a player suffered a groin strain. Finally, self-administered surveys vs. one- to-one personal, telephone or mail interviews do not give Why we conducted this study the same results. Further questions were: Should a single team or a single league be studied for one season or more In our review of the medical literature, we found a con- than one season? Can we compare men with women, or siderable variation in the incidence of football injuries youth with adult players? that were reported by different investigators. We realised that these differences may be caused, in part, by method- Research design: In many injury studies, players were ological differences such as, for example, different injury asked to remember injuries in their past. This method definitions. In the same way, methods of data collection, is called retrospective and leads to the problem of bias observation periods, study designs, and sample char- recall: the longer the recall period, the more details are acteristics play a role. Whilst it was clear that the lack forgotten. This means that only the most severe injuries of standardisation disallowed the comparison of injury and the injuries with the most medical intervention are studies in football, it was however difficult for us to esti- remembered. Therefore, prospective studies became the mate the magnitude of the influence of these different norm where only newly occurring injuries are recorded. methodologies on the reported incidences of football injuries. Therefore, we began to think about developing Observation period: The observation period that is a system to allow multiple sports to be compared with studied is another crucial point. There are published each other. studies on periods of all lengths, from one competition to half a season, from a full season to a full calendar year and even more than one year. Further decisions to be Aims of the study taken are: Do we include the pre-season training? Do we assess only games or games and training? UÊ,iÛiÜÊÌ iÊ`vviÀiÌÊiÌ `}iÃÊ>««i`ÊÊÌ iÊ evaluation of football injuries UÊ>ÞÃiÊÌ iÊyÕiViÊvÊ`vviÀiÌÊ`iwÌÃÊ>`Ê`>Ì>Ê How we collected the data collection methods on the incidence of football inju- ries F-MARC decided to record injuries on a weekly basis for at least one year. For one year, all teams included in this prospective study were visited weekly by a physician who Factors influencing the results of injury study examined each player. This lead to 264 football players from the Czech Republic being systematically followed. How to define an injury: When investigating the inci- In addition, the players were asked to complete a ques- dence of injuries, one must first define “injury” “Foot- tionnaire at the end of the year. Their answers were then ball injury” is a general term; but there was no consen- compared with the weekly injury reports of the physi- sus among sports physicians about its exact definition, cians. except that the injury was a result of participation in football. The many questions arising in this regard have The F-MARC definition of a football injury is “any been elaborated in the previous chapter. physical complaint caused by football” F-MARC recommends the additional documentation of the con- Method of data collection: There were also many ques- sequences of the injury with respect to the duration of tions with regard to the best way to collect data. Firstly, restrictions in the participation in, or the absence from who reports an injury? Athletes may under-report inju- (time loss) regular training sessions and/or matches. ries and their severity. Why would they do this? Simply because they want to play! The trainer or physiotherapist may or may not report the injury to the doctor because Results many minor injuries do not need a physician’s supervi- sion and the doctor’s position may be influenced by con- In the retrospective questionnaire of the players, their fidentiality issues. Video analysis is an option, but not personal incidence of injuries as well as their history of football-related complaints was significantly lower than FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 9
Weekly Player What we learned from this study physician reports recall These findings were very important for our future Players reporting 1 injury 29.5 30.6 approach to the study of injury incidence. Our data showed just how poor the use of retrospective recall Players reporting 2 injuries 20.5 8.9 could be for studying injury history in sports. Our con- Players reporting 3 injuries 11.0 4.8 clusion was that most retrospective reports of injuries should be considered as an under-reporting of the actual Players reporting > 3 injuries 20.8 0.8 frequency of injury. As such, based on our previous lit- erature review and these results, F-MARC recommended prospectively studying injuries over a full year for games Injuries per player and training including preseason, using continuous data
Mild injuries 1.1 0.1 recording rather than any form of recall. To evaluate the causes of football injuries, we also suggested that each Moderate injuries .68 .21 injury should be further classified by the timing (presea- son or competition period, warm-up, match or training) Severe injuries .32 .35 and the situation (for example, indoor or outdoor, foul play, type of equipment used, Fig. 2.2.1.1). Any injury 2.1 .66
Injuries per 1000 hrs of 7.3 2.03 exposure
% with any complaint 91.3 61.7
Tab. 2.2.1.1 Summary of injury (% of total) reporting by physician weekly reports vs. player recall at the end of the year. that reported by the physicians during the weekly fol- low-up examination reports. (Tab. 2.2.1.1). For exam- ple, the weekly physician reports showed that there were an average of 2.1 injuries per player, yet the players recalled only 0.66 injuries per player; that means that, on average, players only recalled about one third of the actual injuries recorded by the physicians in their weekly reports. The players were very accurate at recalling severe injuries that caused symptoms or absence from play for more than four weeks. But they remembered only about every third moderate injury and less than 10% of the mild injuries. The shorter the duration of symp- toms and the further in the past the injury occurred, the more frequently it was forgotten. Another finding was that the more injuries suffered, the poorer the recall of those injuries. Players injured only once were accurate in their recall, but those who were injured more often showed a much poorer recall of their injuries. Players were accurate at recalling the circumstances of injury Fig. 2.2.1.1 F-MARC injury report form such as overuse, training or game and contact (none, no Duration: 1996 - 1998 foul, fouled), but less accurate with regard to injury loca- Country: Czech Republic tion; they under-reported thigh and lower leg injuries Reference: and over-reported ankle and knee injuries. Similar to the Junge A, Dvořák J (2000). Influence of definition and data col- individual injury rate, the injury rate per 1,000 hours of lection on the incidence of injuries in football. Am J Sports Med exposure calculated from the physician’s reports was over 28 (5 Suppl): S 40-46 three times higher than that reported by the players. 10 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.2.2 Consensus on the Injury Definition and full participation is referred to as an ‘‘early recurrence’’, Data Collection Procedures one occurring two to 12 months after a player’s return to full participation as a ‘‘late recurrence’’ and one occur- ring more than 12 months after a player’s return to full The need for a common approach to football participation as a ‘‘delayed recurrence’’. injury research Simply sustaining an injury is only one part of the prob- As outlined in the previous chapters, it had become lem. The group also had to define the severity of injury: very clear to F-MARC that variations in definitions and methods in sports injury research led to problems in What is a severe injury? interpreting research study results. Despite repeated calls The number of days that have elapsed from the date of for common strategies to be adopted, basic differences injury to the date of the player’s return to full participa- in definitions and implementation were continued to be tion in team training and availability for match selection found in studies of sports and football injuries. There- determines the injury severity. fore, FIFA and F-MARC decided to host an Injury Con- UÊÃ} ÌÊäÊ`>ÞÃÊÃÌ sensus Group. Using what is called a “nominal group UÊ>Ê£ÎÊ`>ÞÃÊÃÌ consensus model”, the invited experts with a long history UÊ`Ê{ÇÊ`>ÞÃÊÃÌ in the study of football injuries were asked to develop a UÊ`iÀ>ÌiÊnÓnÊ`>ÞÃÊÃÌ consensus statement on definitions and methodological UÊÃiÛiÀiÊÓnÊ`>ÞÃÊÃÌ issues when investigating football injuries. They had to address and define key issues for data collection as well Finally, the group had to define exposure according to as guidelines for reporting surveillance, risk factor and match and training. Exposure is the denominator in intervention studies. reporting injury rates. Rates of occurrence are generally reported as injuries per 1,000 player hours. In football, rates are reported per 1,000 match or training hours. Defining an injury What is match exposure? The starting point for the consensus group was what we Play between teams from different clubs. might think would be a simple definition: What is training exposure? What is a football injury? Team-based and individual physical activities under the Any physical complaint sustained by a player that results control or guidance of the team’s coaching or fitness from a football match or football training, irrespective of staff that are aimed at maintaining or improving players’ the need for medical attention or time loss from foot- football skills or physical condition. ball activities. An injury that results in a player receiving medical attention is referred to as a ‘‘medical attention’’ injury and an injury that results in a player being unable Reporting an injury to take a full part in future football training or match play as a ‘‘time loss’’ injury. Finally, the group suggested the following methodologi- cal concepts to improve reporting, interpreting and com- The next task was to define a “recurrent injury” because paring football research studies: players get hurt multiple times and it is important to UÊ-ÌÕ`iÃÊà Õ`ÊLiÊvÊ>Ê«ÀëiVÌÛi]ÊV ÀÌÊ`iÃ}ÊÌÊ define what is a new injury and what is a re-injury for minimise the occurrence of errors associated with the most accurate reporting of various aspects of injury recall, which is a problem with retrospective study incidence. designs. UÊ-ÌÕ`iÃÊà Õ`ÊÀiVÀ`Êi`V>Ê>ÌÌiÌÊ>`ÉÀÊÌiÊ What is a recurrent injury? loss injuries. An injury of the same type and at the same site as an UÊÕÀiÃÊà Õ`ÊLiÊV>ÃÃwi`ÊLÞÊV>Ì]ÊÌÞ«i]ÊL`ÞÊ index injury and which occurs after a player’s return to site and mechanism of injury (traumatic or overuse) full participation from the index injury. A recurrent inju- and whether the injury was a recurrence. A traumatic ry occurring within two months of a player’s return to injury refers to an injury resulting from a specific, FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 11
identifiable event and an overuse injury to one caused by repeated micro-trauma without a single, identifi- able event responsible for the injury. UÊ/ iÊV>ÌÊ>`ÊÌÞ«iÊvÊÕÀiÃÊÃ Õ`ÊLiÊÀiVÀ`i`Ê using the individual categories. When the number of injuries are few, categories may need to be combined. UÊ"Ì iÀÊ«ÀÌ>ÌÊV>Ìi}ÀiÃÊÌ >ÌÊÃ Õ`ÊLiÊ>Ê«>ÀÌÊvÊ all injury studies include whether the injury occurred during a match or during training, whether contact was involved, whether the contact was a violation of the rules. UÊ/ iÊÃÌÕ`ÞÊ««Õ>ÌÊÃ Õ`ÊÀ>ÞÊVÃÃÌÊvÊÀiÊ than one team of players and the study should last for a minimum period of one season (including pre-sea- son), twelve months, or the duration of a tournament.
Special attention is needed for players who enter or Experts of the consensus meeting on injury definition in 2005 leave the study after the study begins as well as players Front row: R. Bahr, J. #UNŪ¨J, W. Meeuwisse, A. Anderson entering the study with existing injuries. Intervention Back row: J. Hägglund, A. Junge, P. McCrory, C. Fuller, J. Ekstrand and risk factor studies require power calculations prior to beginning the project. UÊÊVÊÃiÌÊvÊvÀÃÊÃ Õ`ÊLiÊÕÃi`ÊvÀÊ>ÊÀiVÀ`Ê keeping. The forms used by F-MARC for their injury studies are a good place to start when developing materials for keeping records. UÊÕÀiÃÊÃ Õ`ÊLiÊÀiVÀ`i`Ê>VVÀ`}ÊÌÊÌiÊÊÌ iÊ match using 15-minute intervals.
What we learned from this meeting Prof. Colin Fuller, PhD, University of Nottingham This consensus group was able to come to an agreement on definitions of injury, recurrent injury, severity and training and match exposures in football. The group accepted criteria for classifying injuries in terms of loca- Duration: 2005 - 2006 tion, type, diagnosis and causation combined with the Countries: International best methods for recording players’ baseline information, Cooperation: Centre for Sports Medicine, University of injuries and training and match exposure. For research- Nottingham, Nottingham, UK; Department of Social Medicine and Public Health Science, Linköping University, Linköping, ers performing injury surveillance, they gave recom- Sweden; Oslo Sports Trauma Research Center, Norway; mendations on how the incidence of match and training Centre for Health, Exercise and Sports Medicine, University of injuries should be reported and proposed a checklist of Melbourne, Melbourne, Australia; and Sport Injury Prevention issues and information that should be included in pub- Research Centre, University of Calgary, Calgary, Canada. lished reports of studies of football. References: Fuller CW, Ekstrand J, Junge A, Andersen TE, Bahr R, Dvořák J, Hägglund M, McCrory P, Meeuwisse WH (2006). Consensus statement on injury definitions and data collection procedures in studies of football (soccer) injuries. Simultaneous publication in Br J Sports Med 40(3): 193-201, Clin J Sport Med 16(2): 97-106; and Scand J Sport Med Sci 16(2): 83-92 Fuller CW, Bahr R, Dick RW, Meeuwisse WH (2007). A framework for recording recurrences, reinjuries and exacerba- tions in injury surveillance. Clin J Sport Med 17(3): 197-200 12 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.2.3 Injury Surveillance in Multi-Sport the different needs. However, the most important prin- Events ciples and advantages of the system were preserved, such as the definition of injury, injury report by the doctor responsible for the athlete, daily reports independent Why we conducted this study of whether or not an injury occurred, and one report form per team and not per injury or athlete. Based on The protection of athletes’ health by preventing inju- this procedure, a simple and concise injury report form ries is an important task for international sports federa- including the most important variables was developed tions. Systematic injury surveillance is able to provide and tested during the 2007 World Championships of directions for injury prevention in different sports. But the International Association of Athletics Federations comparison of injury incidence between sports is diffi- (IAAF) in Osaka. cult indeed, not only due to lack of standardisation of methods, but also due to the different nature of sports. On the one hand, conducting a comparative study dur- Results ing a major tournament, such as FIFA World Cups™ or the Olympic Games, offers the great advantage that The following key points of the system were identified: multiple sports with athletes of a comparable skill level participate and that the observation period is defined by Definition of injury: the event. Furthermore, a high standard of environmen- UʺÞÊÕÃVÕÃiiÌ>ÊV«>ÌÊiÜÞÊVÕÀÀi`Ê`ÕiÊÌÊ tal factors, such as the quality of the playing fields and competition and/or training during the tournament equipment, is guaranteed. On the other hand, the large that received medical attention regardless of the conse- number of teams from different backgrounds and with quences with respect to absence from competition or diverse medical support makes it more difficult to obtain training.’’ reliable information about the incidence, occurrence and UÊÕÀiÃÊà Õ`ÊLiÊ`>}Ãi`Ê>`ÊÀi«ÀÌi`ÊLÞʵÕ>- characteristics of injury. Therefore, a standardised and fied medical personnel (team doctor, physiotherapist) feasible injury-reporting system for multi-sport events to ensure valid information on the characteristics of would immensely assist in optimising the protection of the injury and a comparable standard of data. In gen- the health of athletes. eral, the chief doctor of the national team should be responsible for reporting the injuries of their athletes. The team doctors should report all newly incurred Aims of the study injuries (or the non-occurrence of injuries) daily on the provided injury report form and should return it UÊÊ iÛi«Ê>ÊÕÀÞÊÃÕÀÛi>ViÊÃÞÃÌiÊvÀÊÕÌëÀÌÃÊ daily. tournaments involving team and individual sports, UÊ/ iÊÃ}iÊ«>}iÊvÀÊvÀÊ>ÊëÀÌÃÊÕÀiÃÊÌ >ÌÊÀiViÛiÊ using the 2008 Olympic Games in Beijing as an exam- medical attention from the team doctor during the ple day or, if no athlete is injured, the non-occurrence of UÊ Ài>ÌiÊ>Êëi]ÊyiÝLi]Ê>VVi«Ì>Li]ÊÃiÃÌÛi]ÊÀi«Ài- injury, require documentation of: accreditation num- sentative and immediate/timely system as a role model ber of the athlete, sport and event, round/heat/train- for future studies ing, date and time of injury, injured body part, type of injury, cause of injury and an estimate of the expected duration of subsequent absence from competition How we collected the data and/or training.
Based on the system well-established for international Cause of injury: football tournaments and used for all team sports dur- 1. An overuse injury refers to an injury resulting from ing the 2004 Olympic Games, a group of experienced repeated micro-trauma without a single, identifiable researchers set out to develop a scientifically sound and event responsible for the injury and a traumatic injury concise system to be implemented for both team and refers to one caused by a specific, identifiable event. individual sports at the 2008 Olympic Games. To be Overuse injuries should be divided into two groups applicable for both individual and team sports, the origi- based on the onset of symptoms. A non-contact nal injury-reporting system had to be modified to meet FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 13
trauma is defined as a traumatic event without contact with another athlete or object, such as a fall. 2. A recurrent injury is defined as an “injury of the same location and type, which occurs after an athlete’s return to full participation from the previous injury”. 3. Contact events are categorised as contact with another player, a moving object (e.g. ball, puck, racket) or a static object (e.g. hurdles, net, goalpost). If applica- ble, it should be indicated whether or not the injury is caused by a violation of the rules of the respective sport. 4. Playing field conditions (e.g. uneven ground) include alterations of the playing field by the weather (e.g. PD Dr A. Junge, F-MARC, and Prof. L. Engebretsen, IOC slippery ground).
Absence in days: UÊ/ iÊÌi>Ê`VÌÀÊÃÊ>Ãi`ÊÌÊ«ÀÛ`iÊ>ÊiÃÌ>ÌiÊvÊÌ iÊ number of days that the athlete will not be able to undertake their normal training programme or will not be able to compete. Duration of absence from sport is regarded as an indicator of injury severity. UÊ>ÞÃÃÊvÊ`>Ì>Êà Õ`ÊVÕ`iÊÀiëÃiÊÀ>Ìi]ÊvÀi- quency and characteristics of injury, athletes included, exposure and injury incidence for competition and training separately.
What we learned from the study IOC / F-MARC group during Olympic Games in Beijing 2008 A concise injury surveillance system for multi-sports events has been developed for both team and individual sports and tested during the 2007 World Champion- ships of the International Association of Athletics Fed- erations (IAAF) in Osaka. The system has been accepted by experienced team doctors and shown to be feasible for single-sport and multi-sport events. It can be modi- fied depending on the specific objectives of a certain sport or research question; however, a standardised use of injury definition, report forms and methodology will ensure the comparability of results. It will be used dur- ing the 2008 Olympic Games in Beijing and should serve as a role model for future studies in single and mul- ti-sport events. Duration: 2007 - 2008 Countries: International Cooperation: IOC, FINA, IIHF, OSTRC, IAAF Reference: Junge A, Engebretsen L, Alonso JM, Renström P, Mountjoy M, Aubry M, Dvořák J (2008). Injury surveillance in multi-sport events: the International Olympic Committee approach. Brit J Sports Med 42: 413–421 14 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.3 Injuries during the Football Season
2.3.1 Injuries of Male Players of Different strains the most common diagnoses. The average number Age and Skill Level of injuries per player per year was 2.1, ranging from 1.8 to 3.8 (Tab. 2.3.1.1). Injuries were classified as mild (52%), moderate (33%), or severe (15%). Almost half of all inju- Why we conducted these studies ries were contact injuries and half of all the contact inju- ries were associated with foul play. Nine out of ten play- Most coaches and parents who watch numerous games had ers had some football-related complaint. Only 23 players developed some observation regarding injuries in older vs. reported no injuries and no complaints related to football. younger age groups, or between high vs. low level play- ers. Some believed that older players suffer more injuries The younger players (14-16 years old) had slightly fewer than younger players, others that highly skilled players injuries per player and a lower injury rate than the 16-18 are injured more and again others that highly skilled play- years old players yet the data for the 16-18 years old was ers had fewer injuries than players of poorer skill. Another nearly comparable with the adults. The injury rate during question was whether there were regional differences. We training for the low level players was more than twice as therefore decided to look further into the injury incidence high as that of similar aged players of high level. Game question by collecting information on injuries in different injury rates for the low level players were almost twice as age groups, skill levels and regions. high as those of the high level players. For the adult play- ers, if one assumes that local teams are of lower skill than competitive amateur teams and both are of lower abil- Aims of the studies ity than the third league and top level players, a similar pattern of injury rate is seen with the lower level adults UÊÛiÃÌ}>ÌiÊÊ>Ê«ÀëiVÌÛiÊ>iÀÊÌ iÊV`iViÊvÊvÌ- having a much higher rate of injury than the more skilled ball-related injuries and complaints among football play- adults. ers of different ages and skill levels UÊ «>ÀiÊÌ iÊV`iViÊ>`ÊVÀVÕÃÌ>ViÃÊvÊvÌL>Ê injuries in youth players of two European regions Football-related complaints
We were also interested in football-related complaints that How we collected the data were unrelated to injury. The most frequent complaint was in regard to the lumbar spine (26% of players) followed A total of 264 players of different age groups and skill lev- by the ankle (22%), thigh (19%), head (18%) and knee els were observed for one year; players in the higher lev- (17%). It is interesting that an area not generally listed as a els of play trained and competed more. All injuries and frequent site of injury (the spine) is cited by over one-quar- complaints as well as the game and training exposure ter of the players with the high level 14-16 years old regis- were recorded. The injured players were examined weekly tering the fewest complaints (14%) and the top level adults by physicians and all injuries were assessed according to having the most players with complaints (52%). the International Classification of Diseases (ICD10 - an international standard for classifying medical conditions) with regard to the injury type and location, the treatment Comparison of two European regions required, and the duration of subsequent performance limi- tations. The regional comparison involved weekly follow-ups for 311 youth players over one year with complete reports on 180 players from the Czech Republic and 131 from the Results Alsace region (Germany/France) using the same method- ology. The comparison of injury data revealed no substan- Five hundred and fifty-eight injuries were documented. tial differences between players from the Alsace region and Two hundred and sixteen players (82%) suffered one or the Czech Republic in injury incidence per 1,000 hours of more injuries and only 48 players (18%) had no injury. exposure, degree of injury severity, or the circumstances in As expected, the ankle and knee were the two most com- which the injuries occurred. Players from the Czech Repub- mon injury locations with ligament sprains and muscle lic spent more time in training and playing football than players from the Alsace region did, but the ratio of training FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 15
Adult players Youth 16-18y Youth 14-16y
Top 3rd league Amateur Local High level Low level High level Low level
Training hours 307.4 337.1 184.3 133.8 267.7 148.5 249.9 135.6
Game hours 51.3 60.2 46.3 54.7 55.4 40.6 51.4 32.2
Training /game ratio 6.0 5.6 4.0 2.4 4.8 3.7 4.9 4.2
Injury per player
TOTAL 2.0 1.8 2.1 3.8 2.2 2.6 1.8 1.9
Mild .86 .71 .94 2.25 1.23 1.59 1.03 .87
Moderate .95 .68 .59 1.23 .78 .55 .53 .59
Severe .19 .45 .53 .44 .22 .45 .24 .48
Tab. 2.3.1.1 Exposure time and average number of injuries per player in different age and skill-level groups hours to match hours was similar. Again, when the players were grouped according to playing ability, the incidence of injury per 1,000 hours of exposure was generally higher in the low-skill groups than in the high-skill groups.
We found a higher proportion of injuries were caused by foul play in the Czech Republic. We also found that signifi- cantly more Czech players agreed that it was acceptable for a player to commit a “professional foul” if required to do so in view of the score and the importance of the match.
What we learned from the studies Set up for the epidemiological study in Prague
The incidence of injuries varied between players of different age and skill level. Part of the explanation for the patterns observed could be related to the amount of training and subsequent level of fitness. Low level players trained at half the exposure of the high level players, yet had somewhat similar numbers of injuries meaning their rates would be around twice as high. The number of matches was similar, but with less preparation they suffered more injuries leading to the higher injury rate. This indicates that training, coach- ing and fitness are effective injury prevention measures. This also showed that increasing the ratio of training hours to match hours, meaning either train more or compete less, Duration: 1996 - 1998 is a factor in injury reduction. This F-MARC study sug- Countries: Czech Republic, Germany, France gested that prevention programmes promoting fair play and Cooperation: Czech Football Association improvement in techniques and skills may reduce the inci- References: dence of injuries. Peterson L, Junge A, Chomiak J, Graf-Baumann T, Dvořák J (2000). Incidence of football injuries and complaints in differ- ent age groups and skill level groups. Am J Sports Med 28 (5 Suppl): S 51-57 Junge A, Chomiak J, Dvořák J (2000). Incidence of football injuries in youth players – Comparison of players from two European regions. Am J Sports Med 28 (5 Suppl): S 47-50 16 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.3.2 Severe Injuries of Male Players of 18.5%. With regard to diagnoses joint sprains clearly dominated (30%), followed by fractures (16%), muscle strains (15%), ligament ruptures (12%), meniscal tears Why we conducted this study and contusions (8%), and other injuries. The most fre- quent location for severe injuries was the knee (29%), The injury literature categorises severity of injury accord- before ankle (19%) and spine (9%). ing to time lost from work. A person with a mild inju- ry would miss less than one week of work, a moderate Of the knee injuries, just under one quarter were inju- injury keeps a person out of work for one to four weeks ries to the anterior cruciate ligament and another quar- and a severe injury would keep a person out of work for ter were meniscal injuries. About two thirds of the knee four weeks or more. According to our own results, about injuries did not involve contact with another player. 80-90% of football injuries from the hip and below are Five knee injuries happened during match play and four mild or moderate. When considering the potential pop- of these players had a history of prior knee injury, one ulation of football players, however, the public health during the same game. The two oldest players who sus- impact of the 10-20% of injuries that are severe would tained a serious knee injury consequently retired from be substantial. As a next step in our research programme, play. we therefore wanted to analyse factors related to severe football injuries in players by age (14 to 42 years) and Nearly 60% of severe injuries occurred during games. skill level (local teams to first league teams). Two thirds of all severe injuries happened at away matches. There was no real pattern to the location on the field where the injury occurred. Injuries were evenly Aims of the study distributed across playing positions.
UÊ>ÞÃiÊÃiÛiÀiÊÌÀ>Õ>ÌVÊ>`ÊÛiÀÕÃiÊÕÀiÃÊVÕÀÀi`Ê Forty-six percent of injuries were caused by contact and by football players of different ages and skill levels 54% involved no body contact. Nearly one third of UÊ iÃVÀLiÊÌ iÊÌÀÃVÊ>`ÊiÝÌÀÃVÊv>VÌÀÃÊyÕiV}Ê severe injuries were a result of foul play. Just over half of the occurrence of these injuries all injuries received no treatment on the field or in the dressing room after training/competition.
How we collected the data All but one of the groin injuries were non-contact and half were felt to be from overuse. The average age of We followed up on 398 players for one year in the Czech these players was 19 years. Twenty-four percent of the Republic. After a baseline examination, all teams were injured players had suffered an injury to the same, previ- visited weekly by a physician, who documented all inju- ously injured, body part. ries and complaints. All players who sustained a severe injury were asked to see the orthopaedic surgeon, who The average time lost due to injury was 9.2 weeks. then conducted a standard clinical examination and Three-quarters of the injured players fully returned to an analysis of the medical history. All players answered play in less than eight weeks, but about 10% were out a questionnaire concerning the circumstances of their of football for more than six months. The incidence of injury (for example, training, game, contact) and their severe injuries per 1,000 hours in the low level players judgment of the situation (for example, foul play). was twice that of the high level players.
Severe injuries were evenly spread across the age groups. Results The most frequent injuries in the 14-16 year olds were to the spine, joint sprains and contusions (Fig. 2.3.2.1). During the one year observation period the 398 players In the 16-18 year olds, the most common injuries were sustained 686 injuries. Of these injuries, 113 (16.5%) joint sprains (Fig. 2.3.2.1) and fractures. In the 18-25 were classified as severe injuries and we were able to year olds, muscle strains and joint sprains were the most obtain details on 97 (86%) of the severe injuries. The common. Finally, in players 25 years and older, ligament most important findings were: Trauma was the cause of ruptures, meniscal tears and muscle strains predomi- 81.5% of the severe injuries and overuse was the cause nated. Increasing age was associated with increases in FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 17
Age groups
14-16 16-18 18-25 25-41
35
30
25
20
% injuries 15
10
5
0
Spine Joint Fracture Ligament Rupture Contusion Joint Sprain Muscle Strain Meniscus Tear Dislocation
Fig. 2.3.2.1 Type of injury in different age groups muscle strains, ligament ruptures and meniscal tears and a decrease in joint sprains, contusions as well as spinal injuries (Fig. 2.3.2.1).
What we learned from the study
From these results, the following factors were deter- mined to influence the occurrence of severe injuries: first, personal or so-called intrinsic factors: age, previ- ous injuries, joint instability, abnormality of the spine, poor physical condition, poor football skills, or inad- equate treatment and rehabilitation of injuries; second, PD Dr J. Chomiak during the epidemiological study in Czech Republic environmental or so-called extrinsic factors: subjective exercise overload during practices and games, amount and quality of training, playing field conditions, equip- ment such as wearing of shin guards and taping and vio- lations of existing rules (foul play). These findings lend further support that critical factors in preventing injuries is complete rehabilitation from a prior injury along with improved skill and fitness.
Duration: 1996 - 1998 Country: Czech Republic Cooperation: Czech Football Association Reference: Chomiak J, Junge A, Peterson L, Dvořák J (2000). Severe inju- ries in football players – Influencing factors. Am J Sports Med 28 (5 Suppl): S 58-68 18 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.3.3 Injuries of Female Players of the from nine teams (aged 22.4 ± 5.0 years) for one com- German National League plete outdoor season. Injury epidemiology data is usu- ally reported as the rate of injury per 1,000 hours, so each team trainer documented exposure to football for Why we conducted this study each player on a weekly basis. Each team physiotherapist reported all injuries with regard to their location, type FIFA President Joseph S. Blatter once said “We have and circumstances of occurrence. An injury was defined seen the future of football and that future is feminine.” as any physical complaint associated with football that In 2004, it was estimated that there were over 20 mil- limited sports participation for at least one day. lion female players in over 100 nations with over six mil- lion female players in the US alone. The FIFA Women’s World Cup 1999 final in the US drew over 90,000 spec- tators – history’s largest audience for a women’s event. But despite the growth in participation in women’s foot- ball, the study of women’s football had lagged behind. Research on other sports had shown that it is a mistake to train women using the same guidelines as normally used for men. When this happened, the rate of injury to women rose dramatically over that of men. The unique physiology of women and the differences in capacity versus men required that women in sports train differ- ently than men. While there had been some work pub- lished on training women, especially in track-and-field and swimming, there was little reported on women in football. There were only a few studies on any aspect of women’s football, be it fitness, technique or tactics. Numerous injury epidemiology studies investigated on men’s football, but the data on female football was Results scarce. It has been known for some time that there is a clear difference between men and women in the rate of Of the 165 players followed, 115 players (correspond- injuries to the anterior cruciate ligament (ACL) of the ing to 70%) reported 241 injuries, meaning that each knee. Female football players sustain three to six times injured player sustained about two injuries. In this more knee ligament injuries than men. As the F-MARC study, 16% of injuries were due to overuse and 84% mission was to explore the nature of football injuries, it were traumatic. Forty-two percent of the traumatic seemed appropriate to focus our attention on women injuries happened during training (2.8 per 1,000 hours football players. Thus, we undertook a large scale pro- training), and 58% during match play (23.3 per 1,000 ject on injuries to females playing in the German profes- match hours). The ratio of training to match hours as a sional league. factor in injuries and performance in this study was 5.9, meaning that each female player trained about six hours for each match hour. Considering this ratio, the match Aim of the study injury rate was over eight times greater than the train- ing rate. Just over half of the traumatic injuries were due UÊ>ÞÃiÊÌ iÊV`iViÊ>`ÊÀÃÊv>VÌÀÃÊvÊvÌL>ÊÕ- to contact and the remaining traumatic injuries occurred ries in elite female football players without any contact (Fig. 2.3.3.1). The most frequent site of injury was to the thigh, knee and ankle, as all sus- tained about the same number of injuries (Fig. 2.3.3.2). How we collected the data Regarding the type of injury, the most frequent diagno- sis was an ankle sprain. Injury severity was determined In an attempt to determine injury incidence in high according to time lost from play. According to this, level women’s football, we studied the German national 51% of injuries were classified as minor, 36% as mod- league. Data was obtained on 165 female football players erate, and 13% as severe. Half the severe injuries were FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 19
Contact Non-contact comparably low training injury rate. An important find- 80 ing of this investigation was the frequent occurrence of 72 ACL ruptures. Consequently, we recommended that 60 there should be a special focus on prevention of ACL 40 ruptures in female football players, mostly occurring in 29 23 21 non-contact situations. 20 15 11 10 9
number of injuries 7 0
Tackle Others Foul play Collision Running Shooting Jumping Changedirection in Hit by ball
Fig. 2.3.3.1 Mechanisms of injury
20 18 19 18
15 11
% 10 8 7 6 5 5 Germany wins the FIFA Women‘s World Cup China 2007™
0
Foot Head Trunk Thigh Knee Ankle
Lower leg
Upper extremity Fig. 2.3.3.2 Location of injury to the knee (Tab. 2.3.3.1). In this study, eleven anteri- or cruciate ligament ruptures were observed, all during match play (2.2 injuries per 1,000 match hours). Seven occurred while changing direction, the other four during tackling (n=3) or due to foul play (n=1).
Injuries with absence of more than one month
s RUPTURES OF KNEE LIGAMENTS INCL ELEVEN !#, RUPTURES s 3IX LIGAMENT RUPTURES OF ANKLE s 4WO FRACTURES LOWER LEG FOOT s 4WO STRAINS OF THIGH s /NE KNEE SPRAIN s 3IX OTHERS
Tab. 2.3.3.1 Injuries resulting in absence of more than one month Duration: 2003 - 2004 Country: Germany What we learned from the study Cooperation: German Football Association, University of Saarland, Germany The injury rates reported were similar to those reported Reference: for some male players, but lower than what F-MARC Faude O, Junge A, Kindermann W, Dvořák J (2005). Injuries had seen at major women’s international competitions. in female soccer players - a prospective study in the German As with males, there was a high match injury rate and a national league. Am J Sports Med 33(11): 1694-1700 20 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.3.4 Injuries in the Tunisian Professional Results Leagues A total of 479 players from 18 professional Tunisian football teams were followed for 13 weeks. There was Why we conducted this study substantial variability in injury rate between the teams which could be real or might represent differences in A popular phrase is “football is football”. This means record keeping. Overall, the incidence of injuries was that the game is the same no matter where it is played: 4.7 per 1,000 hours of exposure to football, but the scoring, tactics, skills, patterns of play, fitness and more rates for individual teams ranged from 1.3 to over 17 are similar regardless of where the game is being played. in the first league and 1.5 to 9.2 in the second league Of course there are some cultural differences: the Euro- per 1,000 hours of exposure. As with other studies, we pean and South American games do display some dif- separated training and overuse injuries from match inju- ferences, but that does not mean that someone from ries and saw that the incidence of overuse and training Norway could not play with a group of Peruvians. If injuries was similar in both leagues (Fig. 2.3.4.1). For this phrase on the commonality of football were correct, both leagues, approximately 70% of all injuries occurred would it also be true for injuries? We knew there were without contact with another player. some differences between men and women regarding selected injuries, most notably the rate of anterior cruci- Compared to that, the average incidence of match inju- ate ligament injuries. But when it came to men’s inju- ries was significantly higher in the first league (22.5 inju- ries, the vast majority of injury studies reported in the ries per 1,000 match hours) than in the second league literature have been conducted on European players. As (7.2 injuries per 1,000 match hours, Fig. 2.3.4.2) but most observers of the game will comment on the afore- each value could have been influenced by extremely high mentioned cultural differences in tactics, we wondered if (first league) or low (second league) rates at some match- there might be cultural differences in the injury profile es. too. Therefore we intended to analyse the injuries suf- fered by players in predominately Arabic countries. These injury rates, while substantial and worthy of reduction, were much lower than those seen in inter- national tournaments reported by F-MARC. A quarter Aim of the study of all injuries were re-injuries, i.e. were of the same type and in the same location as a previous injury. Whenever UÊ>ÞÃiÊÌ iÊvÀiµÕiVÞ]ÊV >À>VÌiÀÃÌVÃÊ>`ÊVÀVÕ- we see such a high incidence of re-injury, the first ques- stances of injuries suffered by players of the Tunisian tion is in relation to the decision to return to play: either professional football league a player was allowed to return to play before rehabilita- tion was complete or was allowed to return to play with- out appropriate preventive measures like a brace to sup- How we collected the data port a prior ankle sprain.
This study was conducted over an entire professional In approximately one third of injuries, a strain of the league season. All teams in the first and second Tunisian thigh muscle was diagnosed. Additionally, ten muscle professional football leagues were asked to participate. ruptures of the thigh were reported whereas two muscle During the spring season of 2002, any football inju- ruptures occurred in the lower leg. Forty-one injuries ries that resulted in absence from at least one scheduled (23%) were sprains of the ankle (n=35) or knee (n=5). training session or match were reported by the team doc- Injuries that constituted severe tissue damage included tors on a weekly basis. Incidence and rate of injury were three fractures (nose, rib, metatarsal), two dislocations described according to their diagnosis and circumstances (foot, elbow), three ruptures of the knee ligaments and of occurrence. For each player, the coaches recorded the one meniscus lesion. amount of time in training and matches, as well as the reason for any absences. Sixty-one percent of the injuries resulted in absence from training or matches for up to one week, one third of the injuries resulted in absence for eight to 28 days, and 11 injuries in absence for more than 28 days. The over- FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 21
all incidence of injuries resulting in absence for at least What we learned from the study one month was 0.3 per 1,000 hours exposure, although four of the 11 severe injuries occurred in one team. The So, could we say that “football is football” when it comes majority of these injuries (73%) were sustained during to injuries? The overall incidence of injury in the first matches, but only two of them were the result of con- Tunisian professional league was similar to that reported tact with another player. Injuries resulting in a subse- for high-level European teams, but was lower than what quent absence of more than one month affected mainly had been reported for major international tournaments. the knee (two ligament ruptures, two sprains) and the The major difference, however, was in the fraction of thigh (three muscle ruptures, one contusion with hae- total injuries that were non-contact in nature and this matoma); the other three severe injuries included a frac- percentage was substantially higher in these Arabic play- ture of the metatarsal bone, inflammation of the Achilles ers. Some consider that non-contact injuries are among tendon and pubalgia. Of the four long lasting knee inju- the most preventable of injuries, so it seemed advisable ries, three occurred in the same team, which was also the that these teams improved their efforts in the prevention team with the highest overall incidence of injury. of injuries. Preventive interventions aiming at improve- ment in the quality of training and adequate rehabilita- tion after injury were recommended to reduce the rate 6 of injury.
4 3.3 3.2 Injuries Injuries with absence of more than 28 days 2 First league Second league s 4WO LIGAMENT RUPTURES IN THE KNEE 0 s 4WO SPRAINS OF THE KNEE Fig. 2.3.4.1 Incidence of overuse injuries and injuries during training s 4HREE MUSCLE FIBRE RUPTURES IN THE THIGH s /NE CONTUSION WITH HAEMATOMA IN THE THIGH s /NE TENDONITIS OF THE !CHILLES TENDON s /NE FRACTURE OF THE METATARSAL BONE s /NE PUBALGIA 30
22.5 20 Injuries First league 10 7.2 Second league 0 match injuries per 1000 match hours Fig. 2.3.4.2 Incidence of match injuries
Duration: 2001 - 2002 Country: Tunisia Cooperation: Tunisian Football Association Reference: Junge A, Khouaja F, Dvořák J (2002). Incidence and characte- ristics of injuries in the Tunisian professional football league. Internal report. 22 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.3.5 Injuries in the Congo National Football Results League A total of 310 forms from 155 matches could be ana- lysed. There were 932 injuries recorded, corresponding Why we conducted this study to six injuries per match and 182 injuries per 1,000 play- ing hours. Of these, 883 (94.6%) were mild, meaning Information on the incidence, characteristics and causes they did not cause any absence from play. Time-loss of injuries in African players is scarce. As F-MARC had injuries occurred with a frequency of 9.8 per 1,000 play- shown earlier, data reported in studies from Europe ing hours. No injury caused an absence from play of and the United States was not necessarily transferable more than a month, and five injuries (10%) an absence to Africa. Injury frequency and characteristics vary with from one to four weeks. The most frequent injury type different styles and levels of play, but also between coun- was a contusion (65% of all injuries). An ankle sprain tries and geographical regions. With regard to African was the most frequent diagnosis, accounting for 27% of league players, one survey in seven clubs of the premier all injuries and 40% of time-loss injuries. league in Nigeria reported an injury prevalence of 81.6% during the 2006 football season. However, due to the With regard to circumstances of injuries, more injuries study methods, the data was not comparable with stud- occurred during the second (57.6%) than during the ies using the definitions of the injury consensus. In fact, first half of matches (42.4%). Almost all injuries were none of the few studies performed in African players was caused by contact with another player (98%), and of of sufficient quality with regard to design and methodol- these 85% (777 injuries) resulted from foul play accord- ogy to allow for comparison of data or conclusions on ing to the assessment of the recording physicians. Two injury frequency. Still, the existing data hinted at possi- thirds of these were consequently sanctioned by the refe- bly high frequency and in some cases considerable sever- ree. ity of injuries, raising major concerns, particularly when considering the limited access to qualified sports injury care in these players.
Aim of the study
UÊ iÌiÀiÊÌ iÊV`iViÊ>`ÊV >À>VÌiÀÃÌVÃÊvÊvÌL>Ê injuries among African league-level players
How we collected the data
Three stadiums in Kinshasa were selected for their pitch quality meeting FIFA standards. Only match and not training injury frequency and characteristics were record- ed to facilitate data collection. During the first round of the 2006-2007 football season, 180 matches were played in these stadiums, plus a further 28 during the second round. Three independent physicians familiar with the F-MARC injury recording procedure were designated to record all injuries for both teams of a match. Injury defi- nition referred to any injury resulting from play regard- less of time loss. For the expected absence from play in more severe injuries, they had to confirm their estimate with the team’s medical staff. FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 23
What we learned from the study
This was the first study of African players which, by virtue of the methodology used, allows for the compari- son of the findings with previous studies based on the F-MARC recording principles. One distinction how- ever, which might have influenced results, was the use of dedicated physicians as recorders as league teams in the Congo do generally not possess of medical staff. The injury frequency found in these African league players (182 injuries per 1,000 hours of match play) was six to 12 times higher than what has been reported in studies from other regions (12-35 injuries per 1,000 hours of match play). While the pitch conditions and equipment might partly explain this difference, the recording by a physician exclusively attending to this task could also result in higher numbers of recorded injuries. The negli- gible occurrence of injuries without contact with another player (2%) and which are supposed to be due to fatigue or lack of concentration was another major difference to previous studies where these injuries occurred about 12 to 30 times more often. Apart from the recording meth- od, a different style of play has to be considered as the vast majority of injuries were caused by foul play.
No major difference was found in the location and char- acteristics of injury which mirrored the findings of previ- ous studies. As common in football, the ankle was the most frequently injured joint, distortions of the same the most frequent diagnosis and contusions the most fre- quent type of injury.
In conclusion, despite minor methodological differenc- es, the study confirmed the trend towards higher injury frequency in African players indicated by studies apply- ing different methods. More studies in African elite and amateur players are needed to balance the interpretation of these data and to better weigh them against the lack of access to qualified care for risk assessment. Future studies need to take the findings of this study in con- sideration in their design in order to establish the much needed evidence for future prevention approaches in Duration: 2006 - 2008 African players. Country: Congo Cooperation: Fédération Congolaise de Football-Association Reference: Zerguini Y, Bungu-Kakala J, Junge A, Dvořák J (2010). Etude des Blessures lors d‘une Compétition National Africaine de Football - A propos du Championnat EPFKIN 2006-2007 á Kinshasa (RD Congo). [Examination of injuries in an African national football league. The 2006-2007 EPFKIN championship in Kinshasa (Congo DR). Journal de Traumatologie du Sport 27: 171–176 24 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.4 Injuries during Football Competitions
2.4.1 Injuries during FIFA Competitions each match. The response rate was 84% on average, but 1998 - 2001 as teams and physicians became more familiar with the forms and responsibilities, the response rate in the most recent competitions was 100%. Why we conducted this study
Major international sport competitions like the vari- Results ous FIFA competitions and the Olympic Games attract a large number of spectators and are highly entertain- A total of 901 injuries were reported from 334 matches ing for the viewing audience. The competitive pressures which gives a gross incidence of 2.7 injuries per match are so intense that it should not be surprising that the (Tab. 2.4.1.1) or 88.7 injuries per 1,000 match hours. incidence of injury during international championships The competition with the highest injury rate was the is quite high. From the very beginning, a better under- FIFA U-20 World Cup 2001 (4.7 injuries per match) standing of the nature of injury at major competitions and the lowest rate (1.3 injuries per match) was reported seemed highly desirable for F-MARC. While compara- in the FIFA Women’s World Cup 1999 and the FIFA tive information on the risk and incidence of injuries in Futsal World Cup 2000. In Futsal however this was mis- different sports could provide most important insights, leading due to the shorter match duration, the injury we have already elaborated in the previous chapters on rate per 1,000 hours of futsal was in fact over double of the problems of the many different methods and specific that of outdoor football. The average rate of injury in definitions of injury, severity, diagnosis, level of com- men’s football was just under twice of that of women petition, and more. Consequently, F-MARC wanted to (2.4 vs. 1.3 respectively for FIFA competitions and 3.7 assess exposure-related incidence of injuries in different vs. 2.1 for Olympic competitions, Fig. 2.4.1.1). types of sports using the same methodology. The rate of injury that resulted in missing training or competition was 35 per 1,000 match hours or approxi- Aims of the study mately one injury per match. Player-to-player contact was a factor in 86% of the injuries and approximately UÊ iÛi«Ê>ÊÕÀÞÊÀi«ÀÌ}ÊÃÞÃÌiÊvÀÊÕÃiÊ`ÕÀ}Ê half of all injuries were caused by foul play. The ankle major sporting competitions and thigh were the most common locations for injury. UÊ«iiÌÊÌ ÃÊÃÞÃÌiÊ`ÕÀ}ÊÊV«iÌÌÃÊ>`Ê Nearly 60% of all injuries were contusions. On average, Olympic Games there was one concussion and 1.3 fractures per compe- UÊ iÃVÀLiÊÌ iÊV`iVi]ÊVÀVÕÃÌ>Vi]Ê>`ÊV >À>VÌiÀÃ- ÌÌ°Ê/ iÊÃÌÊÃiÛiÀiÊÕÀiÃÊÊÎäÊ`>ÞÃÊÕÌÊvÊ«>Þ®Ê tics of injuries in international football competitions were to the knee with most of them being ligament tears and foot/ankle fractures. While just over half of the inju- ries occurred during the second half, there was no rela- How we collected the data tionship between the time and severity of injury.
The only way to obtain valid comparative informa-
tion within football is for one group to use a constant 4 3.7 set of definitions and a common methodology that has been demonstrated to be effective, reliable and valid. 3 2.4 2.1 F-MARC developed an easy to use injury-reporting sys- 2 Men tem to analyse the incidence, circumstances and char- 1.3 Men 1 Women acteristics of injury during major international football Women Number of injuries competitions. This modified comprehensive injury 0 report form was implemented during twelve internation- World Cup Olympic Games al football competitions during 1998-2001; male and 1998/99 2000 female, futsal and outdoor, Olympic Games, and FIFA Fig. 2.4.1.1 Injuries per match in male and female players World Cups from U-17 through to the FIFA World Cup™. The physicians of all participating teams were specially trained and asked to report all injuries after FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 25
No of injuries Injuries per Tournament No of matches Player hours (total) match FIFA World Cup France 1998 64 2046 149 2.4 FIFA Women’s World Cup USA 1999 32 776 30 1.3 FIFA Confederations Cup Mexico 1999 16 248 13 1.7 FIFA U-17 World Championship New Zealand 1999 32 1039.5 53 1.7 FIFA World Youth Championship Nigeria 1999 52 957 104 3.6 FIFA Club World Championship Brazil 2000 14 313.5 30 3.2 Men’s Olympic Football Tournament Sydney 2000 32 1023 116 3.7 Women’s Olympic Football Tournament Sydney 2000 16 495 32 2.1 FIFA Futsal World Championship Guatemala 2000 40 220 42 1.3 FIFA Confederations Cup Korea/Japan 2001 16 528 33 2.1 FIFA U-17 World Championship Trinidad & Tobago 2001 32 1056 93 2.8 FIFA World Youth Championship Argentina 2001 52 1435.5 206 4.7 OVERALL 398 10137.5 901 2.7
Tab. 2.4.1.1 Incidence of injury in FIFA competitions and the Olympic Games
What we learned from the study
We showed that the F-MARC injury reporting system could be used as a routine matter in FIFA competitions. The number of injuries per match differed substantially between the competitions for players of different age, sex and skill level. The consistent findings in many of the details of injury such as location, diagnosis, etc demon- strated the high quality of the data obtained.
At the same time, the problems, challenges and demands inherent in studying a single competition and trying to make overall statements about injury rates became obvi- ous. In football as in any sport, a single match is sim- ply a snapshot of “the game”. Any competition is like a short movie, but analysis of multiple competition settings and the data from hundreds of matches gives The winning team of the 1998 FIFA World Cup™ probably a more accurate picture of match-related inju- ries. For example, if only the FIFA Women’s World Cup 1999 was studied, the injury rate would appear to be fairly small, while the rate for women in the 2000 Olympic Games was nearly twice as high. If our deci- sion had been to focus on men at the FIFA U-20 World Cup 1999 or the 2000 Olympic Games, the injury rate Duration: 1998 - 2001 would be thought to be alarming – nearly four injuries Countries: International per match. Acknowledging that any one competition Cooperation: All team physicians of the competitions may be an extreme for all kinds of reasons, when all were Reference: Dvořák considered collectively, we were likely to get a more con- Junge A, J, Graf-Baumann T, Peterson L (2004). sistent view on injury incidence at world championship Football injuries during FIFA tournaments and the Olympic football events. Games 1998-2001 - development and implementation of an injury-reporting system. Am J Sports Med 32 (1 Suppl): S 80-89 26 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.4.2 Injuries during the 2002 FIFA World Cup Results Korea/Japan™ A total of 171 injuries were reported from the 64 match- es, which is equivalent to an incidence of 2.7 injuries per Why we conducted this study match or 81.0 injuries per 1,000 match hours. Between one and two injuries per match resulted in absence from All athletes accept a certain risk of injury when they step subsequent training or match (Tab. 2.4.2.1 and 2.4.2.2). on their chosen field of play. Within any sport there are specific and predictable patterns of injury that vary Compared with the table in the chapter on “Review of according to age, gender and level of play. While study- the literature”(2.1) on epidemiological data, this injury ing the recreational football player will give information rate of 81 per 1,000 game hours is over double of that about the masses of players in a sport, studying the elite of the highest rate reported in the literature. This rate demonstrates the extremes of injury likely in a sport. is also the highest amongst all other FIFA competitions as detailed in the previous chapter “Injuries during FIFA The FIFA World Cup™ is the largest, most popular competitions”. Slightly more than a quarter of all inju- single sport event in the world, viewed by staggering ries were non-contact and 73% were contact injuries. numbers of spectators. This quadrennial competition is Half of the contact injuries (37% of all injuries) were the pinnacle of achievement for a player, their team and caused by foul play as rated by the team doctor and the their country and an enormous source of pride for their injured player, yet only 21% of the situations that led to fans. The pressure on those players then can be substan- an injury were identified by the referee as a foul. The top tial, meaning that their risk of injury might be higher in five locations for injury were the thigh, lower leg, ankle, the FIFA World Cup™ than in domestic competitions. head and knee (in descending order). Injuries tended to Using F-MARC’s proven reliable data collection proce- increase with time in each half (Fig. 2.4.2.2). The pat- dure for FIFA competitions, we wanted to focus on the terns of injury were similar in the group matches and the incidence, circumstances and characteristics of injury knock-out rounds. during the 2002 FIFA World Cup Korea/Japan™; the
first ever FIFA World Cup™ in Asia. Numbers Number No Contact Contact of injuries of injuries contact no foul foul with Aims of the study time lost
UÊ>ÞÃiÊÌ iÊV`iVi]ÊVÀVÕÃÌ>ViÃÊ>`ÊV >À>VÌiÀÃ- Concussion 4 1 0 2 2 tics of injury during the 2002 FIFA World Cup™ Upper 83052 extremity UÊ «>ÀiÊÌ iÊw`}ÃÊÜÌ Ê`>Ì>ÊÀi«ÀÌi`ÊvÀÊ«ÀiÛÕÃÊ international men’s football tournaments Trunk 2 2 1 1 0 Hip 6 6 3 2 1 Groin 9 8 8 1 0
How we collected the data Thigh 30 26 17 4 8 Knee 22 15 4 11 6 The physicians of 32 participating teams (Fig 2.4.2.1) Lower leg 29 15 5 6 16 were required to report on all injuries after each match Ankle 25 19 3 8 12 on the standardised F-MARC injury report form. Because F-MARC had been doing this for all FIFA com- Foot 14 8 4 3 5
petitions since 1998, the team doctors were well aware Tab. 2.4.2.1 Number and circumstances of injury of their role in this data collection process. All team doctors attended a pre-tournament meeting to confirm the procedures and their responsibilities. As such, our response rate was 100% for FIFA World Cup™ inju- ries.
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 27
Fig. 2.4.2.1 Participants of the FIFA team physician workshop during the 2002 FIFA World Cup Korea/Japan™
foul noncontact Noncontact Contact injuries (n=45)* injuries (n=122)* contact, mechanism no foul not reported Estimate of n (%) n (%) 40 absence 35 No absence 5 (11.9) 47 (40.5) 30 1-3 days 15 (35.7) 43 (37.1) 25 4-7 days 12 (28.6) 15 (12.9) 20 7-28 days 8 (19.0) 10 (8.6) 15 >28 days 2 (4.8) 1 (0.9) Number of injuries 10 * The estimated duration of absence is missing for 3 noncontact and 6 contact injuries. 5
Tab. 2.4.2.2 Estimated duration of absence in non-contact and 0 contact injuries
0-15 >90 16-30 31-45 46-60 61-75 76-90 | 1st half | | 2nd half | minute What we learned from the study of the match While the incidence of injuries during the 2002 FIFA Fig. 2.4.2.2 Number of injuries in relation to time in the match World Cup™ was similar to those reported for the regarding mechanism of injury 1994 and 1998 FIFA World Cups™, there were more severe injuries that led to absence from subsequent train- ing or competition. That fact and the increased number of injuries toward the end of each half might indicate fatigue issues in the preparation for the FIFA World Duration: 2002 Cup™. It had been suggested that under-performance Countries: International and injuries might be due to match density in the weeks Cooperation: All team physicians of the 2002 FIFA World and months leading up to the FIFA World Cup™. Cup™ While all players signed a fair play pledge prior to the Reference: competition, awareness of the importance of fair play Junge A, Dvořák J, Graf-Baumann T (2004). Football injuries had still to be increased and the role of fair play in the during the FIFA World Cup 2002. Am J Sports Med 32 (1 prevention of injury needed to be stressed. Suppl): S 23-27 28 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.4.3 Injuries during the 2006 FIFA World Cup In addition to this injury assessment by the team doc- Germany™ tors, all on-pitch treatments during matches were cat- egorised and digitally recorded. These on-pitch treat- ments during play were compared against the written Why we conducted this study injury reports from the team doctors.
To further follow-up on our findings at the 2002 FIFA World Cup™, F-MARC conducted another study on Results injury incidence at the largest and most widely watched single sport competition in the world four years later. A total of 145 injuries were reported (68.7 injuries per While F-MARC principally applied the same meth- 1,000 match hours or 2.3 injuries per match). For com- od as in the previously described studies of injuries at parison, in 2002, there were171 injuries (80.96 injuries every FIFA competition since 1998, at the 2006 FIFA per 1,000 match hours or 2.7 per match; Tab 2.4.3.1). World Cup™ in Germany we followed the consensus Accordingly, there were marginally fewer injuries in the statement on injury surveillance with respect to defini- 2006 FIFA World Cup™ than in 2002. tion, methodology and implementation published in 2006. This consensus defines an injury as “any physical The number of injuries to the thigh from 2002 to 2006 complaint sustained by a player that results from a foot- was reduced (Tab. 2.4.3.2) and there were fewer head ball match or football training, irrespective of the need for injuries reported in the 2006 FIFA World Cup™ than medical attention or time loss from football activities”. An in the 2002 competition. Thirteen head injuries were injury that results in a player receiving medical attention registered at the 2006 FIFA World Cup™ (6.15 per is referred to as a “medical attention” injury and an injury 1,000 player hours) compared with 25 in 2002 (11.83 that results in a player being unable to fully participate per 1,000 player hours). Only one concussion occurred in future football training or competition as a “time loss” in 2006, whereas four were recorded in 2002. In this injury. competition, injuries increased in the first half, but var- ied within the second half, not approaching the level seen in that final 15 minutes of the first half. Aim of the study When the videos of on-pitch treatments were compared UÊ ÌÕiÊÌ iÊÕÀÞÊÃÕÀÛi>ViÊvʽÃÊy>}à «Ê with the written reports, only about half of the injuries event at the 2006 FIFA World Cup™ treated on the pitch were listed on the physician’s report as an injury.
How we collected the data What we learned from the study F-MARC used the same injury surveillance methods as described in the previous chapters. Again, all definitions There are several possible reasons for the slightly lower and duties of the team doctor were explained and dis- injury rate in 2006. First of all, in the 2006 FIFA World cussed at the official FIFA Team Workshop held prior Cup™ the national teams had a longer period for prepa- to the competition in March in Düsseldorf in Germany. ration, whereas in 2002 the national teams left almost Each team doctor was required to submit the standard immediately after the end of the domestic season within F-MARC injury report form after each match defining their own countries. In the case of head injuries, another the time of injury, location and type of injury, severity (a possible explanation is the stringent application of the physician-based estimate of absence), whether the physi- laws of the game by the referees. Based on F-MARC cian felt a foul occurred, whether the referee sanctioned research results, The International Football Association the foul and whether there was treatment (on the field Board gave referees the authority to severely sanction or after the match). These forms were collected by the what were felt to be injurious fouls such as intentional FIFA Medical Officer at the respective venue and were elbows to the head. In our view, the consequent decrease then faxed to the FIFA medical office. in head injuries supported the importance of scientific evidence as a convincing factor for the guardians of the laws of the game and the interpretation by referees. FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 29
Competition 2002 FIFA World Cup 2006 FIFA World Cup Location and All With All With Japan/Korea™* Germany™ Diagnosis absence absence
No of matches 64 64 Head 25 5* 13 4 Response rate, 100 (128) 100 (128) % (n) Upper 8 3*125* extremity Match hours docu- 2112 2112 mented Trunk 6 6 15 11* No of injuries 171 145 Hip2211 Injuries per 1000 h 80.96 68.7
Injuries per game 2.7 2.3 Groin9864* Circumstances, % (n/total number) Thigh 30 26 21 16* Non-contact 27 (45/167) 27 (38) injuries Knee 22 15* 18§ 17§ Contact injuries 73 (122/167) 73 (104) 1 Contact injury 51 (59/115) 61 (57/93) Lower leg 29 15* 30 19* caused by foul Foul sanctioned by 52 (28/54) 57 (32/56) Ankle 25 19* 24§ 16*§ the referee 0 Time, % (n) Foot 14 8* 6 5 First half 54 (88) 50 (66)
Second half 46 (72+3) 50 (64 +2) Tab. 2.4.3.2 Location of injuries during the 2002 FIFA World Cup™ and 2006 FIFA World Cup™ Estimated severity of injury, % (n)
0 Days 33 (53) 30 (39)
1–3 Days 37 (59) 33 (43)
4–7 Days 17 (27) 15 (19)
>1 Week, 11 (18) 18 (23) <1 month >1 Month 2 (3) 5 (7)
Missing (11) (14)
Injuries with subse- 107 97 quent absence Injuries per 1000 h 50.7 45.9
Injuries per game 1.7 1.5
Tab. 2.4.3.1 Comparing the characteristics of injury at two FIFA World Cups™ Final, Berlin. Italy celebrates winning the 2006 FIFA World Cup™
Duration: 2006 Countries: International Cooperation: All team physicians of the 2006 FIFA World Cup™ Reference: Dvořák J, Junge A, Grimm K, Kirkendall D (2007). Medical report from the 2006 FIFA World Cup Germany™. Br J Sports Med 41: 578-581 30 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.4.4 Injuries of Female Players in Top-Level Women’s World Cups 2002 and 2004, the FIFA U-20 International Competitions Women’s World Cup 2006 and Women’s Olympic Football Tournaments in the 2000 and 2004 Olympic Games. As usual, the physicians of all attending teams Why we conducted this study were instructed in the use of the single-page form, on which all injuries during a given match or, when appli- From the very beginning, F-MARC has realised the dis- cable, the non-occurrence of injury were recorded, at a crepancy between the ever growing popularity of wom- pre-competition instructional meeting. For each match, en’s football and the limited research directed to the both team doctors were asked to return the completed female player. Accordingly, we had undertaken a study form for their team to the FIFA Medical Officer. Confi- on 165 female football players from nine teams in the dentiality of all information was ensured. An injury was German national league for one complete outdoor sea- defined as any physical complaint during a match which son in 2003/2004 as described in a previous chapter. received medical attention from the team doctor, regard- The team physiotherapists had reported all physical less of the consequences with respect to absence from the complaints associated with football that limited sports rest of the match or training. In the first competition participation for at least one day as well as their location, (FIFA Women’s World Cup 1999), an earlier version of type and circumstances of occurrence. The injury rates the form was used, which did not include the physician’s reported in that study were similar to those reported for judgment about foul play and the consequences of the male players. There had been a high match injury rate injury. and a comparably low training injury rate while ACL ruptures occurred rather frequently. Results In general, the published work on injuries in women’s football focused mostly on injuries to elite players dur- A total of 387 injuries were reported in the seven competi- ing their competitive season, yet injuries during major tions. This is equivalent to 2.2 injuries per match or 67.4 international competitions assuming a high public pro- injuries per 1,000 player hours. The injury rates ranged file and placing considerable pressure on players, were from 1.3 injuries per match in the FIFA Women’s World investigated infrequently. In the previously described Cup 1999 to 2.9 injuries per match in the FIFA U-20 study on twelve major international football competi- Women’s World Cup 2006 (Tab. 2.4.4.1). tions, F-MARC had reported that the incidences of inju- ry in female players in the 1999 FIFA Women’s World The overall injury rate was similar for each half, but the Cup and the football competition of the 2000 Olympic lowest rate occurred during the first 15 minutes of each Games were considerably lower than the rates in the cor- half. Most injuries occurred during player-to-player con- responding competitions for male players. Therefore, tact. F-MARC decided to give these competitions particular attention. The lower extremity was most commonly affected, fol- lowed by the head and neck, trunk and upper extremity (Tab. 2.4.4.2). The exact body parts injured most often Aim of the study were the ankle (24%) and head, followed by thigh, knee and lower leg. Most injuries were diagnosed as contusions UÊ>ÞÃiÊÌ iÊV`iVi]ÊV >À>VÌiÀÃÌVÃÊ>`ÊVÀVÕ- (45%), sprains or ligament ruptures (26%) and less often stances of injuries occurring in top-level international strains or muscle fibre ruptures. Twelve injuries were diag- women’s football competitions nosed as a concussion, 13 ligament ruptures, nine frac- tures, eight dislocations and two lesions of the meniscus. The most common diagnosis was an ankle sprain (16%), How we collected the data followed by contusions of the head, thigh and lower leg and injuries to the knee ligaments. There were seven liga- Data collection was undertaken following the established ment ruptures and 15 sprains of the knee. F-MARC method immediately post match at seven international women’s football competitions: the FIFA Only 16% of all injuries were non-contact. In the opinion Women’s World Cups 1999 and 2003, the FIFA U-19 of the team doctor, 35% of all contact injuries were due FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 31
to foul play. However, the referee sanctioned only half of bers reported in men’s competitions. Possible explana- those injuries. tions for more concussions being diagnosed in females might be because there is more caution evident in the Tournament Injuries per Injuries Time loss Time loss match per 1000 injuries per injuries women’s game or that some concussions in the men’s match hrs match per 1000 matches were missed or some concussions were recorded match hrs as contusions. FIFA Women’s 1.3 39 World Cup A primary distinction with the circumstances of injuries 1999 in males was that about half of all injuries in men are Women’s 2.1 65 0.8 24 due to foul play while in women, only about one third Olympic Football of injuries were a result of foul play. Tournament 2000 Location Total Without With time FIFA U-19 2.8 85 1.6 49 time loss loss Women’s World Cup Head/neck 67 32 17 2002 FIFA Women’s 1.7 52 0.9 27 Trunk 33 12 14 World Cup 2003 Upper Extremity 32 15 13 Women’s 2.3 70 1.0 30 Olympic Hip/groin 12 8 4 Football Tournament 2004 Thigh 47 19 21 FIFA U-19 2.2 68 0.7 20 Knee 43 8 23 Women’s World Cup 2004 Lower leg 41 27 8 FIFA U-20 2.9 89 1.0 29 Women’s Ankle 93 33 44 World Cup 2006 Foot/toes 12 5 5 Overall 2.2 67.4 1.0 29.8
Tab. 2.4.4.2 Number of injuries by location for women’s world cham- Tab. 2.4.4.1 Incidence of injury in women’s world competitions pionships
What we learned from the study
The incidence of injury in international top-level wom- en’s football competitions was within the range of values previously reported for elite male and female club play- ers, but still lower than the rates from equivalent inter- national men’s competitions. However, the diagnoses and mechanisms of injury among the female players differed substantially from those previously reported in male football players. Duration: 1999 - 2006 Countries: International Most of the injuries affected the lower extremity, espe- Cooperation: All team physicians of the competitions cially the ankle, knee and thigh, a finding also reported Reference: previously for elite male and other female football play- Dvořák J, Junge A (2007). Injuries of Female Football Players ers, with an ankle sprain being the most frequently diag- during Top-level International Tournaments. Br J Sports Med nosed injury. The frequency of head injuries diagnosed 41 (1 Suppl): i3-i7 as concussions was substantially greater than the num- 32 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.4.5 Injuries during the FIFA Futsal World on the standardised form after each match. Due to the Cups 2004 and 2008 different duration of futsal matches and a smaller num- ber of players, number of injuries per match would not allow for comparison with football, so we also calculat- Why we conducted this study ed injuries per 1,000 player hours and per 1,000 player matches as had been recommended for team sports. Futsal is a variant of association football played on a smaller pitch with a smaller ball, both indoors and out- doors. It is the official FIFA-recognised version of five- Results a-side football and as such has similarly strictly defined Laws of the Game. It is played on a hard surface without The average response rate throughout all three events was using boards or walls, allowing it to be staged on hand- 93%. In total, 253 match reports were analysed, corre- ball or basketball courts. Having its roots in some Euro- sponding to 843 player hours. This resulted in 165 inju- pean countries and South America, futsal is continuously ries overall which translated into 1.3 injuries per match, gaining more and more supporters worldwide. The first 195.6 injuries per 1,000 player hours and 130.4 injuries FIFA Futsal World Cup was played in 1989. per 1,000 player matches.
The game is considered a “school of football” with high With regard to circumstances, more injuries (64%) demands on technique and skills, speed and agility. It occurred during contact with another player and less than is therefore used for youth development in many coun- half of these injuries were due to foul play. Overall, one tries. Considering this broad use in youth players, it is quarter of all injuries was due to foul play. Based on the a concern that it is far less extensively studied from a judgement of the team doctors, two thirds of these foul sports medical and scientific perspective than football. plays were consequently sanctioned by the referees. There A few studies on its physical demands showed that fut- was no difference in injury occurrence between the first sal includes more high intensity activities than football. and second half of matches. With regard to injuries, some studies on indoor football had shown inconsistent results when compared with 11- About 70% of all injuries concerned the lower extremity, a-side outdoor football, and nothing was known on fut- with the second most frequent location being the head sal injuries. We therefore decided to gain a better under- and neck with 13%. The knee was the most often affected standing of injuries in futsal in order to be able to design body part prior to the thigh and ankle. Most injuries were targeted prevention measures. classified as contusions, followed by joint sprains and liga- ment ruptures. Information on the expected loss of play- ing time due to the injury was available in 84% of all inju- Aim of the study ries, and showed that almost half of the injuries resulted in some absence from play, most of them of a duration of UÊ>ÞÃiÊÌ iÊV`iViÊ>`ÊV >À>VÌiÀÃÌVÃÊvÊÕÀÞÊ`ÕÀ- one to three days. ing FIFA Futsal World Cups and compare the results with FIFA World CupsTM What we learned from the study
How we collected the data This study was the first to provide a more detailed pic- ture of the frequency and characteristics of injuries in We investigated three Futsal World Cups in 2000, futsal based on a scientifically validated recording meth- 2004 and 2008. As our objective was to compare the od. In absence of comparable data from futsal, the most frequency and characteristics of injuries in futsal with important and relevant comparison to make was the one injuries in football, we applied exactly the same injury with football. Importantly, this would need to consider recording definitions and system as had been used at all the different duration of matches, rules and player num- other FIFA World Cups™. An injury was defined as bers. Therefore, injury frequency had to be based on the any physical complaint resulting from match play and time effectively played and not on match incidence. attended to by the team doctor. The team doctor would record the details of injuries that occurred in their team FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 33
A major finding was the 2.6 times higher injury rate in futsal as compared to football when relating the inci- dence to the time spent playing. However, when com- paring the frequency of injuries related to player hours, the incidence was in fact similar for both games. Dif- ferently from what might be expected given the smaller pitch dimensions, fewer injuries in futsal were caused by contact with another player, and fewer injuries were due to foul play than in football.
With regard to severity, fewer injuries in futsal (about a half) resulted in absence from play as compared to foot- ball where these accounted for more than two thirds of all injuries. As in elite football players, most of the inju- ries occurred at the lower extremity with contusions and ankle sprains being the most frequent diagnoses. There was a higher incidence of groin strains in futsal, possibly related to the higher agility and speed of play. Concus- sions also occurred markedly more often in futsal than in football (3.6 times) where rule changes in force since 2006 had led to a reduction of concussions.
The insights gained in this study need to be substanti- ated in further investigations, in particular with regard to injury causes in order to be able to develop effective prevention methods for futsal players. This would apply especially to concussions and groin injuries as the more Team Brazil, the FIFA Futsal World Champion 2009 frequent injury types compared to football.
Duration: 2000 - 2008 Countries: International Cooperation: All team physicians of the 2000, 2004 and 2008 FIFA Futsal World Cups Reference: Junge A, Dvořák J (2010). Injury risk of playing football in Futsal World Cups. Br J Sports Med; 44(15): 1089-1092 34 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.4.6 Injuries and Illnesses at the 2010 FIFA “incidence”, illnesses were defined as any physical com- World Cup South AfricaTM plaint (unrelated to injury) newly incurred during the event. Pre-existing chronic disease was not to be report- ed unless an exacerbation necessitated medical attention Why we conducted this study by the team doctor. Both training injuries and illnesses had to be reported daily. During three consecutive FIFA World Cups™, and multiple youth and women’s events, F-MARC had recorded all injuries occurring during matches, resulting Results in a comprehensive database allowing for comparison between different player groups and observing trends Overall, the 2010 FIFA World Cup™ comprised 64 over time. However, much less was known about inju- matches and 736 players. As half of the teams were ries occurring during training and illnesses of players expelled after the group matches and the remaining teams during these events. The European Football Confed- stayed for a variable further period of time, all calculations eration UEFA had documented training injuries dur- for illnesses and training injuries were made based on ing its championships in 2004 and 2008 showing that player days which amounted to a total of 13,179. Overall they resulted in absence from play during elite events in response rate by team doctors was 97.4% with four match football. F-MARC had considerably contributed to the reports missing, and in about 13% of the daily non-match expansion of the injury recording system to include ill- day reports the training times were either missing or illeg- nesses at the 2008 Olympic Games. In a pilot study dur- ible. ing the FIFA Confederations Cup 2009, F-MARC had found an incidence of illnesses of 16.5 per 1,000 play- A total of 125 injuries were reported, resulting in an inci- er days with the majority being respiratory tract infec- dence of two injuries per match. Almost two thirds of tions. It was therefore decided to extend the established the injuries resulted from contact with another player, surveillance of injuries during matches to training inju- less than a quarter of these due to foul play. Injury fre- ries and illnesses occurring at any time during the 2010 quency showed a continuous increase with the duration FIFA World Cup™ in order to give more meaning to of play and was highest during the last 15 minutes of the Confederations Cup data by comparison. matches. As previously seen, almost three quarters of the injuries were to the lower extremities, with contusion of the thigh and lower leg as well as a thigh strain being the Aims of the study most frequent diagnoses. About a third of the injuries did not prevent the player from continuing to play, and half UÊ>ÞÃiÊÌ iÊV`iViÊ>`ÊV >À>VÌiÀÃÌVÃÊvÊÕÀiÃÊÊ of them resulted in an absence from play of one to three both match play and training during the 2010 FIFA days. Only two injuries resulted in absences of more than World CupTM a month. The overall incidence of time-loss injuries was UÊ>ÞÃiÊÌ iÊV`iViÊ>`ÊV >À>VÌiÀÃÌVÃÊvÊiÃÃiÃÊÊ 1.3 per match. players during the 2010 FIFA World CupTM During training sessions, 104 injuries occurred, corre- sponding to 7.9 injuries per 1,000 training hours. About How we collected the data 40% of injuries occurred in contact with another player, a quarter was classified as overuse injuries and about 13% as All team doctors were informed in detail of the planned a recurrence of a previous injury. The most frequent diag- extended investigations at the team workshop four noses where ankle sprains and thigh strains. About 57% months prior to the event. The existing and well-estab- of training injuries resulted in an absence from play, in lished injury recording system during matches at FIFA half of them this absence was estimated to be one to seven competitions was amended to include training injuries days. and illnesses. The definitions of injury and recording parameters remained the same, but in addition team During the event, 99 illnesses occurred in 89 players doctors were asked to provide the duration of training (12.1% of all players), corresponding to 7.7 per 1,000 sessions and document injuries occurring during the player days. Most illnesses concerned either the respiratory same. In compliance with the definition of the term or the digestive system, with the most frequent diagnosis FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 35
being an upper respiratory tract infection (almost a third illnesses complied with what would be usually expected of cases) followed by gastroenteritis (21%) and sleep dis- in a travelling party. orders (10%). The most frequent symptoms were pain, fever, diarrhoea/vomiting and dyspnoea/cough. Causes identified were in the vast majority infections and less often environmental. Medication was the most often used therapy, with antibiotics and oral analgesics, either alone or in combination, being the most frequently used type of medication. Most of the illnesses did not cause any absence from play (59%) or only a short absence of one to three days with an average time loss per illness of 1.8 days.
What we learned from this study
There was a continuation of the downward trend in match injuries observed over the previous three FIFA World Cups™ both for total injuries and time-loss inju- ries per match. The location and type of injuries did not differ much as compared to previous competitions, but the cause of injury showed a much higher proportion of injuries occurring without contact with another player (36% in 2010 as compared to 27% in 2002 and 2006). This could cautiously be explained as a consequence of too high match loads on players resulting in fatigue, an explanation which would be supported by the increase of injury frequency with time during matches. Less than a quarter of injuries were due to foul play, which devi- ates markedly from previous observations and needs to be assessed further.
Training injuries did not differ substantially with regard to severity, but there were differences in the cause and type of injury. The frequency of time-loss training inju- ries was similar as in the UEFA studies at the EURO. Illnesses occurred in 12% of players, which would be a proportion almost twice as high as was found at the swimming and athletics championships and the 2010 Winter Olympic Games also investigated by F-MARC. As the duration of these events varies considerably, how- ever, the way to compare them is illness related to player days. Doing so, the results were indeed similar as com- pared to, for example, the athletics championships. Duration: 2010 - 2011 Overall, the trend towards fewer injuries at FIFA World Countries: International Cups™ was considered as being extremely positive and Cooperation: All team physicians of the 2010 FIFA World a result of the many preventive efforts by FIFA and CupTM F-MARC over the years. Illnesses occurring during the Reference: event did not present a major problem for participating Dvořák J, Junge A, Derman W, Schwellnus M (2011). Injuries teams, either with regard to frequency or severity and and illnesses of football players during the 2010 FIFA World consecutive absence from play. Their characteristics of Cup. Br J Sports Med; 45: 626-630 36 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.4.7 Injury Surveillance in World Football ation because of the different setting and rules of these Tournaments 1998-2012 games.
Why we conducted this study Results
Protecting the health of their athletes should be a key From 1998-2012, 1,681 matches were played in the 53 concern for all international sports bodies, and injury top-level tournaments, and the team doctors returned surveillance is an important prerequisite for injury pre- 3,091 completed injury report forms to the FIFA Medical vention. FIFA started to systematically document all Officers. This corresponds to an average response rate of injuries incurred by players during its tournaments as 92%. early as 1998. Until the end of 2012, football injuries have been surveyed in all 51 FIFA tournaments as well A total of 3,944 injuries were reported from 1,546 match- as in the four Olympic Games (2000-2012), and valu- es, which is equivalent to 2.6 injuries per match. The able insights on the incidence and characteristics of foot- incidence of injury varied between 1.9 (FIFA Women’s ball injuries could be gained. This study is unique in World Cups) and three (FIFA U-20 World Cups) inju- that no other report on such comprehensive number of ries per match in the different types of tournaments. In tournaments or over a period of 14 years has yet been general, the injury incidence was lower in tournaments published. for female players compared with the respective tourna- ments for male players (except for the Olympic Games). The incidence of injuries in male players decreased in the Aims of the study FIFA World Cups™ and in the football tournaments of the Olympic Games from 1998 to 2012. The opposite UÊ/Ê>>ÞÃiÊÌ iÊV`iVi]ÊV >À>VÌiÀÃÌVÃÊ>`ÊVÀVÕ- trend was observed for female players in the FIFA Wom- stances of football injury during FIFA tournaments en’s World Cups 1999 to 2007, the football tournaments and the Olympic Games from 1998 to 2012, and to of the Olympic Games from 2000 to 2008, and the FIFA discuss trends in injury incidence in different types of U-17 Women’s World Cups 2008 to 2012 (see Figures tournaments during this period 1 and 2). For the World Cups, it could be shown that the contrary trends for men and women were due to the changes in the number of contact injuries. Method Most injuries affected the lower extremity (70%), fol- During a pre-tournament meeting the team doctors of lowed by injuries to the head and neck (15%), trunk (8%) all participating teams were instructed on how to fill in and upper extremities (7%). The majority of injuries were the standardised injury report form. The injury report sustained during contact with another player while 20% form consisted of one single page on which all injuries of all injuries were due to non-contact activities. Based on occurring during a given match, or when applicable the judgment of the team doctors, almost half (47%) of the non-occurrence of injury, should be described by the contact injuries were caused by foul play. In tourna- the team doctors in tabular form after each match. An ments of female players, significantly fewer contact inju- injury was defined as any physical complaint (including ries were caused by foul play than in the respective tour- concussion) that occurred during a match and received naments of male players (except for the FIFA U-19/U-20 medical attention from a team doctor, regardless of its World Cups). Since only half of the injuries incurred consequences with respect to absence from the match during matches (47%) actually prevented players from or training. For all injuries, information had to be participating in a match or training, the overall incidence documented on: time of injury (minute in the match), of time-loss injuries was 1.1 per match. The incidence injured body part and type of injury, circumstances of time-loss injuries was similar in male and female play- (non-contact, contact, foul play) and consequences of ers when the same types of tournaments were compared, injury (referee’s sanction, treatment, time loss in training except for the FIFA World Cup™ where the injury rate or match). The FIFA Futsal World Cups and the Beach was significantly lower in female players. Soccer World Cups were not included in the data evalu- FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 37
What we learned from the study
During the past 14 years, injury incidence in top-level football tournaments changed: while the injuries rate in male players decreased, the opposite trend was observed in female players. These changes seem to be influenced by playing style and refereeing. A strict application of the Laws of the Game is thus an important means of injury prevention. Beyond that, more detailed studies on injury mechanism and refereeing in injury situations are needed to make specific recommendations for future injury prevention in top-level tournaments.
Duration: 1998 - 2012 Countries: International Cooperation: All team physicians of the world football tourna- ments Reference: Junge A, Dvořák J (2013). Injury surveillance in World Football Tournaments 1998-2012. Br J Sports Med 47:782-788 38 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.5 Risk Factors and Injury Causation
2.5.1 Risk Factors of Injuries in Different Ages 19 years of age. A majority of the players (82%) were and Skill Level injured during the observation period.
The baseline assessment as well as the questionnaire Why we conducted this study showed several differences between the injured and the uninjured players. This allowed us identify 17 risk fac- The F-MARC approach to prevention is based on a risk tors for injuries covering a wide spectrum of issues such management model. In order to prevent injury, the fac- as previous injuries, acute complaints, inadequate reha- tors that contribute to injury must be identified. Once bilitation, poor health awareness, life-event stress, play- the various risk factors have been identified, studies need ing characteristics, slow reaction time, low endurance, to test just which factors are significant predictors of insufficient preparation for games and more. In a next injury. After the particular factors have been identified, step, the individual risk factors were added and a predic- prevention programmes can be designed. Once designed, tive sum was calculated for each player. We hypothesised these programmes need to be tested continually to see if that the more baseline risk factors present, the higher the they do indeed reduce injuries before being communi- probability of that player incurring an injury in the ensu- cated to the players on a broad base. ing year. When F-MARC was established, the medical literature contained only incomplete and contradictory informa- tion on risk factors for football injuries. So, after having Risk factors for football injuries established the frequency and characteristics of football injuries, we turned to the risk factors as the next step in s .UMBER OF previous injuries our approach to prevention. s 7EARING BANDAGES TO TREAT ACUTE INJURY s 0AIN IN THE JOINTS s !GE OF BEGINNING FOOTBALL OLDER THAN SIX Aims of the study s $ID NOT BEGIN FOOTBALL IN A CLUB s 2ECENTLY CHANGED TO ANOTHER CLUB UÊ>ÞÃiÊÌ iÊyÕiViÊvÊÌÀÃVÊ>`ÊiÝÌÀÃVÊÀÃÊv>V- s "ODY FAT PROPORTION tors on the occurrence of football injury s 3MOKING UÊ Ài>ÌiÊ>ÊÕÌ`iÃ>Ê«Ài`VÌÀÊÃVÀiÊvÀÊvÌL>Ê s $RINKING ALCOHOL MORE THAN TWO DAYS A WEEK injuries s 2EACTION TIME s ,IFE EVENT STRESS s -USCULAR WARM UP FAIRLY POOR OR POOR How we collected the data s %NDURANCE PULSE RATE BEATSMIN FIVE MINUTES after 12-minute run Following our scientific principles, F-MARC undertook s 3ELF RATING DRIBBLINGLONG PASSING a prospective project: after performing a baseline exami- (average to poor) nation of possible predictive variables, almost 400 Czech s -ORE A hFIGHTERv THAN TECHNICIAN WHEN GETTING PAST players were followed up weekly for one year to register an opponent subsequent injuries and complaints. The baseline inves- s %XHAUSTED OR ACHINGSTIFF MUSCLES BEFORE A GAME tigation included a medical examination, a football-spe- (often or always) cific test, and a questionnaire to obtain information on s 2EGENERATION DURING PREPARATION PERIOD potential injury predictors and then all players were fol- (one day a week or less) lowed up weekly for one year to register subsequent inju- ries and complaints. Figure 2.5.1.1 shows the relationship between the sum of risk factors and the proportion of those players with that sum of risk factors. For example, about 65% of the unin- Results jured players had no risk factors while only about 35% of the injured players had no risk factors. For the injured 398 players from the Czech Republic had weekly fol- players, the more baseline risk factors, the more these low-ups over one year, and complete information was players were injured. With but a few exceptions, if a play- obtained from 264 players (67%). The players averaged er had five or more risk factors, they suffered an injury FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 39
during that season. If we used two risk factors as the cut- work load in a session and throughout the season, a rea- off score, more than 80% of the players were correctly sonable training/match relationship and more. Medical classified as to whether they went on to incur an injury professionals need to ensure adequate rehabilitation and (Tab. 2.5.1.1). Another important finding was that the recovery, pay attention to player’s complaints and suggest more baseline risk factors, the more severe the injury preventive measures. Finally, officials and administrators (Fig. 2.5.1.2). The multidimensional sum of risk factors need to continually look at the rules with an eye towards was a reasonable way to identify who might be injured, safety. but failed to correctly identify the nature of injury, e.g. contact vs. non-contact. Uninjured Injured uninjured Number of previous injuries injured 17.0 36.2 (more than 6) 100 Pain in the joints 4.3 15.9 80 (more than ‘a little’) Muscular warm-up 60 6.5 19.4
% (fairly poor or poor) 40 Self rating of dribbling or 26.2 45.8 passing (average to poor) 20 Recent change of club (yes) 12.8 31.4 0 0 123456 7>7 Sum of risk Fig. 2.5.1.1 Proportion of uninjured and injured players in relationship Sum of risk factors to the sum of risk factors <2 66.7 14.7
6 >2 33.3 85.3 5.27
5 Tab. 2.5.1.1 Frequency of selected risk factors (% of total) 4.53 4.07 4
3 2.21 Sum of risk 2
1
0
mild severe no injury moderate Fig. 2.5.1.2 Sum of risk factors and injury severity
The research group during the risk factor study in Prague 1996 What we learned from the study
Having determined that multiple risk factors are indica- Duration: 1996 - 1998 tive of potential injury, it made sense to try and deter- Countries: Czech Republic, Germany, France mine how to reduce those risk factors. If a player could Cooperation: Czech Football Association reduce their number of risk factors, they should be reduc- Reference: ing their risk of injury. But how to achieve that? Players Dvořák J, Junge A, Chomiak J, Graf-Baumann T, Peterson L, themselves need to work on their own to improve their Rösch D, Hodgson R (2000). Risk factor analysis for injuries in fitness, skill, lifestyle habits and maintain a commitment football players – possibilities for a prevention program. Am J to fair play. Further, coaches need to ensure they prop- Sports Med 28 (5 Suppl): S 69-74 erly apply training principles for warm-up, progression of 40 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.5.2 Risk Factors for Injuries in Elite Female The physiotherapist also recorded injuries and rea- Football Players sons why a player was unable to participate. An injury was defined as “any physical complaint associated with football (received during training or match play), which Why we conducted this study limits athletic participation for at least the day after the day of onset”. A player was injured until she was able to Epidemiological data on injuries in elite female foot- participate fully in games and/or training. An overuse ball players had been rare for a long time. Consequent- injury was the consequence of repetitive micro-trauma. ly, F-MARC had aimed to contribute to the body of An injury was traumatic if it was caused by a single trau- knowledge and conducted prospective epidemiological matic incident. Traumatic injuries were classified further studies in professionals and world championship events, as contact or non-contact. which found that in high level female football, injury incidence is as high as in professional male football. Results Risk factors in elite football had also been only incom- pletely evaluated. In Iceland, increasing age and previous In these elite female football players, we found the fol- injury were the main risk factors for injury. In contrast, lowing (see also Tab. 2.5.2.1): age was not a factor in lower division Swedish female players. Although many possible variables had been UÊ/ iÊÌ>iÃÌÊ«>ÞiÀÃÊ£ÇxV®Ê >`ÊÌ iÊ } iÃÌÊÀ>ÌiÃÊvÊ evaluated in studies on risk factors, only a few consistent injury. results had been reported. This could have partly been due to differences in, for instance, the gender or skill UÊ/ iÊ i>ÛiÃÌÊ«>ÞiÀÃÊ>ÃÊÜiÊ>ÃÊÌ iÊ«>ÞiÀÃÊÜ Ê >`Ê level of the populations investigated. However, no study played the most matches in the previous season had so far analysed risk factors for injuries in elite female showed the highest non-contact injury rate. football players, and we therefore decided to finally address this issue. UÊÕÀi`Ê«>ÞiÀÃ]ÊiëiV>ÞÊÌ ÃiÊÜÌ ÊVÌ>VÌÊÕ- ries, were found to have the least training and total exposure time. Aims of the study UÊ/ iÊ«>ÞiÀÃÊÜÌ ÊÌ iÊ } iÃÌÊ>ÌV ÊiÝ«ÃÕÀiÊ{xÊ UÊ`iÌvÞÊÀÃÊv>VÌÀÃÊvÀÊÕÀiÃÊÊvi>iÊvÌL>Ê hours per season) had the lowest injury rate. players in the German national league on the basis of player characteristics UÊ*>ÞiÀÃÊÜÌ Ê>Ê«ÀiÛÕÃÊ ÊÀÕ«ÌÕÀiÊ >`Ê>Ê } ÊÀÃÊ UÊÊ>Ê«ÀëiVÌÛiÊ>iÀ]Ê`VÕiÌÊÌ iÊÕÀÞÊV- of another rupture. However, a history of an ankle or dence over an entire outdoor season knee sprain was not predictive of another sprain.
UÊ/ iÊÕÀÞÊÀ>ÌiÊvÀÊ`ivi`iÀÃÊ>`ÊÃÌÀiÀÃÊÜ>ÃÊ}Ài>ÌiÀÊ How we collected the data than for midfielders or goalkeepers. Injuries to field players were mostly contact injuries while injuries for All twelve teams of the German women’s professional the goalkeeper were mostly non-contact. league were invited and eight teams submitted complete data. Each team was contacted weekly to ensure compli- UÊÊÌÌ>ÊvÊÈÓ¯ÊvÊ«>ÞiÀÃÊÜiÀiÊiÌ iÀÊÕÕÀi`ÊÀÊ ance and update data records. A total of 143 players were sustained only one injury during the season; 15% followed over an entire season. had two injuries, 13% had three injuries and 10% had four or more injuries. Thus, the players who sus- The coach reported exposure and the physiotherapist for tained four or more injuries accounted for 30% of all each team recorded baseline information. This included reported injuries. anthropometric data, position, preferred leg, prior season matches and a detailed medical history with emphasis on UÊ ÀiÊÕÀiÃÊVVÕÀÀi`ÊÌÊÌ iÊ`>ÌÊLÊiëiV>ÞÊ past ligament injuries. more ankle injuries, ligament ruptures and contusions. FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 41
Total Dominant Non-dominant X² p Value
Mechanism Overuse 22 16 6 4.545 0.03
Contact 81 52 29 6.747 0.01
Non-contact 73 37 36 0.014 0.91
Body part Thigh, groin, hip 56 33 23 1.786 0.18
Knee 42 25 17 1.524 0.22
Lower leg 19 7 12 1.316 0.25
Ankle 41 27 14 4.122 0.04
Foot, toe 18 13 5 3.556 0.06
Diagnosis Sprain 66 33 33 0.000 1.00
Including rupture of liga- 26 18 8 3.846 0.049 ment *
Contusion 36 24 12 4.000 0.046
Strain 33 19 14 0.758 0.38
Fracture 2 1 1 0.000 1.00
Others 39 28 11 7.410 0.01
Total 176 105 71 6.568 0.01
Significant p values are in bold. * This row shows only the number of complete ligament ruptures (grade III sprains), which are also included in the row above (all sprains grade I–III). Data in this row are not included in the totals at the bottom.
Tab. 2.5.2.1 Mechanism, affected body part as well as diagnosis of injuries as related to the injured leg
What we learned from this study
This study pointed out the importance of identifying players with risk factors with regard to e.g. anthropo- metric characteristics, playing position and injury his- tory. Once identified, it appeared appropriate to indi- vidualise training programmes for injury prevention as was already recommended for other training contents for example, improving conditioning training to reduce the risk of late match injuries. In addition, the rules and application of the rules, especially in contact situations, Duration: 2003 - 2004 should be considered by the responsible football associa- Country: Germany tions. We concluded that appropriate education of refer- Cooperation: Schulthess Klinik, Zurich; University of ees in the awarding of more stringent penalties for foul Saarland, Germany play could also help to decrease injury risk. Reference: Faude O, Junge A, Kindermann W, Dvořák J (2006). Risk fac- tors for injuries in elite female soccer players. Br J Sports Med 40: 785-790 42 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.5.3 Tackling Situations of Male Players UÊ iÌiÀiÊÜ V ÊÌ>ViÃÊ >ÛiÊÌ iÊ}Ài>ÌiÃÌÊÕÀÞÊ during FIFA Competitions potential UÊÛiÃÌ}>ÌiÊ«>ÞiÀýÊiÀÀÀÃÊ>ÃÃV>Ìi`ÊÜÌ ÊÌ>V}ÊÊ the context of international football Why we conducted these studies UÊ`iÌvÞÊ>`ÊV>ÃÃvÞÊÌ>ViÊ«>À>iÌiÀà UÊ+Õ>ÌvÞÊÌ iÊvÀiµÕiVÞÊvÊÌ>ViÃÊÌ >ÌÊ} ÌÊi>`ÊÌÊ Risk is the chance of something adverse happening. injury and rank those tackles with the greatest propen- Although adverse events typically result in harm such sity for injury as substantive loss or personal injury, they provide UÊ`iÌvÞÊÜ iÀiÊV >}iÃÊÌÊÌ iÊ>ÜÃÊvÊvÌL>Ê>LÕÌÊ important learning experiences. If a work-related event tackling might produce a reduction in the level of happens, most organisations take the opportunity to injury in football identify, analyse, and get some understanding of the underlying causes of the event in order to develop pro- cedures that would prevent such an occurrence from How we collected the data happening again. Specifically in football, an adverse event like a tackle is scrutinised by the referee at the We used the video recordings from 123 matches in time. Sometimes, the sport’s governing bodies use video three FIFA competitions to identify tackling parameters coverage after the match has concluded. However, such (direction, action, mode, match time, contact location, retrospective assessments have more often been used to diagnosis and severity). Consistent with the F-MARC ensure that players and teams are held accountable and projects at FIFA competitions, team doctors had to pro- punished for foul actions rather than to use the informa- vide reports of post-match medical attention to players. tion to act in a proactive manner to determine risk that would allow injuries to be reduced or prevented. A total of 8,572 tackles were assessed of which 3,464 Most observers of the game would agree readily that (40.4%) were fouls. A total of 299 incidents required tackling is the most dangerous action in football. on-pitch medical attention and 131 of these (44%) were F-MARC had learned from previous work that player- from foul tackles, 76 (25%) of which lead to a post- to-player contact is responsible for nearly 50% of post- match physician report. Of the over 8,000 tackles, 200 match injury reports and foul tackles for nearly 30% of resulted in post-match injury reports and 96 of these on-pitch and 20% of post-match medical reports. Being (48%) were from foul tackles (Fig. 2.5.3.1). Of those tackled, as opposed to tackling, was shown to be respon- players whose injury generated a post-match report, sible for more than 60% of injuries. In another study, 74% were the tackled player. A little over half of those F-MARC also investigated how well (or how poorly) injured lost no time as a result of their injury and 30% referees detect injury-provoking activities during the of the injuries were minor. There were no differences in stresses of competition. The referees, however, must not severity or playing position whether the player was tack- bear all the weight of judgment on injuries – the players led or was the tackler. also make decisions that can lead to injuries. Referee and player decisions plus rules interpretation affect the out- No medical attention come of these player-to-player confrontations. No foul
We felt that with some understanding of tackle param- On-pitch medical attention
eters it could be possible to identify changes to the laws Tackle of football relating to tackling to reduce the level of inju- ry in football. To improve safety of players during these No medical attention risky situations, we needed to detail just what actions Foul went into a tackle and the outcome of that tackle. On-pitch medical attention
Fig. 2.5.3.1 Consequences of tackling Aims of the studies
UÊ i>ÀÊ ÜÊÌ>V}Êi>`ÃÊÌÊvÌL>ÊÕÀià UÊ iÛi«Ê>ÊV>ÃÃwV>ÌÊÃÞÃÌiÊvÊÌ>Vià FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 43
The critical findings about tackling What we learned from the studies
Of special interest in this project were the tackling These are probably the only investigations into tack- action, mode and direction that led to injury. Con- ling in such detail with comparison in relation to player versely to what was believed prior to the study, tackles error. Our analysis suggested that player error during from the side were twice as likely to require post-match tackling, inadequacies in the laws and/or their applica- medical attention as tackles from behind. Injuries to the tion by referees were equally responsible for the high lev- head or neck (for both players) and the torso (for tack- els of injury observed. ling players) were most likely to receive on-pitch medical attention while injuries to the foot (for both players) and Although referees play a major role in managing on- the lower leg and thigh (for tackling players) were less pitch incidents, the greater responsibility for injuries likely to receive on-pitch medical attention. Tackles with rests with the football’s ruling bodies to ensure the Laws the greatest tendency for injury involved clash of heads of the Game are adequate, implemented efficiently, and two-footed tackles (for tackled players) and clash of and that players are held accountable for serious inju- heads, two-footed tackles, jumping vertically and tackles ries resulting from their errors whether by poor tackling from the side (for tackling players). From information technique, lack of experience, or deliberate violation of like this, a framework of injury mechanisms and risk of the laws of football. This study showed that, different to injury was developed (Tab. 2.5.3.1). previous belief, tackling from the side is far more dan- gerous than tackling from behind. The laws of football Tackle category/injured player’s status relating to tackling need to be continuously reviewed to ensure greater protection from injury by reducing the Framework sector Tackled Tackling overall level of risk and by protecting players from tack- Very high Clash of heads Clash of heads les with the highest propensity for injury. High Two footed - Side - Jumping vertically - Two footed
Standard - Front - Sliding-in - Side - Staying on feet - Sliding in - Upper-body contact - Staying-on-feet - One footed - Jumping vertically - Upper-body contact - One-footed - Use of arm/hand
Low Behind - Front - Behind - Use of arm/hand
Very low
Tab. 2.5.3.1 Framework sector corresponding to the propensity for each tackle category to cause injury for tackled and tackling players
We estimated that 44% of the injuries that required on- pitch attention were due to player error and rules inad- Duration: 2000 - 2002 equacies were responsible for the remaining 56%. The Countries: International relationships for injuries that required post-match medi- Cooperation: University of Leicester, UK cal attention was similar (48 %and 52% respectively). References: Fuller CW, Smith GL, Junge A, Dvořák J (2004). The influence of tackle parameters on the propensity for injury in internation- al football. Am J Sports Med 32 (1 Suppl): S 43-53 Fuller CW, Smith GL, Junge A, Dvořák J (2004). An Assessment of Player Error as an Injury Causation Factor in International Football. Am J Sports Med 32 (1 Suppl): S 28-35 44 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.5.4 Video Analysis of Ankle Injuries Results
Of these 76 injuries, 52 (69%) were contusions, 20 Why we conducted this study (26%) were sprains, and four (5%) were fractures. The injuries were nearly equally split between the two halves. In our precedent studies, we had established that the In 72 of the 76 cases, these injuries involved direct most common location of injury is to the ankle, knee player-to-player contact which often happened during and thigh with ankle injuries in particular ranging upright tackling from the side or behind. The forces and between three and nine per 1,000 player hours. It was direction of impact lead to injury. Fouls were called in also known that football players are more predisposed about half to two thirds of the times an injury occurred. to arthritis of the ankle joint than is the general popula- tion. The high prevalence of arthritis in the ankle among Significantly more injuries involved a tackle from retired football players also supported that there was an the side with a lateral or a medial tackling force. The important need to identify the causes and mechanisms injured limb was usually weight-bearing at the time of of foot and ankle injuries. injury. The injuries that resulted in the most time lost from football happened when the limb was weight- Player-to-player contact is a risk factor in the majority bearing. The most common foot and ankle positions at of football injuries, but it would make intuitive sense to the time of injury were pronated/neutral in the sagittal have as complete an understanding as possible for the plane (foot pointed straight ahead) for weight-bearing most frequent injuries. Consequently, F-MARC wanted limbs, and plantar flexed/neutral in the coronal plane to establish a full accounting of the mechanisms leading (foot pointed laterally) for non-weight-bearing limbs. to the most frequent injuries to the foot and ankle so The most common foot and ankle rotations at the time that if a prevention programme were developed, the pro- of injury were external (23 or 30%) and eversion (28 or gramme would have substantive impact for those practi- 37%). sing this programme. Despite the more severe incidents involving the weight- bearing limb, referees were no more likely to punish a player for a foul on a weight-bearing limb than they Aims of the study were to penalise for an incident to the non-weight-bear- ing limb. Most of the incidents leading to injury were UÊ iÌiÀiÊÌ iÊëiVwVÊiV >ÃÃÊvÊ>iÊÕÀÞÊ punished with a sanction for a foul (Tab. 2.5.4.1). from match video recordings of injuries UÊÃÃiÃÃÊÌ iÊÀi>Ìà «ÃÊLiÌÜiiÊvÌÉ>iÊÕÀiÃÊ>`Ê Tackle direction foul play and tackle type Foul Not foul Front 4 2 Side 31 21 How we collected the data Behind 13 5
Tab. 2.5.4.1 Number of injuries deemed to be fouls as a function of The study was designed to obtain information on ankle tackle direction (n=76) injuries across the age spectrum of international com- petitions. We studied four international competitions (1998 FIFA World CupTM, FIFA U-17 World Cham- What we learned from the study pionship 1999, 2000 Olympic Games, and FIFA U-20 World Championship 2001) These four competitions Ankle injuries differ from knee ligament injuries because were chosen so that a wide range of ages could be stud- the ankle is damaged during contact while the majority ied (U-17, U-20, U23 and full nationals). Video record- of knee injuries show no direct contact. The majority of ings from 180 matches were reviewed against the phy- ankle injuries were caused by tackles involving lateral or sician reports of ankle injuries. Recordings of 85 ankle medial forces that created a corresponding eversion (the and 29 foot injuries were examined for common factors sole of the foot rolls out) or inversion (the sole of the of injury and 76 of these recordings were of sufficient foot rolls in) rotation of the foot. If the player stayed quality for analysis. on this foot, the risk for severe injury was far higher. A primary football-specific mechanism was identified: FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 45
player-to-player contact with impact by an opponent on the medial aspect of the leg just before or at foot-strike resulting in a laterally directed force causing the player to land with the ankle in a vulnerable, inverted position. A laterally directed blow to the ankle (Figure 2.5.4.1) may not be the cause of the injury, but rather place the ankle into a particularly vulnerable position that cannot be corrected prior to the ligament tearing.
The proportions of injuries that were deemed to be the result of a foul were very similar whether or not the inci- dents were a time loss injury. Rules enforcement had drastically reduced the incidence of tackles from behind and we suggested that similar enforcement needed to be applied to tackles from the side. Whether the penalty should be a yellow card, red card, or a possible timed suspension is a matter for the rule makers to consider. Legal tackles can still lead to injury.
Fig. 2.5.4.1 Proposed mechanism of a lateral ankle sprain during tackling. Illustration reproduced with permission. ©Oslo Sports Trauma Research Center/T. Bolic
Duration: 2001 - 2003 Countries: International Cooperation: Harvard Combined Orthopaedic Surgery Program, Boston, Massachusetts, USA; University of Leicester, UK Reference: Giza E, Fuller CW, Junge A, Dvořák J (2003). Mechanisms of Foot and Ankle Football Injuries. Am J Sports Med 31 (4): 550-554 46 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.5.5 Causation of Injuries in Elite Female UÊ/>V}Ê`iÊvÊÌ iÊÌ>V}Ê«>ÞiÀÊÃÌ>Þ}ÊÊviiÌ]Ê Players sliding in, jumping vertically)
UÊ/>V}Ê>VÌÊ>`«Ìi`ÊLÞÊÌ iÊÌ>V}Ê«>ÞiÀÊi Why we conducted this study footed, two-footed, use of arms, use of upper-body, use of head) It had been reported that ‘‘the women’s game is rapidly changing not only in playing dynamics but also the dis- UÊ >ÌV ÊÀiviÀii½ÃÊ`iVÃÊvÕ]ÊvÕ]ÊÞiÜÊV>À`]Ê tinct athletics of the players’’. Accordingly, public inter- red card) est in women’s football is constantly on the rise. This reflected a positive trend in the international standing of UÊ"«ÌV ÊÌÀi>ÌiÌÊ`iwi`Ê>ÃÊ>ÞÊi`V>Ê>ÌÌi`>ViÊ female football players and of the sport in general, and seen on video more and more international competitions have been integrated within the official calendar of FIFA. UÊ/iÊÊÌ iÊ>ÌV
However, enhanced physical condition, and especially UÊ-ÌÀ}Ê«>ÞiÀÊ`iwi`Ê>ÃÊÌ iÊ«>ÞiÀÊ«ÕÌÌ}ÊÊ>VÌÛiÊ higher match exposure, may lead to an increased risk force in the incidence leading to injury of injuries in the female player. Some publications sup- ported with findings of F-MARC had indicated a lower injury rate for women than for men yet older findings Results had shown the opposite. It had been stated that age and skill-level may have more of an influence than gender There were 293 injuries reported and 233 injuries could alone. We therefore intended to investigate further the be categorised using the parameters in this project. Of mechanisms of injury in women’s football to gain a bet- the 233, a total of 200 were due to contact and 33 were ter understanding of the risk factors involved in order to non-contact injuries. develop effective prevention programmes. Sixty percent of all contact injuries were to the lower extremity. More specifically, contact injuries were cen- Aims of the study tred on the head and neck (20%), ankle (19%) and thigh (13%). Of the non-contact injuries, over half were UÊ>ÞÃiÊÌ iÊÛ>ÀÕÃÊÌ>V}Ê«>À>iÌiÀÃÊÌ >ÌÊi>`ÊÌÊ to the lower extremity. The non-contact injuries to the injury in women’s football head and neck as well as trunk injuries were all due to UÊÛiÃÌ}>ÌiÊÌ iÊiV >ÃÃÊvÊÕÀÞÊÊÜi½ÃÊvÌ- accidental ball impact. ball UÊ «>ÀiÊÌ iÃiÊÜÌ ÊÀiÃÕÌÃÊÀi«ÀÌi`Ê«ÀiÛÕÃÞÊvÀÊ men’s football Tackling details
Most tackles that led to injury in females were from the side How we collected the data (52%), front (38%), and behind (11%). One-footed tack- les or tackles with an upper body action accounted for 86% We studied six FIFA women’s competitions from 1999 of all injuries. Injuries from a two-footed tackle were all to to 2004. Injuries were recorded using the established F- the tackled player (Tab. 2.5.5.1). MARC injury reporting procedures. Videotapes of each match were provided by FIFA Information Systems and There was no difference in injuries according to playing used to identify relevant parameters of injury. For each position, time in match, type or stage of competition. Goal- contact injury recorded on videotape, the following fac- keepers were injured from tackles from the front while for- tors were determined: wards and defenders were hurt from tackles from the side. Defenders sustained more injuries as the tackling player UÊ/>V}Ê`ÀiVÌÊvÊÌ iÊÌ>V}Ê«>ÞiÀÊÜÌ ÊÀiëiVÌÊÌÊ than any other position. Non-contact injuries were most the tackled player (behind, side, front) common in forwards and least in midfielders. This type of injury increased by 30% in the second half of play. FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 47
Injuries Injuries laws of the game. Differently from men’s football, the use per 1000 per 1000 # 1-footed tackles - tackles - of elbow in aerial challenges was rarely seen as a cause of women men injury in women’s football. From behind Findings like these once more cautioned F-MARC against Standing 10 9 3.4 12.7 applying what we know about men’s football to the wom- Side 5 5 10.3 14.8 en’s game. These gender differences in tackle properties jumping 6 0 2.6 15.9 need to be taken into account by the match referees to From the ensure the safety of the players. side Standing 54 36 5.9 31.6
Side 30 28 19.7 27.2
jumping 19 4 8.7 62.9 From the front Standing 33 23 21.5 15.3
Side 28 21 66.7 25.5
jumping 15 4 42.3 61.2
Tab. 2.5.5.1 Summary of women’s tackling injuries
Time loss injuries
Half of all injuries led to some time loss. This was a con- stant across all variables of injury (location, playing posi- Distribution of injuries in female football players tion, time of injury, various tackle parameters). Fourteen time-loss injuries leading to seven or more days away from play were identified on the videotapes. Four of the 14 were non-contact injuries and all required the players to be sub- stituted. The ten contact injuries were equally split between tackles from the front or side. The referee sanctioned the offending player in three instances (one yellow card) and all but one was substituted within ten minutes of the tackle.
What we learned from the study
Player-to-player contact is a major cause of injury in inter- national top-level football. It is often presumed that the player being tackled is the one who gets injured, but most we found in this study that injuries occur about equally to the player executing the tackle and the player being tackled.
This study identified several differences in the causation of Duration: 1999 - 2006 injuries between women’s and men’s football. Tackles from Countries: International Cooperation: University of Zurich, Switzerland; University of behind were rarely seen in injury situations in female play- Nottingham, UK ers, whereas sliding-in tackles were shown to have a much Reference: higher risk than in men’s football. Several investigations Tscholl P, O’Riordan D, Fuller CW, Dvořák J, Gutzwiller F, had identified elbowing as frequent high-risk tackling- Junge A (2007). Causation of injuries in female football players mechanisms and these have led to suggested changes in the in top-level tournaments. Br J Sports Med 41(1 Suppl): i8-i14 48 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.5.6 Tackling Situations of Female Players in tact between at least two players occurred. At least one of Top-Level Competitions the players had to be challenging for the ball. The tack- led player was defined as the player being either in pos- session of the ball or the player from the team in control Why we conducted this study of the ball immediately prior to contact.
With the aim of prevention, it is not only important to Every tackle had the following factors recorded know the number of injuries sustained in football train- ing and matches, but also to understand the circum- UÊ/>ViÊ`ÀiVÌÊqÊvÀÊLi `]ÊÃ`iÊÀÊvÀÌ stances in which they occur. Tackling is the most dan- UÊ/>ViÊ`iÊqÊÃÌ>Þ}viiÌ]ÊÃ`}ÊÀÊÕ«}Ê gerous aspect of football play, so a full understanding vertically of tackling should help with developing suggestions for UÊ/>ViÊ>VÌÊqÊivÌi`]ÊÌÜvÌi`]ÊÕÃiÊvÊ>ÀÉ injury prevention. hand, upper body or head challenge UÊ,iviÀiiÊ`iVÃÊqÊvÕ]ÊvÕ]ÊÞiÜÊV>À`]ÊÀi`ÊV>À` Contact injuries during tackling and collisions had been UÊ"«ÌV ÊÌÀi>ÌiÌÊqÊ>ÞÊi`V>Ê>ÌÌi`>ViÊÃiiÊÊ reported to be responsible for between 44% and 87% of video all traumatic injuries in men’s, women’s and adolescents’ UÊ/iÊÊÌ iÊ>ÌV football. In 1995, the English FA reported that 37% of UÊÞÊÌ>ViÊÜ iÀiÊÌ iÊ>ÌV ÊÜ>ÃÊÌiÀÀÕ«Ìi`ÊLÞÊÌ iÊ all injuries or more than 90% of all contact injuries were referee, a player was on the ground for more than 15 due to tackling actions. In earlier reports, “tackle action” seconds, a player appeared to be in pain or a player did not include unintentional collisions, use of elbows received medical treatment during the match and heading, whereas in later publications, all mecha- nisms that lead to contact between two or more players Corresponding to injuries reported as the number per were considered as a tackle. 1,000 player hours, we expressed the tackles per 1,000 player hours and number of injuries per 1,000 tackles. However, the available, if limited, data on tackling and injury in football was focused exclusively on men’s foot- ball. While at first glance the games appear to be simi- Tackle analysis lar, F-MARC had already found subtle as well as obvious differences between the men’s and women’s game from A total of 3,531 tackles were analysed. This worked out tactics to skills to injuries. Consequently, it was only to 147 tackles per match (or 1.6 tackles per minute). logical for us to specifically analyse tackle mechanisms in Over 60% of the tackles were from the side and in female players, too. 65% of all tackles, the tackling player stayed on her feet. Combining these two factors showed that 44% of all tackles were by a player on her feet tackling from Aims of the study the side. Sliding tackles accounted for only 12% of all tackles, but nearly two thirds of all sliding tackles came UÊ>ÞÃiÊÌ>Vi>VÌÃÊÊÜi½ÃÊvÌL>Ê`ÕÀ}Ê from the side. While tackles from the side while standing match situations was the most common tackle for both women and men, UÊÃÃiÃÃÊÌ iÀÊÀëÌiÌ>Ê>ÃÊvÕVÌÃÊvÊ«>ÞiÀýÊ>}i]Ê the rate of this tackle was far greater for women than for playing position and stage in a competition men (Tab. 2.5.6.1). UÊ «>ÀiÊÌ iÊÀiÃÕÌÃÊ>LÕÌÊÌ>ViÊ«>À>iÌiÀÃÊLÃiÀÛi`Ê in women’s football with the results reported previ- A standing tackle from the side had the lowest injury ously for men’s football rate (16 per 1,000 tackles). Sliding tackles from the front had the highest injury rate (126 per 1,000 tackles). However, the referees sanctioned tackles from behind How we collected the data and sliding tackles the most.
A total of 24 matches from four FIFA competitions and The different tackle codes were similar across time of the two Olympic Games were studied. A tackle referred to match, but 46.1% of all yellow cards were given in the any incident during normal play where an obvious con- last 15 minutes of each half with no differences between FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 49
the first and second half. The incidence of injurious situ- except for sliding-in tackles. While sliding-in tackles had ations per tackle and on-pitch treatments for the last 15 previously been shown to have the highest propensity for minutes of each half was more than that observed in the injury, they were not specially regarded by the referees first 30 minutes of each half. in injury situations. Therefore, it was concluded that the context of sliding-in tackles and referees’ decision had to Over half of the tackles were to midfielders, yet when be elaborated further to ensure players’ health. controlling for the number of players playing each posi- tion, forwards were the most tackled players at an aver- age of 13 challenges per match. There were few dif- ferences in tackle parameters according to the type of competition or the stage (group vs. knock-out) of the competition.
% all tackles Tackles per match Women Men Women Men From behind Standing 14.1 17.5 20.8 12.2
Side 2.3 4.7 3.4 3.3
jumping 10.9 13.2 16.0 9.2 From the side Standing 43.9 22.9 64.6 15.9
Side 7.3 13.3 10.7 9.3
jumping 10.5 3.4 15.4 2.3 From the front Standing 7.3 16.0 10.8 11.2
Side 2.0 7.3 3.0 5.1
jumping 1.7 1.7 2.5 1.2
Tab. 2.5.6.1 Comparison of tackles in women and men
What we learned in this study
Risky situations are difficult to define and to determine in football. This study highlighted the importance of determining general match characteristics and tackling information to improve our understanding of injury causation in women. Differences in the tackle mecha- nisms associated with injury and risky situations in female players were shown. An increase in the number of tackles, risk situations and yellow cards towards the end of each half together with the increasing fatigue may Duration: 1999 - 2006 partially explain the increased late-match frequency of Countries: International Cooperation: University of Nottingham, UK injury. Reference: Tscholl P, O’Riordan D, Fuller CW, Dvořák J, Junge A (2007). Tackles leading to injury were sanctioned more fre- Tackle Mechanism and Match Characteristics in Female Elite quently by the match referees than non-injury tackles, Tournaments. Br J Sports Med 41 (1 Suppl): 15-19 50 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.5.7 Refereeing in Injury Situations that resulted in injuries. The results of the video analysis, referee’s decision, and panel conclusion were compared.
Why we conducted this study The incidents leading to 148 contact injuries were iden- tified on videotape of which the referees reached a con- Because of their unique role, the referee can be consid- sensus decision on the foul/non-foul status of 139 inci- ered an extrinsic factor in injuries. In their previous stud- dents. Further, a total of 128 head/neck injuries was ies, F-MARC had shown that contact is a factor in half reported by the team doctors, of which the incidents to three-quarters of all acute football injuries and that leading to 84 injuries were identified on videotape. For foul play is an important risk factor for injury. But not the general injuries, the match referees identified 47% all contact leads to injury and not all injuries from con- and the panel identified 69% to have resulted from foul tact are called a foul. Referees must decide quickly, in a play. The match referees and panel agreed on 70% of very public setting, whether the contact was or was not the decisions. The referee panel was in good agreement within the laws of the game. In fact, our research had (91%) with the match official on the decision where a revealed that football players appear to suffer from high foul occurred, but agreed with the match official only levels of injury from tackles that match referees deem to 49% of the time when no foul was called. Most of the be fair. general injuries occurred in the attacking goal area and involved a vertical jump or aerial contact. As a next step in our approach to prevention of inju- ries in football, we therefore decided to investigate and For head/neck injuries, the match referees identified identify whether these injuries occur because the current 40% and the panel identified 49% as foul play. The rules are inadequate to protect the players from injury match referees and the referees’ panel agreed on 85% of or because referees cannot implement the existing rules the decisions. There was no typical situation involving effectively during competition. head/neck injuries meaning the referee did not have any specific cues prior to an injury. This resulted in further disagreement by the referee panel on the presence of a Aims of the study foul (94% agreement) or no foul (only 20% agreement) at the time of a head/neck injury (Tab. 2.5.7.1). The sit- UÊ iÌiÀiÊÜ iÌ iÀÊÀiviÀiiÃÊVÕ`ÊÀi>LÞÊ`iÌvÞÊÌ iÊ uation where the referee panel identified a foul that the legality of incidents leading to injury match referee had not identified involved actions with UÊ iÌiÀiÊÜ iÌ iÀÊÌ iÊÀÕiÃÊvÊvÌL>Ê>`iµÕ>ÌiÞÊ a vertical jump. Notice that whereas for general injuries protect players from injury there was better agreement on head/neck injury fouls in UÊ iÌiÀiÊÜ iÌ iÀÊÕÀiÃÊVVÕÀÊ>ÃÊ>ÊÀiÃÕÌÊvÊ«>ÞiÀÃ½Ê the attacking goal area, in head/neck injuries the pro- non-compliance with the rules with special focus on portion of injuries that were awarded a foul decreased head/neck injuries by both the referee and the panel as the attack moved toward goal (Tab. 2.5.7.2).
Howe we collected the data Referees’ panel B decision Match referee’s decision Foul Nonfoul Strictly following our principles, the study was again Foul 30 2 based on the standardised F-MARC reports of team Nonfoul 10 39
doctors on the details of match injuries from twelve Tab. 2.5.7.1 A comparison of decisions by the match referee and the FIFA competitions (398 matches). In addition, we col- panel on head/neck injury incidents lected video recordings of tackles to identify the factors of the foul and injury. A tackle referred to any event that occurred during the normal course of a match and What we learned from the study involved physical contact between two or more players while one or more of the players challenged for posses- The referees taking part in the FIFA competitions were sion of the ball. Then, a panel of FIFA international ref- among the best referees from around the world; how- erees with an average number of 8.8 years’ experience as ever, the match referees were required to make decisions an international referee assessed the legality of incidents in difficult circumstances and within very short time FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 51
Ratio of fouls awarded to number of injuries It was, therefore, the effectiveness with which referees (number of incidents) could identify foul situations during match and the will- General injuries Head/neck injuries ingness of players to comply with the rules of football Area of Match Panel A Match Panel B pitch referees referees referees referees that were the main issues to be addressed by FIFA as Defensive football’s governing body. **** goal area Defensive 0.70 0.85 * * midfield Attacking 0.49 0.77 0.50 0.72 midfield Attacking 0.21 0.36 0.28 0.31 goal area
Tab. 2.5.7.2 Proportion of injury situations identified as fouls by the match and panel referees, as a function of the area of the pitch (n = 139) *Ratio not provided as the total number of incidents was less than 6 frames. The panel referees were on average more expe- rienced than the match referees and were not exposed to the pressures experienced by the match referees during their decision-making process as they had the advantage of viewing each incident in isolation and as often as nec- essary to reach a decision.
Referee taking a decision during a match at the 2006 FIFA World Cup Referee cautioning a player with the yellow card during a match at the Germany™ 2006 FIFA World Cup Germany™
Our results indicated that the current rules of football were adequate to protect players from injury for the majority of situations and that contact injuries were more likely to be caused by players’ failure to comply with these rules. Match referees, however, often failed to award fouls and punish players for incidents that led to injury. However, in the specific case of incidents leading to head/neck injuries, the decisions reached by match referees were generally more reliable. The increased Duration: 2002 - 2003 awareness of head injury may have led to more strict Countries: International enforcement of the rules by the match referee. Cooperation: University of Leicester, UK Reference: The more information that a referee can obtain regard- Fuller CW, Junge A, Dvořák J (2004). An assessment of football ing actions that lead to injury could well lead to refer- referees’ decisions in incidents leading to player injuries. Am J Sports Med 32 (1 Suppl): S 17-22 ees and referees’ observers arriving at similar decisions. 52 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.5.8 Risk of Injury on Artificial Turf The third study was performed on twenty European elite level teams (15 male, 5 female) playing home matches on artificial turf prospectively; their injury risk when Why we conducted these studies playing on artificial turf was compared with the risk on grass. Individual exposure, injuries (time loss) and injury Football has traditionally been played on natural grass. severity were recorded by the team medical staff. However, artificial turf has become more popular with an increasing number of pitches being built in countries where the climatic conditions are unsuitable for grass Results pitches. In 2006, FIFA approved the use of artificial turf for all matches. In addition to match play issues, The main findings of the two studies of the US college artificial turf provides a year-round, all-weather training and university players showed no major differences in surface. Still, acceptance of artificial turf by players has either the risk or the cause of training or match inju- remained limited because of a continuing perception of ries on artificial turf and grass in both male and female a different pattern of injury and an increased injury risk. football players. Neither did the severity nor the causes Before FIFA could widely promote artificial surface, the of injury differ significantly between the two surfaces in football community needed proof that these new prod- both genders. In both match and training the most com- ucts are no different from grass in terms of injury risk. mon injury location on both surfaces was the lower limb Preliminary data from the FIFA U-17 World Cups in in both genders. Three to four times more matches and 2003 and 2005 had suggested no significant difference training hours were analysed for grass than for artificial in the incidence, nature, cause and severity of injuries turf, which accounts for the difference in injury numbers sustained on both surfaces, but the study had been too recorded. small for definite conclusions. During matches, a total of 848 injuries for men (artifi- cial turf: 183, grass: 665) and 946 for women (artificial Aims of the studies turf: 134, grass: 812) were recorded. The injury rate on grass for male (23.92) and female (21.79) players UÊ «>ÀiÊÌ iÊV`iVi]Ê>ÌÕÀi]ÊÃiÛiÀÌÞÊ>`ÊV>ÕÃiÊvÊ per 1,000 match injuries was similar to previous find- match and training injuries sustained on grass and ings and there were no differences in match injuries as artificial turf by American collegiate male and female compared to artificial turf for men (25.43 injuries/1,000 football players match hours) or for females (19.15 injuries per 1,000 UÊ «>ÀiÊÌ iÊV`iViÃÊ>`ÊÕÀÞÊ«>ÌÌiÀÃÊvÊvi>iÊ match hours, Tab. 2.5.8.1). There were also no surface- and male elite teams when training and playing related differences for non-season-ending time-loss inju- matches on artificial turf and natural grass ries. The most common injuries during matches were for men a lateral ankle sprain, hamstring strain and concus- sion; for women a lateral ankle sprain, concussion, and How we collected the data ACL tear.
The two studies in the US on match and training inju- During training, three to four times more teams were ries were conducted on American college and university analysed on grass. A total of 818 injuries to men (arti- football teams over two seasons – for 52 men’s and 64 ficial turf: 189 grass: 629) and 774 to women (artificial women’s teams (in 2005) and 54 men’s and 72 wom- turf: 122, grass: 652) were recorded. Similarly to the en’s teams (in 2006). The studies included all organised matches, no differences in training injuries for males on matches from their pre-season, in-season and post-sea- artificial turf vs. grass (3.34 vs. 3.01 injuries/1000 train- son football competitions. Detailed injury reports were ing hours respectively) or for females (2.60 vs. 2.79 inju- recorded on the playing surface, location, diagnosis, ries per 1,000 training hours respectively) were found. severity and cause of all match injuries. The number The most common training injuries were in men lateral of days lost from training and match play was used to ankle sprain, groin strain and quadriceps or hamstring define the severity of an injury. The incidence of inju- strain; in women lateral ankle sprain, quadriceps or ry was documented per 1,000 player match or training hamstring strain and concussion. hours. FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 53
Match Training
Play setting Females Males Females Males
Grass 21.79 23.92 2.79 3.01
Artificial turf 19.15 25.43 2.60 3.34
Tab. 2.5.8 .1 Overall injury rates (per 1000 player hours) by gender, play setting
The later study on elite level teams recorded 2,105 inju- ries during 246,000 hours of exposure to football. Sev- enty-one percent of the injuries were traumatic and 29% were overuse injuries. There were no significant differ- ences in the nature of overuse injuries recorded on both surfaces for either gender. The incidence (injuries/1,000 player hours) of acute (traumatic) injuries did not dif- fer significantly between both surfaces, for men (match 22.4 vs. 21.7; RR 1.0 (95% CI 0.9–1.2); training 3.5 v 3.5; RR 1.0 (0.8–1.2)) or women (match 14.9 v 12.5; RR 1.2 (0.8–1.8); training 2.9 v 2.8; RR 1.0 (0.6– 1.7)). During matches, men were less likely to sustain a quadriceps strain (P 5 0.031) and more likely to sustain an ankle sprain (P 5 0.040) on artificial turf.
What we learned from these studies
The large number of athletes (college/university teams and elite level teams) investigated in the studies provided an ide- al setting to compare the risks of injury on artificial turf and grass. The adequate statistical power of the studies for the Duration: 2003 - 2008 first time allowed analysing injury subcategories to a greater Countries: England, USA, Sweden depth. The main results showed generally no differences Cooperation: University of Nottingham, UK; National in the risk of acute injuries between play on artificial turf Collegiate Athletic Association, USA, Linkoeping University, and natural grass in male and female players, in training or SWE matches, and at adult elite level or amateur youth level. References: However, there might be differences in the pattern of Fuller CW, Dick RW, Corlette J, Schmalz R (2007). Comparison of the incidence, nature and cause of injuries sus- injury sustained on these two surface types. Indications of tained on grass and new generation artificial turf by male and a lowered risk of muscle strains when playing on artificial female football players. Part 1: match injuries. Br J Sports Med turf compared to grass, were found in the elite level teams. 41(1 Suppl): i20-i26 These tendencies of a difference in injury pattern between Fuller CW, Dick RW, Corlette J, Schmalz R (2007). the two types of surfaces need to be investigated further in Comparison of the incidence, nature and cause of injuries sus- tained on grass and new generation artificial turf by male and studies with larger cohorts and a higher statistical power. female football players. Part 2: training injuries. Br J Sports Med 41(1 Suppl): i27-i32 Ekstrand J, Hägglund M, Fuller CW (2011). Comparison of injuries sustained on artificial turf and grass by male and female elite football players. Scand J Med Sci Sports;21(6):824-832 54 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.5.9 Influence of Match Events on Injury website. A yellow/red card, injury and goal were defined Incidence during FIFA World Cups™ as potentially game-disrupting incidents (PGDI).
Why we conducted these studies Results
Football is a sport of a highly competitive nature, espe- From the three FIFA World Cups™, 441 injuries were cially at the top level. Changes in the score, foul play, reported, giving an overall injury incidence of 67.8 per injuries or yellow/red cards may have a profound impact 1,000 match hours. There were statistically significant on the course of a match. They may influence players’ differences in the injury incidence related to the changes attitudes, emotion, concentration, behaviour and team in the score and to the teams’ drawing/losing/winning strategies, and thereby affecting the risk of injury. status. The injury incidence was lowest during the initial 0-0 score and highest when the score was even but goals In FIFA World Cups™ (and other international tourna- had been scored. Teams currently winning had a higher ments), the importance of the result of a single match is injury incidence than drawing or losing teams. There crucial, which might emphasise the specific roles of the were also statistically significant differences in the injury different playing positions (i.e. forwards having to score incidence between the playing positions, with forwards goals), and consequently affect their risks for suffering an having the highest injury incidence, followed by defend- injury. Furthermore, FIFA World Cups™ are tourna- ers, midfielders and goalkeepers. ments with intense match schedules, which could hypo- thetically lead to incomplete recovery between matches, The injury incidence was significantly higher during and therefore increase the risk of injuries. Few studies on match periods within the minute of or during a five- the relationship between recovery time and injury inci- minute period following a PGDI than in other periods dence in top-level football have been published. of the match. The frequency of PGDIs had a tendency to increase towards the end of each half (Fig. 2.5.9.1), and a yellow card was the most frequent PGDI. Aims of the studies The incidence of non-foul injuries was significantly UÊÛiÃÌ}>ÌiÊÌ iÊÀi>ÌÃ «ÊLiÌÜiiÊÕÀÞÊV`iViÊ higher than of foul play injuries. Lower leg and ankle and changes in the score of the match, teams’ current injuries were significantly more often caused by foul drawing/losing/winning status, red / yellow cards, than non-foul play, whereas the opposite was observed injuries and foul play, as well as differences in the for thigh injuries. Contusions were a significantly more injury incidence between the playing positions often caused by foul than non-foul play, while the oppo- UÊÛiÃÌ}>ÌiÊÌ iÊÀi>ÌÃ «ÊLiÌÜiiÊÕÀÞÊV`iViÊ site was found for muscle strains/ruptures/tears. Foul and recovery time between matches play injuries were significantly less severe (defined by UÊ>ÞÃiÊ`vviÀiViÃÊLiÌÜiiÊvÕÊ«>ÞÊÕÀiÃÊ>`Ê resulting days of absence from playing/training football) foul injuries with regard to injury types and locations, than non-foul play injuries. No significant differences as well as match circumstances in which they occur between the incidence of foul play and non-foul injury regarding match period, teams’ current drawing/losing/ winning status or playing position were observed. We How we collected the data also found a linear relationship between number of fouls and of injuries in a match (Fig. 2.5.9.2). The studies were based on team doctors’ post-match injury reports from the FIFA World Cups™ in 2002, 2006 and 2010. The injury data were obtained through What we learned from these studies the injury surveillance system developed by F-MARC, and methods applied are in accordance with the consen- The high injury incidence following PGDIs could be a sus statement on injury definition and data collection potential target for intervention. Opportunities for sanc- procedures. Other match information were retrieved tions, including temporary expulsion from a match for from FIFA’s official match statistics for all 192 match- players committing violent fouls, could be considered. A es of the same tournaments, accessed on FIFA’s official few minutes’ absence for the player violating the rules could FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 55
theoretically help to re-establish the players’ concentration on the game more rapidly.
Considering the positive association between number of fouls and of injuries in a match, efficient intervention in the beginning of the match may be important. A possible way could be the referees’ early interventions in matches that start with high foul frequencies, for example by severely sanctioning foul play or communicating with the team cap- tains and/or management in order to caution the teams, or resolutely instruct them to play fairly.
The relationships between injury incidence and match events, playing positions and recovery time require future research, as they may provide clinically significant targets for interventions.
Fig. 2.5.9.2: Average number of fouls per matches in matches with diffe- rent number of injuries
Duration: 2002 - 2010 Countries: International References: Ryynänen J, Junge A, Dvořák J, Peterson L, Karlsson J, Börjesson M (2013). The effect of changes in the score on injury incidence during three FIFA World Cups. Br J Sports Med 47:960-964 Ryynänen J, Dvořák J, Peterson L, Kautiainen H, Karlsson J, Junge A, Börjesson M (2013). Increased risk of injury following red and yellow cards, injuries and goals in FIFA World Cups. Br J Sports Med 47:970-973 Fig. 2.5.9.1: Average incidence of injury and number of other potentially Ryynänen J, Junge A, Dvořák J, Peterson L, Kautiainen H, game-disruptive incidents during the course of the match. Karlsson J, Börjesson M (2013). Foul play is associated with injury incidence: an epidemiological study of three FIFA World Cups (2002-2010). Br J Sports Med 47:986-991 56 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.6 Head Injuries
2.6.1 Head and Neck Injuries during FIFA How we collected the data Competitions We analysed incidents resulting in head/neck injuries in 20 FIFA competitions (men and women) from 1998 Why we conducted this study to 2004. Again, team doctors provided medical reports using the same methodology as the other F-MARC As in other contact sports such as basketball, ice hockey injury studies on frequency, characteristics, risk factors and rugby the risk of concussion in football players had and causes. We defined injuries by the need for players always been a major concern and the risks associated to receive post-match medical attention from their team with head injuries had been recognised by FIFA for a doctors. To assess the incidents leading to injury, we long time. There was also a concern that repeated head obtained video recordings of heading incidents and stud- injuries may lead to long-term brain damage. Despite ied these videos to identify a range of parameters associ- these concerns and the potential of long-term disability, ated with the incidents. recognition of head injuries had not received the atten- tion that other injuries had. The English Football Asso- ciation stressed that “a head injury is a potentially seri- Identifying head injuries ous injury which can lead, in a small number of cases, to significant complications. No head injury is trivial.” From the physician reports, we identified a total of 248 But while the football medicine community had gained head/neck injuries of which 163 were identified and a good understanding of ankle, knee, muscle and other analysed on video sequences (Tab. 2.6.1.1). The most injuries, head injuries had not been studied to the same common injuries were contusions (53%), lacerations degree as other injuries. Therefore, F-MARC decided to (20%) and concussions (11%). The incidence of all further investigate into the matter. A major first step in head/neck injuries was 12.5/1,000 player hours (men: the prevention of any injury is recognising the factors 12.8; women: 11.5) and 3.7 for time-loss injuries (men: that lead to injury. 3.5; women: 4.1).
There was some minor variation in injury rates between Aims of the study tournaments and gender, but overall, the rates seemed to be fairly consistent (Tab. 2.6.1.2). The most common UÊ/Ê`iÌvÞÊÌ ÃiÊÀÃÊv>VÌÀÃÊÌ >ÌÊ >ÛiÊÌ iÊ}Ài>ÌiÃÌÊ causes of injury involved aerial challenges (55%) and impact on head and neck injuries in international the use of the upper extremity (33%) or head (30%). 49 football injuries resulted from head to head contact (Fig. 2.6.1.1) UÊ ÞÊÕÃ}ÊÛ`iÊ>>ÞÃÃ]ÊvÕÀÌ iÀÊ`iÌiÀiÊÌ iÊV- of which 16% were concussions. The unfair use of the dence and causes associated with head/neck injuries upper extremity was significantly more likely to cause UÊ iÌiÀiÊÌ iÊÀi>Ìà «ÊvÊ«>ÞiÀ½ÃÊ}i`iÀÊ>`Ê>}iÊ an injury than any other player action. The male player with injury diagnosis used his upper extremity far more frequently than did the female player and for males, this type of challenge was unfair over half the time. What is concussion? Only one injury (a neck muscle strain) occurred as a result of heading the ball throughout the 20 competi- Concussion is the temporary loss of normal brain tions, which was equivalent to 0.05 injuries/1000 player function as a result of an injury. A player does not hours. Form the data obtained from our analysis, we need to have lost consciousness to suffer concussion. were able to generate a series of risk factors by sex, age The player may be confused or unaware of the time, and diagnosis (Tab.2.6.1.3). date or place for a while after the injury. The terms concussion and minor traumatic brain injury can be used interchangeably.
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 57
Injury most likely to cause injury involved the use of the upper diagnosis extremity or the head, but in the majority of cases the ref-
As identified by team As identified by videotape eree deemed the challenges to be fair and within the current physicians laws of the game.
Men Women All Men Women All Group most Location of incident on pitch possession status common cause prior to challenge direction of challenge mode Concussion 8 22 11 9 26 12 of injury risk of challenge action during challenge intent factor Fracture/ 26 326 3 dislocation Gender Men: Defensive outfield free ball from the side jumping use of upper extremity fair challenge Contusion 57 41 53 59 34 54 Women: Defensive outfield free ball from the Laceration/ 21 15 20 24 17 23 front jumping use of head fair challenge abrasion Tournaments < 20 years: Attacking outfield free ball from Others 12 17 13 5 17 8 for players the side jumping use of upper extremity fair aged challenge Tab. 2.6.1.1 Percentage of injury type in male and female players > 20 years: Defensive outfield free ball from the side jumping use of head fair challenge
Tournament Incidence of injuries Injury Concussion: Attacking outfield free ball from per 1,000 player hours diagnosis the front jumping use of head fair challenge
All injuries Lost time injuries Contusion: Attacking outfield free ball from the side jumping use of upper extremity fair Men Women Men Women challenge
FIFA U-17 World Cup 11.1 – 4.1 – Laceration/abrasion: Defensive outfield free ball from the side jumping use of head or upper FIFA U-19 World Cup – 11.1 – 4.7 extremity fair challenge
FIFA U-20 World Cup 15.8 – 4.1 – Tab. 2.6.1.3 Most common causes of head /neck injuries as a function Olympic Games 16.8 13.2 3.8 4.4 of players’ gender and age and diagnosis of injury
FIFA Club World Cup 9.6 – 3.2 –
FIFA Confederations Cup 10.7 – 1.9 –
FIFA World Cup™ 10.1 10.9 2.4 2.8
All 12.8 11.5 3.5 4.1 tournaments
Tab. 2.6.1.2 Incidence of head and neck injuries per 1000 player hours in male and female players
What we learned from the study Fig. 2.6.1.1 Head-to-head contact
Our analysis identified consistent factors in head/neck inju- ries. First, the majority of injuries occurred in what might Duration: 2004 be considered to be low-risk areas of the football pitch (e.g. Countries: International defensive and attacking outfields) rather than in the highly Cooperation: University of Leicester, UK Reference: critical penalty areas where matches can be decided through Fuller CW, Junge A, Dvořák J (2005). A six year prospec- risks that players might be prepared to take. Next, most of tive study of the incidence, aetiology and causes of head and the injuries were a consequence of aerial challenges, from neck injuries in international football. Br J Sports Med 39 (1 the side or front, for a high, free ball. Finally, the actions Suppl):i3-9 58 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.6.2 Biomechanical Aspects of Head Injuries and motion analysis software which allowed the devel- opment of a mathematical model of heading and ball impact that was tested on one player and permitted Why we conducted these studies investigation of heading technique later in the other players. Heading as the intentional use of the unprotected head to control and advance the ball is a most unique aspect Through the use of a computer, we made modifications of football. Media reports and earlier scientific infor- to how the athlete performed the skill and the outcome mation on perception deficits in a fraction of football- on impact, head and ball trajectories, as well as accelera- ers had fed the growing controversy regarding potential tion and loads on the head. We could also make changes long-term consequences of repeated low-severity head to the structural properties of the ball and the closing impacts of heading. While there was substantial emotion velocity, the motion of the torso, activation of muscle as about this sensitive topic, there had been little scientific modifiers of heading skill. data available on skill and forces that occur when head- ing a football.
F-MARC decided to use modelling impact and skill anal- ysis to study the effects of heading in football. Modelling impact and skill analysis are mathematical and labour- intensive undertakings that attempt to use objective data and reasonable assumptions to form an understanding of the task of heading in football. Therefore, we decided to take a stepwise approach.
Aims of the studies
UÊ iÛi«ÊÌ iÊ>LÀ>ÌÀÞÊÌÃÊii`i`ÊÌÊÃÌÕ`ÞÊÌ iÊL- mechanics of heading UÊ`iÌvÞÊ i>`}ÊÃÌÀ>Ìi}iÃÊÌ >ÌÊ} ÌÊÀi`ÕViÊÌ iÊ potential for injury UÊ««ÞÊÌ iÊÌÃÊ>`ÊÌiV µÕiÃÊÌÊÌ iÊÃÌÕ`ÞÊvÊ i>`}Ê using human subjects Fig. 2.6.2.1 Bite plate mounted with an accelerometer UÊÌÌi«ÌÊÌÊ`iÌvÞÊÃÌÀ>Ìi}iÃÊÌÊ«ÀÛiÊ i>`}ÊÌiV - nique Applying the model
We then looked at how severe the impact of heading is How we modelled head impacts of heading with respect to accepted head injury calculation. The human model was developed through simulated head- First, it was necessary to develop the methods, mechani- ings at 6-7m/s. The model included varying parameters cal and mathematical, to study heading. Second, we such as torso/head alignment, neck muscle tensing and tested the methods in the lab for determining the bio- follow-through (Fig. 2.6.2.2). The derived mathematical mechanical response of a human heading a football. We model was modified by changing elements of the neck used biomechanical studies on seven active football play- musculature. Our simulation model was then verified by ers, aged 18-20. Each player underwent medical screen- comparing the model against complex video and accel- ing and then was instrumented with bite plate mounted erometry analysis of three skilled volunteer footballers. accelerometers (Fig. 2.6.2.1) and EMG electrodes on the Finally, we took the data from our model to see if the major neck muscle groups. Balls were delivered at two technique of heading could be “improved” to reduce the speeds (six and eight m/s or 13 and 18 mph) and the risks of heading. We asked the players to modify their players demonstrated several specific heading manoeu- heading technique to match that of the model and used vres. Bony landmarks were tracked via high speed video the same video analysis (Fig. 2.6.2.3). FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 59
The responses of the head were tested against current What we learned from the studies injury assessment functions of mild traumatic brain injury which come from a number of sources that have Using biomechanic modelling methods as F-MARC had studied settings like motor vehicle accidents, bicycle applied them in this study demonstrated that the accel- accidents, falls and others. Finally, we developed a Head erations heading causes to the head of a player are below Impact Power Index that we hoped would have a better the levels associated with brain injury. predictor picture of mild brain injury.
Fig. 2.6.2.2 Positive sign conventions of the numerical model for the head, neck, and torso In fact, heading led to accelerations that are well within accepted tolerance limits of head injury in trauma sci- ence.
Further, changing the skill of heading led only to incon- sistent benefits on a reduction of loading on the head. Consequently, no firm recommendations on changing current heading techniques could be made.
Duration: 2002 - 2003 Country: Canada Cooperation: Biokinetics and Associates Ltd, Canada References: Shewchenko N, Withnall C, Keown M, Gittens R, Dvořák J (2005). Heading in Football. Part 1: Development of biome- chanical methods to investigate head response. Br J Sports Med Fig. 2.6.2.3 Trajectories of subject, landmarks and ball 39 (1 Suppl): i10-i25 Shewchenko N, Withnall C, Keown M, Gittens R, Dvořák J (2005). Heading in Football. Part 2: The biomechanics of ball heading and head response. Br J Sports Med 39 (1 Suppl): i26- i32 60 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.6.3 Biomechanical Analysis of Head Impacts How we modelled impacts of head/arm-to-head
This project was designed to measure the head accel- Why we conducted this study erations resulting from impacts of the upper extremity (elbow or hand-to-head) and head-to-head and relate Football is an aggressive game and head impacts occur. this to the risk of mild traumatic brain injury using the Therefore, the incidence of head injury had long been a Head Impact Power Index developed by F-MARC. concern in football. Our previous studies had shown that heading in itself is rather unlikely to cause head injury Modelling sports impact is an extremely challenging and the technique itself was of little importance for the undertaking. For many people, biomechanical data (like impact of heading on a players head. But players may linear and angular velocities, moments, shear forces, etc) sustain head injury from impacts with the ground, post is far more difficult to comprehend when compared to or some body part of a player. Video analysis of heading physiological data (like heart rate) or performance data duels had shown that most injuries are caused by head- (like running speed, jump height). The first thing that head and head-elbow impacts. More than that, there had needs to be done is identify those impacts to be mod- been the impression of an escalating trend of head impact elled. Therefore, F-MARC provided match videos of 62 delivered by the upper extremity or head of an opposing cases of head impact. Of these, 38% were caused by the player in world-class level football. Whether this occur- upper extremity and 30% by the head of the opposing rence was intentional or accidental, it seemed necessary player. The video analysis revealed the typical impact to F-MARC to investigate the nature and potential of points and representative impact speeds. Typically, the these impacts to cause traumatic brain injury. upper extremity hit the head of the opposing player using either an elbow strike or a lateral strike with the Therefore, we decided to dedicate an individual study to hand. These impacts were then re-enacted in the labora- the investigation of the impacts from the upper extrem- tory by six volunteer football players striking an instru- ity or head to the head of an opposing player. In biome- mented Hybrid III pedestrian model crash test manikin chanics, the aim is to measure the energy of impact and (Fig.2.6.3.1). relate it to the disruption of tissues and other structures. The ultimate aim of such analysis is to reduce injuries by Head-to-head impacts were re-enacted using two instru- better understanding. Biomechanical data can be related mented test manikins (Fig. 2.6.3.2 and 2.6.3.3). Math- to medical outcome and help to gain a better under- ematical modelling of the impacts was carried out using standing of human impact tolerance. equations routinely used in monitoring motor vehicle accidents with special attention to head impact. The Accordingly, we intended to investigate the biomechani- sensors used in biomechanical research are very sensi- cal likelihood of the impacts of arm-to-head and head- tive and collected data at sometimes thousands of bits to-head to result in traumatic brain injury or even neck of information a second. With over a few hundred trials injury. We planned to reproduce impacts similar to what performed in this project, a considerable amount of data we had seen during play in the biomechanics labora- was collected. tory and then use the Head Impact Power Index that F-MARC had developed in our previous study to calcu- The laboratory set-up used for these scenarios were rep- late the risk. resentative of the video analysis of actual injuries. The elbow-to-head setting showed the impacts to occur between 1.7-4.6m/s and lateral hand strikes at 5.2-9.3 Aims of the study m/s resulting in a low risk of concussion (<10%) or neck injury risk (<5%). That these velocities are low and not UÊ i>ÃÕÀiÊ i>`Ê>VViiÀ>ÌÃÊ`ÕVi`ÊLÞÊÕ««iÀÊiÝÌÀi- likely to lead to a concussion does not imply that other ity and head-to-head impact injuries (like contusions, lacerations, etc.) are unlikely. UÊ,i>ÌiÊÌ ÃÊÌÊÌ iÊÀÃÊvÊ`ÊÌÀ>Õ>ÌVÊLÀ>ÊÕÀÞÊ Head-to-head impacts happened at 1.5-3.0m/s and the using the Head Impact Power Index higher velocities represented a high concussion risk (up UÊ i>ÃÕÀiÊÕ««iÀÊiVÊvÀViÃÊ>`ÊÌÀµÕiÃÊÌÊ`V>ÌiÊÌ iÊ to 67%). Impacts from higher velocity contact would concurrent potential for serious neck injury increase the risk of concussion. Finally, we measured upper neck forces and torques for the potential of con- FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 61
current serious neck injury. This revealed only a low the impacts may exceed the parameters used in the labo- neck injury risk (<5%). ratory.
Fig. 2.6.3.1 Laboratory setup for elbow-to-head impact
Fig. 2.6.3.3 Falling carriage apparatus
Fig. 2.6.3.2 Laboratory setup for head-to-head impact
What we learned from the study
Serious to severe neck injury due to upper extremity and/or head impact is at a low risk. Mild traumatic brain injury risk due to the same is also minor to non-exist- ent for upper extremity impact using the model of this project. Still, this is not to excuse other relevant injuries such as contusion, lacerations, facial bone fractures, jaw Duration: 2002 - 2003 dislocations or neck strains. Conversely, head-to-head Country: Canada impact was found to pose a high risk of concussion, Cooperation: Biokinetics and Associates Ltd, Canada whether intentional or not, and justified more strin- Reference: gent efforts to reduce their occurrence. However, as in Withnall C, Shewchenko N, Gittens R, Dvořák J (2005). any modelling study, the data only represents the con- Biomechanical investigation of head impacts in football. Br J straints of the laboratory setting. In actual match play, Sports Med 39 (1 Suppl): i49-i57 62 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.6.4 Biomechanical Analysis of Ball using our model, we were able to look at the differences Properties in ball construction under wet/dry conditions to deter- mine dynamic ball characteristics experimentally. Lin- ear and angular accelerations of the head were measured Why we conducted this study and compared to injury assessment functions and Head Impact Power. We also used the numerical model to Footballs have evolved over the years from an inflat- assess neck responses. ed pig’s bladder to a leather encased bladder. The first guidelines were set in 1872 with regard to the ball. The It was interesting to see that three of the five balls used current laws of the game set standards for the ball: cir- in this project gained water weight that exceeded the cumference of 680-720mm, mass of 410-450 grams and + Ê}Õ`iiÃÊVÀi>ÃiÃÊvʳÓÓ¯ÊÌʳ{ǯ®Ê/>L°Ê inflation pressures of 600-1100g/cm2 (0.6-1.1 bar). The 2.6.4.1). VÕÀÀiÌÊÊ+Õ>ÌÞÊ Vi«ÌÊ+ ®ÊÃiÌÃÊ>ÀÀÜiÀÊ standards on circumference and mass plus restrictions on The effect of water had variable effects of ball response shape, size, water absorption, pressure loss, rebound and properties: some balls with the lowest responses when balance. FIFA-sanctioned matches must use balls that dry had the highest results when wet. If ball mass is V«ÞÊÜÌ ÊÌ iÊ+ ÊÀiµÕÀiiÌð reduced by up to 35%, the responses on the head are also decreased by up to 23%-35% in both the numerical Heading is a specific and essential part of the game and and subject trials. yet the impacts of heading have been implicated in mild and acute neuropsychological impairment. Some pub- Similar decreases in neck axial (forces that try to either lished studies had suggested that ball characteristics press or separate the head from the trunk) and shear affect the impact response of the head; however, the (forces that push the head front, back, right or left) biomechanics of the interaction of the ball on the head responses were observed. If the inflation pressure was were not well understood. Consequently, the next step reduced by 50%, head and neck responses were reduced of F-MARC in their approach to head injuries was that by up to 10%-30% for the subject trials and numerical we wanted to study whether ball mass, pressure and con- model. struction characteristics can help reduce head and neck impact response. Ball Type Condition Pressure Mass (kg) Water (bar) Uptake
Fevernova Dry 0.8 0.444 3% Tri-lance Aims of the study Wet 0.8 0.458 UÊÕÀÌ iÀÊ>``ÊÌÊÕÀÊÕ`iÀÃÌ>`}ÊvÊLiV >VÃÊÊ Mitre White Dry 0.8 0.428 41% heading Wet 0.8 0.603 UÊ iÌiÀiÊvÊ i>`ÊÀiëÃiÃÊV>ÊLiÊV >}i`ÊLÞÊ>ÌiÀ- adidas World Dry 0.8 0.439 22% ing ball properties such as mass and pressure Cup 1974 UÊ ÝÌi`ÊÌ ÃÊiÊvÊÀiÃi>ÀV ÊÌÊÛiÃÌ}>ÌiÊ i>`ÊÀiëÃ- Wet 0.8 0.534 es with differing variations in ball mass, pressure and adidas Dry 0.8 0.445 4% construction Santiago Orange Wet 0.8 0.463 How we modelled ball impacts adidas Dry 0.8 0.412 47% Santiago Brown The methods we used were the same as reported in the Wet 0.8 0.604 two previous chapters on the biomechanical modelling in head impacts. Heading responses under ball impact Tab. 2.6.4.1 Water absorption of different ball models. (6-7m/s) were modelled from controlled trials on three human subject trials. Three ball masses and four ball Biomechanical response reductions up to 15% were pressures were investigated for frontal heading. Further, observed between different ball constructions and the wet condition generally resulted in greater head and FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 63
F-MARC meeting with the Biokinetics Group, Ottawa/Canada neck responses of up to 20%. See table 2.6.4.2 for a results from modified heading techniques will make any summary of responses from changing ball characteristics. skill recommendations difficult to implement. It was concluded that to reduce ball mass and inflation pressure would lead to improvements in both the peak Another option would be to reduce ball mass and infla- linear acceleration and power index. Other ball charac- tion pressure. Our study showed that improving the teristics such as stiffness and construction must be con- classical ball characteristics of mass and pressure might sidered in conjunction with traditional ball characteris- have immediate effect on heading scenarios regardless tics. of the player’s skills. Though research on a wider range of ages, skill, sex, heading scenarios, etc. will aid in the Ball Type Linear Angular Power further understanding and improvement of heading bio- Acceleration Acceleration Index mechanics, changes to the ball characteristics have been Baseline mass, === shown to provide on overall benefit and can be effec- pressure tively implemented. The possible fall-off in playabil- Lowest mass ++ ++ +++ ity and handling characteristics using balls with reduced
Low mass ++ - +++ mass and/or pressures would need to be balanced against the possible safety benefits. The constraints provided by Low pressure ++ -- ++ Ì iÊ >ÜÃÊvÊÌ iÊ>iÊ>`ÊÌ iÊ+ ÊÜÕ`Ê >ÛiÊÌÊLiÊ reviewed. High pressure -- -- +*
*Data exhibited large test variability.
Tab. 2.6.4.2 Summary of head responses for various ball character- istics.
What we learned from the study
There are a number of options that can reduce impact on the head, neck or both. One option is to improve the Duration: 2003 - 2004 heading technique. As described, some heading tech- Country: Canada niques provided benefits by reducing a few aspects of the Cooperation: Biokinetics and Associates Ltd, Canada head responses while providing greater player skills for Reference: controlling the ball and perhaps greater appreciation of Shewchenko N, Withnall C, Keown M, Gittens R, Dvořák J the game. But while we can identify a set of technique (2005). Heading in football. Part 3: Effect of ball properties on suggestions than might make heading safer, inconsistent head response. Br J Sports Med 39 (1 Suppl): i33-i39 64 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.6.5 Biomechanical Analysis of Headgear Aim of the study
UÊ Û>Õ>ÌiÊÌ iÊivviVÌÛiiÃÃÊvÊÌ ÀiiÊÌÞ«iÃÊvÊvÌL>Ê Why we conducted this study headgear
As laid out in the previous chapters, the possibility of brain injury as a result of heading received wide media How we studied headgear in the lab attention, creating a safety concern for football and its players. However, the body of research on the neuro- We conducted controlled tests using both a human logical, neuropsychological and cognitive impairments volunteer and a surrogate head/neck system to quanti- among active amateur and professional players as well as fy the impact reduction of three commercial products retired professional players has produced mixed results (Fig. 2.6.5.1a-c) in response to ball impact speeds of with no clear consensus on the reasons why a fraction 6-30m/s and in head-to-head contact with a closing of football players showed some cognitive deficits. The speed of 2-5m/s. reported research findings based on players of the 1970s and earlier had limited applicability to the modern play- er because those former professionals had used older generation balls or had other influencing factors.
As F-MARC had already shown, the most common cause of head injury was from player-to-player contact, unexpected head-to-ball impacts from close range and head-to-elbow impacts. We had also documented that no concussive head injuries could be related to voluntary heading. Fig. 2.6.5.1a Full90
Still, in view of parental concerns over the safety of heading and the possibility of head injury, soft, protec- tive headgear was developed and marketed for use by football players of all age and skill levels for protection against the impact of heading and direct contact with other hard surfaces like an opponent’s head, elbow, the ground, the post and other hard surfaces. While the manufacturers reported substantial reduction in impacts from hard surfaces, the devices were only bit by bit assessed by independent laboratories for verification of methods and results. In addition, no device had been Fig. 2.6.5.1b Head Blast studied in a clinical trial involving football players.
While it might make intuitive sense that a soft surface between two hard surfaces should reduce the force of impact, there is little data to support commercial prod- ucts that has stood the test of peer review in the scien- tific literature. Completing the biomechanical analysis of heading impacts, F-MARC therefore decided to test commercial football headgear in the laboratory and determine whether they had an effect on head and neck impact responses. Fig. 2.6.5.1c Kangaroo
Fig. 2.6.5.1 Protective headgear used in this study mounted on the surrogate head form FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 65
A single skilled player was instrumented (Fig. 2.6.5.1) to measure linear and angular head accelerations and then exposed to low severity impacts during head- ing in the unprotected state and the protected state wearing the headgear. The high severity impacts and head-to-head impacts (Fig. 2.6.5.2 and 2.6.5.3) were studied with a surrogate head form instrumented to measure linear and angular head responses. The sub- ject and surrogate responses were compared with pub- lished injury assessments associated with mild trau- matic brain injury.
Results Fig. 2.6.5.2 Volunteer prepared for heading (bare head configuration shown) The data showed that at low and high speed ball impacts, whether using the human or the dummy head form, headgear failed to appreciably alter the impact response on the head during heading. The acceleration of the head, when wearing any head protection, was within the variability seen for the unprotected condition. The surface that underwent the greatest deformation was the surface that is absorbing the impact and high speed video showed that the ball, being the softer surface, appeared to absorb most of the impact of heading. The responses observed in all ball-to-head tests indicated a low risk of mild traumatic brain injury.
The findings from head-to-head impacts showed that each headgear provided a measurable improvement in reduction of impact (Tab. 2.6.5.1). Fig. 2.6.5.3 High speed ball cannon set-up relative to test head form Head-to-temple Forehead-to-rear (Full 90 headgear shown)
Product Linear Angular Linear Angular of the colliding heads means that a compliant headgear A -22.1 -25.7 -24.5 -31.9 helps reduce the impact by dissipating energy. B -19.0 -14.1 -17.9 -16.6 C -55.6 -55.9 -57.7 -45.7
Tab. 2.6.5.1 Average percent reduction in head acceleration for each headgear
What we learned from the study
If headgear was to be worn in football, the effective- ness of that headgear and its limitations would need to be well understood. F-MARC tested three commercially Duration: 2003 - 2004 available football headgear and these were found to offer Country: Canada Cooperation: Biokinetics and Associates Ltd, Canada no protection from ball heading and high speed ball Reference: impact, but did offer some protection against impact Withnall C, Shewchenko N, Wonnacott M, Dvořák J (2005). from another player’s head. The relatively high stiffness Effectiveness of headgear in football. Br J Sports Med 39 (1 Suppl): i40-i48 66 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.6.6 S-100 Beta Serum Levels after normal exercise as well as in other patients who had sus- Controlled Heading tained a minor traumatic brain injury.
Sixty-one male young (average age = 15 years old) ama- Why we conducted this study teur football players performed routine football training (that incorporated controlled heading) for 55 minutes. One problem with concussion is that it is not visible Data was compared to 58 other male amateur football using current imaging methods in the way a fractured players of similar age who performed one hour of nor- bone is visible on routine x-ray. Another problem was mal exercise training without head contact and also to 81 the concern by the public about whether repeated sub- young male patients who were seen early after traumatic concussive impacts of purposeful heading might lead brain injury and who were evaluated by computed tomog- to head injuries in football players, and whether these raphy (CT) scans for detection of intracranial lesions. might actually be comparable to those of patients with These head injury patients were further divided accord- a minor traumatic brain injury. Therefore, the medical ing to whether or not the CT scan showed evidence of community that studied head injury continued to look a lesion. For the training athletes, venous blood samples for a “test” that would be more objective than symptoms were drawn before the training (Fig. 2.6.6.1), then at reported by the patient. about one hour and six hours after training. For the head injury patients, blood was drawn at about one and six Another option for confirmation of the diagnosis would hours after injury. be some evidence of brain injury in the blood. If such a factor could be identified to be reliable evidence of brain Pre- 1 hour post 6 hours training post injury, then another piece of the diagnostic puzzle that is heading and head injury could become available. After Heading group .15 .18 .15 brain injury, the neuroprotein S-100 Beta is released into Normal exercise group .10 .11 .09 the circulation and is considered to be a reliable marker Patients with a .62 .32 of brain damage. Brain cells are held together by a com- + CAT scan plex scaffolding of supporting cells. When the brain is Patients with a .10 .08 injured, some of these supporting cells also become dam- – CAT scan aged and release specific compounds into the blood. In + CAT = patients with a CAT scan positive for head injury the absence of brain injury, the levels of one of these – CAT = patients with a CAT scan negative for head injury proteins in the blood, S-100 Beta, are negligible, but become measurable in the blood following brain injury. Tab. 2.6.6.1 Average S-100 Beta (ng/ml) results by time and group To complement the information collected in their bio- mechanical studies, F-MARC now intended to assess the Results biochemical aspects. Routine exercise led to, essentially, no change in S-100 Beta levels. The players who were involved in heading Aims of the study practice had a slight elevation after one hour that had returned to normal within six hours (Tab. 2.6.6.1). It UÊ i>ÃÕÀiÊÌ iÊÃiÀÕÊiÛiÃÊvÊ-£ääÊ iÌ>Ê>vÌiÀÊ>ÊÌÀ>}Ê was interesting that when the subjects in the heading session containing controlled heading activities group were divided by age, the two younger groups (12- UÊ «>ÀiÊÌ iÊ«ÃÌ i>`}Ê-£ääÊ iÌ>ÊÀiëÃiÃÊÜÌ Ê 13y and 14-15y) had significantly higher S-100 Beta lev- normal exercise and patients who sustained a mild els than the oldest group (16-17y, Fig. 2.6.6.2). Those traumatic brain injury patients whose CT scan was negative for lesions showed S-100 Beta levels similar to the exercise group while those patients with a CT scan that was positive for a How we collected the data lesion showed S-100 Beta levels three to five times high- er than the uninjured patients or athletes. Notice that We decided to evaluate the neuroprotein S-100 Beta none of the exercising groups, regardless of age, reached serum levels in young amateur football players early after the levels found in those patients with a CT scan that controlled heading, compared to early measurements after was positive for intracranial lesions. FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 67
Fig. 2.6.6.1 Taking blood samples
Fig. 2.6.6.2 S-100 Beta serum levels in different age groups
What we learned from the study
This study showed that controlled repetitive heading in young amateur football players leads to a small tran- sient increase of S-100 Beta levels one hour after train- ing that returned to pre-training levels at about six hours after training. No longer lasting increase of S-100 Beta Duration: 2000 - 2001 levels indicating damage of brain cells was observed after Country: Germany controlled repetitive heading. After heading, S-100 Beta Cooperation: University of Munich levels were significantly elevated compared to normal Reference: exercise. The patients who had a positive CAT scan for Mussack T, Dvořák J, Graf-Baumann T, Jochum M (2003). brain lesions had both higher and longer lasting elevated Serum S-100B protein levels in young amateur soccer play- levels of S-100 Beta, and no exercising player had levels ers after controlled heading and normal exercise. Eur J Med consistent with that of the injured patients. Res;8(10):457-464 68 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.6.7 Serum Levels of S-100 Beta after Minor ing session without heading and after a low-intensity Head Trauma training session with heading exercises only
Why we conducted this study How we collected the data
Football is one of the few sports to use an unprotected All players in the elite Norwegian league, the Tippeli- head to control and advance the ball. There had been an gaen, were invited to participate prior to the 2004 and increasing concern that heading could lead to chronic 2005 seasons. The total number of players followed over brain injury like that seen in boxing. This was first pos- these two seasons were 289 (2004) and 332 (2005), tulated in 1992 based on a series of cross-sectional stud- meaning that the study covered 621 player seasons. ies using neurological exams, neuropsychological tests, Baseline morning blood sampling prior to both seasons computer tomography scans and electroencephalography was performed for all teams during their pre-season exams on active and older retired Norwegian football training camp. Post-match or training samples were players. Since then, the neurological deficits found in a obtained immediately after play or training as well as the small fraction of football players were a matter of debate next morning (twelve hours post-match). as studies had shown different results. In our own stud- ies, F-MARC had found that heading duels leading to The two match groups were differentiated according to head-head or head-elbow impact expose players to an whether there was no recorded head trauma or wheth- increased risk of head trauma and had been hypothesised er there was head trauma recorded during play. A head as the mechanism for the reported cognitive deficits trauma was defined as follows: a player appeared to rather than heading itself. receive an impact to the head (including the face and the neck), the match was interrupted by the referee, and, As mentioned, an important issue had always been to the player laid down on the pitch for more than 15s. A actually recognise that a concussion has occurred. There total of 228 head impacts that met these inclusion crite- is no conclusive, objective test or image that verifies the ria were identified on video from 352 matches and 69 of presence of a concussive injury. Several different mark- these head traumas were followed up by blood sampling. ers for brain injury had been investigated and the S- 100B protein seemed to be the most promising marker Training sessions were either of high intensity with no for evaluation of traumatic brain injury in patients with heading or low intensity including heading. The high minor head injury. Elevation of S-100B indicates some intensity sessions were aimed at mimicking match play level of structural damage to the brain. but heading was disallowed. Players were questioned after both sessions assessing their level of fatigue and Studies in small groups of players suggested that S-100B how often they headed the ball during the current day’s is increased after playing a football match and appears to training compared to a regular match (much less, less, a be related to the number of headers. The F-MARC study little less, the same, a little more, more or much more). described in the previous chapter had shown a transient This score was then divided into the two groups of “less” increase in S-100B levels after controlled heading. How- and “the same or more” for analysis. ever, no large-scale prospective study had assessed S- 100B levels after minor head impacts in football and we decided to address this problem. Results
One question that is asked frequently is just how often Aims of the study does a player actually head a ball during a match. In the 2004 season in Norway, the average number of headers UÊÃÃiÃÃÊÜ iÌ iÀÊÀÊ i>`Ê«>VÌÊÊvÌL>ÊVÕ`Ê was 5.7 showing wide variability according to the play- cause injury to the brain tissue, measured as an ing position. Midfielders headed 2.8 times on average, increase in the serum S-100B central defenders 9.6 times. UÊ «>ÀiÊ-£ää ÊVViÌÀ>ÌÊ>vÌiÀÊ>Ê i>`Ê«>VÌÊ occurring during a regular match, after a regular match with no head trauma, after high-intensity train- FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 69
High-Intensity Exercise Group Heading Group
Level of fatigue vs. match1 No. of headings vs. match2
Less Same or more Less Same or more S100B sample (N=19, 53%) (N=17, 47%) (N=10, 29%) (N=25, 71%)
Baseline 0.043 0.045 0.061 0.039
One hour sample (B1) 0.070 0.075 0.078 0.066
Twelve hour sample (B12) 0.041 0.047 0.052 0.041
Table 2.6.7.1 Average S-100B values* (ng/ml) by training emphasis, player perceptions and time
*0.12ng/ml = clinical value to be exceeded to document structural brain injury 1 rating the level of fatigue from training compared to a match 2 rating of the number of headers during training compared to a match
All the four different conditions led to moderate, but significant increases in serum S-100B concentration that returned to baseline by the next day. While the increase was higher for the two match conditions when compared to the two training conditions, there were no significant differences between the two match groups at any time point (Tab. 2.6.7.1). Had the head injury group demonstrated higher S-100B levels, there might have been some evidence of structural injury. Players who headed ten times or more during the respective match exhibited a trend towards a higher serum S-100B concentration at baseline compared to the players who headed three times or less.
What we learned from this study
It appeared that S-100B increases for a brief time after football training and matches. There is the possibility of an additive effect of heading and high-intensity exercise, but the minor head impacts of this study did not seem to cause any additional increase in S-100B beyond the levels seen after a regular game. Thus, this study found no evidence of significant structural injury to the brain after these minor head impacts in football. However, it may still be that S-100B might not be the ideal marker Duration: 2004 - 2005 for brain injury in athletes due to the confounding effect Countries: Norway, Germany of physical activity. Cooperation: Oslo Sports Trauma and Research Center, Norway; Ludwig-Maximilians University, Munich, Germany Reference: Straume-Naesheim T, Andersen TE, Jochum M, Dvořák J, Bahr R (2008). Minor head trauma in football and serum levels of S100B. Neurosurgery 62(6):1297-1305 70 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.6.8 The Value of Neuropsychological the National Football League, National Hockey League Testing after Head Injuries and many university athletic programmes began clinical concussion management programmes that featured neu- ropsychological testing as a critical tool. Why we conducted these studies The use of these brief test batteries serve mostly as a It had been stated that only one out of five concussions screening approach to cognitive assessment. Brief test are recognised by the players after a head impact in a batteries allow baseline assessment of many athletes in match, indicating that many players continue to play the pre-season, but do not allow for comprehensive eval- with undiagnosed concussions. Thus, an important issue uation of cognitive processes. So there are limitations to for the sports physician when assessing and managing Ì iÀÊÕÃiÊ>`ʵÕiÃÌÃÊÌÊLiÊ>ÃÜiÀi`°Ê+ÕiÃÌÃÊiÊ concussions had always been the reliance on the subjec- the most appropriate battery of tests, interpretation of tive reporting of symptoms by athletes. Cognitive func- the tests and the control of factors that can affect test tion testing had been used for the study of brain func- performance. tion for a very long time, but the last two decades had seen a wide expansion in the use of neuropsychological Which ground are we at? testing in the evaluation of concussion injury. The idea Which team are we playing today? that neuropsychological tests could be used to provide an Who is your opponent at present? objective measure of cognitive recovery in the concussed athlete initially arose from work in severe traumatic brain Which half is it? injury. Later, computerised testing programmes that can How far into the half is it? be administered to multiple people using portal comput- Which side scored the last goal? ers had been introduced. These programmes were new Which team did we play last week? and still needed to be validated against the long accepted Did we win last week? and traditional paper and pencil tests. It seemed there- fore critical to F-MARC to provide football physicians Tab. 2.6.8.1 The Maddocks questions for use after a head injury with guidance on the best test to use.
At the sideline Aims of the studies The sideline clinician needs a simple and valid tool to UÊ-Õ>ÀÃiÊÌ iÊ`vwVÕÌiÃÊÊ`>}Ã}Ê>ÊVVÕÃà determine whether an athlete is concussed to aid in UÊ iÃVÀLiÊÌ iÊV >i}iÃÊÊ`iÛi«}ÊÀiÌÕÀÊÌÊ«>ÞÊ decisions such as removal from play for detailed assess- guidelines ment. In the early 1990s, the so-called “Maddock’s ques- UÊ- ÜÊÌ iÊÌiÀ>VÌÊvÊÃÃÕiÃÊÊÌiÀ«ÀiÌ}ÊiÕ- tions” were validated using Australian Rules football and ropsychological data showed that a simple sideline test of recent and remote UÊ-Õ>ÀÃiÊÌ iÊÃÃÕiÊvÊVVÕÃÃÊÊvÌL> memory could be sensitive at separating concussed from non-concussed athletes (Tab. 2.6.8.1). Another option is the “Standardised Assessment of Concussion (SAC)” Which test is best? that can also be given on the sideline, but is more com- plex and takes longer than the Maddock’s questions. Traditional approaches to cognitive assessment involv- The most recent sideline assessment tool, the “Sport ing extensive testing by trained neurophysiologists, was Concussion Assessment Tool (SCAT)” combining all impractical for the evaluation of large groups of athletes. the previous tests, was developed at the 2nd International At about the same time in the US and Australia, two Symposium on Concussion in Sport in Prague in 2004. research groups began to study the use of abbreviated A detailed summary of that conference is contained neuropsychological assessment in sports concussion. The within the chapter on improving standards of care. establishment of the “45’ test” battery developed for the American football team Pittsburgh Steelers proved that a brief battery of tests were a reliable and valid adjunct in the clinical management of sports concussion. From this, FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 71
Past History Psychological factors Genetic factors Previous concussions Test anxiety Age Other head injuries Depression/ Intelligence Educational background other emotional states Gender Previous testing race Handedness visual acuity Other factors Auditory acuity cognitive function Test performance Test-setting/distractions Methodolical factors Motivation Testing situation Fatigue Practice/learning effects Random variance/chance Administrator expertise
Fig. 2.6.8.1 Factors that can influence test performance
(Fig. 2.6.8.1). This is where much of the controversy Follow-up and return-to-play issues about suggesting that heading is a factor arises when there are so many other factors that might have affected After a concussion is diagnosed, the strategy changes test results. during follow-up because of known deficiencies after concussion injury. Mild or moderate deficits can occur to such brain functions as reduced planning, impaired What we learned from the studies memory and learning, reduced attention and informa- tion processing plus slowed reaction times and wider It has to be emphasised that neuropsychological assess- variations in their responses to testing. ment should not be the sole basis of a return to play decision. Football should follow the recommendations Some may be tempted to use cognitive testing as the of the 2nd International Symposium on Concussion in criteria for return to play. However, it has to be empha- Sport in Prague. The major points are that a sideline sised that neuropsychological assessment should not be assessment of concussion that can be performed by non- the sole basis of a return to play decision. Testing is but medical personnel should be used such as the Maddock’s an aid to clinical decisions. Neuropsychological testing questions or the SCAT. Once a concussion has been should not be done while the player is symptomatic. confirmed, the injury immediately becomes a medical Here, testing adds little to this decision because a symp- issue requiring medical management. Finally, return to tomatic player is not going to be allowed to participate play requires a “back to baseline” performance on cogni- regardless of the outcome of cognitive testing. Over test- tive function tests at rest and after exercise plus follow- ing may confound results due to practice effects. Most ing the stepwise return to play outlined by the Prague clinicians wait for all symptoms to resolve at rest and consensus. during exercise before using testing as the final step in the return to play decisions. In the future, computerised testing may be a more widely applied procedure than tra- ditional paper and pencil tests.
Duration: 2005 Countries: Australia, Norway Interpreting the tests Cooperation: University of Melbourne, Australia; Oslo Sports Trauma and Research Center, Norway Once test results have been obtained, to what are the References: results compared to? Should they be compared to exist- McCrory P, Makdissi M, Davis G, Collie A (2005). The value of neuropsychological testing after head injuries in Football. Br ing norms that are available for the various test proce- J Sports Med 39 (1 Suppl): i58-i63 dures? Or should they be compared with their own base- Straume-Naesheim T, Andersen TE, Bahr R (2005). line test results? This of course means that pre-injury Reproducibility of computer based neuropsychological testing baseline tests were gathered. Then there is the issue of among Norwegian elite football players. Br J Sports Med 39 (1 confounding factors that might influence test results Suppl): i64-i69 72 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.6.9 Effects of Heading Exposure and heading actions per match), player career, etc. The Cog- Previous Concussions Sport™ tests for seven different subtasks: Simple Reac- tion Time (SRT), Choice Reaction Time (ChRT), Con- gruent Reaction Time (CgRT), Monitoring (MON), Why we conducted this study One-Back (OBK), Matching (Match) and Learning (Learn). The stimulus for all tasks consists of play- The football community had become aware that a frac- ing cards with responses given using the keyboard. The tion of football players displayed some cognitive dys- heading actions of 18 players observed in four matches function in factors like short-term memory, information were counted and correlated with their self-reported val- processing, concentration and more from earlier studies. ues. As laid out in the previous chapters, these studies had since come under question because researchers raised methodological issues pertaining to alternative hypoth- Results eses other than routing heading as the reason for the noted dysfunction. Those earlier studies, while drawing A total of 137 players, that means just about more than attention to the issue, implicated heading the ball as the half of players, reported having had one or more concus- cause while ignoring alternative hypotheses. Later reports sions and 112 players reported a football-related concus- stated that the reported deficits are more likely to be the sion. Defensive players reported to head the ball most result not from routine heading, but from head injuries, frequently, followed by attackers. The manual count in specifically concussions – the most common of serious 18 players showed an average of 8.5 headings per player head injuries. per match.
After having addressed the value of neuropsychological The first thing of interest then was if there was a positive testing after head impacts more generally, F-MARC con- association between the numbers of previous concus- sidered it necessary to further investigate the association sions and match heading exposure. It should be expected between previous concussions and heading exposure with that the players who head the ball the most should be neuropsychological test performance. We also felt that, at the greatest risk of head injury (Fig. 2.6.9.1). This as all previous studies had looked at a limited number of assumption, based on the figure, appeared to be true players for a shorter period of time, it was necessary to – those who head the ball the most are the ones most follow a larger number of players for an entire league sea- likely to have had a concussion. The estimated lifetime son in order to get a more reliable picture of the effects of heading exposure as well as the self-reported number of heading and concussion in football. Further, we intended headings were correlated with the number of previous not to use a paper and pencil, but a computer based test. concussions.
The next item of interest was whether there was a rela- Aim of the study tionship between how much a player heads the ball and their neuropsychological performance, but there was no UÊ Ý>iÊÌ iÊ>ÃÃV>ÌÊLiÌÜiiÊ«ÀiÛÕÃÊVVÕÃÃÃÊ association with heading exposure and test performance. and heading exposure with computer based neuropsy- >3 chological test performance among Norwegian profes- sional football players 2
How we collected the data 1
Two hundred and seventy-one players in the Norwegian professional football league, the Tippeligaen, performed 0
two consecutive CogSport™ baseline computer-based Never(N=3) Total number of previous concussions number of previous Total (N=65) (N=19) neuropsychological tests prior to the 2004 season and (N=65) (N=91) 1–5 times 6-10 times > 20 times completed a questionnaire assessing previous concus- 11-20 times Fig. 2.6.9.1 Relationship between estimated heading per match and sions, match heading exposure (self-reported number of concussion history FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 73
Neither match nor lifetime heading exposure showed 19 players scored below the 95% confidence interval for any association with the neuropsychological test perfor- one or more of the tasks. The 95% confidence interval mance of these players. represents the scores encompassing 95% of people who have taken the test. These 19 players with the lowest When the CogSport™ data is plotted against concus- scores were no different from the rest of the players in sion number, we see a horizontal line (Fig. 2.6.9.2), terms of the number of previous concussions or life- which means no relationship between test results and time or match heading exposure adding more evidence concussion number. If, however, cognitive performance against heading as a factor in low neuropsychological was related to concussion injury, then test performance performance. should become poorer in players with more concussions.
Obviously, not everyone scores the same on these tests What we learned from the study and there will be players who perform poorly on the assessments. What about these players who had the This study is, by far, the largest study to date on neu- poorest performance on these tests? Of the 271 players, ropsychological test performance in football players. Similar to other studies, we found an association between 2000 1500 heading frequency and concussion. Contrary to previous 1000 findings among footballers, we found no impairments in this group of professional footballer players if compared 500 400 to the normal range defined by the test manufacturers. 300 200 We also failed to find a relationship between previous concussions, heading exposure and test performance. 100 Simple reaction time Our findings did not confirm that either concussive or 2000 1500 the repetitive sub-concussive traumas from heading have 1000 a cumulative effect causing brain function impairments among football players. 500 400 300 However, as stated in the summary on injuries in FIFA 200 competitions, studying one team or league or tourna- 100 Choice reaction time The back task ment must be expanded to give the most stable conclu- 2000 1500 sions on this most important topic. 1000
500 400 300 200 Cogsport mean reaction time (log 10 scale, ms) Cogsport mean reaction 100 Congruent reaction Matching task 2000 1500 1000
500 400 300 200
100 Monitoring task Learning task Duration: 2004 Country: Norway Cooperation: Oslo Sports Trauma Research Center, Norway 0 (N=133) 0 (N=133) Reference: 1 times (N=55)2 times (N=43)3 times (N=16) 1 times (N=55)2 times (N=43)3 times (N=16) Dvořák >4 times (N=22) >4 times (N=22) Straume-Naesheim T, Andersen TE, J, Bahr R (2005). Effects of heading exposure and previous concussions on neu- Total number of previous concussions ropsychological performance among Norwegian Elite football- ers. Br J Sports Med 39 (1 Suppl): i70-i77 Fig. 2.6.9.2 CogSport™ test results plotted against concussion history 74 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.6.10 Do Minor Head Impacts in Football How we collected the data Cause Concussive Injury? Baseline neuropsychological testing was completed by the professional football players in the Norwegian elite Why we conducted this study league, Tippeligaen, prior to the 2004 or 2005 seasons. During both league seasons, the players were observed Chronic traumatic brain injury, due to multiple head during all regular matches and all head impacts were traumas, has been known to occur in professional box- recorded. A player who experienced a head impact dur- ing since in 1928. It was presumed to be caused by a ing a league match was evaluated by the local medical cumulative effect of concussive and sub-concussive head personnel immediately after the match. This includ- impacts. As reported in the previous chapters, results ed completing a form assessing acute symptoms, the from studies performed in football in the nineties had Glasgow Coma Scale, and the presence and duration led to the concern that repetitive head impacts during of loss of consciousness and amnesia. All players with play could also cause cognitive impairment among foot- head impacts completed a follow-up test the following ballers. These studies had several shortcomings and later day. They were compared to a control group consisting studies did not produce conclusive evidence that cogni- of players who were tested the morning after a regular tive impairment occurs as a result of general football play match where no head impacts were recorded. or normal football heading. The F-MARC studies con- ducted with regard to blood markers of brain injury and A one-year follow-up with computer-based neuropsy- neuropsychological testing had clearly confirmed these chological testing (CogSport™) was also conducted findings. where the players who had experienced one or more head impacts were compared to the players without any However, in 2004, a study from the Norwegian football recorded head impacts. The test battery consisted of elite league revealed an incidence of events with a head seven different tasks assessing the psychomotor function, injury potential of 22.0 per 1,000 playing hours. Fur- decision-making, simple attention, divided attention, ther, it was shown that four out of five concussions were working memory, complex attention, and learning and not recognised by the players. As the majority of profes- memory, all using on-screen playing cards as stimuli. sional footballers play more than 450 matches during their career, the total career exposure to head impacts and the potential for head injury in football is consider- Results able indeed. Baseline neuropsychological testing results did not dif- It had been stated that computerised neuropsychological fer among the different groups. A total of 228 impacts tests may detect cognitive deficits in concussed athletes to 141 players were identified on video from the 352 who were seemingly asymptomatic at the time of testing. matches observed and 44 of these were followed up with F-MARC intended to add computerised neuropsycho- a CogSport™ test. These cases included six concussions logical test information to the clinical assessment of play- of which five showed loss of consciousness. ers and for the first time assess brain function after head impacts during football matches, irrespective of whether The players with head impacts had a greater change in the impacts were diagnosed as concussions or not. reaction time from baseline to follow-up compared to the players who had not suffered head impacts with regard to the three simplest tasks of the test: psychomo- Aims of the study tor function, decision-making and simple attention (Fig. 2.6.10.1). UÊ iÌiÀiÊÜ iÌ iÀÊÀÊ i>`ÊÌÀ>Õ>ÃÊÊiÌiÊvÌ- ball cause measurable impairment in brain function Half of the players with recorded head impacts report- UÊÛiÃÌ}>ÌiÊÜ iÌ iÀÊÌ iÀiÊÜ>ÃÊ>ÞÊV >}iÊÊiÕÀ«ÃÞ- ed one or more symptoms at the time of the incident. chological test performance from one year to the Headache was the most common symptom, followed next in individuals who had experienced one or more by dizziness and concentration problems. The players minor head impacts during the course of the previous reporting acute symptoms after the impact showed the season FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 75
largest deficits when tested, but deficits were also dem- What we learned from the study onstrated among asymptomatic players. A reduced test performance was found after minor head Players who experienced one or more head impacts dur- impacts in football as compared to results prior to the ing the 2004 season also showed a reduction in neu- impacts. The largest reductions were found for the play- ropsychological performance when tested prior to the ers who showed symptoms at the time of testing. The 2005 season (Fig. 2.6.10.2). However, none of these study is also the first to demonstrate neuropsychological footballer players were impaired when compared to deficits after minor head impacts where the player did results to be expected in an average population. not report any acute concussive symptoms. Our findings emphasise the need for increased awareness of concussion signs and symptoms, not only among the team’s medical personnel, but also among the players themselves. Con- cussive symptoms are often not recognised by the players and, if recognised, symptoms are often not reported.
It is important to note however, that the impairment was found when comparing the test results prior to and after the head impacts in the respective player. But when com- pared to the results of an average population, there was no impairment and therefore the long term consequence of this finding is uncertain.
Fig. 2.6.10.1 Change (%) in reaction time from baseline to follow-up for the Head Impact Group and the Match Control Group. Data are also shown for symptomatic and asymptomatic players in the Head Impact Group. *p<.05 vs. the Match Control Group; **p<.01.
Duration: 2004 - 2005 Fig. 2.6.10.2 Change (%) in reaction time from baseline 2004 to Country: Norway baseline 2005 for players with (Season One Head Impact) and with- Cooperation: Oslo Sports Trauma Research Center, Norway out (Season One Control) a registered head impact during the 2004 season (N=144). Reference: Straume-Naesheim T, Andersen TE, Holme IM, McIntosh AS, Dvořák J, Bahr R (2009). Do Minor Head Impacts in Soccer Cause Concussive Injury? – A Prospective Case Control Study. Neurosurgery 64(4):719-725 76 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.7 Injuries of Referees and Assistant Referees
2.7.1 Injuries in FIFA Competitions loskeletal complaints. The referees were also asked to report on their refereeing qualifications and experience, other medical problems and time spent in training and Why we conducted these studies in matches retrospectively.
According to FIFA’s “big count”, there were more than During the competitions, the characteristics and conse- 840,000 registered referees and assistant referees in 2006 quences of all injuries and complaints incurred by the worldwide. In the last ten years, several studies had 63 male and 36 female officiating referees were pro- examined various aspects of performance and training of spectively documented. During the two FIFA World football refereeing. During a competitive match, a refer- Cups™, the referees and assistants travelled by air from ee may cover a distance of between nine and 13 km, part the headquarters to their appointed matches at the ven- of these with high intensity such as sprinting. Backwards ues. For each match, a physiotherapist documented the and sideways running are typical movements of the ref- injuries and complaints. Confirmation of the diagnosis eree during the course of a match. In fact, the elite level was made by a physician at the referees’ headquarters. referee is generally exposed to similar physical demands Every acute injury incurred during match or training as those placed on a midfielder. But, in comparison to was recorded according to the consensus statement on the players they need to control, they are not only up to injury definition described in chapter two, and also used 15 to 20 years older and rarely full time professionals, by F-MARC in our studies on football players. All mus- but also cannot be substituted during a match. A referee culoskeletal complaints that received medical attention must therefore be prepared to perform at high intensity were also recorded. throughout the match and clearly is exposed to a certain risk of injury. Results While some studies had addressed the physical demands of refereeing, very little was known on injuries and mus- Compared to their female counterparts, the male refer- culoskeletal complaints in referees. In a study on elite ees were older (41 vs. 35 years) and had a longer career, Swiss referees, F-MARC had found that almost 90% of holding their official license for on average 19 vs. 12 these had had some sort of complaint and almost a third years, and their FIFA license for an average of eight vs. suffered an acute injury in the twelve months under six years, during which time they had also been officiat- investigation. We therefore decided to further investigate ing international matches. Almost 85% of the male ref- these health issues in the international elite referees at erees, but less than two thirds of female referees received FIFA’s flagship events. training advice from expert staff.
More female than male referees had incurred an injury Aims of the studies and suffered from musculoskeletal complaints during their career (Tab. 2.7.1.1). The locations of these inju- UÊÛiÃÌ}>ÌiÊÌ iÊÕÀiÃÊ>`ÊÕÃVÕÃiiÌ>ÊV«>ÌÃÊ ries and complaints were similar for women and men. of all referees and assistant referees selected for the Complaints were mostly located in the hamstrings, 2006 FIFA World Cup™ calves, low back and knees. The most prevalent injury UÊÛiÃÌ}>ÌiÊÌ iÊÕÀiÃÊ>`ÊÕÃVÕÃiiÌ>ÊV«>ÌÃÊ diagnoses for both were muscle strains which accounted in female referees selected for the FIFA Women’s for more than half of all injuries. More specifically, ham- World Cup 2007™ string and calf strains as well as ankle sprains were suf- fered most often.
How we collected the data During the FIFA Women’s World Cup 2007, the frac- tion of female referees with an acute injury was almost During the preparation camps for the 2006 FIFA World twice as high as the fraction of their male counterparts at Cup™ in Germany and the FIFA Women’s World Cup the 2006 FIFA World Cup™. However, the incidence 2007™ in China, all 123 male and 81 female referees of injuries of 20.8 for male and 34.7 for female refer- pre-selected for the competitions completed a specially ees per 1,000 match hours was considerably lower than developed questionnaire on their injuries and muscu- compared to male and female players with injury rates FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 77
of 68.7 resp. 81 per 1,000 match hours at the respective skeletal complaint during their career. However, due to competitions. The most common acute injuries in both the known problems with limited recall, these reports of genders were hamstring strains, calf strains, and ankle complaints during a career of several years might repre- sprains. Musculoskeletal complaints were reported to sent rather an under-reporting than the true incidence. the same degree for male and female referees. There were slight differences with regard to the most frequent loca- Considering the high prevalence of musculoskeletal tions of complaints between the two genders, but both complaints, the injury profile, and the high physiological men and women often reported low back pain. demands of refereeing, F-MARC strongly recommend- ed the development of specific injury prevention pro- Male referees Female referees grammes and their integration into the fitness training routine of the male and female referee. Complaints during career (%) 62.8 76
Injuries during career (%) 40.7 48
Injury incidence match career 0.1 0.6 (per 1000 hours)
14 14 Injuries during WC (n) (total 63) (total 36)
Injuries WC (%) 22.2 38.9
Injury incidence WC match 20.8 34.7 (per 1000 hours)
Complaints during WC (%) 34.9 33.9
Tab. 2.7.1.1 Injuries and complaints of male and female referees at FIFA World Cups™
What we learned from the studies
These two studies addressed the incidence of injuries and complaints of the world’s best male and female ref- erees. The female referees suffered considerably more injuries and complaints during their career prior to and also at the FIFA Women’s World Cup™. It is possible that this difference is due to a lack of specific physical preparation of the female referees. While male FIFA ref- erees have been systematically supported by expert fit- World Cup referee performing a sprint during a training session. ness coaches since 2000, their female counterparts were only recently enrolled in similar programmes. Other Duration: 2006 - 2008 possible explanations include general gender differences Countries: International in fitness levels, neuromuscular characteristics, coping Cooperation: All referees of the competitions and perception of pain. References: Bizzini M, Junge A, Bahr R, Helsen W, Dvořák J (2009). As in football players, muscle strains and ligament Injuries and musculoskeletal complaints in referees and sprains were the most common injuries. Differently assistant referees selected for the 2006 FIFA World Cup™ - from players however, the FIFA referees reported more Retrospective and prospective survey. Br J Sports Med 43(7): injuries during training than during matches. The inci- 490-497 dence of match injuries was substantially lower than that Bizzini M, Junge A, Bahr R, Dvořák J (2009). Female soccer reported for the football players at the respective compe- referees selected for the FIFA Women’s World Cup 2007 – A tition. About two thirds of the male referees and three survey of injuries and musculoskeletal complaints. Br J Sports quarters of the female referees had some sort of musculo- Med 43(12): 946-942 78 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.7.2 Injuries of Referees at All Levels of Play cal complaints caused by either refereeing a match or by in Switzerland the training for officiating. The referees were also asked to report on their refereeing qualifications and experi- ence, other medical problems and time spent in training Why we conducted this study and in matches retrospectively.
The study of the 204 male and female referees selected At amateur level, 489 active referees representing a rep- for the recent FIFA World Cups™ (see previous chap- resentative sample of all Swiss referees officiating at the ter) alerted F-MARC to the high frequency of injuries different levels of play including youth were interviewed and musculoskeletal complaints among referees and by telephone using essentially the same questionnaire confirmed our view that this group requires the same as above, but adapted for the specific conditions of a preventive efforts as players. However, the FIFA World telephone interview. Cup™ group represented mainly professionals and in fact corresponds to only 0.02% of all registered referees in the 208 member associations of FIFA worldwide. In Results players, injury incidence varies with the level of play, therefore F-MARC also wanted to look at the next lower The male elite referees were on average 36 years old and level of referees and decided to examine injury incidence held their official license for about 16 years. They had and complaints in the elite referees of the top leagues in been officiating in the top leagues for about 7.5 years. Switzerland. The amateur referees were of similar average age (36.6 years) and had a shorter career, holding their official However, the number of elite referees on national level is license for on average of twelve years. Elite match referees again small compared to the number of referees involved trained for about 6.4 hours a week, whereas the assistant in amateur football. In Switzerland, the 71 referees offici- referees trained less than their superiors (4.7 hours) but ating in the two top divisions represent only 1.6% of the about the same time as reported by the amateur referees 4452 registered referees (season 2005/06). As in players, (4.8 hours). this large number of amateur football referees contrasts with the fact that there is hardly any research done on With regard to injury and physical complaints, some the injuries and complaints of these referees caused by important differences were observed between the two their activities in football. Therefore, F-MARC decided groups: In the elite referees, 44% had suffered from to additionally examine the amateur referees in Switzer- at least one injury during their career whereas about land, using a similar assessment as for the elite referees. only one quarter of the amateur referees had (s. Table 2.7.2.1). Elite referees suffered 62% of their injuries during training and 39% in matches as compared to far Aims of the study fewer training injuries (21%) than match injuries (79%) in referees on lower levels. In both groups, thigh muscle UÊÛiÃÌ}>ÌiÊÌ iÊÕÀiÃÊ>`ÊÕÃVÕÃiiÌ>ÊV«>ÌÃÊ (hamstring) strain and ankle sprain where the most com- of all Swiss Top Division referees and assistant referees mon diagnoses. UÊÛiÃÌ}>ÌiÊÌ iÊÕÀiÃÊ>`ÊÕÃVÕÃiiÌ>ÊV«>ÌÃÊ of a representative group of Swiss referees and assistant Another important difference between the two groups referees at all levels of play was the frequency of musculoskeletal complaints. Eighty-six percent of the elite referees reported com- plaints caused by their refereeing but only about one How we collected the data quarter of the referees at lower levels of play suffered from complaints. During a training camp organised by the Swiss Refer- ees Association, all 71 referees and assistant referees of the two top divisions were asked to complete a specially developed questionnaire and were subsequently inter- viewed to gain more information about the reported injuries. The questionnaire asked for injuries and physi- FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 79
Elite referees (n=71) Amateur referees (n=489)
Referees injured during career 31 (44%) 110 (23%)
Injuries during career 41 155
Injuries during last year 19 44
Incidence of match injuries last year per 1000 match hours 6.8 2.1
Tab. 2.7.2.1 Injuries of elite and amateur referees in Switzerland
What we learned from the study
The injury frequency in elite referees corresponded to the 2006 FIFA World Cup™ selection. Increasing inci- dence of injuries with the level of play is also observed in players (s. chapter 2). Sprains and strains, the most com- mon types of injury also corresponded with the findings in players. Strains are the most frequent non-contact injuries in players, and it has to be remembered that in referees, different from players, the vast majority of inju- ries are non-contact in nature.
The far higher proportion of training injuries in Swiss elite (62%) and FIFA World Cup™ selection referees (82%) as compared to lower levels of play (21%) may be explained by the higher number of hours spent in train- ing by the elite referees compared with the amateur ref- erees of the present study.
The prevalence of musculoskeletal complaints dur- ing their career was substantially lower in amateur than in elite referees. Apart from different methodological Elite assistant referee in action during a match. approaches, the difference might also be partly explained by the high demands of matches and training at national and international level. Duration: 2005 - 2008 This study once more confirms the need for effective pre- Country: Switzerland vention programmes for referees. These have to include Cooperation: Swiss Referees Association, Swiss referees at all amateur referees, all the more as these are not subject to levels of play any age limit. References: Bizzini M, Junge A, Bahr R, Dvořák J (2009). Injuries and musculoskeletal complaints in referees - A complete survey in the top divisions of the Swiss Football League. Clin J Sport Med 19(2): 95-100 Bizzini M, Junge A, Bahr R, Dvořák J (2011). Injuries of foot- ball referees: a representative survey of Swiss referees officiating at all levels of play. Scand J Med Sci Sports 21(1):42-47 80 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.8 Injuries in Other Sports
2.8.1 Comparison of Injuries in Football and How we collected the data in Rugby We opted to compare football and rugby (rugby union) in youth. This prospective cohort study followed a simi- Why we conducted this study lar design as our earlier work in the Czech Republic and other countries and was conducted in New Zealand. The difficulty of interpreting comparative injury informa- The F-MARC research team (Fig 2.8.1.1) focused on tion within one sport and across sports had been one of twelve football school teams and ten rugby school teams the first findings of F-MARC on injuries in football. In our of male amateurs aged 14–18 years, giving us a total of review of the medical literature, we found only a few stud- 145 football and 123 rugby players over one season. The ies in which exposure-related incidences of injury in differ- study began with an initial baseline examination for spe- ent types of sport were compared. Many studies focus on a cific player characteristics and their level of performance single sport in a specific setting. Community and nation- (Fig. 2.8.1.2). During the observation period, a physi- wide studies have difficulty in definitions, data collection cian visited the team weekly and documented all injuries and implementation while those using emergency rooms related to sports participation. or insurance databases are limited to players seeking medi- cal treatment. There are a few projects that have attempted to study multiple sports at the youth level using a variety of different methods. The studies of team sports typically look at ice hockey, handball, basketball, football and rugby and attempt to rank sports on injury incidence and risk. As sports participation is routinely advised for health, it is important for the medical community to be aware of the specific risks of injury in different sports.
In terms of total number of member associations, rugby ranks behind only football when considering the number of nations playing the sport worldwide. A rugby union (as opposed to rugby league) team consists of 15 players a-side. A match is two 40 minute halves with a five to ten minute half-time. Rugby union is a full-body contact game. While protective equipment is not compulsory, New Zealand Fig. 2.8.1.1 The F-MARC research team Rugby Union domestic safety law requires compulsory use of mouth-guards in all matches below international class. In rugby union as in football, most injuries affect the lower Results limbs, followed by the head and neck or upper limbs. The incidence of rugby injuries in adult male players varies from We have repeatedly mentioned the ratio of training to 12–53 injuries per 1,000 playing hours, for schoolboys from match hours as an influencing factor on injury inci- seven to 65.8 injuries. The incidence of injury in youth play- dence. In this study, the ratio for football and rugby was ers seems to increase with age. We now wanted to compare 1.57 and 2.96, both well below what was reported else- injuries in the two most popular ball sports. where by F-MARC where we saw ratios of five or high- er (for example, 5.9 in German female players). When comparing the incidence of football and rugby injuries, Aim of the study we found that rugby union was associated with a signifi- cantly higher rate of 49.5 injuries per 1,000 player hours UÊ «>ÀiÊÌ iÊV >À>VÌiÀÃÌVÃÊ>`ÊV`iViÊvÊÕÀiÃÊ than football where this rate was 27.9 (Tab. 2.8.1.1 and in male youth amateur football and rugby players Fig. 2.8.1.3).
The differences were pronounced for contact injuries, injuries of the head, neck, shoulder and upper extrem- ity, as well as for fractures, dislocations and strains. The FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 81
concussion injury rate was nearly five times greater in Football Rugby rugby than in football (0.32 vs. 1.45 concussions per Injury Rate/1000 1,000 hrs) and fracture/dislocation injury rates were % % per/1000 hrs five to seven times higher in rugby players. Rugby play- hrs ers suffered 1.5 times more overuse and training injuries Circumstance in relation to exposure time and 2.7 times more match injuries than football players. Whereas age had no effect Overuse/training 34 15.4 34 22.4 in rugby players between 16 and 17 year olds (50.1 vs. 50.6), the incidence of injury increased by nearly 50% Match 66 47.5 66 129.8 in football players of similar age (23.5 vs. 35.1). Three rugby players, but no football players, had to cease from further participation in sport because of severe injury. Contact
No 52 14.4 33 16.4
Yes 48 13.5 67 33.0
Location
Head/neck 5 .66 16 3.93
Hip/trunk/UE 18 1.01 42 4.1
Groin/LE 77 3.58 43 3.51 Fig. 2.8.1.2 Medical examination
What we learned from the study Severity The incidence of injury in New Zealand school teams playing football or rugby union is high when compared No absence 69 19.4 79 39.1 with other youth team sports, probably because of the low ratio of hours spent in training in relation to the 1-7 days 20 5.6 11 5.4 hours spent playing matches. More specifically, the inci- dence of match injuries was more than twice as high in 8-21 days 7 2.0 8 3.8 rugby players compared with football players. The great- er severity of rugby injuries was shown by the higher >21 days 3 1.0 2 1.2 incidence of fractures and dislocations in the rugby play- UE = upper extremity ers compared with the football players. Consequently, LE = lower extremity the development and implementation of preventive Tab. 2.8.1.1 Summary of injury incidence and injury rate for football interventions to reduce the rate and severity of injury and rugby union was recommended by F-MARC. 49.5 50
40 Duration: 2001 - 2002
30 27.9 Country: New Zealand Rugby teams Cooperation: New Zealand Soccer, New Zealand Rugby Union 20 Reference: Football teams no of injuries 10 Junge A, Cheung K, Edwards T, Dvořák J (2004). Injuries in 0 youth amateur soccer and rugby players - comparison of inci- Injuries per 1000 hours exposure dence and characteristics. Br J Sports Med 38(2): 168-172 Fig. 2.8.1.3 Incidence of injuries in football and rugby 82 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.8.2 Injuries during the Olympic Games in capturing injury information that had been productive in Athens 2004 previous work: Before the competition started, all medi- cal staff met to agree on the procedure and definitions for the different aspects of injury. After each competitive Why we conducted this study match, a standardised one-page injury report form was filled in by the physician of the participating teams or by It had always been the aim of F-MARC to establish and the official medical representative of the sport. apply standard definitions and data collection proce- dures for the investigation of injury rates, so that these The average number of injuries per match ignores the rates could be compared across different ages, levels of number of players in a match and the duration of a competition, genders, and competitions. As mentioned, match. An exposure-time related incidence of injuries numerous studies had analysed injury incidence in a per 1,000 player hours is widely used, but the playing variety of sports, but the results of these studies could time is hard to determine in some team sports due to a not be compared, because of the different injury defini- continuous clock (e.g. football), a non-continuous clock tions, methods of data collection, observation periods, (e.g. basketball) or no clock at all (e.g. baseball, softball, study designs and sample characteristics. Only a few volleyball). Therefore, we decided to express a player’s studies compared exposure-related injury incidences in individual risk of injury for the different sports as in different sports using the same methodology, but many “injuries per player matches”. of these investigations were restricted to schoolchildren, nationwide sport leagues or showed other limitations. Only one project at the Australian University Games, a Results multi-sport event featuring 5106 participants compet- ing in 19 sports, looked across sports at a high level of We obtained data on 456 out of 488 team sport matches competition in 1994. It was concluded then that ice corresponding to a response rate of 93%, meaning we hockey, handball, basketball, football, rugby and field obtained records on 93% of all matches; an excellent hockey shared a relatively high risk of injury. The great participation for the first attempt at a multi-sport event. advantages of conducting a comparative study during a We could analyse 911 forms covering 6,953 player- major international tournament are that multiple sports matches. A total of 377 injuries were reported which is with players of a comparable skill level can be included equivalent to an incidence of 0.8 injuries per match or and that the observation period is defined by the event. 54 injuries per 1,000 player matches. Furthermore, a high standard of environmental factors, such as the quality of the playing fields and equipment, The incidence, diagnosis and cause of injuries differed is guaranteed. substantially between the team sports leading to specific profiles of injury in each sport (Fig. 2.8.2.1 and Tab. 2.8.2.1). Handball, football, and basketball all had rates Aim of the study per 1,000 player hours exceeding 70 while the rates for the remaining sports were substantially lower. More than UÊÊ>ÞÃiÊ>`ÊV«>ÀiÊÌ iÊV`iVi]ÊV >À>VÌiÀÃÌVÃÊ that, football and handball had nearly twice the injury and causes of injuries in all team sport tournaments rate than the next highest sport, basketball. (football, handball, basketball, field hockey, baseball, softball, water polo, volleyball and beach volleyball) Half of all injuries affected the lower extremity and 24% during the 2004 Olympic Games of the injuries involved the head or neck. The two most prevalent diagnoses were contusion of the head and ankle sprain. The majority of injuries (78%) were caused How we collected the data by contact with another player and half of these injuries were, in the opinion of the recording physician, a result During the 2004 Olympic Games, 14 team sport tourna- of foul play. However, a significantly higher percent- ments were contested: football, handball, basketball, field age of non-contact than of contact injuries resulted in hockey, water polo, volleyball (both men’s and women’s absence from match or training. competitions) baseball (men only), and softball (women only). We used the standardised F-MARC procedure for FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 83
On average, 42% of the injuries were expected to pre- Sport Number of Number Injuries Injuries vent the player from participating in sport for some matches of injuries per match per 1000 hrs time. The incidence of time-loss injuries per 1,000 play- er matches was substantially higher in males (24.7) than Football – 32 77 2.4 73 men in females (15.9). Time-loss injuries most frequently Football – 20 45 2.3 70 affected the ankle (20%), knee (13%), thigh (12%) and women head (10%). There were 15 injuries that were of suf- Handball – 44 49 1.2 89 ficient severity to keep a player out of competition for men four or more weeks: eight fractures, one shoulder dislo- Handball – 33 65 2.0 145 cation, four knee ligament ruptures, one meniscal injury women and one ankle ligament rupture. Basketball – 42 27 0.6 96 men 120 all injuries Basketball – 42 28 0.7 100 time-loss women 100 injuries Field hockey – 42 36 1.2 47 men 80 Field hockey – 29 8 0.4 14 60 women Water polo – 44 17 0.4 40 men Water polo – 20 1 0.05 20 women Volleyball – 38 5 0.1 0 men
Incidence of injuries per 1000 player matches Volleyball – 38 2 0.05 Football Softball Handball Baseball women Basketball Volleyball Water polo Field hockey Baseball 32 16 0.5 Fig. 2.8.2.1 Number of injuries per 1000 player matches
Softball 32 1 0.03
Tab. 2.8.2.1 Number of matches and injury incidence from the What we learned from the study Olympic Games 2004
It was once more confirmed that it is difficult to com- pare injuries in different sports due to their different nature. For example, the total number of injuries in dif- ferent sports is biased by the number of games and par- ticipants in each sport. Nevertheless, following a strictly standardised method, the risk of injury in different team sports can be compared. Even if the incidence and char- acteristics of injuries are not identical in all sports, pre- vention of injury and promotion of Fair Play are relevant Medical representatives of the Team Sports Federations during 2004 topics for almost all team sports and need to be part of Olympic Games in Athens the respective strategy to protect the health of the play- ers. Duration: 2004 Countries: International Cooperation: IHF, FIBA, FIH, IBAF, ISF, FINA, FIVB, IOC Reference: Junge A, Langevoort G, Pipe A, Peytavin A, Wong F, Mountjoy M, Beltrami G, Terrell R, Holzgraefe M, Charles R, Dvořák J (2006). Injuries in team sports tournaments during the Olympic Games 2004. Am J Sports Med 34(4): 565-576 84 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.8.3 Handball Injuries during Major medical attention from the team doctor regardless of the International Competitions consequences with respect to absence from the match or training. For each match, both team doctors were supposed to return the completed single page form for Why we conducted this study all injuries or, where applicable, the non-occurrence of injury for their team to a medical representative of the Together with football, volleyball and basketball, hand- IHF. The incidence of injury was expressed as the num- ball is one of the most popular sports in Europe. Team ber of injuries per match and additionally as the number handball is a high-intensity sport with frequent physical of injuries per 1,000 player hours. contact between the players. As per 2004, the Interna- tional Handball Federation (IHF) officially numbered 150 member federations representing approximately Results 800,000 teams and more than 19 million sportsmen and women. As in football, several authors had analysed the A total of 478 injuries were reported from the six tourna- incidence of handball injuries, but the results were dif- ments, which corresponded to an incidence of 108 inju- ficult to compare because of differences in study design, ries per 1,000 player hours or 1.5 injuries per match. The injury definition, observation periods and level of play. incidence of injury varied between the different types of Most studies were on adolescent players, only two stud- tournaments; it was the lowest in the 2002 Women’s ies each looked on adult amateur players and major European Cup and the highest in the women’s tourna- international tournaments. The information on handball ment of the 2004 Olympic Games. In general, the inci- injury in top-level players however was very limited. The dence of injuries increased towards the middle of each comparative F-MARC study on injuries in eight team half and decreased towards their ends. Half of the con- sports during the Olympic Games 2004 as described in tact injuries, or 45% of all injuries, were caused by foul the previous chapter had shown that the incidence of play as judged by the team doctor and the injured player. injuries per 1,000 playing hours was highest in hand- However, only 60% of these injuries were sanctioned by ball. As knowledge of the incidence, circumstances and the referee. The most frequent diagnosis was a contusion. characteristics of handball injuries would considerably aid in developing preventive programmes, a standard- The injuries affected most frequently the lower extrem- ised approach as developed by F-MARC in football for ity (42%), followed by injuries of the head (23%), recording the data was required. upper extremity (18%) and trunk (14%). The most fre- quent diagnosis was contusion of head (14%) followed by an ankle sprain (8%). The majority of injuries were Aim of the study caused by contact with another player. Time loss injuries occurred on average 27 times per 1,000 player hours, and UÊ>ÞÃiÊÌ iÊV`iVi]ÊVÀVÕÃÌ>ViÃÊ>`ÊV >À>VÌiÀÃ- were significantly more frequent in men than in women. tics of team handball injuries in women and men dur- Less than a quarter of the injuries prevented the player ing the major international tournaments from participating in a match or training for up to one week, 5% of the injuries led to a longer absence. Regard- ing time loss injuries only, the incidence was the highest How we collected the data in the Olympic Games in men and women, and the low- est in the Europe Cup and the Women’s World Cup. Injury incidence was recorded at six major handball competitions. The injury-reporting system applied fol- Overall, the incidence of injury was similar for men and lowed the established F-MARC scheme, except for the women. Furthermore, the location and type of injuries exchange of the word ‘‘football’’ to ‘‘handball’’ in the did not vary significantly between men and women. injury report form. During a pre-competition instruc- Women incurred significantly more non-contact injuries tional meeting, the physicians of all teams participat- than men (20% vs 12%), but significantly less injuries of ing were asked to report all injuries incurred during the women than of men were expected to result in absence competition and were instructed about how to fill in the from play. injury report forms. An injury was defined as any physi- cal complaint incurred during the match that received FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 85
What we learned from the study
The F-MARC system proved feasible and achieved excel- lent cooperation of physicians in handball, too. After an initial learning phase, response rates reached almost 100%. Similar to the findings in football, the incidence of injuries in elite players was considerably higher than in adult amateur players during a season. This was prob- ably caused by several factors, such as the higher speed of the game, the tougher play and the high number of matches during a short period of time. Different from football, incidence, location and type of injuries did not significantly differ between men and women.
Importantly, the head was the most frequently injured body part. While more research is needed in handball, the incidence of head injuries should be followed care- fully in the future. In football, the Laws of the Game had been changed following F-MARC research on the risk factors for severe head injuries. Fair play proved to be an essential aspect of injury prevention in hand- ball, too, and close cooperation with the referees will be required to make handball a safer sport.
Duration: 2001 - 2004 Countries: International Cooperation: IHF, all team physicians of the Men’s World Cups 2001 and 2003, Women’s European Handball Championship 2002, Women’s World Cup 2003 and Olympic Gijs Langevoort (IHF), one of the founding members of the group of Games 2004 medical representatives of the Team Sports Federations Reference: Langevoort G, Myklebust G, Dvořák J, Junge A (2007). Handball injuries during major international tournaments. Scand J Med Sci 17: 400–407 86 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.8.4 Sports Injury during the 11th IAAF Results World Championships The physicians or responsible physiotherapists of 49 national teams covering 1,660 of the registered athletes Why we conducted this study took part in the study and returned a total of 333 injury report forms. The team doctors’ injury reports covered The protection of the athletes’ health by preventing on average 68% of the registered athletes. In addition, injuries is an important task for any international sports injury reports from the medical centres were received dai- federation. Injury surveillance reports on the incidence, ly. A total of 192 injuries were reported, with no signifi- mechanism, location and severity of injuries offer oppor- cant difference between men and women regarding loca- tunities to develop specific preventive strategies. Numer- tion, cause and severity of injury but for type of injury. ous authors have analysed injury incidence in a variety of sports, but the results of these studies could not be com- On average, almost ten per cent of the competing athletes pared, because of the different injury definitions, meth- were injured during the championship and 5.3% suffered ods of data collection, observation periods, study designs a time loss injury. Eighty per cent of the injuries affected and sample characteristics. While injury surveillance had the lower extremity; the most common single diagnosis been proven to be feasible and provided important infor- was thigh strain. A quarter of the injuries were incurred mation in several team sports tournaments, little expe- during training, the vast majority (71%) in competition, rience existed concerning injuries in competitions for five during warm-up for competition and one during individual sports. Therefore, when the IOC decided to cool-down. In most cases the injury was caused by over- conduct an injury surveillance study in all sports during use (44%) either with gradual or sudden onset. On aver- the 2008 Olympic Games in Beijing, the system estab- age, 7.2 injuries per 100 athletes were reported during lished in team sports needed to be tested for its feasibil- the competitions with 4.2 time-loss injuries per 100 ath- ity in individual sports. letes. Injuries in competitions were reported from all dis- ciplines, except hammer throw, javelin, women’s 400m, women’s high jump, women’s long jump and 1500m Aims of the study wheelchair. In relation to the number of competing ath- letes, the risk of incurring a time-loss injury during com- UÊ,iVÀ`Ê>`Ê>>ÞÃiÊ>ÊëÀÌÃÊÕÀiÃÊVÕÀÀi`ÊÊV- petition was highest in heptathlon (23% of the athletes), petitions and/or training during the 11th IAAF World followed by women’s 10,000m, women’s 3000m steeple- Championship 2007 chase, decathlon and men’s marathon. UÊ1ÃiÊÌ iÊiÝ«iÀiViÊÌÊ`iÃ}Ê>ÊÃ>ÀÊÃÌÕ`ÞÊ`ÕÀ}ÊÌ iÊ Beijing Olympic Games What we learned from the study
How we collected the data Even though based on the established F-MARC proce- dure for team sports tournaments, the injury report sys- The established injury-reporting system originally devel- tem proved feasible and practicable for individual sports oped by F-MARC for team sports competitions was during the IAAF’s World Championships 2007 and modified to be applicable for both individual and team achieved good acceptance by the national team doctors. sports. The most important principles of the system are The data suggested that the injury surveillance system comprehensive definition of injury, injury report by the covered almost all athletes for the first six days of the doctor responsible for the athlete, a single-page report of championship. However, the response rate of team doc- all injuries, and daily report irrespective of whether or tors decreased during the last three days of the champi- not an injury occurred. All national team doctors were onship, and thus, it is estimated that the true injury inci- asked to report all newly incurred injuries or the non- dence of the championship was higher than reported. occurrence thereof on the standardised one page injury report form. In addition, the medical centre in the sta- It was concluded that, following further adaptations to dium reported daily on the injured athletes treated there. the organisational and logistical specificities of the event, the system was suitable for implementation during the 2008 Olympic Games in Beijing. FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 87
The Congress of IAAF which approved the injury study at the 11th IAAF World Championship
IAAF - research group during the 11th IAAF World Championship 2007 in Osaka
Duration: 2007 Countries: International Cooperation: IAAF, IOC, all physicians of the 11th IAAF World Championship Reference: Alonso JM, Junge A, Renström P, Engebretsen L, Mountjoy M, Dvořák J (2009). Sports injury surveillance during the 2007 IAAF World Athletics Championships. Clin J Sport Med 19(1): 26-32 88 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.8.5 Injuries during the 2008 Olympic Games guished from missing data; the response check is easier; in Beijing and injury documentation is promoted as a matter of routine. In addition, the medical centres at the different Olympic venues and the polyclinic in the Olympic Vil- Why we conducted this study lage reported daily on the injured athletes treated there. Only injuries incurred during the period of the Games Comparison of injury incidence between sports is dif- were included in the analysis. ficult, not only due to lack of standardisation of meth- ods, but also due to the different nature of sports. Major events such as the Olympic Games offer several advan- Results tages in this regard. The observation period is clearly defined, athletes of a comparable skill level compete in The physicians of 92 national teams took part in the multiple sports and a high standard of environmental study and returned a total of 1,314 injury reports on factors, such as the quality of the competition grounds 9,672 athletes (88% of all athletes). Though some partic- and equipment, is guaranteed. At the same time, the ipating NOCs did not return forms on all days (response large number of individuals and teams from different rate 80%), the injury surveillance system is likely to have backgrounds and with varying medical support make it covered almost all athletes. A total of 1055 injuries were more difficult to obtain reliable information about the reported, with no significant difference between men and incidence, occurrence and characteristics of injury. Based women regarding the location, type and severity of inju- on the injury reports routinely used in football, a group ry. On average, almost every tenth athlete was injured of experts from different international sports federations, during the Games; approximately one out of twenty ath- under the leadership of F-MARC and the IOC, had letes incurred a time-loss injury. developed a concise injury surveillance system for multi- sports events for both team and individual sports, that More than half (55%) of the injuries affected the lower had been tested during the 2007 World Championships extremity, 20% the upper extremity, 15% the trunk and of the International Association of Athletics Federations 10% the head. The most common diagnoses were thigh (IAAF) in Osaka. The system had been accepted by strains and ankle sprains. About a quarter of injuries were experienced team doctors and shown to be feasible for incurred during training, three quarters in competition. single-sport and multi-sport events. One third of the injuries were caused by contact with another athlete, followed by overuse (22%) and non-con- tact injuries (20%). In relation to the number of regis- Aims of the study tered athletes, the risk of incurring an injury was highest in taekwondo, football, hockey, handball, weightlifting UÊ«iiÌÊÌ iÊÕÀÞÊÃÕÀÛi>ViÊÃÞÃÌiÊÊ>Ê"Þ- and boxing where more than 15% of the athletes got pic sports injured. UÊ,iVÀ`Ê>`Ê>>ÞÃiÊ>ÊëÀÌÃÊÕÀiÃÊVÕÀÀi`ÊÊV- petitions and/or training during the Olympic Games 2008 in Beijing What we learned from the study
A standardised injury surveillance system proved feasible How we collected the data at this multi-sports event for both team and individual sports. Acceptance and compliance by NOC physicians The team doctors of all NOCs participated in an was good. The data suggested that the survey covered instructional meeting prior to the start of the event and almost all athletes. However, as not all participating were informed about how to complete the injury report NOCs returned daily reports, it is estimated that the forms. All National Olympic Committees (NOC) Head injury incidence is slightly higher than recorded. Foot- Physicians were asked to report all injuries or the non- ball belonged to the six sports with the highest injury occurrence of injuries daily on a specially designed inju- incidence with more than 15% injured players during ry report form. It is important that a daily statement is the Games. required regardless of whether injuries have occurred or not. In this way, the absence of injury can be distin- FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 89
Match opening ceremony at the women‘s tournament in Beijing Maradona and Ronaldinho in Beijing
Opening Ceremony of the Olympic Games in Beijing 2008 Argentina and Nigeria, finalists at the Olympic Games in Beijing
Duration: 2007 - 2008 Countries: International Cooperation: IOC, FINA, IIHF, OSTRC, IAAF; all national physicians Reference: Junge A, Engebretsen L, Mountjoy M, Alonso JM, Renstroem P, Aubry M, Dvořák J (2009). Sports injuries during the Summer Olympic Games 2008. Am J Sports Med 37(11): 2165-2172 90 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.8.6 Sports Injuries and Illnesses during the in their absence, a team physiotherapist were asked to 2009 FINA World Championships report daily on all newly incurred injuries and illnesses, or the non-occurrence thereof. Reporting forms could be submitted at confidential mailboxes adjacent to Why we conducted this study swimming pools, by fax and by electronic submission. In addition, the LOC medical teams at the medical sta- F-MARC had for some years assisted other sporting tions at the venues submitted daily reports, too. Injury codes to establish their own injury surveillance systems and illness definitions followed those recently used at the based on the experiences made in football. Aquatic 2008 Olympic Games and only included newly incurred sports have followers all over the world and are enjoyed events requiring medical attention during training and by many people on a recreational basis, while at the same competition. Chronic conditions were not recorded time being among the most popular Olympic sports. unless an acute exacerbation required medical attention. Injury incidence and characteristics were first looked at as a part of investigations at multisport events such as the Olympic Games, but no studies had been under- Results taken during exclusively aquatic events. Also, nothing was known about illnesses in aquatic athletes apart from Overall response rate by the medical staff from partici- indications from anti-doping activities that a comparably pating countries was 42% with variation among the dif- large proportion of aquatic athletes use asthma medica- ferent disciplines and countries. This related to 67% of tions. It was therefore decided to take the occasion of the all athletes being included in the study (n=1745). The so far largest aquatic sports event, the 13th FINA World majority of injuries (83%) and illnesses (73%) were Championships with almost 2,600 athletes, to investi- reported by team doctors, the remainder by the LOC gate both injuries and illnesses among the participating medical teams. athletes. Importantly, the event included five disciplines (swimming, water polo, diving, synchronised swimming In total, 171 newly incurred acute injuries were report- and open water swimming) requiring an approach suit- ed during the Championships, equivalent to an injury able for both individual and team sports. rate of 65.6/1000 athletes. Female athletes had a higher risk of injury (68.4 per 1,000 athletes) than male ath- letes (52.1 per 1,000 athletes). Most injuries affected the Aim of the study upper extremity (36.8%), followed by the lower extrem- ity (27.5%), head/neck (19.3%) and trunk (16.4%). The UÊ>ÞÃiÊÌ iÊvÀiµÕiVÞÊ>`ÊV >À>VÌiÀÃÌVÃÊvÊÕÀiÃÊ most frequently injured body parts were the shoulder and illnesses during the 13th Fédération Internationale (14.6%) and head (12.3%). The most common types of de Natation (FINA) World Championships 2009 injury were sprains and skin lesions.
Half of the injuries occurred during competition, and How we collected the data half during training. The most frequent injury cause was overuse (38%) followed with great distance by non- As this was the first time such extensive recording was contact trauma and contact with another athlete. Only undertaken at a FINA event, careful preparation and 21 (13%) of all injuries resulted in absence from training information of all parties was required which needed to or competition. Overall injury risk was highest in diving include FINA medical staff, LOC medical staff and the and lowest in swimming. medical staff of participating countries. Written infor- mation was broadly distributed in due advance, sup- A total of 184 acute illnesses were reported during the plemented by information sessions at the venues just Championships, half of them concerned the respira- prior to the event. These information sessions included tory tract followed by, less often, the gastrointestinal instructions on the completion and submission of the tract. The most frequent symptom was pain. Most often reporting forms. reported causes of illness were infections and, although to a much lesser extent, environmental. Only 30 illnesses Instructional booklets and reporting forms were dis- resulted in absence from competition or training, which tributed to all reporting parties. The team doctors or, corresponded to 1% of all registered athletes. FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 91
What we learned from the study
For a first-time undertaking, a response rate covering about half of the athletes participating in the Champion- ships appeared acceptable. It has to be considered, how- ever, that this might have resulted in underestimation of overall injury and illness incidence as half of the athletes were excluded. Less than 7% of all athletes suffered inju- ries during the Championships, which is in line with the frequency observed in aquatics during the 2008 Olym- pic Games. The majority of injuries concerned the upper extremity, with the shoulder and lower back the most often injured body part. The by far most frequent injury cause was overuse, and future prevention programmes in aquatics should therefore concentrate on the prevention of overuse injuries. Contact injuries occurred only in water polo as the only contact sport in aquatics.
The most important finding however was the very low incidence of injuries that caused absence from competi- tion or training of less than 1%. Even if underestimated, this means a very low risk of serious injury in aquatic sports.
Slightly more than 7% of registered athletes suffered from acute illness which is again compliant with findings at other elite sports events. The high frequency of res- piratory tract infections in elite athletes has been report- ed previously and is thought to be related to training- induced immune suppression plus crowding at sports venues.
Duration: 2008 - 2010 Countries: International Cooperation: Fédération Internationale de Natation (FINA) Reference: Mountjoy M, Junge A, Alonso JM, Engebretsen L, Dragan I, Gerrard D, Kouidri M, Luebs E, Shapar FM, Dvořák J (2010). Sports injuries and illnesses in the 2009 FINA World Championships (Aquatics). Br J Sports Med 44(7): 522-527 92 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.8.7 Sports Injuries and Illnesses during the centres at the Vancouver and Whistler Olympic clinics 2010 Winter Olympic Games reported daily on all athletes treated for injuries and ill- nesses. F-MARC once more assisted in the collection, assertion of completion and analysis of data. Injury Why we conducted this study definition included any newly incurred musculoskeletal complaint, whether in training or competition, requir- Protection of the athletes’ health is a clearly articulated ing medical attention and regardless of an absence from objective of the International Olympic Committee. In training or competition caused. Illness definition was 2008, F-MARC had assisted the International Olympic one of any newly occurring physical complaint unrelated Committee in implementing a comprehensive injury to injury. and illness surveillance system at the XXIX Summer Olympic Games. The comprehensive injury recording through the medical staff of the participating National Results Olympic Committees and the sports medicine clinics revealed that almost 10% of all athletes incurred an inju- All 33 NOCs with more than ten registered athletes ry during the Beijing Games. The incidence of injuries were included in the analysis of the response rate. These and illnesses varied substantially between sports. Based countries represented 2,417 of the total of 2,567 athletes on the findings on illness occurrence at the Champion- (1,045 females, 1,522 males) from 82 NOCs participat- ships of International Federations, it was considered ing at the games. The reported 287 injuries and 185 ill- important to include illnesses occurring Olympic Games nesses resulted in an incidence of 111.8 injuries and 72.1 at future events. Longitudinal surveillance of injuries and illnesses per 1,000 registered athletes. illnesses was hoped to provide valuable data to identify high-risk sports and disciplines where not yet done by On average, 11% of athletes suffered an injury during the individual sporting codes. This would then form the the event. Female athletes were more often injured than foundation for introducing tailored preventive measures male athletes. In relation to the number of registered both in the individual sport and at multisport events in athletes, the risk of sustaining an injury was highest for future. bobsleigh, ice hockey, short track, alpine freestyle and snowboard cross. In these sports, 15-35% of all registered athletes were affected. Aim of the study Conversely, the injury risk was lowest for the Nordic UÊ>ÞÃiÊÌ iÊvÀiµÕiVÞÊ>`ÊV >À>VÌiÀÃÌVÃÊvÊÕÀiÃÊ skiing events (biathlon, cross country skiing, ski jump- and illnesses during the XXI Winter Olympic Games ing, Nordic combined), luge, curling, speed skating and in Vancouver in 2010 freestyle modules with less than 5% of registered athletes affected by injuries.
How we collected the data The most frequent injury cause was non-contact, fol- lowed by contact with a stationary object followed by The data collection method followed the procedure at contact with another athlete. Injury location and type the 2008 Summer Olympic Games taking into account differed with the sport. The head, cervical spine and knee the lessons learnt then as documented in the IOC Inju- were the most common injury locations. Injuries were ry Surveillance system. In addition to injuries incurred evenly distributed between training (54%) and compe- during training and competitions, acute illness occur- tition (46%). Less than a quarter (23%) of the injuries ring at any time during the event and requiring medi- resulted in an absence from training or competition. cal attention was to be reported. Based on written infor- mation provided in due advance, and oral information In skeleton, figure and speed skating, curling, snowboard given during a session prior to the event at the venue, cross and biathlon, every tenth athlete suffered from at all National Olympic Committees’ (NOC) head physi- least one illness. More female than male athletes suffered cians were asked to report daily the occurrence (or non- from an illness. In 113 illnesses (62.8%), the respiratory occurrence) of newly sustained injuries and illnesses on system was affected. The most frequent symptoms were a standardised reporting form. In addition, the medical pain and dyspnea/cough. About a third of illnesses were FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 93
expected to result in absence from training or competi- tion.
What we learned from the study
At least 11% of the athletes incurred an injury dur- ing the games, and 7% of the athletes an illness. The incidence of injuries and illnesses varied substantially between sports, and a number of high-risk sports were identified as one of the objectives of the study. As com- pared to the Summer Olympics considerably more head injuries and concussions occurred, with the latter affecting 7% of all athletes. In the future, risk factor and injury mechanism analyses in these high-risk Olympic winter sports will be essential to better direct injury pre- vention strategies.
With regard to illnesses, education of athletes on the prevention of infectious diseases and a reduction of the risk of infection in crowded sport venues will go a long way to achieve reductions in respiratory tract diseases as the major illness group found.
Duration: 2009 - 2011 Countries: International Cooperation: IAAF, IOC, all physicians of the 11th IAAF World Championship Reference: Engebretsen L, Steffen, K, Alonso JM, Aubry M, Dvořák J, Junge A, Meeuwisse M, Mountjoy M, Renström P, Wilkinson M (2010). Sports injuries and illnesses during the Winter Olympic Games 2010. Br J Sports Med 44(11): 772-780 94 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.8.8 Sports Injuries and Illnesses during data collection the response rate of all NOCs with more the 2012 Summer Olympic Games in than 30 participating athletes was recorded, and they London were frequently visited in order to encourage continuous medical reporting throughout the Games. Seventy-four of the 204 NOCs had more than 30 par- Why this study was conducted ticipating athletes; these comprised 89% of all athletes. Throughout the 17 days of the London Games, the 74 There is a risk of injury in any sport, and irrespective NOCs submitted a total of 1204 of a maximum of 1258 of whether incurred during training or in competi- forms (96%). tions; injuries may seriously harm an athlete’s health and development. According to the Olympic Charter, one of the main roles of the International Olympic Committee Results (IOC) is thus to encourage and support measures pro- tecting the health of athletes, and as previous research A total of 10,568 athletes (44% women, 56% men) par- has shown, systematic injury surveillance is the foun- ticipated in the London Olympic Games. The NOCs dation for developing effective preventive measures in and LOCOG medical staff reported 1,361 injuries sports. and 758 illnesses. At least 11% of the athletes incurred an injury during the Games while 7% of the athletes Following up the injury surveillance system developed incurred an illness. by F-MARC and routinely applied in all international The number of injuries during competition and train- football tournaments since 1998, the IOC entrusted ing was similar with 55% occurring in competition and a group of experts with the development of an injury 45% during training. The four most commonly reported surveillance system for multi-sports events. This injury injury mechanisms were overuse (n=346, 25%), non- surveillance system was successfully implemented in contact trauma (n=275, 20%), contact with another ath- the2008 Beijing and in the 2010 Vancouver Olym- lete (n=197, 14%) and contact with a stationary object pics, and it was further developed for the 2012 Summer (n=164, 12%). The injury rates in women and men were Olympic Games in London as described in this study. similar. The risk of an athlete being injured was the high- est in taekwondo, football, BMX, handball, mountain bike, athletics, weightlifting, hockey and badminton, Aims of the study and the lowest in archery, canoe slalom and sprint, track cycling, rowing, shooting and equestrian. More than a UÊ/Ê>>ÞÃiÊ>ÊÕÀiÃÊ>`ÊiÃÃiÃÊ`ÕÀ}ÊÌ iÊÓä£ÓÊ third (35%) of the injuries were expected to prevent the Summer Olympic Games in London athlete from participating in competition or training. UÊ/ÊV«>ÀiÊ`vviÀiÌÊ}i`iÀÃÊ>`ÊëÀÌà About 41% of the illnesses affected the respiratory sys- tem, and the most common cause of illness was infec- tion (46%). Women significantly suffered more illnesses How we collected the data than men (86.0 vs. 53.3 illnesses per 1,000 athletes). The rate of illness was highest in athletics, beach volleyball, All National Olympic Committees (NOCs) were football, sailing, synchronised swimming and taekwon- informed about the study four months in advance of the do. About one fifth of the illnesses incurred during the Olympic Games, and one day before the opening of the Games were expected to result in absence from training Games, the medical staff of the NOCs was invited for or competition. a meeting covering the details of the study. During that meeting, the daily injury and illness report forms as well as an instructional booklet detailing the study protocol What we learned from the study were distributed. Employing the IOC injury and illness report forms for multi-sports events, the daily occur- The incidence and characteristics of injuries and illness- rence (or non-occurrence) of injuries and illnesses was es during training and competition varied substantially reported by the medical staff of all National Olympic between sports and gender. The continuous surveillance Committees (NOC) and by the medical staff operating of injury and illness is a fundamental prerequisite for in the polyclinic and medical venues. Throughout the athlete health protection, and international sports bod- FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 95
ies should continue to implement reliable injury and illness surveillance systems. Only by monitoring the development over several years can changes in potential risk factors and mechanisms of injuries and illnesses be identified. This, in turn, will allow us to develop, intro- duce and update preventive measures, tailored for each specific sport.
Duration: 2012 Countries: International Cooperation: IOC and medical staff of participating countries Reference: Engebretsen L, Soligard T, Steffen K, Alonso JM, Aubry M, Budgett R, Dvořák J, Jegathesan M, Meeuwisse WH, Mountjoy M, Palmer-Green D, Vanhegan I, Renström PA (2013) Sports injuries and illnesses during the London Summer Olympic Games 2012. Br J Sports Med 47:407-414 96 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.8.9 Injuries in 13 International Athletics Results Championships On average 30.9% of the national teams (290 of 939) participated in the study, these included 79.6% of the Why this study was conducted registrations. The team doctors returned a total of 1,678 injury report forms, equivalent to a response rate of the Participating in athletics is associated with an injury participating countries of 86.3%. WIC 2010, WYC risk, which varies between age, gender, country, type of 2009, WJC 2010 and OGs 2008 and 2012 were not championships and discipline category. It is of interest included in the analysis, because the necessary data were to improve the knowledge of incidence and character- not available. istics of injury to determine the most relevant injuries (high frequency and/or severity) and the discipline cat- A total of 1,470 injuries were reported, equivalent egories with the highest risk of injury. to 81.1±4.2 injuries per 1,000 registrations of which 36.7±2.9 were expected to result in absence from sports Studies on injuries during championships and through- (Fig. 2.8.9.1). The incidence of time-loss injuries was sig- out training season have substantially different results. nificantly higher in competition (29.0±2.6) than in train- Therefore, the International Association of Athletics ing (5.8±1.9), and in outdoor (46.4±4.0) than in indoor Federation has systematically surveyed all athletics inju- (23.7±6.2) or youth/junior championships (13.2±4.0). ries in their competitions since 2007 in order to develop While most in-competition time-loss injuries were strategies for health protection of their athletes. reported during short distance events (32.5%), combined events had the highest incidence of in-competition time- loss injuries (106±26.5). The most frequent diagnosis Aims of the study was thigh strain (28.2%), followed by lower leg strain and ankle sprain. Injury location varied between different UÊ/Ê>>ÞÃiÊÌ iÊvÀiµÕiVÞÊ>`ÊV >À>VÌiÀÃÌVÃÊvÊÕÀiÃÊ discipline categories: in long distances the lower leg, in during 13 international athletics championships from marathon the foot and in throwing the upper extremity 2007 to 2012 regarding different types of champion- were mainly affected. ships and discipline categories UÊ/ÊV«>ÀiÊÌ iÊÕÀiÃÊÊ`vviÀiÌÊÌÞ«iÃÊvÊV >«- onships and discipline categories What are the new findings?
Overall 81.1±4.2 injuries per 1,000 registrations were How the data were collected documented during 11 international athletics champion- ships from 2007 to 2012. More injuries were incurred The IAAF and EAA used the injury-reporting system during competition than in training. On average developed for the International Olympic Commit- 58.4±3.7 (29.0 ±2.6) in-competition (time-loss) injuries tee (IOC) for all international athletics championships per 1,000 competing athletes were reported. since 2007. The team doctors and the Local Organising The incidence of all and of time-loss injuries was higher Committee reported daily all injuries on a standardised in outdoor than in indoor or in youth/junior champion- injury report form during each championship. The 35 ships. However, more data from indoor and youth/jun- disciplines were summarised into eight different catego- ior championships are necessary to draw conclusions. ries. Incidences of all (time-loss) injuries and training The incidence of all and of in-competition time-loss (time-loss) injuries were calculated as number of injuries injuries was highest in combined events and marathon, per 1,000 registrations, whereas incidences of in-compe- and lowest in throwing disciplines. The highest number tition (time-loss) injuries were calculated as number of of injuries (30% of all) was observed in short distance injuries per 1,000 competing athletes. events due to the high number of athletes competing in these disciplines.
Injuries affected most frequently the thigh in jumps, short and middle distances, race walk and combined events, the lower leg in long distances, the foot in mara- FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 97
Fig 2.8.9.1 Number of all and time-loss injuries during training and competition in different discipline categories (*For some injuries information on discipline (competition or training) or time loss is missing or injury occurred apart from discipline)
thon, and the upper extremity in throwing events. Thigh strain was by far the most frequent diagnosis in indoor, outdoor and youth/junior championships.
What we learned from the study
The incidence of injuries varied substantially between different types of athletics championships and between discipline categories. On average 4% of the athletes incurred a time-loss injury during an athletic champion- ship. The use of uniform definitions and data collection methods is of great importance to ensure comparable results and allow pooling of data sets to reach greater sample sizes. Injury surveillance during championships should focus on in-competition (time-loss) injuries. Spe- cial attention should be paid to injuries in combined events and long distances including marathon (because of the highest injury incidence) and short distances (due to the highest number of injuries). Future prevention studies should focus on (thigh) strain to better under- stand the injury mechanism and risk factors and to ana- lyse the efficacy of adapted preventive measures.
Duration: 2007 - 2012 Countries: International Reference: Feddermann N, Junge A, Edouard P, Branco P, Alonso JM (2014). Injuries in 13 International Athletics Championships. Br J Sport Med 48:513-522 98 PREVENTION OF FOOTBALL INJURY | F-MARC PROJECTS
3 Prevention of Football Injury
3.1 Review of Literature 1. Establish the extent of the football injury problem 2. Establish the aetiology and mechanism of football injury What was known on prevention of injuries 3. Introduce preventive measures 4. Test the effectiveness of the preventive measures by There are hundreds of research articles on injuries and repeating the first step their prevention in sports. The challenge for any particu- lar research group or physician is finding, reading, inter- preting and finally evaluating all these papers. A review Incidence and characteristics article summarises the numerous papers on football inju- ries in a single paper and also provides an evidence-based Several investigators had studied the incidence, causes evaluation of their content. This way, football medicine and risk factors of football injuries in male professional physicians could read a single paper and get informa- players; however, epidemiological data on injuries in tion from a large number of previously published papers female football players was still limited. From the data without having to search, find and finally assess each reviewed, it could be estimated that, on average, every paper with regard to its scientific value. elite male football player incurs approximately one per- formance-limiting injury each year. The overwhelming In our first review on the incidence of football injuries in majority of injuries were due to trauma, mostly dur- 2000, F-MARC had concluded on the inconsistency of ing matches with between one quarter and one half of the data reported. We had also identified the problems all traumatic injuries being non-contact in nature and where more research was urgently needed. In the follow- about one quarter of all injuries being re-injuries. Inju- ing years, F-MARC conducted own studies in order to ries were a little more frequent in the second half as play- close these gaps and establish further details on football ers become fatigued. injuries, always in view of our aim to eventually devel- op evidence-based prevention strategies. As a next step, Football injuries predominately affected the ankle, the it was therefore required to once more assess the in the knee and the muscles of the thigh and calf. The most meantime considerably grown body of knowledge on common injuries were sprains, strains and contusions. injury incidence, aetiology and mechanisms, but in addi- Other important factors were contact with another play- tion also the evidence on the possibilities and results of er and here particularly foul play. prevention in order to move forward in the direction of developing a F-MARC prevention programme. Ways of preventing football injuries
Aims of the review Most prevention programmes include the following gen- eral activities: UÊ>ÞÃiÊÌ iÊÌiÀ>ÌÕÀiÊÊÌ iÊV`iViÊvÊÕÀiÃÊÊ UÊ7>ÀÊÕ«Ê>`ÊVÊ`ÜÊÜÌ ÊëiV>Êi« >ÃÃÊÊ football stretching UÊ>ÞÃiÊÌ iÊÌiÀ>ÌÕÀiÊÊÌ iÊV >À>VÌiÀÃÌVÃÊ>`ÊV>ÕÃiÃÊ UÊ`iµÕ>ÌiÊÀi >LÌ>ÌÊ>`ÊÌiÊvÀÊÀiVÛiÀÞÊvÀÊ>Ê of injuries in football injury UÊ,iÛiÜÊÌ iÊVÕÀÀiÌÊÜi`}iÊÊÌ iÊ«ÃÃLÌiÃÊvÀÊ UÊ«ÀÛiiÌÊÊwÌiÃÃÊÜÌ ÊëiV>Êi« >ÃÃÊÊ«À«- preventing injuries and the effectiveness of prevention rioceptive training programmes UÊ*ÀÌiVÌÛiÊiµÕ«iÌ UÊ`Ê«>Þ}Êwi`ÊV`Ìà UÊ>ÀÊ«>Þ What did the medical literature tell us about injuries in 2004? Other programmes add further items to this general list such as pre-competition screening, nutrition and hydra- F-MARC reviewed and reported on 62 papers that dis- tion, improved technique and better injury recording. cussed injury incidence and injury prevention. Our liter- ature review was structured in accordance with the typi- cal methods used to prevent injuries: F-MARC PROJECTS | PREVENTION OF FOOTBALL INJURY 99
Reference Intervention Control Players Intervention Result group group
Ekstrand 6 teams 6 teams male 17-37 yrs multi-modal intervention program Fewer injuries in the intervention than in the et al. 1983 control group
Heidt et al.2000 42 players 258 players female 14-18 yrs Frappier Acceleration Training Program Significantly lower incidence of injury in the trained than in the untrained group
Junge et al.2002 101 players 93 players male 14-19 yrs multi-modal intervention program Fewer injuries in the intervention than in the control group
Tropp 60 players, 65 players 171 players male senior Use of orthosis or Ankle disk training Both techniques reduce the frequency of et al. 1984 with previous ankle ankle sprains in players with previous ankle problems problems
Surve 117 players 260 players male senior Instruction to wear a semi-rigid A semi-rigid orthosis significantly reduced the et al. 1996 without and orthosis on the previously sprained ankle incidence of recurrent ankle sprains in players 127 players with or on the dominant ankle with previous history of ankle sprains previous ankle sprains
Söderman 62 78 players female mean Balance board No preventive effect on severe knee injuries et al. 2000 players 21 yrs training or ankle sprains
Caraffa 20 teams 20 teams Proprioceptive training Significant reduction of ACL injuries et al. 1996
Hewett 97 players 193 players female high Preseason neuro-muscular training A trend towards a higher incidence in the et al. 1999 school program untrained than in trained group
Askling 15 players 15 players male mean 25 Training with eccentric overload Fewer injuries in the training than in the et al. 2003 control group
Mandelbaum et 1885 players 3818 teams female PEP programme Significant reduction of ACL injuries al. 2005 14-18
Tab. 3.1.1 Studies on the prevention of injury in football players
they may require surgery and extended rehabilitation. Studies on prevention of football injuries Programmes that prevent injury to the anterior cruciate ligament were a subject of some scrutiny. It does appear Nine studies on the multi-modal intervention pro- that training of neuromuscular and proprioceptive per- grammes in the prevention of football injuries were formance as well as improvement of jumping and land- found in the literature (Tab. 3.1.1). These programmes ing technique seems to decrease the incidence of anterior included a wide variety of exercises and were consist- cruciate ligament injuries in female athletes. ent in showing fewer injuries in the intervention group when compared with a control group. A common con- cern with general programmes is that they usually have What we learned from the review many activities and it is unknown which combination(s) of activities are actually behind the reduction in injury. Multi-modal intervention programmes may result in a reduction in injuries in general. However, more well- Ankle sprains are the most common joint injury in foot- designed studies were required to evaluate the effects of ball, and therefore the ankle should clearly be a focus specific preventive interventions. Proprioceptive and/or of football injury prevention. Ankle sprains can be pre- coordination training seemed to prevent severe knee inju- vented by external ankle supports and proprioceptive/ ries and recurrent ankle sprains. Prevention programmes coordination training, particularly in players with previ- probably have different effects in male and female play- ous ankle sprains. Proprioception is the sense of the rela- ers, and are more effective in groups with an increased tive position of neighbouring parts of the body. Football risk of injury. Future studies should monitor compliance players often consider an ankle sprain as a nuisance and of players with the programme because this was found to fail to appreciate what is required for the ankle to heal be an essential factor for its effectiveness. by returning to play before the ligaments have healed, or playing without some form of ankle support. Duration: 1998 - 2003 Reference: Dvořák The knee is the next most common site of ligament Junge A, J (2004). Soccer injuries: a review on incidence injuries, but these can lead to greater time loss because and prevention. Sports Medicine 34 (13): 929-938 100 PREVENTION OF FOOTBALL INJURY | F-MARC PROJECTS
3.2 Development of Prevention Programmes
3.2.1 “The 11” – A Prevention Programme for ing movements to toughen tissues and train nerve cells Amateur Players to stimulate a specific pattern of muscle contraction so the muscle generates as strong a contraction as possible in the shortest amount of time. Sport-specific plyomet- The need for prevention rics, agility and speed are the key for responding to the football demands on the field. According to our review of the literature, several preven- tive programmes had been developed and proven effec- Three exercises aim at core stabilisation: “the bench”, tive in reducing the incidence of football injuries. How- “sideways bench” and “cross-country skiing”. The so- ever, none of these programmes had been implemented called “Russian” or “Nordic” hamstrings were included in the everyday training routine of football life. To effec- to increase eccentric hamstring strength. Three exercises tively reduce injuries on a large scale, any prevention in an “active” single leg stance with weight on the fore- programme clearly had to address the amateur player. foot were chosen to train proprioception and balance. Under the leadership of F-MARC, a group of interna- The centre of attention is the bent knee, bent hip and tional experts set out to filter the essence of injury pre- straight leg alignment (“knees over toes”). Dynamic vention out of the large body of knowledge. Our chal- stabilisation and jump technique are trained with three lenge was to create a simple, catchy and time-efficient exercises: “jumps over a line” (forward-backward, side- preventive programme. ways), “zigzag shuffle” and “bounding”. These exercises include plyometric training of the leg muscles, straight leg alignment (no “kissing knees”) and landing on the The essentials of “The 11” forefoot with bent knees and hips.
Uʺ/ iÊ££»ÊV«ÀÃiÃÊÌiÊiÛ`iViL>Ãi`ÊÀÊLiÃÌ«À>VÌViÊ exercises being enhanced by education and promotion ... plus fair play of Fair Play. UÊ/ iÊ«À}À>iÊÃÊ`iÃ}i`ÊÌÊÀi`ÕViÊÌ iÊÃÌÊV- However, football injury can only partly be prevented by mon football injuries identified by F-MARC, such as improved physical condition. Knowing that a substantial ankle sprains, hamstring and groin strains and liga- amount of injuries are caused by foul play, the regard for ment injuries in the knee. fair play is an essential aspect in the prevention of injury. Uʺ/ iÊ££»ÊÀiµÕÀiÃÊÊiµÕ«iÌÊÌ iÀÊÌ >Ê>ÊL>]ÊV>Ê be completed in ten to 15 minutes and should be per- formed as a matter of routine. Distribution and implementation of “The 11” UÊ/ iÊ«À}À>iÊV>ÊLiÊ«iÀvÀi`ÊÊÌ iÊwi`ÊÜÌ Ê the players wearing their usual equipment and football The F-MARC experts offered FIFA the best available boots. knowledge and state of the art of medical science trans- UÊ/ iÊiÝiÀVÃiÃÊV>ÊLiÊV>ÀÀi`ÊÕÌÊ>ÞÜ iÀiÊ>ÌÊ>ÞÊÌi]Ê lated into a simple programme. It was now up to FIFA, ideally daily and not only during training sessions or the confederations and the member associations to dis- matchdays. seminate the messages to their players and implement the preventive programme on a broad scale.
The ten exercises... “The 11” comes as a DVD with instructions included as a booklet to reinforce learning. “The 11” is available The exercises focus on core stabilisation, eccentric train- in five languages (English, French, German, Italian and ing of hamstrings, proprioceptive training and dynamic Spanish). A poster of “The 11” and a list of frequently stabilisation with plyometrics and straight leg align- asked questions are also available to support the DVD ment. Core stability and strength is essential to control (Fig. 3.2.1.1). trunk, pelvis and the lower extremity, while an optimal neuromuscular control of the lower extremities is crucial for joint stability. Plyometric training involves practic- F-MARC PROJECTS | PREVENTION OF FOOTBALL INJURY 101
Fig. 3.2.1.1 “The 11” poster
The insurance connection Compensation Corporation of New Zealand, in coop- eration with New Zealand Football, to educate coaches A possible way to reinforce, stimulate and speed the on “The 11”. implementation of this preventive programme amongst the member associations is to search for appropriate partners who have the utmost interest to reduce inju- Duration: 2003 - 2004 ries in football, e.g. insurance companies. It was a lucky Countries: International coincidence or maybe a logical development, that fol- Cooperation: International experts in football injuries and lowing publication of the F-MARC preventive study and prevention the presentation of “The 11”, the Swiss National Acci- Reference: dent Insurance Fund (SUVA) approached F-MARC to F-MARC (2005). “The 11” - The prevention programme. collaborate in a nationwide launch of “The 11” together Manual and DVD. Official publication of the Fédération with SUVA and the Swiss National Football Association Internationale de Football Association (FIFA), Zurich, (SFV). This was followed by a request from the Accident Switzerland 102 PREVENTION OF FOOTBALL INJURY | F-MARC PROJECTS
3.2.2 “FIFA 11+” A Complete Warm-Up The prevention exercises Programme The second part of the warm-up programme lasts about ten minutes and consists of strength exercises, plyo- The need for an advanced version metrics and exercises for neuromuscular training (bal- ance and coordination). For each of these six exercises, Based on their practical experience with different injury there are three progression levels that will increase the prevention programmes for amateur players, an interna- degree of difficulty and also provide variation to the pro- tional group of experts developed an advanced version gramme. After three to four weeks of training on one they called “FIFA 11+”. The advanced programme aims progression level, the team can move on to a more dif- to prevent football injuries, with a focus on prevent- ficult level, based on the judgement of the coach. If an ing the two most common injury types in female youth individual player is struggling with a progression level, football, i.e. ligament injuries to the ankle and to the and is not able to do the exercise as prescribed, she or he knee. Therefore, the advanced programme combines key should stay on the previous level until she or he is able exercises from “The 11” and the “PEP” programme (see to step up to the next level. The progression for the exer- 5.3). As another aim was to provide a complete warm- cises is prescribed as modifications in the execution of up programme to ease the inclusion in existing training the exercises, and/or as increased duration and number schemes, running exercises were included, too. Hence, of repetitions. this advanced programme can and indeed should replace the usual warm-up prior to training. Distribution and implementation of “FIFA 11+”
Essentials of the “FIFA 11+” F-MARC experts used their latest experience and best knowledge to further improve the F-MARC prevention UÊ/ iÊ«À}À>iÊ}°ÊΰӰӰ£®ÊÃÌ>ÀÌÃÊÜÌ Ê>Êi} Ì programme “The 11” into a complete warm-up pro- minute running session, with forward, backward gramme. Again, it is now up to FIFA, the confederations and sideways jogging. The intensity of the running and the FIFA member associations to disseminate the programme gradually increases, and can be very high. messages to their players and implement the preventive This part of the programme will be performed in all programme on a broad scale. training sessions and matches. UÊ/ iÊÃiV`Ê«>ÀÌÊvÊÌ iÊ«À}À>iÊV«ÀÃiÃÊvÊViÀ- “FIFA 11+” comes as a poster and a DVD with instruc- tain exercises as described below. tions, included as a booklet to reinforce learning. “FIFA UÊ/ iÊÌ À`Ê>`Ê>ÃÌÊ«>ÀÌÊvÊÌ iÊ«À}À>iÊVÃÃÌÃÊvÊ 11+” is available in four languages (English, French, a two-minute intensive running session with more German and Spanish). running, sprinting and cutting, to provide the players with a final warm-up and preparation for the training session. The second and third parts of the programme are only to be performed prior to the training sessions, not matches. UÊ ÕÀ}Ê>ÊiÝiÀVÃiÃ]ÊÌ iÊvVÕÃÊÃÊÊiiÊVÌÀÊ>`Ê awareness, landing techniques and cutting and plant- ing, all factors known to be important in preventing Duration: 2006 - 2008 ankle and knee injuries. Countries: Norway, USA UÊvÌiÀÊ>Êà ÀÌÊ«iÀ`ÊvÊv>>ÀÃ>ÌÊÌ iʺʣ£³»Ê Cooperation: Oslo Sports Trauma Research Center, Norway; can be completed in 20 minutes, and will replace the Santa Monica Orthopaedic and Sports Medicine Group, ordinary warm-up programmes teams typically use. Research and Education Foundation, California, USA Reference: Bizzini M, Junge A, Dvořák J (2011). FIFA 11+. A complete warm-up programme to prevent injuries. Manual and DVD. Official publication of the Fédération Internationale de Football Association (FIFA), Zurich, Switzerland F-MARC PROJECTS | PREVENTION OF FOOTBALL INJURY 103
FIFA 11+
PART 1 RUNNING EXERCISES · 8 MINUTES
RUNNING RUNNING RUNNING 1 2 3 STRAIGHT AHEAD HIP OUT HIP IN
The course is made up of 6 to 10 pairs of parallel cones, approx. 5-6 metres apart. Walk or jog easily, stopping at each pair of cones to lift your knee and rotate your Walk or jog easily, stopping at each pair of cones to lift your knee and rotate your Two players start at the same time from the fi rst pair of cones. Jog together all hip outwards. Alternate between left and right legs at successive cones. 2 sets. hip inwards. Alternate between left and right legs at successive cones. 2 sets. the way to the last pair of cones. On the way back, you can increase your speed progressively as you warm up. 2 sets
RUNNING RUNNING RUNNING 4 5 6 CIRCLING PARTNER SHOULDER CONTACT QUICK FORWARDS & BACKWARDS
Run forwards as a pair to the fi rst set of cones. Shuffl e sideways by 90 degrees to Run forwards in pairs to the fi rst pair of cones. Shuffl e sideways by 90 degrees to As a pair, run quickly to the second set of cones then run backwards quickly to meet in the middle. Shuffl e an entire circle around one other and then return meet in the middle then jump sideways towards each other to make shoulder- the fi rst pair of cones keeping your hips and knees slightly bent. Keep repea- back to the cones. Repeat for each pair of cones. Remember to stay on your toes to-shoulder contact. ting the drill, running two cones forwards and one cone backwards. Remember to and keep your centre of gravity low by bending your hips and knees. 2 sets. Note: Make sure you land on both feet with your hips and knees bent. Do not let take small, quick steps. 2 sets. your knees buckle inwards. Make it a full jump and synchronize your timing with your team-mate as you jump and land. 2 sets
PART 2 STRENGTH · PLYOMETRICS · BALANCE · 10 MINUTES
LEVEL 1 LEVEL 2 LEVEL 3 THE BENCH THE BENCH THE BENCH 7 7 7 STATIC ALTERNATE LEGS ONE LEG LIFT AND HOLD
Starting position: Lie on your front, supporting yourself on your forearms and Starting position: Lie on your front, supporting yourself on your forearms and Starting position: Lie on your front, supporting yourself on your forearms and feet. Your elbows should be directly under your shoulders. feet. Your elbows should be directly under your shoulders. feet. Your elbows should be directly under your shoulders. Exercise: Lift your body up, supported on your forearms, pull your stomach in, and Exercise: Lift your body up, supported on your forearms, and pull your stomach Exercise: Lift your body up, supported on your forearms, and pull your stomach hold the position for 20-30 sec. Your body should be in a straight line. Try not to in. Lift each leg in turn, holding for a count of 2 sec. Continue for 40-60 sec. Your in. Lift one leg about 10-15 centimetres off the ground, and hold the position for sway or arch your back. 3 sets. body should be in a straight line. Try not to sway or arch your back. 3 sets. 20-30 sec. Your body should be straight. Do not let your opposite hip dip down and do not sway or arch your lower back. Take a short break, change legs and repeat. 3 sets.
SIDEWAYS BENCH SIDEWAYS BENCH SIDEWAYS BENCH 8 8 8 STATIC RAISE & LOWER HIP WITH LEG LIFT
Starting position: Lie on your side with the knee of your lowermost leg bent to 90 Starting position: Lie on your side with both legs straight. Lean on your forearm Starting position: Lie on your side with both legs straight. Lean on your forearm degrees. Support your upper body by resting on your forearm and knee. The elbow and the side of your foot so that your body is in a straight line from shoulder to and the side of your foot so that your body is in a straight line from shoulder to of your supporting arm should be directly under your shoulder. foot. The elbow of your supporting arm should be directly beneath your shoulder. foot. The elbow of your supporting arm should be directly beneath your shoulder. Exercise: Lift your uppermost leg and hips until your shoulder, hip and knee are in a Exercise: Lower your hip to the ground and raise it back up again. Repeat for 20-30 Exercise: Lift your uppermost leg up and slowly lower it down again. Repeat for 20- straight line. Hold the position for 20-30 sec. Take a short break, change sides and sec. Take a short break, change sides and repeat. 3 sets on each side. 30 sec. Take a short break, change sides and repeat. 3 sets on each side. repeat. 3 sets on each side.
HAMSTRINGS HAMSTRINGS HAMSTRINGS 9 9 9 BEGINNER INTERMEDIATE ADVANCED
Starting position: Kneel on a soft surface. Ask your partner to hold your ankles Starting position: Kneel on a soft surface. Ask your partner to hold your ankles Starting position: Kneel on a soft surface. Ask your partner to hold your ankles down fi rmly. down fi rmly. down fi rmly. Exercise: Your body should be completely straight from the shoulder to the knee Exercise: Your body should be completely straight from the shoulder to the knee Exercise: Your body should be completely straight from the shoulder to the knee throughout the exercise. Lean forward as far as you can, controlling the movement throughout the exercise. Lean forward as far as you can, controlling the movement throughout the exercise. Lean forward as far as you can, controlling the movement with your hamstrings and your gluteal muscles. When you can no longer hold the with your hamstrings and your gluteal muscles. When you can no longer hold the with your hamstrings and your gluteal muscles. When you can no longer hold the position, gently take your weight on your hands, falling into a push-up position. position, gently take your weight on your hands, falling into a push-up position. position, gently take your weight on your hands, falling into a push-up position. Complete a minimum of 3-5 repetitions and/or 60 sec. 1 set. Complete a minimum of 7-10 repetitions and/or 60 sec. 1 set. Complete a minimum of 12-15 repetitions and/or 60 sec. 1 set.
SINGLE-LEG STANCE SINGLE-LEG STANCE SINGLE-LEG STANCE 10 10 10 HOLD THE BALL THROWING BALL WITH PARTNER TEST YOUR PARTNER
Starting position: Stand on one leg. Starting position: Stand 2-3 m apart from your partner, with each of you standing Starting position: Stand on one leg opposite your partner and at arm’s’ length Exercise: Balance on one leg whilst holding the ball with both hands. Keep your on one leg. apart. body weight on the ball of your foot. Remember: try not to let your knees buckle Exercise: Keeping your balance, and with your stomach held in, throw the ball Exercise: Whilst you both try to keep your balance, each of you in turn tries to push inwards. Hold for 30 sec. Change legs and repeat. The exercise can be made more to one another. Keep your weight on the ball of your foot. Remember: keep your the other off balance in different directions. Try to keep your weight on the ball diffi cult by passing the ball around your waist and/or under your other knee. knee just slightly fl exed and try not to let it buckle inwards. Keep going for 30 sec. of your foot and prevent your knee from buckling inwards. Continue for 30 sec. 2 sets. Change legs and repeat. 2 sets. Change legs. 2 sets.
SQUATS SQUATS SQUATS 11 11 11 WITH TOE RAISE WALKING LUNGES ONE-LEG SQUATS
Starting position:Stand with your feet hip-width apart. Place your hands on your Starting position: Stand with your feet hip-width apart. Place your hands on your Starting position: Stand on one leg, loosely holding onto your partner. hips if you like. hips if you like. Exercise: Slowly bend your knee as far as you can manage. Concentrate on pre- Exercise: Imagine that you are about to sit down on a chair. Perform squats by Exercise: Lunge forward slowly at an even pace. As you lunge, bend your leading venting the knee from buckling inwards. Bend your knee slowly then straighten it bending your hips and knees to 90 degrees. Do not let your knees buckle inwards. leg until your hip and knee are fl exed to 90 degrees. Do not let your knee buckle slightly more quickly, keeping your hips and upper body in line. Repeat the exercise Descend slowly then straighten up more quickly. When your legs are completely inwards. Try to keep your upper body and hips steady. Lunge your way across the 10 times on each leg. 2 sets. straight, stand up on your toes then slowly lower down again. Repeat the exer- pitch (approx. 10 times on each leg) and then jog back. 2 sets. cise for 30 sec. 2 sets.
JUMPING JUMPING JUMPING 12 12 12 VERTICAL JUMPS LATERAL JUMPS BOX JUMPS
Starting position: Stand with your feet hip-width apart. Place your hands on your hips if you Starting position: Stand on one leg with your upper body bent slightly forwards Starting position: Stand with your feet hip-width apart. Imagine that there is a like. from the waist, with knees and hips slightly bent. cross marked on the ground and you are standing in the middle of it. Exercise: Imagine that you are about to sit down on a chair. Bend your legs slowly until your Exercise: Jump approx. 1 m sideways from the supporting leg on to the free leg. Exercise: Alternate between jumping forwards and backwards, from side to side, knees are fl exed to approx 90 degrees, and hold for 2 sec. Do not let your knees buckle Land gently on the ball of your foot. Bend your hips and knees slightly as you land and diagonally across the cross. Jump as quickly and explosively as possible. Your inwards. From the squat position, jump up as high as you can. Land softly on the balls of your and do not let your knee buckle inward. Maintain your balance with each jump. knees and hips should be slightly bent. Land softly on the balls of your feet. Do not feet with your hips and knees slightly bent. Repeat the exercise for 30 sec. 2 sets. Repeat the exercise for 30 sec. 2 sets. let your knees buckle inwards. Repeat the exercise for 30 sec. 2 sets.
PART 3 RUNNING EXERCISES · 2 MINUTES
RUNNING RUNNING RUNNING 13 14 15 ACROSS THE PITCH BOUNDING PLANT & CUT
Run across the pitch, from one side to the other, at 75-80% maximum pace. 2 sets. Run with high bounding steps with a high knee lift, landing gently on the ball of Jog 4-5 steps, then plant on the outside leg and cut to change direction. Accelerate your foot. Use an exaggerated arm swing for each step (opposite arm and leg). Try and sprint 5-7 steps at high speed (80-90% maximum pace) before you decelerate not to let your leading leg cross the midline of your body or let your knees buckle and do a new plant & cut. Do not let your knee buckle inwards. Repeat the exercise inwards. Repeat the exercise until you reach the other side of the pitch, then jog until you reach the other side, then jog back. 2 sets. back to recover. 2 sets.
Fig. 3.2.2.1 “FIFA 11+” - a complete warm up programme to prevent injuries 104 PREVENTION OF FOOTBALL INJURY | F-MARC PROJECTS
3.2.3 “FIFA 11+ for Referees” PART 1: RUNNING EXERCISES
1 STRAIGHT AHEAD Why we conducted this study 2 CIRCLING PARTNER 3 ZIGZAG SHUFFLING The physiological match demands of refereeing have 4 FORWARDS & BACKWARDS SPRINTS increased over the years due to the development of mod- 5 for MA: SLALOM FORWARDS & BACKWARDS ern football. During a high level match, a referee may for AR: ALTERNATE SHUFFLING cover a mean distance of 11.5km (a mix of walking, run- 6 for MA: FORWARDS & BACKWARDS WITH ROTATIONS ning, sprinting), which is comparable to the distance for AR: CARIOCAS covered by a midfielder. Elite referees may perform up PART 2: STRENGTH, PLYOMETRICS AND BALANCE to 1,270 activity changes (direction changes, as an exam- EXERCISES ple), and take more than 130 decisions during a match. Considering the high demands put on the cardiovascular LEVEL 1 and musculoskeletal system, officiating entails a certain 1 BENCH – ALTERNATE LEGS risk of acute and overuse injuries. 2 SIDEWAYS BENCH – RAISE AND LOWER HIP 3 BRIDGE – ALTERNATE F-MARC studies (See chapter 2.7) showed that the risk 4 HAMSTRINGS – BASIC of non-contact injuries for elite male and female refer- 5 CALF – BASIC ees is similar or lower than that of a football player. The 6 SQUAT JUMPS career prevalence of musculoskeletal complaints (“over- 7 for MA: SINGLE-LEG STANCE - MOVE THE OTHER LEG use”) can be estimated to be at least 90%. The most for MA: FRONT LUNGE common injuries were hamstring strains, calf strains and 8 for AR: LATERAL LUNGE 45° ankle sprains. Musculoskeletal complaints in the low for AR: LATERAL JUMP back, hamstring, knee, calf and Achilles tendon were fre- quent. The injury type and location of musculoskeletal LEVEL 2 complaints were similar among referees at all levels of 1 BENCH – ONE LEG LIFT AND HOLD performance and between genders. 2 SIDEWAYS BENCH – WITH LEG LIFT 3 BRIDGE – ON ONE LEG 4 HAMSTRINGS – ADVANCED Aims of the project 5 CALF – ADVANCED UÊ/ iÊL>ÃVÊ«ÀiÛiÌÊ«À}À>iÊvÀÊ>iÊ>`Êvi>iÊ 6 BOUNDING referees and assistant referees aims to reduce acute 7 for MA: SINGLE-LEG HOPS non-contact injuries and minimise musculoskeletal for AR: LATERAL LUNGE 90° complaints throughout referees’ careers 8 for MA: SCISSORS JUMPS for AR: DOUBLE LATERAL JUMP
PART 3: RUNNING EXERCISES Development and structure of the programme 1 PROGRESSION RUN The “FIFA 11+ for referees” injury prevention pro- 2 LONG SPRINT gramme was developed by an international group of 3 for MA: SHORT DIAGONAL SPRINT experts based on the specific injury profile of referees for AR: SHUFFLING AND SHORT SPRINT and on the “FIFA 11+”. It is a complete warm-up pro- 4 for MA: LONG DIAGONAL SPRINT gramme and should replace the usual warm-up prior to for AR: SHUFFLING AND LONG SPRINT training. The programme has three parts with a total of 18 exercises, which should be performed in the given sequence at the start of each training session. The pro- gramme takes around 20 minutes to complete. Prior to matches, only the running exercises (parts 1 and 3) should be performed. F-MARC PROJECTS | PREVENTION OF FOOTBALL INJURY 105
World cup referees performing “FIFA 11+ for referees” running drills before the technical training session. A key point in the programme is to use the proper tech- nique during all of the exercises: correct posture and good body control, including straight leg alignment, knee-over-toe position and soft landings. For all exer- cises, optimal performance is of great importance (Fig. 3.2.3.1). Therefore, the coach should supervise the pro- gramme and correct the referees if necessary.
Dissemination of the programme
The “FIFA 11+ for referees” programme is available as Fig. 3.2.3.1 Two examples of exercises of the “FIFA 11+ for referees” manual and DVD in four languages, and will be dissem- injury prevention programme. From left to right (above): sideways bench with leg lift, the bench – inated worldwide within the courses of the FIFA Refer- alternate legs eeing Department (Fig. 3.2.3.2). From left to right (below): eccentric hamstring (partner exercise), and the bridge-alternate legs
Duration: 2010 - 2013 Countries: International Cooperation: Refereeing Department of the Italian Football Fig. 3.2.3.2 Elite Italian referees -Serie A- (here with staff and FIFa Federation; FIFA Refereeing Department representatives) are the official ambassadors of the “FIFa 11+ for ref- Reference: erees” injury prevention programme. Bizzini M, Castagna C, Perez-Leguizamon A, Dvořák J (2013). FIFA 11+ for referees. Manual and DVD. Official publication of the Fédération Internationale de Football Association (FIFA), Zurich, Switzerland 106 PREVENTION OF FOOTBALL INJURY | F-MARC PROJECTS
3.2.4 “FIFA 11+ Kids” orientation, anticipation, and attention particularly while dual-tasking as it is a common challenge in football, (2) whole body and unilateral leg stability as well as move- Why we are conducting this study? ment coordination and (3) appropriate fall techniques. Similar to the “FIFA 11+”, a modular approach is used Football is the world’s most popular sport and 58% of with exercises from the three main categories and five officially registered players are younger than 18 years. difficulty levels to be composed for a single training ses- Playing football can induce considerable beneficial sion (warm-up). The development of the programme is health effects, and thus has a great potential to support a a close cooperation between different international insti- healthy lifestyle. However, football also bears the risk of tutions and experts (Dr O. Faude, R. Rößler, University injury. It is therefore necessary to implement preventive of Basel, Switzerland; Dr M. Bizzini, F-MARC, Zurich, measures that reduce the risk of injury and consequently Switzerland; Prof. E. Verhagen, Amsterdam, Nether- support the health benefits associated with playing foot- lands; Prof. T. Hewett, Cincinnati, U.S.A.; Prof. J. Cho- ball. Comprehensive epidemiological data on football miak, Prag, Czech Republic; N. Mathieu, Sion, Switzer- injuries are currently obtained in order to develop prom- land). ising prevention programmes. In a second step, the developed programme will be Several studies evaluated injury prevention programmes evaluated with regard to (a) the feasibility and accept- Ê>`iÃViÌÊ>`Ê>`ÕÌÊ«>ÞiÀÃÊÊ£ÎÊÞi>ÀÃÊ`®°ÊÊÃÌÊ ance among young children and coaches as well as (b) to studies, there was good evidence that injury prevention possible beneficial adaptations in movement skills and programmes were effective. When an injury prevention physical fitness. For this purpose a two-armed cluster- programme failed to show beneficial effects, poor com- randomised controlled trial will be conducted. pliance was considered to be the main reason. Younger This pilot study will include 120 children between seven players seem to have partly different injury characteris- and 12 years who play organised football in Switzerland. tics and, thus, adapted needs in injury prevention. To Twelve teams consisting of approximately ten children date, no study has investigated the prevention of football each will be randomly assigned to either the interven- injuries in children under the age of 13 years. The pre- tion or the control group, respectively. Regular training vention programme “FIFA 11+” was designed for play- should take place at least twice per week. Training and iÀÃÊÊ£ÎÊÞi>ÀÃÊ`®Ê>`Ê >ÃÊà ÜÊÃÕLÃÌ>Ì>Ê«ÃÌÛiÊ match exposure and training contents will be recorded by effects in reducing football injuries. The development of the coaches. an equivalent programme for players younger than 13 years seems necessary. The intervention period will last 12 weeks (24 training session). The injury prevention programme is included at the beginning of the usual football training by replacing Aims of the study the traditional warm-up. The control group will receive the instruction to regularly perform a common warm-up UÊ/Ê`iÛi«Ê>Ê>`>«Ìi`ÊÕÀÞÊ«ÀiÛiÌÊ«À}À>iÊ programme consisting of running and ball-based exercis- for football players under the age of 13 es (sham treatment). UÊ/Ê>>ÞÃiÊ>`>«Ì>ÌÃÊÊÛiiÌÊÃÃÊ>`Ê« ÞÃ- cal fitness as a consequence of the programme Before and after the training period various tests will be UÊ/ÊV`ÕVÌÊ>ÊÕÌViÌÀiÊÌiÀÛiÌÊÃÌÕ`ÞÊÊÌ iÊ conducted. Tests will be performed to assess locomotor “FIFA11+ Kids” programme skills (e.g. balancing, running, jumping) and object con- trol skills (e.g. controlling the ball, dribbling, passing).
How we conduct the survey In the third step, after developing the “FIFA 11+ Kids” programme, F-MARC is currently conducting a large In a first step, there is the need to adapt the existing pro- multi-centre intervention study in four European coun- gramme (“FIFA 11+”) with regard to the particular char- tries: Switzerland, Germany, Czech Republic, and the acteristics of football injuries in younger children (< 13 Netherlands. years). The available programme was complemented with three main categories of exercises focusing on (1) spatial F-MARC PROJECTS | PREVENTION OF FOOTBALL INJURY 107
Balance exercise (throwing the ball)
Core stabilisation exercise
Zig-zag jumping exercise
Duration: 2013 - ongoing Countries: Switzerland, Germany, Czech Republic, Netherlands Cooperation: Dr. Oliver Faude, Roland Rößler, University of Basel, Switzerland References: F-MARC (in preparation). FIFA 11+ Kids. Manual and DVD. Official publication of the Fédération Internationale de Football Association (FIFA), Zurich, Switzerland 108 PREVENTION OF FOOTBALL INJURY | F-MARC PROJECTS
3.2.5 Enforcement of the Laws of the Game medical treatment. Each incident was classified accord- ing to the cause (opponent-player contact, teammate- player contact, ball-player contact or non-contact) and Why we conducted this study body location involved. We also categorised the referee’s decision (no foul, foul for, foul against) and the referee’s The risk of injury during football matches is 1,000 times sanction (no sanction, yellow card or red card). higher than high-risk industrial occupations. A recent The methodology of the UEFA injury system has been study from Oslo Sports Trauma Research Center docu- implemented in Norwegian professional football, using mented an increased incidence of acute match injuries in the time-loss definition of injury. Norwegian professional football from 2002 to 2007. To evaluate the effect of stricter rule enforcement, a Previous studies have found that between 44% and pre-/post-intervention design was employed. Prior to 59% of all acute match injuries at club level are caused the 2011 season video recordings of incidents and inju- by player-to-player contact. Video analyses from FIFA ries from the 2010 season were analysed and refereeing tournaments showed that the match referee identified guidelines were agreed upon according to FIFA regula- 47% of all injuries, and 40% of head injuries as foul tions. This involved sanctioning of two-foot tackles as play. A study in Norwegian professional football con- well as tackles with excessive force and intentional high cluded that most referee decisions were correct accord- elbow with an automatic red card. The plans for stricter ing to the Laws of the Game, but that there might be rule enforcement were introduced to each team in meet- a need for more strict interpretation of the Laws of the ings with referees appointed for the 2011 season. In addi- Game in order to protect players from dangerous play. tion, the study group and the Head of Refereeing in the As a consequence, The International Football Associa- Football Association of Norway held a similar meeting tion Board gave referees the authority to severely sanc- for the media, thereafter, a press conference with a high- tion fouls that were recognised to be injurious, such as profile player, a manager and FIFA representative were intentional elbows to the head and brutal tackles. After organised. this, the incidence of match injuries was significantly lower in the 2010 FIFA World Cup™ for men com- pared to the mean incidence found in the three previous Results World Cups. However, the effect of rule changes and their interpretation have neither been evaluated through A total of 2,140 incidents were identified during the prospective injury surveillance systems nor through vid- three seasons, 419 in 2000, 868 in 2010 and 853 in eo analysis, a key element missing in the current sport 2011. The corresponding overall rate of incidents was injury prevention research portfolio. 74.4 per 1,000 player-match hours of exposure (95% CI: 67.3 to 81.5) in the 2000 season and 109.6 (95% CI: 102.3 to 116.9) in the 2010 season, an increase from Aims of the study 2000 to 2010 (rate ratio: 1.47, 95% CI: 1.31 to 1.66). We observed a higher rate of opponent-to-player contact UÊ «>ÀiÊÌ iÊÀ>ÌiÊvÊV`iÌÃÊÜÌ Ê>Ê«À«iÃÌÞÊvÀÊ and non-contact incidents in the 2010 season. We found injuries between the seasons 2000 and 2010 no change in the awarding of yellow or red cards between UÊ/Ê>ÃÃiÃÃÊÜ iÌ iÀÊ>ÊÃÌÀVÌiÀÊÌiÀ«ÀiÌ>ÌÊvÊÌ iÊ >ÜÃÊ the two seasons. of the Game could reduce the potential for injuries in Norwegian male professional football The rate of contact incidents was 92.7 (95% CI: 86.0 to 99.4) in the 2010 season. After the introduction of strict- er rule enforcement, the incident rate was 86.6 (95% CI: How we collected data 80.3 to 99.4) in the 2011 season, showing no difference between the 2010 and 2011 seasons. We found, howev- We collected videotapes of league matches and injury er, a reduction in the incidence of head incidents (rate information prospectively during the 2000, 2010 and ratio (RR): 0.81, 95% CI: 0.67 to 0.99), and head inci- 2011 season. dents caused by arm-to-head contact (RR: 0.72, 95% CI: An incident was said to occur if the match was inter- 0.54 to 0.97). We found no difference in tackling charac- rupted by the referee, the player stayed down for more teristics or injury rate caused by player-to-player contact. than 15 seconds, and appeared to be in pain or received F-MARC PROJECTS | PREVENTION OF FOOTBALL INJURY 109
What we learned from the studies
We found an increased rate of non-contact and oppo- nent-to-player contact incidents in both heading and tackling duels with a high injury potential in the 2010 season compared to ten years earlier, even if there was no increase in the frequency of duels. We found no differences in the overall rate of incidents after the introduction of stricter rule enforcement. How- ever, the rate of head incidents and arm-to-head inci- dents was lower. This indicates a need for an increased focus on the effect of rule changes and regulations on injury risk. It might also lead to implementation of strict- er rule enforcement in other leagues and tournaments, in order to reduce the number of situations with a high injury potential and hence the injury risk.
Duration: 2010 - 2011 Fig. 3.2.5.1a (top) Characteristics of incidents (n=2140); b (mid- Country: Norway dle) Characteristics of incidents due to opponent-to-player contact Cooperation: Oslo Sports Trauma Research Center, Norway (n=1774); c (bottom) Characteristics of head incidents due to oppo- References: nent-to-player contact (n=510) from video analysis of all games (n=240 Bjørneboe J, Bahr R, Einar Andersen T (2014). Video analysis each season) of situations with a high-risk for injury in Norwegian male pro- fessional football; a comparison between 2000 and 2010. Br J Sports Med 48(9):774-8 Bjørneboe J, Bahr R, Dvořák J, Andersen TE (2013). Lower incidence of arm-to-head contact incidents with stricter inter- pretation of the Laws of the Game in Norwegian male profes- sional football. Br J Sports Med 47(8):508-14 110 PREVENTION OF FOOTBALL INJURY | F-MARC PROJECTS
3.3 Evaluation of the Effects of Prevention Programmes
3.3.1 Prevention of Injuries in Male Youth The prevention programme Amateur Players The prevention programme focused on improvement of the structure and content of the training by education Why we conducted this study and supervision of coaches and players. The programme was designed to reduce the incidence of football injuries While the incidence of football injury had been reported in general, without emphasis on a special type of injury. and investigated in several studies, there were few studies Ten activities that could be considered as predecessors that had reported the results of an injury prevention pro- of the later F-MARC 11 made up the training exer- gramme. The scientific literature on prevention of sports cises. Other factors, such as the amount of training and injury seemed to support the effectiveness of preventive matches, time schedule, player’s equipment and playing interventions, but there were few prospective epidemio- ground were not specifically addressed. logical studies on youth that evaluated the effectiveness of such programmes. Results Often, research and programmes were focused on profes- sionals because of the investment that team owners make The overall incidence of injury was 6.7 and 8.5 injuries in their players. It had become clear that even the profes- per 1,000 hours of training in the intervention and con- sional players have a limited understanding of injury pre- trol groups respectively, representing a 21% reduction vention strategies. In consideration of the vast number in injuries. The prevention programme had more of an of amateur players, whom one might expect to be less effect in the low-skill level teams where the incidence of informed than professionals, F-MARC felt that a better injury was 37% lower than in the control group play- instruction of recreational players and coaches was even ers while there was only a 7% lower injury rate in the more urgently needed. high-level (Fig. 3.3.1.1). The rate of match injuries was decreased by 30% and 18% for the high and low-level teams respectively (Fig. 3.3.1.2). Aims of the study 12 11.1
10 UÊ iÛi«ÊvÊ>Ê«ÀiÛiÌÛiÊ«À}À>iÊvÀÊÞÕÌ Ê«>ÞiÀà UÊ Û>Õ>ÌiÊÌ iÊivviVÌÊvÊÌ iÊ«À}À>iÊÊ>Ê«ÀëiVÌÛiÊ 8 6.78 6.95 study 6.35 6
4 How we collected the data 2 Injuries per 1000 hours This was a prospective cohort study that included an 0 initial baseline examination (for performance and risk factor evaluation) that was followed by a one-year observation period where all football-related injuries High level -6% Low level -37% and physical complaints were documented weekly by a Fig. 3.3.1.1 Injuries per 1000 hours football (training and match)
physician. The teams that participated were male ama- 25 teur players aged between 14 and 19 years that had no 21.6 physician or physiotherapist taking care of the players. 20 18.7 17.7
Seven teams took part in an intervention programme 15 13.1 that stressed education and supervision of coaches and players (intervention group), while seven control teams 10
were instructed to train and play football as usual (con- 5
trol group). Complete weekly follow-ups were available Injuries per 1000 hours in 101 players of the intervention group and 93 players 0 of the control group. High level -30% Low level -18% Fig. 3.3.1.2 Match injuries per 1000 match hours F-MARC PROJECTS | PREVENTION OF FOOTBALL INJURY 111
Dieter Rösch with some members of the prevention group Dieter Rösch with a youth football player
The rates of overuse injuries and training injuries were and training injuries, while unaffected in the high-level unchanged in the high-level teams, however, the inci- teams, were reduced by over 50% in the low-level teams. dence of similar injuries in low-level was 54% lower For the development and implementation of prevention than in the control teams (Tab. 3.3.1.1). programmes, the initial situation of the players and their environmental risks should be considered, such as qual- There were 44% fewer injuries and 21% fewer play- ity of pitches and equipment. Furthermore, an impor- ers suffering an injury for an overall 21% lower injury tant aspect in the prevention of football injury concerns rate in the intervention group. Non-contact injuries are the observance of the Laws of the Game and especially of particular interest as many feel these are the injuries the spirit of Fair Play. A broader view and the inclusion most likely to be reduced by a prevention programme. of other target groups (such as referees, parents, official In this project, the rate of non-contact injuries was representatives and others) will lead us all to a healthier, reduced by nearly 20% in the high level teams and safer game. almost 40% in the lower level teams. Of particular inter- est was the substantial reduction in mild injuries in both groups. The most frequent football injuries are minor, so reducing the mildest of injuries will also have a consider- able impact on the average injury severity.
High skill teams Low skill teams
Non-contact injuries -20% -40%
Mild injuries -27% -39%
Match injuries -30% -18%
Training/overuse injuries +3% -54%
Tab. 3.3.1.1 Percent differences in selected injury rates from control teams by skill level Duration: 1999 - 2000 What we learned from the study Country: Switzerland Cooperation: R. Hodgson, G. Hollier; Football Associations of It is apparent that when an education and prevention Zurich and of North-West Switzerland programme for both coaches and players becomes a reg- Reference: Dvořák ular part of a training programme, injuries are reduced, Junge A, Rösch D, Peterson L, Graf-Baumann T, J particularly in the lower skill level teams. This preven- (2002). Prevention of soccer injuries – a prospective interven- tion programme was especially effective in reducing tion study in youth amateur players. Am J Sports Med 30(5): the rate of football injury in low-level teams. Overuse 652-659 112 PREVENTION OF FOOTBALL INJURY | F-MARC PROJECTS
3.3.2 Prevention of ACL Ruptures in Female How we collected the data Players In 2000, all teams of the Coast Football League in Southern California were contacted and invited to par- Why we conducted this study ticipate in the study. Those teams that chose to par- ticipate were instructed via video and printed literature Women’s participation in sports is continually on the about the details of the prevention programme. rise worldwide. For example, in 1972, the US Congress passed a resolution that effectively allowed women to All players were females between the ages of 14 and 18 participate fully in academic and athletic events with- and performed either their traditional warm-up (con- out gender discrimination. At that time, approximately trol group) or a sports-specific training intervention 300,000 women participated in competitive sport at the called “Prevent Injury, Enhance Performance” (PEP) high school level (age 15-18). By 2003, that number had before their athletic activity over a two-year period. A grown to approximately two million active sports wom- total of 1,041 female players from 52 teams received en. the sports-specific training intervention in a prospective non-randomised trial. The control, untrained, group This dramatic increase in participation had almost inevi- consisted of the remaining 1,905 female football play- tably led to an increase in sports related injuries, but par- ers from 95 teams participating in the same league who ticularly striking was the high incidence of non-contact were age and skill matched. The project was continued injuries to the anterior cruciate ligament of the knee in the 2001 season with 844 females (from 45 teams) in (ACL). Numerous studies had reported females sustain the intervention group and 1,913 female athletes (from non-contact ACL injuries at a rate that exceeded their 112 teams) serving as the age- and skill-matched control male counterparts by two to eight times. Competitive group. team sports such as football, basketball, team handball and volleyball require dynamic stability to withstand the demands of cutting, decelerating, jumping, and landing The PEP programme from a jump. A number of laboratory studies had sug- gested that motor control of the high risk manoeuvres The specific programme used in the intervention con- described was different amongst young women and this sisted of education, stretching, strengthening, plyomet- control might be closely associated with knee instability rics and sports-specific agility drills designed to replace that can lead to ACL injury plus damage to the menisci the traditional warm-up (Tab. 3.3.2.1). The programme and surface cartilage of the bones of the knee. emphasised “soft landings” with deep hip and knee flex- ion and lower extremity control during jumping, land- While the surgical treatment and rehabilitation from ing and change of direction. Video and print resources ACL injuries was well documented and many play- displayed examples of the proper technique. Each player ers returned to their previous level of performance, the in the intervention group received a videotape of the meniscal and cartilage damage would eventually lead PEP programme. The programme was to be a part of to progressive damage and early onset of osteoarthritis. each team’s and player’s warm-up before training and Thus, F-MARC considered a specific prevention pro- competition throughout the competitive seasons. gramme critical to keep female players in the game and protect them from the consequences of this severe injury. Exposure to training and match was reported weekly by the coaches and all knee injuries were reported, also weekly. The criteria for ACL injuries were history, physi- Aims of the study cal examination and confirmed by MRI or arthroscopy. Copies of the MRI or arthroscopy reports were obtained UÊ iÌiÀiÊÌ iÊV`iViÊvÊ ÊÕÀÞÊÊ>Ê>À}iÊ for each non-contact ACL injury. The unit of analysis in league of young female football players this study was limited just to non-contact ACL injuries. UÊ iÌiÀiÊÜ iÌ iÀÊ>ÊiÕÀÕÃVÕ>ÀÊ>`Ê«À«ÀVi«- tive performance programme decreased the incidence of ACL injury in this population of competitive play- ers F-MARC PROJECTS | PREVENTION OF FOOTBALL INJURY 113
Prevent injury and enhance performance program PEP Trained Control % difference*
Exercise Distance Repetitions/time Per 1000 Athlete 0.09 0.49 81.6 Exposures 1. Warm-up Per 100 teams 6.19 32.37 80.9 - Jog line to line 50 yd 1 - Shuttle run 50 yd 1 - Backward running 50 yd 1 Per 1000 3.18 17.6 81.9 players 2. Stretching - Calf stretch NA 2 x 30 s *percent reduction in ACL injuries = [(control-trained)/control] * 100 - Quadriceps stretch NA 2 x 30 s - Hamstring stretch NA 2 x 30 s Tab. 3.3.2.2 Summary of injury rates to the ACL - Inner thigh stretch NA 2 x 30 s - Hip flexor stretch NA 2 x 30 s
3. Strengthening What we learned from the study - Walking lunges 20 yd 2 passes - Russian hamstring NA 30 s - Single-toe raises NA 30, bilaterally It is well known that young females are at risk for non-
4. Plyometrics contact ACL injuries and any prevention programme - Lateral hops 2- to 6-in cone 30 s must be directed at young girls, but should also be used - Forward hops 2- to 6-in cone 30 s for males to reduce the overall rate of ACL injuries. - Single-legged hops 2- to 6-in cone 30 s - Vertical jumps NA 30 s - Scissors jumps NA 30 s The 80% reduction in ACL injuries as a result of the PEP programme clearly showed that a preventive training 5. Agilities - Shuttle run 40 yd 1 programme may well decrease the number and incidence - Diagonal run 40 yd 1 of ACL injuries in female athletes. This work, along with - Bounding run 45-50 yd 1 a number of other prevention studies, suggested that this Tab. 3.3.2.1 The training programme serious injury in females can be dramatically reduced with a specific prevention programme that stresses neu- romuscular control of the lower extremity through the Results use of strengthening exercises, plyometrics, and sports- specific agilities. The proprioceptive and biomechanical Over the full two year period there were a total of six deficits that programmes like this are designed to correct ACL injuries in the PEP trained group and a total of 67 further demonstrate the high-risk present in the female ACL injuries in the control group. During the 2000 sea- player population. This project was encouraging and son, there was an 88% decrease in anterior cruciate liga- supported the further study of prevention programmes ment injury and in 2001, there was a 74% reduction in to decrease ACL injuries in this high-risk population. anterior cruciate ligament tears in the intervention group compared to the age- and skill-matched controls. The Duration: 2003 - 2005 data were analysed according to athlete exposures, by Country: USA team and by player. Cooperation: Santa Monica Orthopedic and Sports Medicine Group Research and Education Foundation, California, USA No matter how the data was analysed, the reduction References: in ACL injuries as demonstrated was always significant Mandelbaum BR, Silvers HJ, Watanabe DS, Knarr JF, (Tab. 3.3.2.2). Overall, there was an 80% reduction in Thomas SD, Griffin LY, Kirkendall DT, Garrett W Jr (2005). ACL injuries as a result of the PEP training programme. Effectiveness of a neuromuscular and proprioceptive training Simply stated, the programme was successful in reducing programme in preventing anterior cruciate ligament injuries in ACL injuries. female athletes: two-year follow-up. Am J Sports Med 33: 1003- 1010 Gilchrist J, Mandelbaum BR, Melancon H, Ryan GW, Silvers HJ, Griffin LY, Watanabe DS, Dick RW, Dvořák J (2008). A randomized controlled trial to prevent non-contact anterior cruciate ligament injury in female collegiate soccer players. Am J Sports Med 36(8): 1476-1483 114 PREVENTION OF FOOTBALL INJURY | F-MARC PROJECTS
3.3.3 Prevention of Injuries in Female of the “FIFA 11+” programme. The “FIFA 11+” includ- Adolescent Amateur Players ed key exercises from “The 11”, but was expanded with additional exercises to provide variation and progression. It also included a new set of structured running exercises Why we conducted this study that made it better suited as a complete warm-up pro- gramme (see box). We asked them to replace their usual F-MARC studies as well as the literature had repeatedly warm-up with the complete exercise programme for reported injury rates in female football players similar every training session throughout the season, and to use to that of their male counterparts. In spite of the urgent the running exercises of the programme as part of their need for preventive programmes, there existed only a warm-up prior to every match. We asked the coaches of few scientifically valid studies on injury prevention in the clubs in the control group to warm up as usual. female football players. In the study described on the “FIFA 11+” - a complete warm-up programme previous pages, we had examined the effect of the struc- tured prevention programme “The 11” over one season The programme consists of three parts: among 2,000 female players aged 13 to 17 years. We The first part is running exercises at slow speed combined with active stretching and controlled partner contacts. had observed no difference in the injury risk between the intervention group and control group. However, these The second part consists of six different sets of exercises, these included results were hard to assess due to the low compliance of strength, balance and jumping exercises, each with three levels of dif- ficulty, the teams. Low compliance is considered an important limitation of injury prevention programmes. The third part is speed running combined with planting and cutting move- ments.
This prompted F-MARC to convene an expert group All parts of the “FIFA 11+” constitute a complete warm-up programme to further develop the exercise programme in order to and are to be performed prior to every training session. The running improve both the preventive effect of the programme exercises of the programme are to be performed as part of the warm-up prior to matches. Once players are familiar with the programme, it takes and the compliance of coaches and players. We decided about 20 minutes to complete. to not only offer variation and progression for the origi- nal “The 11” exercises, but also to include components An injury was defined as any injury during training or of the PEP programme which had proven successful in match causing the player to be unable to fully take part preventing injuries to the anterior cruciate ligament of in the next training or match. In both groups, the coach- the knee in female players. Further, running exercises es reported injuries and participation of individual play- were to be incorporated, too. The aim was to design the ers for each training session and match on weekly regis- new programme “FIFA 11+” as a complete warm-up tration forms. “FIFA 11+” coaches also recorded to what programme prior to training, thereby facilitating the reg- extent the warm-up programme was carried out at each ular performance within existing training schemes. session throughout the study period. Further, specifically trained injury recorders called every injured player to . assess aspects of her injury based on a standardised injury Aim of the study questionnaire. Injury type, location and severity were recorded. UÊ Ý>iÊÌ iÊivviVÌÊvʺʣ£³»]Ê>ÊV«iÌiÊÜ>À up programme designed to reduce the risk of injuries in female youth football Results
During the season, 301 players suffered a total of 376 How we collected the data injuries. Of these, 264 players injured their lower extremities, 121 players in the intervention group and We followed 93 clubs corresponding to 1,892 female 143 in the control group (Table 3.3.3.1). The overall players aged 13 to 17 years, randomised to an interven- incidence of injuries was 3.9 per 1,000 player hours. tion group practising the new programme and a control There were 80% acute injuries and 20% overuse inju- group for one league season of eight months. ries. There was a significantly lower risk of any injury, Prior to the season, the coaches of the clubs allocated to overuse injuries and severe injuries in the intervention the intervention group received instruction and training group compared to the control group. The separate risk F-MARC PROJECTS | PREVENTION OF FOOTBALL INJURY 115
of match injuries, training injuries, lower extremities ing, cutting, jumping and landing is meant to develop injuries, knee injuries and acute injuries was reduced by less vulnerable movement patterns (Fig. 3.3.3.1) and 26 to 38%. players should be encouraged to land with increased hip and knee flexion, and to land on two legs rather than The “FIFA 11+” teams used the prevention programme one. in 77% of all their sessions. The more a team used the programme in their training sessions, the more the risk of injury was reduced.
“The 11” group Control group
All injuries 135 166
Match injuries 96 114
Training injuries 50 63
Lower extremity injuries 121 143
Acute injuries 112 130 Exercise: single-leg balance, throwing ball with partner
Severe injuries 45 72
Tab. 3.3.3.1 Injury incidence in the “FIFA 11+” intervention group and the control group
Exercise: single-leg balance, test your partner Fig. 3.3.3.1 Example of correct (left) and incorrect (right) technique in running exercises
What we learned from the study
This was the first study of sufficient methodological quality to show that a prevention programme is effective in female youth players. The “FIFA 11+” - a complete Duration: 2007 - 2008 warm-up programme (Fig. 3.3.3.1) prevented inju- Country: Norway ries in female youth football players. More specifically, Cooperation: Oslo Sports Trauma Research Center, Norway; injuries in general were reduced by about one third and Santa Monica Orthopaedic and Sports Medicine Research severe injuries by as much as one half in the “FIFA 11+” Foundation, California, USA group as compared to the group performing their usual Reference: warm-up. The new programme achieved higher compli- Soligard T, Myklebust G, Steffen K, Holme I, Silvers H, Bizzini ance, presumably because it can be used as a stand-alone M, Junge A, Dvořák J, Bahr R, Andersen TE (2008). A com- warm-up, includes partner exercises as well as variation prehensive warm-up programme to prevent injuries in female and progression of difficulty. The programme’s focus on youth football – a cluster randomised controlled trial. BMJ 9; awareness and control during standing, running, plant- 337:a2469 116 PREVENTION OF FOOTBALL INJURY | F-MARC PROJECTS
3.3.4 Importance of Compliance with knee alignment, as well as in landing from jumps. The Preventive Programmes coaches were asked to use the programme at every train- ing session for 15 consecutive sessions and thereafter once a week during the rest of the season. They were Why we conducted these studies contacted by telephone and/or e-mail at least once a month to record all training and match activities and Female players have injury rates similar to male play- new injuries for their team. Injured players were inter- ers and most often suffer injuries to the knee, ankle and viewed by specially trained injury recorders to assess thigh, too. As described in our previous study, female aspects of their injury based on a standardised injury players may even be at greater risk of serious injury than questionnaire. males as the rate of anterior cruciate ligament injuries is considerably higher. However, only a few studies on To assess the importance of compliance with the injury injury prevention in female football players had investi- prevention programme further, we also investigated the gated the effect of structured prevention programmes in teams and coaches of the intervention group participat- a prospective way. ing in the study on “FIFA 11+” described in the follow- ing chapter. Attitudes and beliefs of 65 coaches towards F-MARC’s “The 11” and later “FIFA 11+” had been exercise-based prevention were assessed as well as the developed as football-specific prevention programmes individual participation of players in training and match mainly aimed at common injuries of the lower extremi- play (meaning exposure to the game of football, in min- ties on the basis of previous F-MARC research. We utes) and the exact performance of the warm-up at every intended to test the actual effect of these programmes session, again including individual player participation. in female football players following them during one football season. The results of this first study on “The 11” made it clear that we needed to have a closer look at Results compliance with the advanced “FIFA 11+” programme and the influence thereof on injury frequency, too. In “The 11” study, 58 teams (1,073 players) in the inter- vention group and 54 teams (947 players) in the con- trol group were followed during the season lasting eight Aims of the studies months. Every fifth player of the total of 2,020 players sustained at least one injury. No difference was observed UÊÛiÃÌ}>ÌiÊÌ iÊivviVÌÊvʼ¼Ì iÊ££½½ÊÊÕÀÞÊÀÃÊÊ in the proportion of injured players between the inter- female youth football players vention group with 19.0% and the control group with UÊ iÌiÀiÊÌ iÊ«>VÌÊvÊÌ iÊ`i}ÀiiÊvÊV«>ViÊ 20.3%. By far the most injuries were acute (87%) and with “The 11” and “FIFA 11+” on the injury prevent- to the lower extremities (86%). An ankle sprain was ing effect of the programmes the most common type of injury. In 42%, the injury occurred in a non-contact playing situation, while 58% of all acute injuries resulted from player-to-player con- How we collected the data tact (Table 3.3.4.1).
All teams in south-east Norway registered in the Compliance with the programme was defined as at least under-17 league system during the 2005 season were 20 prevention training sessions during the season. Dur- invited to take part in the first study on “The 11”. Of ing the whole observation period, “The 11” teams used 157 teams, 113 teams with a total of 2,100 players the prevention programme at 52% of their training ses- agreed to participate. The prevention programme was sions. During the first half of the season from March introduced to the teams in the intervention group at the through June, the programme was used in 14 (60%) of beginning of the pre-season, with guidance and surveil- all training sessions, and after the summer break in 9 lance by instructors who were each responsible for two (44%). to three teams. The main focus was on performing the exercises properly. The players were encouraged to con- Fifty-two of the initial 65 teams and 56 coaches com- centrate on the quality of their movements, and empha- pleted the “FIFA 11+” compliance study. Teams per- sis was placed on core stability, hip control and proper formed the “FIFA 11+” in 77% of their football sessions F-MARC PROJECTS | PREVENTION OF FOOTBALL INJURY 117
during the season and 60% of these did so twice or even tion of players and coaches to perform the programme more often. Compliance was higher during the first part and put these findings into practice when developing the of the season. Based on this team compliance, individ- “FIFA 11+”. ual player compliance was calculated to be 47% of the maximum programme sessions of teams. No influence of Our second study confirms the correctness of this inter- team compliance on injury risk was found, but players in pretation since compliance with “FIFA 11+” was mark- the highest compliance tertile showed a 35% lower risk edly higher. This study also confirmed the lower injury of injury in general (39% for acute injuries) than those risk for players with high compliance, but it was shown in the intermediate tertile. All coaches believed that that individual instead of team compliance has to be injury prevention is important and 88% perceived their assessed. Further important findings were the influence players to be at either high or moderate risk for injury. of coaches’ attitudes on player compliance and of coa- Low compliance by teams was associated with coaches’ ches’ experience with preventive approaches on the suc- belief that the programme was too time consuming or cess of an injury prevention programme. did not include enough football-specific activities.
“The 11” group Control group
All injuries 242 241
Acute injuries 211 210
Match injuries 169 151
Training injuries 42 59
Lower extremity injuries 181 173
Contact injuries 118 124
Brazil Women National Team performing core stabilization exercises Non-contact injuries 93 86 (FIFA 11+, Part II, Nr. 8.3 with arm variation) under coach supervision (CBF Training Center, Teresopolis, Brazil)
Tab. 3.3.4.1 Injury incidence in “The 11” intervention group and the control group
What we learned from the studies
In “The 11” study, there was no difference in injury rates between the teams in the intervention group who were asked to regularly perform “The 11”, and the teams in the control group who were told to warm up as usual. The compliance of the teams and coaches in “The 11” Duration: 2005 - 2007 group was most likely insufficient to produce the train- Country: Norway ing effects required to reduce injury risk. The average Cooperation: Oslo Sports Trauma Research Center, Norway player in the intervention group had to be considered Reference: non-compliant. In our review of the literature, we had Steffen K, Myklebust G, Olsen OE, Holme I, Bahr R (2008). found that compliance with the programme is an essen- Preventing injuries in female youth football – a cluster-ran- tial factor for success. Volume and intensity are key domized controlled trial. Scand J Sport Med Sci 18(5): 605- determinants for training outcome, therefore effective- 614. Soligard T, Nilstad A, Steffen K, Myklebust G, Holme ness might be improved by fewer exercises with more I, Dvořák J, Bahr R, Andersen TE (2010). Compliance with repetitions to allow for progression and higher intensi- a comprehensive warm-up programme to prevent injuries in ties. F-MARC felt that this would also increase motiva- youth football. Br J Sports Med 44(11):787-793 118 PREVENTION OF FOOTBALL INJURY | F-MARC PROJECTS
3.3.5 Effects of Different Implementations How we collected the data Strategies and Compliance with the “FIFA 11+” During the four-month 2011 football season, coaches and 385 13 to 18-year-old players from 31 elite and lower level teams were introduced to the “FIFA 11+” Why we conducted this study through either an unsupervised website (“control group”) or a coach-focused workshop with (“compre- Adherence of coaches and players to successful injury hensive”) and without (“regular”) additional supervisions prevention programmes is a challenge. There is also by a physiotherapist. Team and player adherence to the a lack of information in the literature regarding the “FIFA 11+”, playing exposure, history and injuries (seek- coaches´ delivery of the programme to the team and the ing medical attention) were recorded. quality of the exercise execution by athletes on the field. Injury prevention interventions will not have a signifi- cant public health impact if they are not widely accepted Results and adopted by the target population, coaches, athletes and other stakeholders in the sports community. Adherence of coaches to the “FIFA 11+” was high in all three groups. Teams in the comprehensive and regu- In previous projects in community-based youth football, lar intervention groups demonstrated adherence to the injury prevention programmes were largely delivered by “FIFA 11+”-programme of 86% and 81% completion coaches who initially were educated by clinical research of total possible sessions, compared to 74% for teams in personnel. Mostly, coaches were introduced to the inju- the unsupervised control group. These differences were, ry prevention programme individually or through an however, not statistically significant. Injury risk of play- instructional workshop where they received theoretical ers was comparable for all three groups of intervention and practical training, including educational material. delivery.
Based on the positive effects of the “FIFA 11+” football injury prevention programme, and as part of its imple- What we learned from the study mentation strategy, the Fédération Internationale de Football Association (FIFA) has developed educational Following a coach workshop, coach-led delivery of the material and created a website where all 11+ resources “FIFA 11+” was equally successful with or without addi- can be downloaded free of charge (i.e. videos explaining tional resources as the on-field involvement of a physi- the exercises, pocket-sized exercise cards for the training otherapist. Proper education of coaches during an exten- field, posters detailing the exercises and their common sive pre-season workshop was more effective in terms performance errors) (http://f-marc.com/11plus/11plus/). of team adherence than an unsupervised delivery of the The success of delivery of an injury prevention pro- “FIFA 11+”-programme to the team. gramme implementation through an unsupervised approach (i.e. website delivery only) has not previously Coach education should therefore continue to play an been evaluated. Furthermore, the added effect of a pro- important role in the way a new neuromuscular injury gramme delivery, specifically involving regular follow-up prevention exercise programme is delivered to football with coaches and players on the field to ensure proper teams and players. Experiences from our recent project execution and progression of exercises, has not previous- in Switzerland demonstrate how an injury prevention ly been examined. programme can successfully be implemented country- wide by coaches. However, more evidence is needed to identify potential barriers and motivators for coaches Aims of the study in the use of an injury prevention programme, and to measure change of behaviour over time. This would UÊ/ÊiÛ>Õ>ÌiÊÌ iÊivviVÌÃÊvÊÌ iÊÌ ÀiiÊ`iÛiÀÞÊiÌ `ÃÊ facilitate a better understanding of coach readiness to of the “FIFA 11+” injury prevention programme on change current practices and behaviour as well as to adherence and injury risk among female youth foot- adopt interventions, such as the “FIFA 11+”, thus estab- ball teams lishing effective implementation strategies outside a con- trolled research environment. F-MARC PROJECTS | PREVENTION OF FOOTBALL INJURY 119
FIFA 11+ coaching courses in USA (Abb 1 and 2: Phoenix, Arizona) and Japan (Abb 3-5 Nagoya)
1 2
3 4
Duration: 2011 5 Country: Canada Cooperation: Sport Injury Prevention Research Centre, University of Calgary, Canada; Department of Sports Medicine, Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway; Centre for Healthy and Safe Sport & the Australian Centre for Research into Sports Injury and its Prevention, University of Ballarat, Victoria, Australia Reference: Steffen K, Meeuwisse WH, Romiti M, Kang J, McKay C, Bizzini M, Dvořák J, Finch CF, Myklebust G, Emery CA A group of Canadian football coaches participating at the first FIFA (2013). Evaluation of how different implementation strategies 11+ instructor course in Calgary, with the study coordinators of an injury prevention program FIFA 11+ impact team adher- Maria Romiti and Kathrin Steffen, University of Calgary (standing, respectively 1st and 3rd from right) and Dr. Mario Bizzini, F-MARC ence and injury risk in Canadian female youth football players. (first row, 2nd from left) Br J Sports Med 47(8):480-487 120 PREVENTION OF FOOTBALL INJURY | F-MARC PROJECTS
3.3.6 Benefits of High Adherence with regard players regardless of how the “FIFA 11+” programme to Performance and Injury Risk was delivered to the team. However, better functional balance and 72% reduced injury risk was found for play- ers who highly adhered to the prescribed exercises during Why we conducted this study the season compared to those with less adherence.
A protective effect on injury risk in youth sports through neuromuscular warm-up training routines has consist- What we learned from the study ently been demonstrated. However, there is a lack of information regarding its impact on the physical perfor- High player adherence to the “FIFA 11+” resulted in mance of players. It is likely easier to motivate coaches significant improvements in functional balance and and players to follow such exercise programmes if they reduced injury risk. Improved neuromuscular control are not only to prevent injuries, but if there also is a appears to be a key element of the “FIFA 11+” injury direct performance benefit. It might be expected that prevention programme. These findings are good news implementing a 20-minute injury prevention pro- for all coaches and players. For football players, proper gramme should improve physical performance. Howev- functional balance and body control are essential for er, conflicting outcomes are currently reported. If there technical and tactical performance to efficiently position were a link between injury risk reduction and perfor- themselves in relation to the opponents. Furthermore, mance outcomes, adoption and sustained adherence to the findings are important for the acceptance and adop- successful programmes would be likely to be easier. tion of the programme as performance improvements should provide additional motivation to coaches to reg- ularly deliver the programme to their players. Interest- Aims of the study ingly, performance outcome and injury risk was similar for players regardless of how the “FIFA 11+” programme UÊ/Ê>ÃÃiÃÃÊÜ iÌ iÀÊ`vviÀiÌÊ`iÛiÀÞÊiÌ `ÃÊvÊ>Ê was delivered to the team. injury prevention programme (“FIFA 11+”) to coach- es could improve player performance UÊ/ÊiÝ>iÊÌ iÊivviVÌÊvÊ«>ÞiÀÊ>` iÀiViÊÊ«iÀvÀ- mance and injury risk
How we collected the data
During the 2011 football season (May-August), coaches of 31 tier 1-3 level teams were introduced to the “FIFA 11+” through either an unsupervised website or a coach- focused workshop with and without additional on-field Duration: 2011 supervisions. Playing exposure, adherence to the “FIFA Country: Canada 11+”, and injuries were recorded for female 13-18- Cooperation: Sport Injury Prevention Research Centre, year old players. Performance testing included the Star University of Calgary, Canada; Department of Sports Medicine, Excursion Balance Test, single-leg balance, triple hop, Oslo Sports Trauma Research Center, Norwegian School of and jumping-over-a-bar tests. Sport Sciences, Oslo, Norway; Centre for Healthy and Safe Sport & the Australian Centre for Research into Sports Injury and its Prevention, University of Ballarat, Victoria, Australia Results Reference: Steffen K, Emery CA, Romiti M, Kang J, Bizzini M, Dvořák J, Complete pre- and post-season performance tests were Finch CF, Meeuwisse WH (2013). High adherence to neuro- available for 226 players. We found that the “FIFA 11+” muscular injury prevention training programme (“FIFA 11+”) can improve dynamic and functional balance perfor- improves functional balance performance and reduces injury mance among 13 to 18-year-old female football players. risk in Canadian youth female soccer players. Br J Sports Med Performance outcome and injury risk was similar for 47(12):794-802 F-MARC PROJECTS | PREVENTION OF FOOTBALL INJURY 121
The German National Team, winner of the 2014 FIFA World Cup, and official FIFA 11+ representatives
The Japan National team, winner of the 2011 Women’s World Cup, and official FIFA 11+ representatives
The Spain National Team, winner of the 2010 FIFA World Cup, and official FIFA 11+ representatives 122 PREVENTION OF FOOTBALL INJURY | F-MARC PROJECTS
3.3.7 Physiological and Performance Effects vertical jump height, stiffness, isometric maximal volun- of “FIFA 11+” tary contraction, rate of force development, star excur- sion balance test, oxygen uptake, lactate and core tem- perature. Why we conducted these studies Eighty-one (n=81) players were randomly assigned to The “FIFA 11+” is a complete warm-up package, which the intervention (n=42; age 23.7±3.7 years) or the con- combines cardiovascular activation and preventive neu- trol group (n=39; age 23.2±3.8 years). The interven- romuscular exercises. It has been developed to be admin- tion group performed the “FIFA 11+” programme three istered as a warm-up routine. A good warm-up should times a week for nine weeks; the control group complet- improve the subsequent performance but should also ed the usual warm-up. The outcome variables measured not be so demanding as to cause detrimental effects before and after the training period were: time-to-stabi- due to fatigue-related factors. However, no studies have lisation and eccentric/concentric flexors strength, eccen- examined the immediate effects of the “FIFA 11+” on tric/concentric extensors strength, balance test, core-sta- performance and warm-up criteria. The key element of bility, vertical jump height, sprint speed, and agility. the programme is the promotion of proper neuromus- cular control during all exercises ensuring correct pos- ture and body control. Although the main purpose of Results the “FIFA 11+” is injury prevention, the knowledge of training effects elicited by this programme can help in Immediately after performing the “FIFA 11+”, the play- identifying the potential mechanisms behind the report- ers increased their ability to sprint, jump, change direc- ed reduction in injury incidence as well. Furthermore, it tions, and balance. This was probably related to physi- might increase the consequent implementation of and ological mechanisms such as increase in baseline oxygen compliance with the programme, if it has additional uptake (+14%) and core temperature (+1%). performance benefits other than injury prevention. The few previous studies, which examined the effects of the Players performing the “FIFA 11+” for nine weeks sig- “FIFA 11+” on performance and neuromuscular control, nificantly improved in their ability to stabilise the body had small sample size and/or were not very well con- after landing on one leg from a jump, core stability, and trolled. leg strength (Fig. 3.3.7.1; Fig. 3.3.7.2).
Aims of the studies What we learned from the studies
UÊÃÃiÃÃÊÌ iÊi`>ÌiÊivviVÌÃÊ>vÌiÀÊ«iÀvÀ>ViÊvÊÌ iÊ The “FIFA 11+” prevention programme can be consid- “FIFA 11+” on various physical performance and ered a good warm-up inducing improvements compa- physiological variables to verify its appropriateness as rable with those obtained from other warm-up routines a warm-up reported in the literature and therefore, it can be proper- UÊ Ý>iÊÌ iÊÌÀ>}ÊivviVÌÃÊvÊÌ iʺʣ£³»ÊÊ ly implemented in the training routine of amateur foot- neuromuscular control, strength and performance in ball teams. male amateur football players Performing the “FIFA 11+” 3 times per week for nine weeks improved the neuromuscular control. In particu- lar, the players increased their ability to stabilise after How we collected the data a dynamic action, which is a relevant skill for football players. Therefore, we can also speculate this is a can- Two studies with a total of 101 amateur male football didate mechanism for explaining the injury prevention players were designed: a study with pre- and post-meas- effect of the “FIFA 11+” and well-reflects the main pur- urement examining the acute effects, and a randomised pose of this programme, which is the neuromuscular controlled trial for examining the performance effects. control training. Indeed, statistically significant effects Twenty players (age 25.5±5.1 years) were tested twice were also found on strength and performance measures before (control period) and once immediately after per- but as the magnitude of the improvements was com- forming the “FIFA 11+” for: 20m sprint time, agility, paratively small, the “FIFA 11+” should not be used as F-MARC PROJECTS | PREVENTION OF FOOTBALL INJURY 123
a replacement for the traditional physical strength and conditioning training but rather as a complement to it.
Fig. 3.3.7.1. Difference after training between the players completing Fig. 3.3.7.2 Difference after training between the players completing the “FIFA 11+” and the control group (abbreviations: ECC PF, eccen- the “FIFA 11+” and the control group. tric strength peak force; CONC PF, concentric strength peak force).
Player performing the the star excursion balance test
Players performing warm up exercises bevor the test battery
Duration: 2010 - 2011 Country: Italy Cooperation: CeRiSM, University of Verona, Italy References: Bizzini M, Impellizzeri FM, Dvořák J, Bortolan L, Schena F, Player performing the core stability neuromuscular control test Modena R, Junge A (2013). Physiological and performance responses to the “FIFA 11+” (part 1): is it an appropriate warm- up? J Sports Sci 31(13):1481-1490 Impellizzeri FM, Bizzini M, Dvořák J, Pellegrini B, Schena F, Junge A (2013). Physiological and performance responses to the FIFA 11+ (part 2): a randomised controlled trial on the training effects. J Sports Sci 31(13):1491-502 124 PREVENTION OF FOOTBALL INJURY | F-MARC PROJECTS
3.3.8 Prevention of Injuries in Male Amateur How we collected the data Players During the 2012 season, Division I and Division II men’s collegiate soccer teams (N=396) were solicited Why we conducted the study to participate in the study. The FIFA 11+ programme served as the intervention programme over the course Soccer is the most widely played sport among both of one collegiate soccer season. The warm-up was uti- males and females, with approximately 300 million reg- lised three times per week for the duration of the sea- istered players globally. The growth of the sport in the son. Athletic exposure (AEs), injury and compliance United States has been unprecedented. It is currently data was recorded in the web-based system HealtheAth- the third most popularly played sport, with over 13 lete™ Injury Surveillance System (Overland Park, Kan- million Americans participating at the youth and adult sas). Sixty-one institutions completed the study: 34 levels (US census). Major League Soccer (MLS) is cur- control (CG) (N=850 athletes) and 27 intervention (IG) rently in its 19th season and has grown to 20 professional (N=675 athletes) institutions (Fig. 3.3.8.1). A Poisson teams within the United States and in Canada since its regression model based on a generalised linear model was inception, with further expansion on the horizon (MLS, utilised to account for cluster effects to compare the rate 2013). In addition, there are approximately 412,000 ratios of the risk of injury between teams. male high school and 23,000 male collegiate soccer play- ers participating in NCAA soccer in the United States (NCAA, 2012) – and the numbers of participants is Results increasing annually. However, there is a direct correla- tion between this growth of the sport, athletic exposure In the CG, 665 injuries were reported for 34 teams and injuries. In the last two decades, the risks and epi- (M=20.15, SD= ±11.01), with a corresponding inci- demiology of soccer injury have been well documented dence rate (IR) of 15.04 injuries/1,000 AEs. In the IG, and numerous attempts have been made to gain a fuller 285 injuries were reported for 27 teams (M =10.56, SD understanding about the mechanism of these injuries =±3.64), for an IR of 8.09 injuries per 1,000 AEs. There and how researchers can prevent or reduce the incidence was a significantly greater proportion of injuries in the of such injuries. CG (70%) compared to the IG (30%), χ2(1)=207.74, p < .001, Φ=.369. A Poisson regression was used to com- Soccer-related injuries are not uncommon amongst pare the total number of days missed between groups, males. However, many of the injury prevention efforts IG versus CG, and for field types, grass versus turf. The were focused solely on female athletes; namely on ACL model was significant, LR χ2(2) =263.06, p < .001. injury prevention. The FIFA 11+ programme has been Total days missed due to injury was significantly high- shown to be effective in the female soccer cohort, but er for the CG (M =13.02, SE = 1.09) than in the IG there is a paucity of research to demonstrate its efficacy (M=9.31, SE =.96). In addition, for each day missed in in the male population. the IG, 1.4 days were missed in the CG, Wald χ2(2)= 7.35, b = .335, se = .124, OR = 1.40. There was no dif- This aim of this manuscript was to describe the recent ference between the groups based on field type (Tab. utilisation of the FIFA 11+ programme in competitive 3.3.8.1). male soccer athletes in the collegiate setting. It eluci- dates the continuation of the international research com- munity to refine and improve the effectiveness of these What we learned from the study types of programmes amongst the soccer community. The FIFA 11+ was shown to significantly reduce injury rates and time loss to injury in the competitive male col- Aim of the study legiate soccer player. The benefits of sport participation are numerous, and far outweigh the risks associated with UÊ Ý>iÊÌ iÊivwV>VÞÊvÊÌ iÊÊ££³Ê«À}À>iÊÊ such. However, the likelihood of incurring an injury by men’s collegiate soccer virtue of participating in soccer should not be underes- timated. We recognise and embrace the need for pro- gramme compliance and further randomised controlled F-MARC PROJECTS | PREVENTION OF FOOTBALL INJURY 125
trials to elucidate the epidemiology, etiology, mechanism of injury(s) and the ultimate reduction and prevention of sports-related injury.
US- and MLS- legends Tony Meola and Ante Razov. Video clips that featured former/current prominent US Soccer players and coaches discussing the importance of injury prevention in soccer were specially produced for this study (http://vimeo.com/25708967 & http://vimeo.com/25708960)
Fig. 3.3.8.1 Description of NCAA Team Randomization and Study Flow (from left to right) Prof. )HŪ´ #UNŪ¨J, Dr. Bert Mandelbaum, Dr. Mario Bizzini before a match in Pretoria (SA) at the 2010 FIFA World Cup
Duration: 2012 Country: USA
Tab. 3.3.8.1 Control versus intervention: injury rates and days lost to Cooperation: Santa Monica Sports Medicine Foundation, injury Santa Monica, CA, USA, University of Delaware, Dept. of Biomechanical and Movement Sciences and Biostatistics Core Facility, College of Health Sciences, Newark, DE, USA Reference: Silvers H, Mandelbaum B, Adenij O, Insler S, Bizzini M, Pohlig R, Junge A, Dvořák J. The efficacy of the FIFA 11+ injury pre- vention program in the collegiate male soccer player (submitted) 126 PREVENTION OF FOOTBALL INJURY | F-MARC PROJECTS
3.4 Implementation of Prevention Programmes
3.4.1 Country-wide Campaign to Prevent How we collected the data Football Injuries in Switzerland Comprehensive teaching material including posters, booklets and DVDs was developed to support the broad Why we conducted the study distribution of F-MARC’s injury prevention programme “The 11”. In Switzerland, all licensed football coaches In view of the comparably high number of injuries have to undergo a basic course and biannual refresher occurring in professional and amateur football we had courses thereafter. It was therefore felt that systematic established in our literature reviews and studies and the inclusion of “The 11” in the training of coaches would popularity of football, injuries are not only a concern be the most effective and efficient way to reach out to for the individual player and their team, but as much the hundred thousands of players in Switzerland. All for health care providers and accident insurers. Several SFV instructors learned not only the essentials of the attempts to estimate the costs resulting from diagnosis, programme exercises from a qualified sports physiothera- treatment, rehabilitation, absence from work etc. had pist, but also how to best teach “The 11” to coaches. shown the considerable impact on national health care systems, depending on the individual setting. This holds The intervention was planned to run over four years. A particularly true for countries with high standards of care representative sample of SFV coaches was interviewed and elaborate payment and compensation schemes. The before and after this period to assess training and match Swiss national accident insurance fund (SUVA) had for frequency including other injury details, and further some time followed the development in football with their knowledge of the programme and issues. increasing concern. In 2003, they had recorded 42,262 football injuries resulting in direct costs of USD 130 million and 500,000 lost working days. Alarmed by Results these statistics, they were looking for sustainable meas- ures to reduce the financial burden caused by the game Of the initially selected 1,574 coaches, 1,027 could be both for their institution and the Swiss economy. interviewed before the intervention. As only 30% of them were finally available for an interview after the F-MARC’s “The 11” injury prevention programme held intervention, a further random sample was drawn from promise to meet exactly these needs when presented to the large SFV coaches´ pool to complement the post- SUVA. Together with the Swiss Football Association intervention sample. Teams usually trained two times (SFV), three parties sharing the same interest in reduc- and had one match per week. Average team size was 19 ing football injuries decided to launch a so far unique players of whom about 14 usually participated in train- project, the implementation of an injury prevention pro- ing. gramme, F-MARC’s “The 11” (see chapter 3.2.1), on a national scale in September 2004. The process and effect Before the intervention, 72% of injuries occurred dur- of this implementation would be scientifically evalu- ing match play, and 85% concerned the lower extrem- ated to gain insight in the challenges of such projects, as ity. The most frequent injury types were thigh strains nothing of this scale had been undertaken before. and ankle sprains. About 70% of injuries were suffered without contact with another player and 88% resulted in absence from training or match play. About a fifth Aims of the study of injuries each resulted in 1-2, 2-4 or more than four weeks absence. UÊV iÛiÊ>ÊÀi`ÕVÌÊvÊ£ä¯ÊÊÕÀiÃÊÊ-ÜÃÃÊ amateur players aged 14-65 years through use of an From 2005 to 2007, 5,549 coaches were trained in “The exercise-based prevention programme 11”, and their rating of the programme was overall good. UÊÃÃiÃÃÊÌ iÊ«ÀViÃÃÊ>`ÊivviVÌÊvÊÌ iÊ>ÌÜ`iÊ«i- After the intervention in 2008, 79% of coaches knew mentation of such injury prevention programme “The 11”, and 57% said they were currently performing the programme with their team(s). Those who did not use “The 11” either did not know the programme, were employing similar exercises, or claimed a lack of time or other priorities. Coaches who employed the programme F-MARC PROJECTS | PREVENTION OF FOOTBALL INJURY 127
portion of coaches knowing the programme (80%) and actually performing it (57%) in 2008 was considered a success of the implementation even though compliance, meaning how regularly and how many of the exercises were performed, could have been improved. In fact, only 40% of coaches instructed exclusively the original exer- cises, and more than half of them only once a week. In this study, however, higher compliance did not result in fewer injuries, which was attributed to the attention paid to correct performance of exercises in this study which might actually be more important. Importantly, “The 11” was able to reduce match injuries by 12% and training injuries by 25% despite suboptimal com- pliance, pointing to the potential of injury prevention through exercise-based programmes in amateur play- ers. These results are even more remarkable as they were achieved in a nationwide launch of the programme and Fig. 3.4.1.1 Injury frequency during match play and training including time loss injuries in Swiss amateur players before and after implemen- not in a controlled research setting as in other studies. tation of F-MARC´s “The 11“ The positive impact was further reflected in the statistics of SUVA who recorded 10% more players, but only 2% instructed on average 3.7 exercises of the programme more injuries in 2008 as compared to 2003, resulting in for a mean duration of 13 minutes either once (59%) or a cost reduction for the insurers and health care provi- twice (33%) per week, and more than half of them had ders. done so for more than six months. Basically all coaches (98%) paid attention to the correct performance of exer- cises.
Teams performing “The 11” in 2008 had an 11.5% lower match injury incidence during the last four weeks as compared to non-11 teams who did not perform the programme, and 17% lower than compared to before the intervention. Non-contact injuries were more mark- edly reduced by 27%. With regard to training injuries over the last four weeks, “The 11” teams had 25% less injuries than non-11 teams in 2008, and 19% less than what had been recorded in 2004 (Fig. 3.4.1.1).
What we learned from the study
The frequency and characteristics of injury as well as the differences between male, female, youth and senior play- ers did not differ from what had been found in injury studies in football before. The proportion of injuries Duration: 2002 - 2008 occurring without contact with another player of 70% Country: Switzerland was higher than what had been reported in other studies, Cooperation: Swiss Accident Insurance Fund, Swiss Football however appeared to be favourable for the effectiveness Association of an exercise-based prevention programme. Reference: Junge A, Lamprecht M, Stamm H, Hasler H, Bizzini M, Tschopp M, Reuter H, Wyss H, Chilvers C, Dvořák J There seemed to be a comparably high motivation of the (2011). Country-wide campaign to prevent football injuries in coaches to implement injury prevention, and the pro- Swiss amateur players. Am J Sports Med 39(1): 57-63 128 PREVENTION OF FOOTBALL INJURY | F-MARC PROJECTS
3.4.2 Country-wide Campaign to Prevent Oceania Player of the Century) to further ensure media Football Injuries in New Zealand coverage.
Community and recreational football players and coach- The New Zealand situation es also were in attendance and a selection of these indi- viduals played a seven-a-side game on the main North New Zealand Football (NZS) and the Accident Com- Harbour Stadium pitch after having completed “The pensation Corporation (ACC) of New Zealand work 11”. The game was used to demonstrate other injury collaboratively on injury prevention initiatives. Obvi- prevention messages including fair play, safe technique ously, both have a vested interest in reducing injuries in and proper hydration. Press releases and invitations were football. In July 2004, ACC and NZS formally initiated sent out in due advance and the event resulted in good a structured, nationwide injury prevention programme. television and newspaper coverage. Subsequent articles ACC provided financial support to NZS to appoint a were published in professional publications and maga- dedicated Injury Prevention Manager (possibly the first zines specifically aimed at players, coaches and medical such appointment within a national football organisa- staff involved in football in New Zealand and beyond. tion), as well as funds to develop the injury prevention Copies of all “The 11” resources were distributed to all programme and strategies. launch attendees and invited guests.
In the ACC financial year 2003, there were 1,240 new football entitlement claims. An entitlement claim is a Distribution of “The 11” in New Zealand moderate to serious injury requiring entitlement beyond medical treatment only, as defined under the New Zea- NZS discussed distribution of “The 11” to its seven land Injury Prevention, Rehabilitation, and Compensa- regional federations and achieved approval in principle tion Act of 2001. Typically, an entitlement claim will for distribution to clubs throughout the country. have a mix of medical, income replacement and reha- bilitation costs associated with an injury. It was calcu- NZS and ACC chose to implement the following “The lated that football entitlement claims cost ACC over four 11” resources kit that FIFA have developed: “The 11” million NZ dollars each financial year. The 1,240 new DVD (Fig. 3.4.2.1), brochure and poster. ACC funded football entitlement claims in 2003 meant an increase of the reproduction of the above resources and promoted 13% from the previous year (1,097 claims). Ninety-five their use by making the resources available to the foot- percent of the people making new football entitlement ball community of New Zealand at no cost. claims were aged 14 or older which is also the target audience of “The 11” and as such, “The 11” fitted well within the NZS Injury Prevention Programme and ini- Distribution in New Zealand occurred primarily in tiatives. three ways:
UÊ/ ÀÕ} Ê>ÊvÀiiÊ« iÊÕLiÀÊ«>`ÊvÀÊLÞÊ ®Ê The launch of “The 11“ for the public to call to obtain a copy of “The 11” resources To generate interest and inform the football commu- UÊ/ ÀÕ} Ê iÜÊ>`ÊÌL>]ÊÌ iÊÃiÛiÊi`iÀ>ÌÃÊ nity on “The 11”, an official launch of “The 11” was of Football in New Zealand and NZS affiliated foot- scheduled for 1 March 2005 at North Harbour Stadium, ball clubs nationwide Auckland, with Professor Jiří Dvořák, FIFA Chief Medi- UÊ/ ÀÕ} ÊÌ iÊ iÜÊ>`Ê-iV`>ÀÞÊ-V Ê-«ÀÌÃÊ cal Officer and chairman of F-MARC, present. Having Council (NZSSSC). Every school in New Zealand FIFA representation present in New Zealand to launch has a sports coordinator and NZSSSC had agreed to “The 11” was intended to create positive media interest distribute “The 11” via the sports coordinators to all and to encourage more people to use “The 11”. It was schools where football is played. proposed that the Minister for Sport, the Honourable Trevor Mallard, be invited to attend the launch as well This distribution system was meant to ensure optimal as some football personalities (e.g. Wynton Rufer, FIFA coverage of “The 11” in New Zealand. F-MARC PROJECTS | PREVENTION OF FOOTBALL INJURY 129
Also identified were target coaches as well as players. The evaluation of success Coaches have a significant influence on the training and playing technique of players and their involvement is an Evaluation occurred in three ways: indispensable part of the implementation of any preven- UÊÊV«>ÀÃÊvÊ ÊiÜÊvÌL>ÊiÌÌiiÌÊV>ÃÊ tion programme. A goal was to train as many registered data. In 2003, there were over 1,200 moderate to seri- coaches as possible in the delivery of “The 11”, but at ous claims and 13,000 minor claims. Claims relating the same time it was recognised that “The 11” can be specifically to knee and ankle soft tissue injuries were used without formal training and that printed and video monitored. resources had been developed with simplicity in mind. UÊÊÌL>Ê-ÕÀÛi>ViÊ-ÌÕ`ÞÊÛÛi`ÊÌii« iÊÌiÀ- This option for independent self-education was particu- views with each of over 500 players on a weekly basis larly important as reportedly only 26% of New Zealand throughout the 2005 football season. adult football players are coached. Training in “The 11” UÊÊÀi}Õ>ÀÊÃÕÀÛiÞÊÌ >ÌÊi>ÃÕÀi`ÊvÌL>Ê«>ÞiÀýÊÜ- was performed by the NZS Senior Physiotherapist and edge, attitude and behaviour towards injury. directed at NZS Technical Department personnel and the National Development Officers who are responsible for “up-skilling” coaches at all levels of the game. Refer- ence to and/or training in “The 11” became part of eve- ry NZS Coaching and Education Scheme course.
New Zealand research team with the coach of national team
Duration: 2004 - 2008 Country: New Zealand Fig. 3.4.2.1 “The 11” DVD Cooperations: Accident Compensation Company, New Zealand Soccer References: “The 11” DVD for soccer. DVD promoting injury prevention for soccer players. http://www.acc.co.nz/publications/index. htm?ssUserText=ACC2137 130 PREVENTION OF FOOTBALL INJURY | F-MARC PROJECTS
3.4.3 From Development to Worldwide to implement an injury prevention programme with Dissemination their team (Fig. 3.4.3.1).
“FIFA 11+” is best taught in a workshop that includes Development of injury prevention programmes theoretical background knowledge and practical demon- stration of the exercises (See chapters 3.3.5. and 3.3.6). In 2000, F-MARC conducted its first study on the pre- Additionally, the cooperation with famous players and vention of football injuries showing 21% fewer injuries coaches acting as “FIFA 11+” ambassadors (see www.f- in the intervention compared to the control group (See marc.com/11plus) has helped significantly in the com- chapter 3). The interventions were focused on improv- munication with coaches and players. ing the structure and content of the training by edu- cating and supervising the coaches and players. The programme included preventive interventions such as improvement of warm-up, regular cool-down, taping of unstable ankles, adequate rehabilitation, promotion of the spirit of fair play and ten sets of exercises designed to improve coordination, stability of the ankle and knee, flexibility and strength of the trunk, hip and leg muscles. Based on the experiences with this study and in coop- eration with international experts, F-MARC developed a basic injury prevention programme for amateur football players called “The 11” (See chapter 3.2.1).
“The 11” was implemented in two countrywide cam- paigns (Switzerland and New Zealand) in cooperation with the national accident insurance company and the national football association. The results of both cam- paigns showed a reduction of training/match injury rates and savings of health-care related costs (See chapters 3.4.1 and 3.4.2).
Based on experiences with “The 11”, the “PEP” (Prevent Injury and Enhance Performance programme) and other exercised-based programme to prevent football injuries, an advanced version (“FIFA 11+”) was developed in 2006 together with the OSTRC and the Santa Monica Orthopaedic and Sports Medicine Research Foundation. Large RCTs showed significant lower frequency of inju- ry in female and male football players practising “FIFA 11+” at least twice a week as a standard warm-up before training (See chapters 3.3.1 – 3.3.3).
Development of dissemination strategy Fig. 3.4.3.1. Guideline “11 Steps to FIFA 11+” The national Football Associations of Spain, Japan, Italy, Brazil and For F-MARC, the coach is the key person to promote Germany integrated “FIFA 11+” in their coaching or physical train- ing/education curriculum. Thus, the world football champions took injury prevention to their players. While the coach, espe- the lead and acted as role models, and other countries (see Figure 2) cially at a low level, has to regard various aspects in the followed. training (e.g. physical preparation, tactics, fair play, team success), it is important to raise the coach’s motivation F-MARC PROJECTS | PREVENTION OF FOOTBALL INJURY 131
Worldwide dissemination of “FIFA 11+” Future directions
FIFA started the dissemination of “FIFA 11+” in its In the next years FIFA and F-MARC will continue the 209 member associations (MAs) in 2009. Related mate- worldwide implementation of the “FIFA 11+”, with par- rial includes a detailed manual, an instructional DVD, a ticular attention on seeking the best possible cooperation poster, a website and a promotional booklet with DVD. with the member associations adopting the “FIFA 11+” All material is available in several languages on www.F- injury prevention programme. MARC.com/11plus. Based on the experience with the countrywide implementation in Switzerland and New Zealand, a guideline on how to implement the “FIFA 11+” injury prevention programme on a larger scale in amateur football was developed. The implementation is conducted either in close cooperation with MAs or via FIFA Coaching Instructor courses.
Fig. 3.4.3.2. World map with countries where coaches attended a FIFA 11+ Instructor course (18/09/2013)
Duration: 1999 - ongoing Countries: International Cooperation: FIFA Technical Department, MAs of Spain, Japan, Italy, Brazil, Germany, Costa Rica, Hong Kong, Netherlands, Denmark, Poland, Hungary, Australia, England, Thailand, Liechtenstein Reference: Bizzini M, Junge A, Dvořák J (2013). Implementation of the FIFA 11+ football warm up program: how to approach and convince the Football associations to invest in prevention. Br J Sports Med 47(12):803-806 132 PREVENTION OF SUDDEN CARDIAC DEATH | F-MARC PROJECTS
4 Prevention of Sudden Cardiac Death 4.1 Pre-Competition Medical Assessment (PCMA)
4.1.1 PCMA at the 2006 FIFA World Cup™ prior the event, the requirements for the performance of the assessment were explained to all team doctors. Pri- or to assessment of the data, all player and team details Why we conducted this study were anonymised by allocating fictional team and player names. In order to retrospectively analyse the paper- Pre-competition medical assessments (PCMA) in sports based data and explore possibilities to improve the ques- at different levels are generally advocated by health pro- tionnaire by using an electronic format, F-MARC asked fessionals and sports organisations alike. Still, to date, the Cerner Corporation, USA, to convert the paper form there is not one specific approach to the PCMA or to into an electronic one and establish an electronic data- establish best practices for risk factor determination base suitable for statistical analysis. Apart from refusal or prior to participation in sports. In general, a standard- non-submission of consent by the player, no exclusion ised, validated PCMA that meets medical standards for criteria were defined for the analysis of data. The criteria quality and provides sensitive screening is highly desir- of analysis were as follows: Completeness of question- able. It seems, however, that the pre-competition medi- naire, quality of information, positive findings on the cal assessment of athletes should be tailored to the type pre-competition medical assessment form. The cardiac and scope of activity in the respective sport, gender, age assessment results were reviewed by two independent and the level of performance. A particular concern is the sports cardiologists. prevention of Sudden Cardiac Death, a tragic event that might be triggered by exercise in case of an underlying heart disease in a player (See chapter 4.2). F-MARC Results decided to develop a standardised PCMA specifically for the world’s elite football players prior to the 2006 FIFA Of all 32 teams participating in the 2006 FIFA World World Cup Germany™ as a pilot project. Cup™, the completed questionnaires of 26 teams cor- responding to a response rate of 81% were returned by their team doctors and entered into the database. In Aims of the study total, the assessments of 582 players could be analysed as the forms of 16 players of four teams were no submitted. UÊ Ài>ÌiÊ>ÊÀiÊ`iÊvÀÊÌ iÊ«ÀiV«iÌÌÊi`V>Ê The average age of the players that took part in the 2006 assessment of international elite football players aimed FIFA World Cup™ was 26.8 years. The average degree at maximum certainty to identify cardiac risk factors of completeness of the whole PCMA among the differ- UÊÃÃiÃÃÊÌ iÊvi>ÃLÌÞÊvÊÃÌ>`>À`Ãi`ÊÀiµÕÀiiÌÃÊvÀÊ ent teams ranged from 78% to 94%. Average complete- international teams from countries with variable medi- ness of the different sections of the PCMA was by far the cal backgrounds highest for the medical history and the general examina- UÊ iVÌÊ`>Ì>ÊÊÀÃÊv>VÌÀÃÊvÀÊÀiÌÀëiVÌÛiÊ>>ÞÃÃÊÊ tion, indicating that the team doctor were well aware of this target group the vital importance of these parts of the PCMA (Tab. 4.1.1.1)
How we collected the data Some deficits regarding the quality of the completion of the form were identified indicating the need for more The design and development of the PCMA form was detailed instruction and further improvement of the focused on the cardiovascular and the musculoskel- design of the form and for the provision of norm values. etal system. It included a 12-lead resting electrocardio- Free text entries were whenever possible to be avoided. gramme (ECG), a maximal exercise test and an echocar- In the summarising assessment of the PCMA, all play- diography. The assessment of the musculoskeletal system ers were considered eligible for competitive football. The was based on the F-MARC Football Medicine Manual. team doctors reported suspected heart disease in three Finally, the examining physician had to conclude on the players, one of them a player with known hypertrophic eligibility of the player for competitive football. cardiomyopathy. Six of the 582 players participating in the 2006 FIFA World Cup™ retrospectively had find- The performance of the FIFA PCMA was requested for ings on echocardiography suspicious of serious cardio- all players participating in the 2006 FIFA World Cup vascular disease demanding further investigation. Germany™. At the FIFA team workshop three months F-MARC PROJECTS | PREVENTION OF SUDDEN CARDIAC DEATH 133
Training Medical General Cardiovascular Laboratory Orthopaedic Summarising history history examination system examinations examination assessment
Completeness 81% 98% 95% 78% 84% 90% 82%
Tab. 4.1.1.1 Player medical questionnaire - average completeness by section
While these findings were not further commented under “notes”, further investigations might still have been con- ducted by the examining physician yet not reported as this had not been explicitly asked for on the form. The main limitation of the exercise stress test was that most of the players were not tested to their maximum capac- ity, which is a pre-condition for a valid interpretation of results.
What we learned from the study
A pre-competition medical assessment for international elite football players was implemented at the 2006 FIFA World Cup Germany™. The excellent response rate demonstrated that such a standardised approach is feasi- ble at an international level despite of different standards of care in the home countries of teams. Based on the findings, the FIFA PCMA was further optimised. Based on the cardiological review, it was decided to remove the exercise testing from the standard PCMA as the addi- tional diagnostic value was considered to be low and acceptance of the test within the scope of the PCMA appeared to have been low. Duration: 2006 - 2008 However, the PCMA form is only one aspect in ensur- Countries: International ing quality of results. The varying standards of medicine Cooperation: All team physicians of the 2006 FIFA World TM worldwide, the exacting organisational aspects of nation- Cup ; Prof. Thomas Lüscher, MD, Switzerland; Simon al teams, the costs and liability issues have to be taken Wallace and Samuel Geraint, Cerner Corporation, USA. into consideration when planning a standardised imple- References: Dvořák mentation. J, Grimm K, Schmied C, Junge A (2009). Pre- competition medical assessment of international elite football players – 2006 FIFA World Cup Germany™. Clin J Sport Med 19(4): 316-321 Thünenkötter T, Schmied C, Grimm K, Dvořák J, Kindermann W (2009). Pre-competition cardiac assessment of football play- ers participating in the 2006 FIFA World Cup Germany™. Clin J Sport Med 19(4): 322-325 Junge A, Grimm K, Feddermann N, Dvořák J (2009). Pre- competition orthopaedic assessment of international elite foot- ball players. Clin J Sport Med 19(4): 326-328 Thünenkötter T, Schmied C, Dvořák J, Kindermann W (2010). Benefits and limitations of cardiovascular pre-competition screening in international football. Clinical Research Cardiology 99(1): 29-35 134 PREVENTION OF SUDDEN CARDIAC DEATH | F-MARC PROJECTS
4.1.2 PCMA at the 8th African U-17 Results Championships The revised version of the PCMA when performed by an independent expert group prior to the competition in Why we conducted this study the host county proved to be feasible and well accepted by team doctors, players and member associations. All The study on the pre-competition medical assessments eight teams qualified for the 8th African U-17 Cham- (PCMA) prior to the 2006 FIFA World Cup™ had pionship 2009 in Algiers took part in the study, cor- shown considerable differences in the quality of data, responding to a total of 155 male players. No language raising concerns on the correct performance of the exam- problems were encountered as the examining physicians inations. Having adapted the F-MARC PCMA accord- spoke English and French. According to the official ing to the results of this study, the idea was to stand- player list, the examined players were on average 16.4 ardise conditions in order to ensure consistent quality. years old (range 14 to 17). The participants originated We chose an approach where we identified a group of from different ethnic groups (approximate classifica- F-MARC experts that would conduct the PCMA on all tion): Bantu (two teams), Semitic-Hamitic (one team), players participating in the competition together with Mande (one team) or a combination of different ethnici- the medical team of the local organising committee ties (four teams). and the team doctors prior to the start of the competi- tion at the location. The 8th African U-17 Champion- In three teams, all players had been medically examined ship organised by CAF in March 2009 was identified as at least once before the PCMA. In the other teams, the an ideal opportunity to test this approach. It would also number of players already examined was lower and var- allow us to gain insight into the medical care and condi- ied considerably, in one team, only one player (6%) had tions for performing the PCMA at a lower level of play ever been assessed before. and in youth male players where we knew from experi- ence that the resources allocated, both financial and Nine (5.8%) players reported cardiac symptoms and two human, differ considerably from senior men’s national players had elevated blood pressure. A total of 40 play- teams across member associations. ers (25.8%) showed abnormal ECG patterns. None of the players with abnormal ECG patterns had any suspi- cious echocardiographic findings. The echocardiogram Aims of the study of one player raised suspicion of early-stage hypertrophic cardiomyopathy, another player’s heart muscle struc- UÊÃÃiÃÃÊÌ iÊvi>ÃLÌÞÊvÊÌ iÊ* Ê«iÀvÀi`ÊLÞÊ>Ê ture showed characteristics of non-compaction cardio- team of experts prior to the competition myopathy, but both players had normal ECGs. Thirteen UÊ-VÀiiÊ>Ê«>ÞiÀÃÊ«>ÀÌV«>Ì}ÊÊÌ iÊnth African (8.4%) players showed echocardiographic findings that U-17 Championship for cardiac risk factors using the required further follow-up. F-MARC standardised PCMA The team doctors were informed about these findings since they were responsible for the decision on the eligi- How we collected the data bility of players to play in the competition. The percent- age of players with altered ECG patterns and echocar- All players were examined by a group of physicians diographic measurements varied substantially between (orthopaedists, cardiologists) during the four days prior different ethnic groups. to the start of the competition. Teams were allocated time slots where all players were guided through a circuit with different stations where the individual parts of the What we learned from the study PCMA were performed by experienced colleagues. The assessment of the musculoskeletal system was based on With adequate preparation, performance of the PCMA the F-MARC Football Medicine Manual. The cardiac on the spot with a team of experts proved feasible and assessment consisted of a medical history, clinical exami- might be a way to avoid varying quality of examination nation, 12-lead resting ECG and echocardiography in impairing the validity of results. However, the shorter accordance with the most recent guidelines. the period prior to the start of the competition, the more F-MARC PROJECTS | PREVENTION OF SUDDEN CARDIAC DEATH 135
restricted are the possibilities for further investigations of suspicious findings.
History taking could be of limited value as players might fear exclusion of the competition. Interpretation of ECG findings poses a challenge in black players as they are known to have significantly more alterations than e.g. Caucasians. This might account for the difficulties in identifying black athletes at risk, leading to the seem- ingly higher incidence of adverse cardiac events in black athletes. Furthermore, ethnic differences in the structure and function of the heart need to be considered when drawing conclusions from examination results.
Duration: 2009 Countries: International Cooperation: All team physicians of the 8th CAF U-17 Championship; Pieter D’Hooghe, MD, Belgium; Winne Meeuwisse, MD, Canada Reference: Schmied C, Zerguini Y, Junge A, Tscholl P, Pellicia A, Mayosi B, Dvořák J (2009). Cardiac findings in the precompetition medical assessment of football players participating in the 2009 African Under-17 Championships in Algeria. Br J Sports Med 43(9): 716-721 136 PREVENTION OF SUDDEN CARDIAC DEATH | F-MARC PROJECTS
4.1.3 PCMA in International Football – Results Feasibility and Considerations All U-20 teams and 89% of U-17 teams confirmed hav- ing performed the PCMA and all U-17 and slightly Why we conducted these studies less than half of the U-20 teams submitted their forms. A total of 147 U-20 and 297 U-17 forms could be Since F-MARC’s initiative at the 2006 FIFA World reviewed and analysed. Cup, the literature on the pre-competition medical assessment (PCMA) in international sport had continu- In African, Asian, Central and South American teams, ously grown. Experts generally agreed on the necessity the team doctor usually coordinated and supervised of the PCMA, advocated the implementation and rec- all examinations and completed the eligibility state- ommended specific approaches. Still, only a few reports ment. Data was organised in separate files per player were published elaborating on the actual practical per- with mostly all original results included. Different from formance of the PCMA in different sports, and little was that, North American and European teams often used known about the challenges facing sports organisations several physicians to complete the examinations, result- and teams when trying to meet the requirements of a ing in variable completeness and quality of data. None standardised PCMA in their individual setting. Having of the players reported any signs or symptoms, only investigated the feasibility of the PCMA at the highest one African player reported what was understood as an level of play in football, F-MARC wanted to assess the event of sudden cardiac death in her family. There were feasibility of the same standardised PCMA at female no abnormal findings on physical examination. In the youth World Cups, a level of play with comparably less ECG of players, the most often reported finding was funding and support as compared to the senior teams in what is called an incomplete right bundle branch block, member associations worldwide. a common finding in athletes. There were no mani- fest pathological findings on echocardiography. In two teams, however, the respective cardiologist reported a Aim of the studies mild backflow from different valves of the heart in eight and nine players, respectively. One cardiologist recom- UÊÃÃiÃÃÊÌ iÊvi>ÃLÌÞÊ>`ÊV«>ViÊÜÌ Ê«iÀvÀ}Ê mended these findings for follow-up whereas the other a comprehensive PCMA in teams participating in the did not. U-17 and U-20 FIFA Women’s World Cups Only one U-20 team accepted the offer to perform the echocardiography at the venue. All other teams consid- How we collected the data ered this to be disruptive to their preparation.
All participating teams of the 2010 FIFA U-17 and All players were declared eligible to play. U-20 Women’s World Cups received a circular highly recommending the performance of the F-MARC stand- ardised PCMA in all their players prior to the competi- What we learnt from the studies tion. At that time, there was not regulatory base to make the PCMA a requirement for participation, therefore the The acceptance of performing the PCMA in female performance remained voluntary. FIFA did not provide youth players among FIFA member associations was funding for the examinations but at the U-20 World remarkably high, and the quality of data submitted par- Cup offered to perform the echocardiography at the ticularly from African, Asian, Central and South Ameri- competition venues at no cost for the teams. Submission can teams exceptionally good. We observed that the of the forms to F-MARC was also voluntary and not quality increased when the team doctor was in control specifically requested. Teams were only asked to confirm of and coordinated all examinations, and completed the if they had performed a PCMA in their players. forms.
The F-MARC PCMA form was slightly amended with An important lesson learnt was the refusal of the major- questions on the menstrual cycle and measurements of ity of teams to perform examinations at the venues calcium and ferritin to assess specific female aspects. prior to the competition since they considered this to F-MARC PROJECTS | PREVENTION OF SUDDEN CARDIAC DEATH 137
be disruptive for their preparation. At the same time, it became clear that the interpretation of the ECG and echocardiographic findings largely depends on the expe- rience of the individual cardiologist with changes in the athlete’s heart.
The high acceptance and compliance of member asso- ciations at the women’s youth World Cups with the PCMA proved its feasibility even at lower levels of play. This was well received by the FIFA administration, and the most important consequence of these studies was the decision of the FIFA Executive Committee to make the PCMA a mandatory requirement at all FIFA World Cups™.
Duration: 2010 - 2011 Countries: International Cooperation: All team physicians of the respective FIFA World CupsTM. References: Tscholl PM, Dvořák J (2011). Pre-competition Orthopaedic Assessment in Elite Athletes – Experiences and General Considerations from International Football. European Musculoskeletal Review 6(4): 260-264 Dvořák J, Grimm K, Schmied C, Junge A (2012). Feasibility of Pre-competition Medical Assessment (PCMA) at FIFA World Cups for female youth players. Br J Sports Med 46(16):1132- 1133 138 PREVENTION OF SUDDEN CARDIAC DEATH | F-MARC PROJECTS
4.1.4 PCMA of Referees and Assistant The 51 referees and assistant referees selected for the Referees FIFA Women’s World Cup 2011™ were examined just prior to the event at the location by a team of F-MARC experts including a female cardiologist. The screening Why we conducted these studies was performed in collaboration with local clinics. The female referees did not undergo exercise testing as they FIFA and F-MARC had been pioneers in performing tended to be younger than their male counterparts and pre-competition medical assessment (PCMA) of players did not exhibit cardiac risk factors. and developed a standardised PCMA which they tested at different levels as described in the previous chapters. There was a considerable body of knowledge in the lit- Results erature on the different approaches to PCMA in young athletes and players. In football, the referee at a match The male referees had an average age of 39 years, the covers distances of comparable length and speed as the female referees of 33 years. player he or she supervises. Different from the players, however, referees are usually considerably older. With One male referee had diabetes and one referee had increasing age, risk factors and causes of sudden cardiac hypertension, both well controlled under treatment. (SCD) tend to change. Above 35 years of age, coronary Approximately 40% of the referees reported a history of heart disease becomes the most frequent cause of SCD cardiovascular disease. About one third of the male ref- in athletes. In view of their age-related risk and the phys- erees showed an abnormal finding on cardiac examina- ical load on referees during matches and training, it did tion such as murmurs on auscultation, suspicious ECG seem highly indicated to screen the world’s best referees changes or mild valve disturbances, however none of in a similar way to players prior to the two highest level these was shown to be of clinical relevance in the follow- international football events for men and women. up investigations. All referees demonstrated excellent physical fitness. Almost all referees showed some patho- logical finding in the orthopaedic examination, mainly a Aims of the studies laxity of the ankle or knee joints, but there was also lim- ited range of motion of the hip or local tenderness over UÊ-VÀiiÊ>ÊÀiviÀiiÃÊÃiiVÌi`ÊvÀÊÌ iÊÓä£äÊÊ7À`Ê the Achilles tendon and groin. Cup™ using the F-MARC standardised PCMA UÊ-VÀiiÊ>ÊÀiviÀiiÃÊÃiiVÌi`ÊvÀÊÌ iÊÊ7i½ÃÊ Among the female referees, four reported a family his- World Cup 2011™ using the F-MARC standardised tory of SCD. However, none of these referees had any PCMA pathological findings on examinations. In the personal medical history, the most commonly reported finding was an allergy. None of the referees had any symptoms How we collected the data at rest or when exercising. There were no pathological findings with regard to blood pressure measurements All 90 referees and assistant referees selected for the 2010 and only mild functional heart murmurs on ausculta- FIFA World Cup™ underwent the standard PCMA tion. All referees were completely asymptomatic and examination including medical history, physical exami- showed no abnormal findings in the resting ECG or nation, blood parameters, resting ECG and echocardiog- echocardiography with the exception of one referee with raphy by a team of F-MARC experts three months prior a change in one aspect of her ECG curve, which was rec- to the competition. All examinations were performed at ommended for regular follow-up. the FIFA Medical Centre of Excellence in Zurich on the occasion of a workshop for the referees at the Home of FIFA. Considering the higher age of the referees as com- What we learnt from the studies pared to players, and the consequently higher probabil- ity of asymptomatic coronary artery disease, all referees None of the female and male referees screened prior to underwent a self-limited exercise ECG in addition to the the FIFA World CupsTM showed any relevant pathologi- standard examinations of the FIFA PCMA. cal findings upon screening with the F-MARC standard- ised PCMA. Both approaches to the performance of the F-MARC PROJECTS | PREVENTION OF SUDDEN CARDIAC DEATH 139
Dr. D.Keller performing an echocardiography examination on a World Cup referee. (additionally, from left to right: Dr. C. Schmied, Dr. M.Bizzini and Prof. J. #UNŪ¨J) PCMA, either at a FIFA Medical Centre of Excellence on occasion of a workshop or prior to the competition at the spot proved to be feasible.
In view of the physical work load and average age of ref- erees in football, the PCMA should be performed regu- larly. The ideal interval will need to be identified based on the risk profile in referees and the progression of the underlying diseases, which differs considerably from that in younger players and athletes.
Duration: 2010 - 2011 Countries: International Cooperation: Christian Schmied, MD, Switzerland; Nina Feddermann, MD, Switzerland; Dagmar Keller, MD, Switzerland References: Bizzini M, Schmied C, Junge A, Dvořák J (2012). Pre- competition medical assessment (PCMA) of referees and assis- tant referees selected for the 2010 FIFA World CupTM. Br J Sports Med 46(5): 374-376. A PCMA in referees should consider an additional exercise ECG, Keller DI, Bizzini M, Feddermann N, Junge A, Dvořák J because of their higher average age (between 35-40 years old at elite (2013). FIFA Women’s World Cup 2011: Pre-Competition level) Medical Assessment of female referees and assistant referees. Br J Sports Med 47:179-181 140 PREVENTION OF SUDDEN CARDIAC DEATH | F-MARC PROJECTS
4.2 Risk Factors and Management of Sudden Cardiac Arrest
4.2.1 Statement on Sudden Cardiac Death mary cause is hypertrophic cardiomyopathy (HCM), an inherent disease of the heart muscle. Above the age of 35 years, the primary cause is coronary artery disease. Why we held the meeting HCM as the most common cause of SCD in young ath- letes is characterised by hypertrophy of, essentially, the On the one hand, regular physical exercise helps to pre- left ventricle of the heart. One to two percent of those vent and treat cardiovascular disease, but on the other suffering from HCM die per year, mostly due to ven- hand sports can serve as a trigger for Sudden Cardiac tricular rhythm disturbances. If there are any symptoms, Death (SCD). Participation in competitive sports in they are predominantly chest pain, dyspnea, rhythm dis- particular increases the likelihood of SCD. The vast turbances and fatigue. A resting electrocardiogramme majority of non-traumatic deaths in sports is caused by (ECG) is important as a screening method because the SCD that occurs up to 90% under the eyes of the public overwhelming number of patients with HCM will show during training or competition. The international foot- an abnormality. However, definite diagnosis of HCM is ball community had to witness such tragedy when Marc made with echocardiography. Vivien-Foé died on the pitch during the FIFA Confed- erations Cup 2003. Screening programmes Any such event, particularly in a young athlete, is not only a tragic event considerably affecting their personal In American athletes, the primary cause of death was entourage, but also the public in general as well as the found to be HCM in 36% of the athletes. The usual sporting world and sports medical community. There- pre-participation examination in the US includes history fore, screening of athletes to identify risk factors for taking and physical examination. This assessment had SCD is a concern for all sports organisations. In Decem- identified only three percent of athletes with suspected ber 2005, the International Olympic Committee (IOC) abnormalities, indicating that history taking and physi- convened an international meeting to in detail address cal examination was ineffective in identifying athletes the problem of SCD in young athletes. with underlying cardiovascular disease.
Italian law requires an annual clinical evaluation for What we learned from the meeting approval of athletes to participate in competitive sports. Since 1971, thousands of young athletes were screened Sudden Cardiac Death is defined as unexpected death by general history, a physical examination and a resting due to a sudden loss of heart function that occurs within ECG. Abnormal or equivocal evaluations were followed- one hour of the onset of symptoms in a person with- up with echocardiography, 24-hour ECG-monitoring out previously recognised cardiovascular conditions and a maximal exercise test as needed. Following this that would appear fatal. This excludes any non-cardiac programme, the major cause of SCD found in Italy causes. Pre-existing heart symptoms or diseases may have was arrhythmogenic right ventricular cardiomyopathy, been known to be present, but the time and mode of another inherited heart muscle disorder. Different from death are unexpected. the American study, HCM caused only one death in The rate of SCD in sportspeople in general or in football athletes (2.0%) vs. 16 in non-athletes (7.3%) in Italy. players is not exactly known. In American high school athletes, predominantly basketball and American foot- The overall prevalence of HCM among young non-ath- ball players, it had been reported to be about one death letes who died suddenly was similar in both countries. in 200,000 athletes. A report on 269 victims of SCD in Among young athletes who died suddenly, however, the Italy showed that 49 were in athletes and the remain- prevalence of HCM was very different: 2% in the Ital- ing 220 were in non-athletes, accordingly, the rate was ian study versus 24% in the American study. It there- 1.6 per 100,000 athletes per year as compared to 0.8 per fore seemed that systematic pre-participation screening 100,000 inhabitants per year. Thus, SCD rate for ath- in Italy effectively disqualified those at risk for SCD, letes was twice as high as the rate for non-athletes. The primarily those due to HCM. The Italian physicians leading causes of non-traumatic sudden death in athletes concluded that a “the identification and disqualification are related to pre-existing cardiac abnormality and age- of affected athletes at screening before participation in dependent. In athletes under the age of 35 years, the pri- competitive sports may have prevented sudden death.” F-MARC PROJECTS | PREVENTION OF SUDDEN CARDIAC DEATH 141
LAUSANNE RECOMMENDATIONS for Sudden FIFA’s responsibility to protect players Cardiovascular Death in Sport IOC Medical Commission, 10 December 2004 The medical community needs to focus on identifying Preparticipation cardiovascular screening for athletes young athletes with HCM as the most common cause under 35 years starting to compete should include: of SCD. FIFA strongly supports preventive screening in football but acknowledges the difficulties in establishing Step 1 standardised requirements. To date, the scientific and Personal history taking (see table 4.2.1.1) medical community have not reached a consensus on Family history taking (see table 4.2.1.1) the ideal pre-competition medical assessment. To further Physical examination with palpation of pulses and heart investigate the matter, the FIFA Medical Committee auscultation and F-MARC developed a specific assessment for all the 12-lead rest ECG players participating in the 2006 FIFA World Cup Ger- many™ (See chapter 4.1.1; Fig. 4.2.1.1). Step 2 Selected cases with a suspicious finding on personal However, apart from the methodological and logistical history, family history of potentially inherited cardiac dis- problems in the implementation of cardiac assessment, ease, or with suspicious physical or ECG findings in Step the exclusion of a player from play leads to numerous 1 require further evaluation by an age-appropriate cardi- ac specialist to qualify the athlete for sport participation. personal, financial, social, ethical and legal consequenc- es and places a high burden on the team doctor. At the same time, the reasons and circumstances in which full Examples of important questions to the player participation should be modified or disallowed are not clearly established. Have you ever fainted or passed out when exercising?
Have you ever had chest tightness, cough, or wheezing which made it difficult for you to perform in sports? Do you have or have you ever had racing of your heart or skipped heartbeats?
Do you get tired more quickly than your friends do during exercise?
Have you ever been told you have a heart murmur, a heart arrhyth- mia, rheumatic fever?
Are you taking any medications at the present time?
Has anyone in your family under the age of 50 years old died sud- denly and unexpectedly? Has anyone in your family been treated for recurrent fainting? The son of Marc Vivien Foé (who died on the pitch in 2003) speaks at Has anyone in your family suffered unexplained drowning while the FIFA Confederations Cup 2009 swimming? Has anyone in your family had an unexplained car accident?
Has anyone in your family had heart surgery? Duration: 2005 Has anyone in your family experienced sudden infant death (cot death)? Countries: International Cooperation: IOC Tab. 4.2.1.1: Some of the questions to be asked to a player as recom- Reference: mended by the IOC IOC Medical Commission, International Olympic Committee. Sudden cardiovascular death in sport: Lausanne recommen- dations; Pre-participation cardiovascular screening. 2004. http://www.olympic.org/Documents/Commissions_PDFfiles/ Medical_commission/IOC_CONSENSUS_STATEMENT_ ON_SUDDEN_CARDIOVASCULAR_DEATH_IN_ SPORT_2004.pdf 142 PREVENTION OF SUDDEN CARDIAC DEATH | F-MARC PROJECTS
4.2.2 Practical Management of Sudden portable, automatic external defibrillator (AED) within Cardiac Arrest on the Field of Play 1-2 minutes has a success rate of 90% for resuscitation by converting the heart rhythm back to normal. The probability of success for any attempt to defibrillate the Why we conducted these reviews player thereafter steeply declines with the time elapsed (about 10% per minute), and, at the same time, the Time and again, the football family is deeply stirred by probability of permanent brain damage increases. Man- reports of apparently healthy players dying on the pitch, ual chest compressions may help to maintain minimal or even the live broadcasting of such tragic events. Due blood flow to the brain, but do not suffice to keep the to the popularity of the game and its broad media cov- victim alive. erage, a series of cases involving popular players has achieved sad publicity over recent years, creating a per- In football, there are several reasons leading to a delay of ception in the media and the public that these events treatment in incidents of SCA. The Laws of the Game occur particularly often in football. Sudden Cardiac are such that medical staff is only allowed to run onto Arrest (SCA) is the unexpected, sudden stop of heart the pitch and provide care to an injured player when action which will inevitably lead to Sudden Cardiac being specifically called to do so by the referee. If a Death (SCD) as described in the previous chapter unless player goes down in the course of action in a match, e.g. immediately treated by an electrical shock. The possible through contact with another player, the referee is usu- causes and underlying disease have also been elaborated ally nearby and may assess the player immediately. If a on in the previous chapter. It does appear from more player collapses due to SCA, this does not necessarily recent studies, that the incidence of SCD might in fact happen during a fight for the ball but might in fact do so be far higher than what had been estimated in 2005. far away of the current match action. Therefore, the ref- The time available to save a player’s life basically is a few eree needs to first become aware of an event which is not minutes in SCA, and there are multiple examples of inci- in the centre of their attention, then recognise the sever- dents at football matches where these minutes elapsed ity, then approach the player and assess them before he without appropriate action. We therefore conducted a may finally call the medical team on the pitch. Given the review of the literature and the current practice in the 1-2 minute time limit mentioned above, all these actions management of SCA in football to identify the reasons might already take up a large part of the time available to for this failure and give recommendations to improve successfully resuscitate the player. the situation. Further, players with SCA often show seizure-like move- ments in the first moments, most likely due to a lack Aim of the reviews of oxygen in the brain, which might be mistaken for a seizure or even normal movement. Players may also UÊ-Õ>ÀÃiÊÌ iÊVÕÀÀiÌÊÜi`}iÊ>`Ê«À>VÌV>Ê>- exhibit what is called agonal breathing which is different agement of SCA in football and conclude on recom- from normal breathing but again might be mistaken for mendations for best practice breathing still taking place. These signs and symptoms, albeit typical, might not be recognised by the insuffi- ciently trained responder, resulting in further delay of How we collected the data diagnosis and treatment of SCA. Until an AED is avail- able for defibrillation, the only indicated action in SCA A review of the current literature, the current regulations is immediate chest compression to maintain some blood and rules applying to medical treatment on the pitch flow to the brain. There are also several examples where and recent examples of SCD and its management in the physician called on the pitch did not take the appro- football was performed. priate action, most likely due to a lack of training in the specific treatment of SCA. Usual sports medicine train- ing rarely includes the acute management of SCA, and Results even less so regular practice of the same under life condi- tions which is essential to exert the required routine pre- In a player collapsing on the pitch because of SCA, an cisely. electrical shock (called defibrillation) performed with a F-MARC PROJECTS | PREVENTION OF SUDDEN CARDIAC DEATH 143
Finally, the availability of an AED within close proxim- kit to each of their member associations and practical ity of the pitch is not yet standard at football matches training at courses to the national football physicians. all over the world. If action is to be taken within 1-2 The recommended change in the provisions of medical minutes, the AED indispensably has to be at hand at the treatment on the pitch necessitates discussions on execu- sideline to allow for immediate emergency response by tive level that have to be informed by medical advice. either the stretcher team or the team doctor. A reasonable rule-of-thumb in the meantime for refer- ees and side-line staff might be to consider every player who collapses without contact with another player or a What we learned from the reviews steady object, and who is unresponsive, to be suffering from SCA. Importantly, movement or breathing does These reviews were inspired by the practical experience not exclude SCA. of the FIFA Medical Committee and F-MARC and several tragic examples of SCD in football. The require- ment of an AED being available at the side-line was standard at FIFA competitions for several years, but it became clear that this availability needed to be extended to lower levels of play and be amended with hands-on training of team doctors and side-line stretcher teams in the diagnosis and treatment of SCA. Training of other individuals present at the pitch such as referees, coaches and other staff in at least chest compression is highly recommended. Further, the action to be taken in case of SCA on the pitch needs to be planned ahead and the plan of action has to be laid down in writing and duly communicated to all medical staff involved in order to clearly identify tasks and responsibilities.
Recommendations for emergency planning for SCA on the pitch
s %VERY TEAM AND VENUE HOSTING FOOTBALL TRAINING OR A competition should have a written emergency response plan for SCA.
s 0OTENTIAL RESPONDERS TO 3#! ON THE FIELD IE COACHES referees, physiotherapists, athletic trainers, and other medical staff) should be regularly trained in cardiopulmo- nary resuscitation and AED use, and demonstrate skills proficiency in this regard. Duration: 2009 - 2014 s !N !%$ SHOULD BE IMMEDIATELY AVAILABLE ON THE PITCH Countries: International during competitions. Cooperation: University of the Witwatersrand, Johannesburg, South Africa s "OTH TEAMS SHOULD REVIEW PRIOR TO THE MATCH THE LOCA- tion of the AED and details of the emergency response References: plan. Kramer E, Dvořák J, Kloeck W (2010). Review of the manage- ment of sudden cardiac arrest on the football field. Br J Sports A course programme was consequently launched based Med 44(8): 540-545 Dvořák on the deficits identified in the practical management Kramer E, Botha M, Drezner J, Abdelrahman Y, J of SCA. Emergency courses were held at both FIFA (2012). Practical management of sudden cardiac arrest on the Medical Conferences 2009 and 2012, at AFC and CAF football field. Br J Sports Med 46(16):1094-1096 Dvořák Medical Conferences and in Brazil in preparation of the Schmied C, Drezner J, Kramer E, J (2013). Cardiac medical staff prior to the 2014 FIFA World Cup Bra- events in football and strategies for first responder treatment on zilTM. CAF in 2012 provided an emergency medical the field. Br J Sports Med 47:1175-1178 144 PREVENTION OF SUDDEN CARDIAC DEATH | F-MARC PROJECTS
4.2.3 FIFA 11 Steps to Prevent Sudden FIFA Medical Emergency Bag (FMEB) Cardiac Death and the FIFA Medical Emergency Bag As the consensus meeting revealed, about 13 emergen- cy medical conditions can be defined that are likely to occur on the football field (Box 4.2.3.1). Taking these Why we initiated this project conditions into account, it was agreed by the experts that the contents of the FMEB should primarily be designed Life-threatening medical emergencies are a rare but pos- to medically manage a player for approx. 60 minutes, sible event in football, and sudden cardiac arrest (SCA) and that it should be aimed at players older than 14 remains the leading cause of death during football. Prop- years of age and with a weight of 50 kg or more. The er prevention strategies, emergency medical planning inclusion of a rigid durable immobilisation-carrying and timely access to emergency equipment are required device was considered mandatory, and the specialists to prevent fatal outcomes. FIFA and F-MARC are com- recommended that a pressurised metered inhaler and mitted to protecting the health of players worldwide. volumetric spacer should be used for acute asthma rath- By formulating the FIFA 11 steps to prevent sudden er than a nebuliser system as this might be difficult to cardiac death in football and providing the FIFA Medi- apply in some stadiums due to logistical difficulties of cal Emergency Bag (FMEB), FIFA and F-MARC pro- having stored oxygen routinely available on scene dur- pose a standard for emergency preparedness and medical ing training or competitions. The contents of the FMEB response to serious or fatal on-field injuries in football. have been selected mainly in a generic format such that all of the items can be replaced if used in an emergency or expired using the equivalent locally available stocked Aims of the project items. A key feature of the FMEB is that the automated external defibrillator (AED) is stored in the FMEB in UÊ/ÊÃÕ««ÀÌÊ>`Ê«ÀÌiÊ>ÊÃÌ>`>À`Ãi`Ê>`ÊVÃÃÌiÌÊ such a way that it is immediately visible and ready to be level of advanced life support and emergency medical applied in an emergency. care on the football field UÊ/Ê«ÀiÛiÌÊ>`Ê>>}iÊÃÕ``iÊV>À`>VÊ>ÀÀiÃÌÊÊÌ iÊ football field FIFA 11 steps to prevent sudden cardiac death (SCD)
How we developed the programme The FIFA 11 steps to prevent SCD in football reflect the insight that a consistent approach to prevention, The FMEB was developed in a process of expert consul- planning and protocol are of utmost importance when tation and consensus encompassing a group of football- it comes to managing life-threatening medical emergen- experienced and actively involved medical specialists cies on the field. The specialists agreed that a pre-par- from the fields of neurology, cardiology, orthopaedic ticipation screening, which identifies athletes with pre- surgery, sports and emergency medicine from countries existing conditions placing them at risk of SCD should including Switzerland, England, the USA, Brazil and be universally supported, and that a Pre-Competition South Africa. Drawing from their extensive experience Medical Assessment (See chapter 4.1) should be routine- with the medical management of international football ly undertaken. They also suggested that an exercise test events, the experts brought together their knowledge should be considered in athletes older than 35 years of to allocate the appropriate contents of a football medi- age and when otherwise indicated. Moreover, the experts cal emergency bag that would be universally applica- pointed out the crucial importance of regular and appro- ble and suitable in a multitude of locations worldwide. priate training measures to ensure that the on-duty They moreover established the FIFA 11 steps to prevent medical personnel is familiar with the emergency medi- sudden cardiac death (SCD), which is a comprehen- cal protocol (EMP) and can function efficiently in life- sive action plan for the management of life-threatening threatening emergencies on the field. It was agreed that emergencies on the field of play. a FMEB with AED must be in position at the field-side before the commencement of all training sessions and all games, and that an adequately staffed and equipped ambulance must be positioned at the field-side before F-MARC PROJECTS | PREVENTION OF SUDDEN CARDIAC DEATH 145
starting of all games. In case of an emergency, immedi- ate recognition of any collapsed player was defined as the initial primary responsibility of the field-of-play medical team, and any football player who collapses and is unre- sponsive, particularly if this occurs without contact with another player, should be regarded as a SCA and sub- jected to immediate AED treatment. A detailed overview of the FIFA 11 steps to prevent sudden cardiac death is presented in Box 4.2.3.2.
Box 4.2.3.1
Box 4.2.3.2
How it will impact future medical emergency practice on the field of play
By providing the FMEB and the FIFA 11 steps to pre- vent SCD, F-MARC is making yet another key con- tribution to the health protection of football players worldwide. Realising the utmost importance of a timely, Duration: 2012 - 2013 effective and universally applicable medical emergency Countries: International plan for life-threatening occurrences on the field and References: Dvořák offering the FMEB to all FIFA Member Associations J, Kramer EB, Schmied CM, Drezner JA, Zidema D, worldwide, FIFA contributed to the prevention of SCA Patricios J, Correia L, Pedrinelli A, Mandelbaum B (2013). The and other life-threatening occurrences in football in the FIFA medical emergency bag and FIFA 11 steps to prevent sud- future. den cardiac death: setting a standard and promoting consistent football field emergency care. Br J Sports Med 47:1199-1202 146 PREVENTION OF SUDDEN CARDIAC DEATH | F-MARC PROJECTS
4.2.4 Cardiac Findings and the Athlete’s In addition, we identified 62 Caucasian Italian players in Heart in African Adolescent Players order to compare the ECG and echocardiography find- ings between the two groups of black African and Cau- casian players. The Italian players were matched to the Why we conducted these studies championship players with regard to their age, training intensity, level of play and the time of examination. The analysis of the forms of the P-Competition Medical Assessment (PCMA) performed prior to the 2006 FIFA World CupTM had revealed a high percentage of ECG Results findings in black players that as per the standard crite- ria used for ECG interpretation at the time would have There were numerous different African ethnic groups been termed abnormal. It was known that black athletes represented among the eight teams. One third of the had a higher risk of Sudden Cardiac Death (SCD) than players had never been examined by a physician before. Caucasian athletes. Therefore, identifying black players Only 9 of the players reported heart symptoms, and two at high risk of SCD appeared particularly important, yet had elevated blood pressure in the clinical examination. there were no criteria how to achieve this as the defined Slightly more than a quarter of the U-17 players showed standard criteria produced a lot of “false positive” results abnormal ECG findings, but none of them had any in black athletes, meaning the ECG would be rated signs of abnormality on echocardiography. There were abnormal, but further investigations did not show any certain changes that were found particularly often. Black abnormality. This implied that there was probably a African players particularly often showed ECG signs of need to develop specific interpretation criteria for the left ventricle hypertrophy. The most frequent finding in ECG of black players and athletes to be able to distin- about half of the black African players concerned what is guish normal from abnormal findings. We therefore called an R wave, and one fifth had a particular change decided to examine the young black African players at in what is called the T wave. It was not possible to assign the CAF U-17 Championship in detail and with a par- structural abnormalities to these changes, meaning that ticular focus on the heart investigations to gain more these players need further follow-up. insight into this matter. Thirteen players had an abnormal echocardiography, two of them showing signs compatible with beginning Aims of the studies cardiomyopathy. Athletes typically show left ventricle hypertrophy. In our study population, Caucasian and UÊ-VÀiiÊ>Ê«>ÞiÀÃÊ>ÌÊÌ iÊnth CAF U-17 Champion- African players had comparable left ventricle dimen- ship 2009 in Algeria for cardiac risk factors using the sions, but African players showed markedly thicker walls standardised F-MARC PCMA of the ventricle, which were more often above the upper UÊ iwiÊÌ iÊ Ê>`ÊiV V>À`}À>« VÊV >À>VÌiÀÃÌVÃÊ normal limit than in Caucasian players. In the same way, found in African adolescent athletes the mass of the left ventricle was larger and more often UÊ iVÌÊ`>Ì>ÊÊV>À`>VÊÀÃv>VÌÀÃÊÊÌ ÃÊÌ>À}iÌÊ}ÀÕ« above the upper normal limit (Fig. 4.2.4.1)
How we collected the data What we learned from the studies
All eight qualified teams for the 8th CAF U-17 Cham- Among African players, abnormal ECG changes were pionship 2009 respectively their 155 players were exam- more frequent in black African than in non-black Afri- ined by a team of F-MARC physicians prior to the com- can players. These ECG changes could however not be petition. All examinations were performed according to related to distinguishable structural changes or diseases the revised F-MARC PCMA form and included medi- of the heart. To establish ECG interpretation criteria for cal history, family history, physical examination, 12-lead black players, it is important to know the interpretation resting ECG and echocardiography. All heart examina- criteria in black non-athletes which so far have not been tion findings were assessed by three cardiologists to min- identified. Therefore, there is a need to establish popu- imise individual error. lation–based data of normal ECGs in adolescent black Africans and correlate it to echocardiographic findings. F-MARC PROJECTS | PREVENTION OF SUDDEN CARDIAC DEATH 147
Compared to Caucasian players, black African players have similar left ventricle cavity, but more often left ven- tricle wall thickening and larger left ventricle mass. This finding of disproportionate wall thickening might be a genetically determined reaction to athletic training in black Africans.
Whenever examining players from different ethnic back- grounds, race-related ECG and echocardiography need to be known in order to avoid false positive findings. Further studies in larger populations are needed to estab- lish the differences between different ethnic groups and develop interpretation criteria for the respective ethni- city.
Fig. 4.2.4.1: Flow chart showing the echocardiographic findings in African athletes according to ECG abnormalities, that is, ‘training- related’ (benign) and ‘training-unrelated’ (possibly expression of car- diac disorder). Among athletes showing ECG abnormalities unrelated to training, one hypertrophic cardiomyopathy was diagnosed.
Duration: 2009 - 2012 Countries: International Cooperation: All team physicians of the 8th CAF U-17 Championships; University of Cape Town, Cape Town, South Africa; University of Zurich, Zurich, Switzerland References: Schmied C, Zerguini Y, Junge A, Tscholl P, Pelliccia A, Mayosi BM, Dvořák J (2009). Cardiac findings in the precompetition medical assessment of football players participating in the 2009 African Under-17 Championships in Algeria. Br J Sports Med 43(9):716-721 Ê*>Ê ]Ê-V i`Ê ]Ê
5 Other Recognised Matters 5.1 Assessment of Player Characteristics
5.1.1 Medical History and Physical How we collected the data Examination We examined 588 football players from Germany, France and the Czech Republic. Players were grouped according Why we conducted this study to the age and skill level of their team. The 144 adult players were categorised into four skill-level groups: top- The physical demands of football on players become level adults (first and second league), third league, ama- more pronounced the higher the level of competition. teur teams (Division), and local teams. The 444 youth A 25-year-old professional plays much harder than a players were divided into two age groups (14- to 16- 25-year-old hobby player. Without the adequate physi- year-old players and 16- to 18-year-old players) and two cal and psychological prerequisites, the individual play- skill-level groups (high and low). Medical histories were er will not be able to cope with the stresses of play. An obtained by a written questionnaire and physical exami- unfit player will play at a far lower intensity than a fit nations were conducted by specially trained physicians. player will. A poorly nourished player, regardless of their Furthermore, the players were asked about currently level of fitness, will tire earlier than a properly fed, well- existing symptoms, limitations in performance and their nourished player. A player with an incompletely rehabil- medical treatment. itated injury will likely “favour” that injury and not play The physical examination incorporated different aspects: at their uninjured potential. The player with joint insta- anthropometric and body fat measurements, and exami- bilities, lower strength or reduced flexibility, etc. will not nation of the most important joints. The anthropomet- play to their best potential and could well be at risk for ric measurements taken consisted of height and weight, an injury. the length and circumference of the extremities, and the circumference of the chest and hips. Body fat was Within the level of play, the demands of the game assessed by means of skinfold thickness measurements increase as the player ages – a 14-year-old plays harder taken at seven sites: chest, axilla, triceps, subscapula, than a ten-year-old. In either case, it is important to abdomen, suprailiac crest, and thigh. For the spine, the know the player’s history and status of current com- degrees of lordosis, kyphosis, and scoliosis (if present) plaints as they prepare to train and compete. F-MARC were measured as well as the active and passive rotation had found that while there are studies that outline physi- of the cervical and the thoracic and lumbar spine. The cal, physiological, and injury profiles of sporting partici- knee joint was assessed for possible pathologic findings pants, most of them showed weaknesses in their subject by means of the Lachmann test, valgus and varus stress selection (e.g. only one team with a limited number of in extension and in 30° of flexion, and the anterior and players) and assessment methods (various studies meas- posterior drawer signs (Fig. 5.1.1.1). With the subject ure the same factors with different methods). In foot- in the standing position, the knee joint axis was judged ball in particular, data on for example the prevalence of as straight, varus, or valgus, and the distances between abnormal findings in the joints of players have seldom the medial femoral epicondyles and between the medial been investigated. Also, very little was known about malleoli were measured. For the ankle joint, the degree complaints of active players. Therefore, F-MARC decid- of supination and pronation, as well as the extent of ed to systematically investigate how these factors relate dorsiflexion, total supination, and total pronation, were to each other. assessed using a goniometer. Possible pathologic signs were documented by performing tests of comparative supination of the ankle joints and anterior drawer signs. Aims of the study The extent of passive extension and flexion of the great toe joint was also measured and expressed in degrees. UÊ-ÌÕ`ÞÊÌ iÊi`V>Ê ÃÌÀÞÊ>`Ê« ÞÃV>Êw`}ÃÊÊ players from different levels of play UÊ iÌiÀiÊÌ iÊÀi>Ìà «ÊLiÌÜiiÊ«>Ì }VÊw`- Results ings in the joints of the lower extremities and the play- er’s medical history The players ranged in age between 14 and 41 years of age with an average age of 18.4 years. The most obvious finding was the high prevalence of physical complaints at all levels of play (Tab. 5.1.1.1) with only one-quarter F-MARC PROJECTS | OTHER RECOGNISED MATTERS 149
Adult players Youth 16-18y Youth 14-16y Complaint Top 3rd league Amateur Local High level Low level High level Low level Headache 10 78822284739
Neck pain 30 10 28 21 12 16 20 11
Low back pain 28 41 52 47 39 39 36 46
Muscle/tendon 38 39 16 42 30 35 31 38
Joint pain 33 46 40 39 37 41 40 44
any complaint 78 76 76 74 73 73 81 84
Tab. 5.1.1.1 Prevalence (percent of players) of complaints in football players of different age and skill levels
Adult players Youth 16-18y Youth 14-16y Top 3rd league Amateur Local High level Low level High level Low level
Any sign of ACL injury 12.5 7.3 16.0 15.6 2.4 23.1 4.2 5.5
at least 1 sign of any liga- 18 32 32 26 16 34 16 25 ment injury in either knee
Ankle instability in either 20 28 24 26 23 29 31 36 ankle
Tab. 5.1.1.2 Percent of players with pathologic signs of knee or ankle ligament injury reporting no past or current complaint. The most fre- prior injuries and most of the injuries were to the non- quent symptoms were pain in the lower back, the joints, dominant leg. It is obviously not advisable to play with and the muscles or tendons followed by headaches and an incompletely healed injury under the false sense of neck pain. Players reported an average of 6.6 previous security that tape and bandages will have a preventive injuries and 15% had prior surgery for a football-relat- effect. F-MARC concluded that in our future research ed injury. At the time of the examination, 24% of the to ensure and maintain the health of football players, we players said they still felt the effects of a previous injury would need to pay more attention to the current patho- which obviously suggested that these player complaints logic findings and complaints as well as the secondary should affect current, and even future, play. Almost one- structural changes that may occur as a result of playing quarter of the players had a pathologic finding in either football. the right or left knee (Tab. 5.1.1.2). Even more play- ers (28%) had instability (anterior drawer) of either the right or left ankle. When evidence of any ankle instabil- ity was separated out by age and ability, our youngest players in the lowest level of play had a higher fraction of instability (36%) than the professionals (20%). While not a statistically proven relationship, evidence of ankle instability symptoms decreased with increasing age and ability level. Pathologic findings of the knee and ankle were associated with previous bony, ligament, soft tissue injuries, or surgery. Fig. 5.1.1.1 Medical examination of the knee
Duration: 1996 - 1998 What we learned from the study Countries: Czech Republic, Germany, France Cooperation: Czech Football Association The high prevalence of physical complaints at all lev- Reference: els of play was impressive. It is remarkable that almost Junge A, Dvořák J, Chomiak J, Peterson L, Graf-Baumann T one-quarter of the players still felt the effects of a pre- (2000). Medical history and physical findings in football players vious injury at the time of the examination. Current of different ages and skill levels. Am J Sports Med 28 (5 Suppl): pain in players with pathologic findings was related to S 16-21 150 OTHER RECOGNISED MATTERS | F-MARC PROJECTS
5.1.2 Psychological Characteristics Inventory, the State Competitive Anxiety Test, and the State-Trait-Anger-Expression-Inventory. Test results were compared with historical results in the scientific literature. Why we conducted this study We also asked for a series of football-specific characteris- tics that included playing experience, positions played, Playing football demands not only good physical perfor- style of play, number of training hours and games, as well mance, but also mental preparation and most probably as aspects of fair play. We also tested the reaction time of specific psychological qualities. The nature of the game players. Simple reaction time to an optical stimulus was requires particular gifts and features that draw people tested twice: once without the influence of physical exer- with specific personality traits to participate. Within the cise and once with the effect of exercise by testing reaction game, only certain players advance up the ladder of the time after completion of a 12-minute run. sport. It might be that players at different levels of play might vary not only in their football skills and their way of playing, but also in psychological factors like concen- tration, reaction time, or competitive anxiety.
F-MARC had produced troubling statistics showing that more than one-quarter of all football injuries were due to foul play. While some injuries are accidental, intentional foul play is an issue in all sports and might be a result of a certain willingness of a player to make a conscious attempt at committing a foul. Changes in the rules of ice hockey and American football to restrict foul play had led to reductions in injury. We hypothesised that a play- er’s psychological traits might just influence how they approach playing football, especially with respect to fair play, and also their risk of injury. Therefore, F-MARC decided to further investigate these traits.
Aims of the study
UÊ Ý>iÊ«ÃÞV }V>Ê>`ÊvÌL>ëiVwVÊV >À>VÌiÀ- istics at different levels of play Fig. 5.1.2.1 Players filling in the questionnaires UÊ>ÞÃiÊÌ iÊÀi>Ìà «ÊLiÌÜiiÊ«ÃÞV }V>ÊV >À>V- teristics and attitudes toward fair play Results
How we collected the data At rest, reaction time was slower for the lower level play- ers, most pronounced in youth players. After exercise, A group consisting of 588 football players from Czech reaction time was significantly shorter in high-level than Republic, Germany and France filled out questionnaires in low-level players of all three age groups. When com- (Fig. 5.1.2.1). As in our previous study, adult players were paring groups, the top level adults and the top level categorised into four skill level groups: top-level (first and 16-18-year-old youth players had the shortest reaction second league), third league, amateur teams (division), times of all (Tab. 5.1.2.1) and local teams. Youth players were divided into two age groups (14- to 16-year-old players and 16- to 18-year- Essentially, the psychological traits were the same across old players) and two skill-level groups (high and low). A the age groups in this study. Coping skills (such as cop- total of 13% of the players were professionals. We assessed ing with adversity, amenability to being coached, confi- psychological characteristics using three established self- dence, mental preparation) were similar regardless of age evaluation questionnaires: the Athletic Coping Skills and level of play. Yet, there were a few differences within F-MARC PROJECTS | OTHER RECOGNISED MATTERS 151
Adult players Youth 16-18y Youth 14-16y Top 3rd league Amateur Local High level Low level High level Low level
Age started playing (y) 6.6 6.4 6.3 6.7 5.9 6.8 5.8 6.7
Years playing 17 16.1 17.1 16.2 9.6 8.9 8.2 7.8
No of games last season 22 25 22 19 27 23 29 24
Training hrs per week 10 8 6 5 7464
Preferred foot
Right (%) 38 48 54 47 50 60 46 67
Left (%) 8 8 17 5 10 12 10 15
Both (%) 54 45 29 47 40 27 45 17
Field leader? 31 26 27 18 35 21 33 17 (% yes) Physical player? 44 58 38 52 46 62 50 58 (% yes)
Tab. 5.1.2.1 Reaction Time of Football Players of Different Age and Skill Levels the age groups. High level youth had fewer worries about What we learned from the study their performance and high level 14-16-year-old youth had more mental strength under pressure and better con- The reaction time seemed in general to be longer in low- centration than lower level players of the same age. Nei- level players than in high-level players. The replies from ther the Sport Competitive Anxiety Inventory (SCAT) the questionnaire regarding fair play clearly indicated that nor State-Trait-Anger-Expression-Inventory was different the rules of the game, its regulations and the spirit of fair across the other football groups. play is not paid sufficient respect by football players.
When comparing the football players against other groups The willingness to commit a “professional foul” was alarm- reported in the literature, the football players had higher ingly high and not associated with any specific personality levels of anger, outward expressions of anger, and com- trait. The players felt that depending on score and match petitive anxiety, but lower levels of anger control. The importance, a “professional foul” might just be needed football players scored lower on all aspects of coping and they would be willing to commit such a foul. To the skills with the exception of “freedom from anxiety”. We psychologist, this means that the “professional foul” is not also looked at the interaction of personality traits and fair a spontaneous act. On the other hand, retaliation would play statements. For example, players who refrained from be committed by those with high levels of anger and poor verbal interaction with the opponents were usually better control over anger expression. prepared, had more focused concentration, were easier to coach, and coped better with adversity and anger. Those who would react to a hidden foul had higher levels of anger and less control of it. In addition, those players had Duration: 1996 - 1998 lower levels of concentration, poor coping abilities, and Countries: Czech Republic, Germany, France were difficult to coach. Ninety-two percent of the play- Cooperation: Czech Football Association ers said they would commit a so-called “professional foul” Reference: if necessary. Half of the players had responded physically Junge A, Dvořák J, Rösch D, Graf-Baumann T Chomiak J when provoked by an opponent, and nearly 60% would (2000). Psychological and sport-specific characteristics of foot- pay back a hidden (unpenalised) foul. ball players. Am J Sports Med 28 (5 Suppl): S22-28 152 OTHER RECOGNISED MATTERS | F-MARC PROJECTS
5.1.3 Assessment of Performance Lengthwise leg splits: The player stands on the board and uses the chair for support. He kneels on the board and extends the other leg straight in front. The distance Why we conducted this study from the groin to the ground is measured.
All sports are a combination of technique, tactics, physi- Single leg knee bend: The player stands on the board and cal fitness and psychological fitness. The complexity of uses the chair for support. They kneel on the board and football is such that the relative importance of each of extend the other leg as far as possible behind them. The these variables can change from match to match. Prob- distance from the groin to the ground is measured. ably one of the reasons that football is played by so many is that the game requires no specific gifts in order to be Forward trunk bending: The player stands on a bench. successful. Some games have traits that are unique to With straight legs, the player bends as far forward as pos- their sports, such as strength and power for American sible. The distance from the fingertip to the ground is football, height for basketball, speed for sprinting or measured. endurance for distance running. In contrast, football, while not requiring any specific trait for success, does require some ability in all aspects of physical fitness. The Football skills most important variables for measuring performance in team sports in general are physical condition and techni- Examples are: cal and tactical performance. However, in football, it was Speed dribbling: The player dribbles the ball around difficult to ascertain the relative importance of each of a specific course for time. The course is laid out over a these variables. 50m linear distance, but the multiple changes of direction increase the overall running distance (Fig. 5.1.3.1).
Aim of the study Long passing: The player gets five attempts to see how many times he can kick a stationary ball into a 2m radius UÊ iÛi«Ê>ÊÃÌ>`>À`Ãi`ÊÌiÃÌÊL>ÌÌiÀÞÊÌÊiÛ>Õ>ÌiÊ« ÞÃV>Ê circle which centre is 36m away. performance characteristics in football players Short passing: The player gets five attempts to see how many times he can pass a dribbled ball into a hockey goal How we collected the data that is eleven metres away.
Again, the 588 football players from Czech Republic, Ger- Shooting: Using a stationary ball 16m from a goal, the many and France of multiple ages and playing levels were player gets three attempts to shoot into each upper cor- examined. The three hour session to assess performance ner. All scoring tests have a progressive scoring system for included a warm-up procedure, tests of flexibility, football accuracy. skills, power, speed and endurance and ended with a cool- down. Some additional stretching was done prior to the flexibility tests.
F-MARC’s battery was prepared to test the various physi- cal demands of a football player’s normal activity.
Flexibility
Examples are: Supine straight leg raise: The player lies on their back, then raises one leg up as far as possible. A partner then Fig. 5.1.3.1 Dribbling at speed test helps raising the leg even further. The angle of the leg to the ground is measured. F-MARC PROJECTS | OTHER RECOGNISED MATTERS 153
Physical fitness Results
Examples are: A large amount of data was generated to establish stand- Two-footed vertical jump: The player stands next to a ards for fitness and skill across a wide range of ages wall, reaches as high as possible and makes a mark with and abilities (Fig. 5.1.3.3). In youth players, dexterity a piece of chalk. Then he jumps as high as possible and tests such as juggling and passing differed significantly touches the wall with the chalk. After three attempts, the between high- and low-level groups. All power, speed, maximum distance from the reach and jump chalk marks and endurance tests discriminated between age and skill- are measured. level groups, especially in youth players. The significant differences between the quality of the warm-up per- Triple jump: Each player stands on one leg, and then formed by the different skill-level groups possibly reflect- executes three successive jumps with that one leg as far as ed the lower standard of training in less skilled players. possible and the distance is then measured. Three attempts are made for each leg. What we learned from the study Four-line sprint: Four lines are drawn on the ground. The player lies on the ground at line B. On command In summary, the F-MARC test battery proved to be a the gets to his feet and sprints to Line A (10m), turns and feasible instrument for assessing physical performance as sprints to line C (20m), turns and sprints back to line B well as football-specific skills. The best predictor of foot- (10m), turns and sprints to line D (30m). The time is ball ability was the speed dribbling test. Our findings recorded by a stopwatch (Fig. 5.1.3.2). Each player runs suggested that analysis of an individual player’s physi- as far as possible in12 minutes. The distance in metres as cal profile, in relation to mean values for a similar age well as the pulse rate are recorded. group and skill level, might be of assistance to the coach in objectively evaluating the effects of a specific training programme. It may also be of use to the responsible phy- sician and physical therapist in monitoring progress dur- ing rehabilitation after football injuries.
Fig. 5.1.3.2 Four-line sprint
25 24.2 22.9 22.3 21.4 21.5 21.3 20.2 20.7 20 Dribble in seconds Duration: 1996 - 1998 15 Countries: Czech Republic, Germany, France Top Cooperation: Czech Football Association Amateur 3rd league Local Player Reference:
16-18y high level16-18y low level14-16y high level14-16y low level Rösch D, Hodgson R, Peterson L, Graf-Baumann T, Junge A, Chomiak J, Dvořák J (2000). Assessment and evaluation of Fig. 5.1.3.3 Mean values of the dribbling test in different age and skill-level groups football performance. Am J Sports Med 28 (5 Suppl): S 29-39 154 OTHER RECOGNISED MATTERS | F-MARC PROJECTS
5.2 Ramadan and Football
5.2.1 Influence of Ramadan on Performance ity, power, speed and a dribbling task. The timing of tests corresponded to their usual match time in the early afternoon. Each player was interviewed regularly during Why we conducted this study the study for their subjective opinions on sleep quality, eating, symptoms and their perception of their training Islam is a major religion with over one billion people liv- and match performance. ing under Islamic laws. One of the most important peri- ods for Muslims is Ramadan when healthy adult Muslims fast from sunrise to sunset for the four-week period. The Results original objectives of this fasting period are physical and mental regeneration combined with intensified praying. In the fourth week of Ramadan, performance was reduced Muslims are invited to abstain from all types of liquid or on a wide range of tests (20m speed, speed dribbling, agil- solid nutrient intake as well as undesirable behaviour dur- ity, endurance and recovery) and was below the initial ing this period of purification with the exact timing of values when tested two weeks after the end of the fasting food and liquid intake depending on the times of sunrise period (Fig. 5.2.1.1). Nearly a quarter of all players felt and sunset. So Ramadan is a phase shift of food intake they ate more during Ramadan while half felt they ate and sleep and less a traditional fast where food is generally less. Weight did not significantly change. Food volume avoided. returned to normal after Ramadan. About 70% of players reported that the quality of their training was poorer dur- Football is the largest spectator sport and as a means of ing the fast, and just over 75% of the players thought that physical exercise the most popular leisure activity in many their match performance was reduced during the fast. Muslim countries. While there had been a number of studies on the physical and clinical effects of Ramadan Sleep volume was reduced by just over 30 minutes during with regard to metabolism, hormones and behaviour, little Ramadan, but nearly three quarters of the players said that was known on the influence Ramadan has on athletic per- the quality of their sleep was poorer than before Ramadan formance. There were also reports on the effects of food because the sleep cycle was disrupted to accommodate restriction and sleep deprivation on performance in the food intake. laboratory. With Muslim footballers playing worldwide and the increasing chance of international matches involv- Finally, a series of symptoms changed during the fast, ing Muslim and non-Muslim teams being contested dur- especially an increase in headache and vertigo (Fig. ing Ramadan, it seemed appropriate to F-MARC to assess 5.2.1.2). In most cases, after the fast, subjective ratings by how the Islamic competitive player is affected by this reli- the players had either returned to pre-Ramadan values or gious period. rebounded above pre-fasting levels. Importantly, nearly all the players believed that their training and match perfor- mance had improved to close to pre-Ramadan levels once Aims of the study the fast had been concluded (Fig. 5.2.1.3).
UÊ iÌiÀiÊÌ iÊivviVÌÃÊvÊ,>>`>ÊÊ« ÞÃV>Ê«iÀ- formance and football performance UÊÃÃiÃÃÊÌ iÊÃÕLiVÌÛiÊ«ÃÊvÊÌ iÊ«>ÞiÀÃÊÊÃÞ«- toms, behaviour and performance
How we collected the data
Ramadan is based on the lunar calendar and in 2004 occurred between 15 October and 13 November. During that period, two professional football teams in Algiers, with a total of 55 players, were followed. Data were col- lected two weeks before, at the end, and two weeks after Ramadan research team in Algier Ramadan. Each player was tested for endurance, agil- F-MARC PROJECTS | OTHER RECOGNISED MATTERS 155
What we learned from the study
This was the first study to focus on competitive football players during Ramadan. Ramadan is different than the laboratory studies of performance during fasting because this religious period is less a fast and more a phase shift in calorie intake and change in sleep patterns. Our results showed that several parameters of physical perform- ance in football players were affected during Ramadan. Fig. 5.2.1.1 By the end of Ramadan, there was poorer performance The players did believe that their training and perform- on speed, agility, endurance and dribbling ability ance were both below normal. However, why such short tests like sprint and ability would be affected by Ram- adan is curious as neither is limited by fuel availability so the change in sleep patterns and their mood during this period might be a more likely explanation. F-MARC recommended that the Islamic competitive athlete needs to develop specific strategies to maintain optimal per- formance during Ramadan.
Fig. 5.2.1.2 Players reported an increase in symptoms by the end of Ramadan such as an increase in increases in headache, fatigue, and vertigo
Fig. 5.2.1.3 The player’s opinion of their training and match perfor- mance declined through Ramadan, but returned to acceptable levels after Ramadan has concluded
Duration: 2004 - 2005 Country: Algeria Cooperation: Centre d’Evaluation et d’Expertise en Medecine du Sport, Alger. Reference: Zerguini Y, Kirkendall DT, Junge A, Dvořák J. (2007). Impact Set up for speed control of Ramadan on physical performance in professional soccer players. Br J Sports Med 41(6): 398-400 156 OTHER RECOGNISED MATTERS | F-MARC PROJECTS
5.2.2 Influence of Ramadan on Physiological How we collected the data and Performance Variables Two years after our first Ramadan study we set out to follow four male junior teams, along with their coaches Why we conducted this study and trainers in Tunis, Tunisia, during the 2006 Rama- dan period from 23 September to 22 October. All play- During Ramadan, healthy adult Muslims fast from sun- ers attended a residential training camp at the Tuni- rise to sunset for a four-week period. Ramadan is a phase sian Football Federation’s training centre three weeks shift of food intake and sleep and less a traditional fast before the start of Ramadan and throughout the study. where food is generally avoided. The time between the The team coaches designed and ran their own train- morning prayers and the midday prayer is used for regu- ing programmes for their specific squad, and the teams lar activities. The afternoon time allows for light intellec- were involved in the programmed competitive matches. tual and physical activities including sports and exercise It was up to the individual players if they observed the such as football. Within the professional clubs and in Ramadan fast or not, and 64 players chose to observe national teams, Muslim players might have to play high the fast while 36 players did not. Throughout the study, profile matches during the fasting period of Ramadan. all meals were prepared in the kitchens of the camp and The combined effects of food and fluid restriction and of were designed to be similar to the diets usually eaten. To changes in the eating and sleeping patterns are therefore account for regional and cultural differences, 16 football of considerable importance to these players. players in Oman fasting during Ramadan were assessed at the same time. In our previous F-MARC study, we had studied Alge- rian professional football players and found a decline On specific test days three weeks before Ramadan, dur- in performance for speed, agility, dribbling speed and ing the second and fourth weeks of Ramadan and into endurance. Players were also queried on sleeping habits the third week after Ramadan, performance tests (sprint, and personal perception of performance and nearly 70% dribbling, vertical jump, agility, passing, shuttle run) of the players thought that their training and perfor- were conducted together with blood tests. In addition, mance were adversely affected during the fast. The phase all players completed the daily questionnaire on subjec- shift of food intake and disruption of sleep patterns tive feelings and perception of training difficulty in the therefore appeared to affect actual and perceived physical three weeks before and the four weeks of Ramadan. performance in these players. These players had been liv- Food and fluid intake was recorded by 24-hour recall ing at home and were therefore following the eating and three times during each phase of the study before, dur- sleeping habits of their families. In order to achieve data ing and after Ramadan. of high scientific value, we would however need to con- duct a so-called controlled study with adequate numbers of trained players comparing performance in those who Results observe Ramadan and those who do not under specified conditions. There was an increase in daily energy intake during Ramadan in the non-fasting group with a concomitant increase in body mass over the month. Energy intake Aim of the study was relatively stable in the fasting group, but there was a small decrease of approximately 0.7 kg in body mass UÊ>Ê>``Ì>ÊvÀ>ÌÊÌÊ>ÜÊ«ÌÃ>ÌÊvÊ during Ramadan. Ramadan fasting had some effects the daily training and dietary regimen in relation to on diet composition with intake of some specific nutri- the mental and physical performance of football play- ents decreased, but the effects were generally small even ers during the month of Ramadan under controlled though the pattern of eating was very different. The training camp conditions daily water intake was high throughout the study period, reflecting the training load and high temperatures. Water intake increased on average by 1.3 l/day in line with the greater energy intake in the non-fasting group. After Ramadan, the dietary variables reverted to the pre-Ram- adan levels. F-MARC PROJECTS | OTHER RECOGNISED MATTERS 157
In the youth football players observing Ramadan dur- We recommended that players should ensure adequate ing the Tunisian residential training camp, none of the sleep and good nutrition during Ramadan to preserve performance variables was negatively affected by fasting football performance and general health. The effect of while nearly all variables showed significant improve- changed sleeping and eating patterns will depend on the ment at the third test session. Changes in performance length of the daylight period, weather conditions and were most likely due to the effects of training and famili- other environmental and cultural factors. arity with the tests. The results of blood tests showed that the changes in eating time and frequency during Ramadan fasting, along with the continuation of normal training load, had no important effect on metabolism.
Finally, fasting players reported that they felt slightly less ready to train during the Ramadan fast. However, there was no increase in their perceived effort during training or in their assessment of training difficulty compared with their ratings before Ramadan, or with that of the non-fasting players during Ramadan. The fasting group consistently reported having about one hour less sleep per night throughout Ramadan without noticing their sleep quality to have altered. However, the fasting play- Ramadan core research team (from left to right) ers reported an increased feeling of tiredness and a slight D. Kirkendall – (USA), A. Junge – (Germany), Z. Bartagi – (Tunesia), Y. decrease in their ability to concentrate. During the two Zerguini – (Algeria), R. Maughan – (England), J. #UNŪ¨J - (Switzerland) week period after Ramadan, the modest changes report- ed by the fasting subjects reverted back to their pre-Ram- adan levels.
The 16 fasting players in Oman following their usual lifestyle during the month of Ramadan confirmed that the shift in food intake and the changes in sleep habits during Ramadan had varied effects on physical perfor- mance. Their perception of training and other perceptu- al feelings were constant over the eight weeks and most of the performance tests were unchanged throughout the study.
What we learned from the study
Previous studies by others and our own study in 2004 Duration: 2006 - 2007 had shown decrements in performance and subjec- Countries: Tunisia, Oman tive variables during Ramadan. In this F-MARC study Cooperation: School of Sport and Exercise Sciences, however, biochemical, nutritional, subjective well-being Loughborough University, Loughborough, United Kingdom; and performance variables were not adversely affected in National Center for Medicine and Scientific Research in Sport, young male football players who followed Ramadan fast- Tunis, Tunisia; Orthopaedic Sports Medicine Unit, Khoula ing in a controlled training camp environment. Based on Hospital, Muscat, Oman our data, the changes in the timing of food intake and Reference: sleep patterns during Ramadan had little effect on objec- Zerguini Y, Dvořák J, Maughan RJ, Leiper JB, Bartagi Z, tive tests of physical performance. In fact, physical per- Kirkendall DT, Al Riyami M, Junge A. (2008). Influence of formance generally rather improved, but match perform- Ramadan fasting on physiological and performance variables in ance was not measured. football players: summary of the F-MARC 2006 Ramadan fast- ing study. J Sports Sci 26(3 Suppl):S3-6 158 OTHER RECOGNISED MATTERS | F-MARC PROJECTS
5.2.3 Ramadan and Sports Performance What we learned from this consensus meeting
Where possible, players should move the schedule Why a consensus on Ramadan and Football? of training to a time of day that allows for appropri- ate nutrition support. Iftar provides an opportunity to Fasting during Ramadan is one of the five pillars of Islam adapt or supplement meals in quantity/quality to meet faith when Muslim believers are asked to refrain from specific needs for fluid, carbohydrate, and protein, espe- eating and drinking from sunrise to sunset. Ramadan cially for recovery after a recent exercise session as well as is held in the ninth month of the Muslim lunar calen- needs for the day. The athlete should make use of spe- dar, and includes a phase shift in the cycles of eating and cial sports foods and beverages to reduce gastrointestinal sleeping. Fasters eat a large meal to break the fast (Iftar discomfort from eating around exercise sessions. Carbo- after sunset), and an equally important meal before sun- hydrate-rich foods should be consumed at the break of rise (Sohour) to get them through the morning hours. fast, at the meal before dawn, and at other meals dur- Depending on day length this can result in a sleep defi- ing the evening, especially where these meals represent cit, however, most surveys have shown that there is little intake before, during or after exercise. Athletes should, if change in the caloric intake of 24 hours during Ramadan. possible, eat immediately after exercise to enhance refu- The decision to compete, train and observe Ramadan dur- elling rate and should consider low carbohydrate choices ing the holy month should always be the athlete’s individ- at the meal consumed before dawn to allow slow release ual choice. The manner of observance of Ramadan varies of glucose. Athletes should try to consume at least 20g between cultures. Athletes who are training or competing of rapidly digested and absorbed high-quality protein should aim to minimise the disruptions to their lifestyle soon after exercise, as well as high-quality protein-rich while following culturally appropriate practices. foods at each meal opportunity during the evening and before dawn. Consumption of ‘‘slow’’ proteins at meals It is easy to assume that an athlete’s performance will be consumed before dawn to help with protein balance over affected if he or she is unable to eat or drink before, dur- the day is advised. Souhour should be eaten as close as ing or after training and/or competition. There has, how- possible to sunrise and players should choose foods that ever, been surprisingly little attention paid to the potential contribute to sports nutrition needs for the day. implications of Ramadan fasting for elite athletes. Studies carried out under the auspices of the F-MARC have sug- Where hydration is likely to be compromised, athletes gested that effects on the performance of football players should minimise unnecessary water losses by avoiding or who pay careful attention to training, nutrition, and life- limiting heat exposure and unnecessary exercise. Strate- style factors are less than might be expected (see also chap- gies to limit requirements for sweating during training ter 5.2.1 and 5.2.2). and competition should include careful choices of cloth- ing, cooling strategies, and limitations to warm-up. To The purpose of the meeting was to collate and review the limit the risk of development of progressive hypo-hydra- evidence relating to all aspects of Ramadan and sports tion, regular monitoring of hydration status of athletes performance with the aim of establishing practical recom- should be undertaken using one of the recognised mark- mendations for athletes, support staff, and sports govern- ers of hydration status. The Souhour meal should be ing bodies. chosen with a view to fluid requirements over the day. Adding energy and inorganic solute (in particular sodi- um) will reduce the post-meal diuresis and promote flu- How we collected the information id retention. Fluid intake should be spread over the wak- ing hours after sunset, with frequent small drinks rather FIFA and the FIFA Medical Centres of Excellence than few large drinks. in Algiers and Doha convened a meeting of experts at Aspetar in November 2011. Twenty experts and physi- Athletes should ensure adequate sleep during Ramadan, cians from 12 countries and three well-known Muslim possibly including an afternoon nap if night-time sleep players (Madjid Bougherra, Nadir Belhadj and Jamal is delayed or interrupted. Athletes should avoid napping Alioui,) contributed to the consensus meeting. at an inappropriate time for prolonged periods, as this will make subsequent sleep more difficult and prolong the adjustment of the biological clock. Training in the F-MARC PROJECTS | OTHER RECOGNISED MATTERS 159
early evening may speed the onset of sleep, but training at that time should be followed by adequate food and fluid intake to promote recovery and to support training goals.
Summary
Currently, there is no single strategy for adaptation, and the best advice is the individual approach. The available evidence indicates that high-level athletes can maintain performance during Ramadan if physical training, food and fluid intake, and sleep are appropriate and well con- trolled. Individualised monitoring of athletes may help to prevent fatigue and overtraining and to reduce the risk of consequent illness and injury. However, competi- tion organisers should consider the needs of Muslim ath- letes who are fasting, when choosing the dates of events and the scheduling events in the month of Ramadan to begin 2–3 hours after sunset is encouraged.
Duration: 2011 Countries: International References: Ramadan and Football (2012). Supplement of the J Sport Sci 30(S1) (for details see Bibliography) 160 OTHER RECOGNISED MATTERS | F-MARC PROJECTS
5.3 Use of Medication and Nutritional by the players or administered to them in the 72 hours Supplements in FIFA Competitions preceding the match. The team doctors also had to note down any non-prescription medicines or food supple- ments taken by the 23 players of their team. Why we conducted these studies Substance intake was calculated as follows: Public interest in the intake of medication by sportsmen UÊÊ ÃÕLÃÌ>ViÊÉÊ«>ÞiÀÊÉÊ>ÌV Êi>ÊÌ>iÊ«iÀÊ«>ÞiÀ® focuses on doping, meaning the abuse of illegal substanc- UÊÊ ÕLiÀÊvÊ`Û`Õ>Ê«>ÞiÀÃÊÀi«ÀÌi`ÊÌÊLiÊÕÃ}Ê>ÊÊ es such as anabolic steroids with the aim of performance substance enhancement. FIFA was one of the first international fed- UÊÊ ÃÕLÃÌ>ViÊÉÊ«>ÞiÀÊÉÊV«iÌÌÊ erations to adopt stringent anti-doping measures in 1970, and since then has meticulously recorded illegal abuse. The extremely low incidence of positive doping tests in Results professional football is testament to the success in pro- tecting players from this health risk. However, legal sub- At the two FIFA World Cups™ (2002, 2006), a total stances prescribed for treatment may also endanger play- intake of 10,384 substances was documented, of which ers’ health due to adverse effects, accentuated by excessive more than half were classified as nutritional supple- use over an extended time period. Eighty percent of the ments. The average consumption in 2002 and 2006 per athletes participating in the Olympic Games 2000 were player was 1.8 substances or 0.8 medications prior to found to use some sort of medication. Studies in profes- each match; the same was reported in 2010 (Tab. 5.3.1). sional footballers had indicated a rather high intake of Some players took as many as seven different substances. both supplements and of non-steroidal anti-inflammato- Only one out of five players did not take any medica- ry drugs (NSAIDs). The FIFA Medical Committee had tion. NSAIDs were the most frequently prescribed sub- since long been concerned about the extensive use of pre- stances, accounting for almost half of all medications scribed drugs in elite football. Therefore, just before the used. More than half of the players took NSAIDs at 1998 FIFA World Cup™ in France a new initiative was least once during the competition and almost one third launched to record the use of medication and nutritional prior to a match. By 2010 the number of players tak- supplements in each player prior to each match on the ing NSAIDs per match increased significantly (p<0.01). doping control form. F-MARC then decided to analyse The range of medication reported was from 0.22 to 3.13 these data not only for FIFA’s flagship event, but also for per player per game; NSAID prescription ranged nearly the youth and women’s competitions to get a clearer pic- 20-fold – from 0.06 to 1.17 NSAIDs per player and per ture of the magnitude of the use of medication and the match. Differences in prescription practice varied enor- health risks associated with this practice in elite football. mously among countries.
Significantly more nutritional supplements were pre- Aims of the studies scribed in 2006 than in 2002 (not reported in 2010), mostly vitamins (41.1%), followed by minerals (21.2%). UÊ Ý>iÊi`V>ÌÊÕÃiÊÊ>iÊÌ«iÛiÊvÌL>Ê There was no correlation between the final ranking of players prior to and during FIFA World CupTM com- the team and the mean number of medications taken per petitions match. UÊ Ý>iÊi`V>ÌÊÕÃiÊÊÊ7i½ÃÊ7À`Ê Cup™ and FIFA U-17 and U-20 World Cups In the two women’s and four youth competitions, a total use of 6,577 medical substances was recorded with an average consumption of 0.63 substances per player per How we collected the data match, the maximum being nine substances in one play- er. In 37.9% (3,959 out of 10,456) of all player reports, On the form to be completed prior to doping control the consumption of at least one form of medication at the 2002, 2006 and 2010 FIFA World Cups™, the prior to the match was declared. In female players, the FIFA Women’s World Cups™ 2003 and 2007, and intake of medication per match (50.1%) was significant- the FIFA U-17 and U-20 World Cup 2005 and 2007, ly higher than that of youth footballers in either age cat- all team doctors were asked to list any medication taken egory (U-17 34.2%, U-20 33.2%; Fig. 5.3.1). NSAIDs F-MARC PROJECTS | OTHER RECOGNISED MATTERS 161
Notably, female players used significantly more medi- cal substances compared with adolescent and adult male football players. Of particular concern was the extensive use of NSAIDs in all groups, which is not supported by scientific evidence. While these drugs have an uncontest- ed painkilling effect, the high prevalence of considerable side effects, particularly with extensive and long-term Tab. 5.3.1: A comparison of FIFA World CupTM 2002, 2006 and 2010 – the use of medication per match and per tournament use, is well known. More than that, their influence on the healing process is controversial and alternative sub- were the most frequently prescribed group of substances, stances are well known. However, despite the recom- representing 38.9% of all reported medication. mendations for their restrictive use, the use of NSAIDs appears to have been broadened to almost any painful Recommendations on NSAID use: condition in football. Similarly, there was a high con- - Lowest possible dose and for shortest possible period sumption of nutritional supplements though very little - One preparation at a time scientific evidence exists regarding their beneficial effects - Prudent application in asthmatic patients in football. - Avoid long-term use - Lower gastro-intestinal adverse effects by using These timely data suggest that medications are widely paracetamol prescribed in elite sport and this may not be consistent with guideline advice. Given that elite players and physi- cians working at the elite level are role models, it is time to seek better and safer alternative management methods for performance continuation in professional athletes.
Fig. 5.3.1: Percentage of players taking medication prior to a match at FIFA women’s and youth competitions
What we learned from the studies Duration: 2007 - 2010 Countries: International TThe data from the 2002, 2006 and 2010 FIFA World Cooperation: All team physicians of the competitions Cups™ showed that there was no change in the high References: use of medication despite several preventive measures. It Tscholl PM, Junge A, Dvořák J (2008). The use of medication had been postulated that there are four types of medi- and nutritional supplements during FIFA World CupsTM 2002 cation use in professional athletes: legitimate therapeutic and 2006. Br J Sports Med 42(9): 725-730 use, performance preservation (treatment of sports inju- Tscholl P, Feddermann N, Junge A, Dvořák J (2009). The use ries), recreational/social use, and performance enhance- and abuse of painkillers in international football: data from 6 ment. While the high intake of medication at the five FIFA tournaments for female and youth players. Am J Sports FIFA World Cups™ and the four youth World Cups Med 37(2): 260-265 was alarming indeed, F-MARC could not scrutinise the Tscholl PM, Dvořák J (2012). Abuse of medication during underlying motivations for such use. international football competition in 2010 – lesson not learned. Br J Sports Med 46(16):1140-1141 162 OTHER RECOGNISED MATTERS | F-MARC PROJECTS
5.4 Age Determination using MRI
5.4.1 Developing a Methodology and Aims of the studies Application in FIFA U-17 Competitions UÊ>ÞÃiÊ>`ÊÛ>`>ÌiÊÌ iÊ ,ÊiÝ>>ÌÊvÊÌ iÊÜÀÃÌÊ to determine the bone age in the age groups from 15-18 Why we conducted these studies years UÊ ÃÌ>Là Ê>}iÀi>Ìi`ÊÀ>ÌÛiÊÛ>ÕiÃÊvÀÊÌ iÊ>iÊ««Õ- FIFA as well as the confederations have established age lation in different ethnicities and different countries limited competitions to guarantee equal competitive UÊ Û>Õ>ÌiÊÌ iÊ>}iÊvÊ>ÊÀi«ÀiÃiÌ>ÌÛiÊÃ>«iÊvÊvÌL>Ê opportunities to the different age groups. Unfortunately, players from international U-17 competitions using registration at birth is not compulsory in some African MRIs of the wrist and Asian countries, and suspicion has been raised that UÊ «>ÀiÊÌ iÊ ,Êw`}ÃÊvÊÌ iÊ«>ÞiÀÃÊvÊ1£ÇÊV- some players might be older than the documented age petitions with the age-related normal population stated in their eligibility documents. Obviously, this dis- crepancy leads to unequal competition as physical matu- rity, and thus age, have a strong influence on the physical How we collected the data performance of adolescent athletes. Further, it had been shown that age, experience, body size and stage of puberty As a first step, a I-VI-point rating scale for grading of fusion considerably contribute to the variance of some football of the wrist bone was developed: a grade of I means no skills. Early-maturing players are more likely to be viewed fusion at all and a grade of VI indicated completely fused as being more “talented” because of their physical advan- bone of the wrist. A VI would indicate that the skeletal tages over their “younger” team mates. growth of the individual has been completed. The discussion about age determination was initiated by the President of the Asian Football Confederation (AFC), For the main study, a total of 496 healthy young football Mr Mohammed Bin Hammam, who asked F-MARC players in the age group between 14-19 years were exa- and the AFC Sports Medical Committee for a scientific mined in four distinct geographic and ethnic countries approach using valid methods in age determination. (Algeria, Argentina, Malaysia, Switzerland). Three inde- The traditional way to estimate the age of adolescents had pendent experts assessed the MRIs without any knowledge been the use of x-rays of the wrist as this gives an indica- of the age of the examined players (Fig. 5.4.1.2). tion of the maturity of the skeleton. The problem howev- er was that x-rays use ionising radiation and such exposure as a screening tool for chronological age in football was neither allowed by international law nor by the World Health Organization (WHO). Therefore, F-MARC wanted to assess whether the newer imaging technique of Magnetic Resonance Imaging (MRI) of the wrist, which avoids the danger of ionising radiation, might be a scien- tifically valid alternative as a means of determining bone age (Fig. 5.4.1.1).
Fig. 5.4.1.2 Assessment of MRI of the wrist
The F-MARC grading of fusion of growth plates
I. Completely unfused II. Early fusion: minimal hyperintensity within physis III. Trabecular fusion of less than 50% of radial cross-sectional area IV. Trabecular fusion of more than 50% of radial Fig. 5.4.1.1 Example of a MRI of the wrist cross-sectional area F-MARC PROJECTS | OTHER RECOGNISED MATTERS 163
V. Residual physis, less than 5mm on any one section degree of fusion, and at the same time there were signifi- VI. Completely fused cant differences between age groups. But for football players from four international U-17 competitions, there was no In a second step, MRIs were done at four international correlation between age and grade of fusion. U-17 football youth competitions to compare the results. In total, 189 players seemed in general to be more mature than a norma- players were examined during the four U-17 competitions; tive population of football players of the same age category. 48 players from each of the FIFA U-17 World Cup Fin- If U-17 players were categorised in age-groups according land 2003, the AFC U-17 championship Japan 2004, and to their official documents, a higher degree of fusion was AFC U-17 championship Singapore 2006, and 45 players observed in all groups. Based on the MRI results of the from the FIFA U-17 World Cup Peru 2005. In the last of wrist, the age stated in the official documents of the U-17 these, three players from one team could not be examined players examined might not be correct in all cases. for logistic and technical reasons. Age 14-15y 15-16y 16-17y 17-18y 18-19y 19-20y Fusion
I 1140165 Results II 10 62 65 37 4 In the general player population, the average age as docu- III 11 16 10 8 mented increased significantly with a higher category of IV 8 152112 fusion meaning that each increasingly older age group V 6 17 32 28 15 showed more mature bone age (Tab. 5.4.1.1). For the VI 1 10 8 6
U-16 age group, none of the 127 players showed complete Tab. 5.4.1.1 Grading of fusion in different age-groups fusion, and in the U-17 group, only one player out of 130 was fused (0.8%). Meanwhile, in the U-18 group 13%, and in the U-19 group 28% of players showed complete fusion. The evaluation of the MRIs by the different experts 6 corresponded to a high extent with each other indicating 5 that the fusing criteria and the readability of the MRI imag- es were appropriate. 4
3
Due to the different definitions for U-17 competitions, all grading of fusion Average players in the AFC competitions were under 17 years of age 2 according to their document, whereas in the FIFA com- U-17 U-17 petitions 71% were already 17 years old. Fourteen players 14-15y 15-16y 16-17y 17-18y 18-19y 19-20y (15%) in the AFC and 25 players (27%) in the FIFA com- | Finnland | Japan petitions had complete fusion of the distal radius (grade VI; Fig. 5.4.1.3 Percentage of subjects by age and fusion level Tab. 5.4.1.3). The respective values of the normative popu- lation were less than 1% of under-17-year-old players and 10% of 17-year-old players. In all four U-17 competitions, Duration: 2003 - 2006 more players had the two highest degrees of fusion (grade V Countries: Switzerland, Malaysia, Algeria, Argentina and VI) than in the age-related general population (AFC, Cooperation: Prof. Juerg Hodler, Balgrist Clinic, University 48% vs. 14%; FIFA, 61% vs. 37%). of Zurich, Switzerland; Dr John George, University of Kuala Lumpur, Malaysia; Dr G Singh, Asian Football Confederation; Dr R Madero and Dr P Ortega, Buenos Aires, Argentina; Dr AY What we learned from the studies Zerguini and Dr N Abed, Algier, Algeria References: In consideration of the biological variability, an estima- Dvořák J, George J, Junge A, Hodler J (2007). Age tion of “true” age of an individual can only be made with Determination by MRI of Wrist in Adolescent Male Football a certain probability. However, in the general player popu- Players. Br J Sports Med 41(1): 45-52 lation, the grades of fusion of the wrist as determined by Dvořák J, Georges J, Junge A, Hodler J (2007). Application of MRI proved to be a reliable method for age determination. MRI of the wrist for age determination in international U-17 Age indicated by the birth certificate highly correlated with soccer competitions. Br J Sports Med 41 (8): 497-500 164 OTHER RECOGNISED MATTERS | F-MARC PROJECTS
5.4.2 Age Determination in U-20 Players Aim of the study
UÊÛiÃÌ}>ÌiÊÌ iÊ«ÃÃLÌiÃÊvÊ ,ÊvÊÌ iÊ>VÊVÀiÃÌÊ>«- Why we conducted these studies physis for the purpose of evaluating skeletal maturation in under-20 (U-20) football players In soccer, age-related tournaments play an important role in guaranteeing equal chances to the competitors for dif- ferent age groups. Giving an incorrect age to compete in How we collected the data a lower age class allows a player to benefit from physical advantages that older players often have over their peers. Magnetic resonance (MR) scans of the iliac crest apophysis An older player with advanced maturity may also increase were prospectively evaluated in 152 German male tourna- the risk of injuries to their opponents, especially in con- ment soccer players aged between 18 and 22 years. The tact sports such as soccer. study was approved by the local ethics committee and is in compliance with German ethical standards. Written However, over-age participants are not always intention- informed consent was obtained from all participants. ally cheating when they play in an inappropriate team. In A four-stage classification system was applied for the assess- particular, players from developing countries in Africa, ment of the apophyseal ossification. Asia, or South America often cannot guarantee the accura- cy of their birth certificates, or their countries do not even UÊ -Ì>}iÊ£Ê"ÃÃvV>ÌÊViÌiÀÊ >ÃÊÌÊÞiÌÊÃÃvi`° issue such certificates. Therefore, the problems of interna- UÊ -Ì>}iÊÓÊ"ÃÃvV>ÌÊViÌiÀÊ >ÃÊÃÃvi`]Ê« ÞÃi>ÊV>ÀÌ>}iÊÊ tional sporting federations are similar to those of judges in has not ossified. criminal proceedings when the adolescents accused have UÊ -Ì>}iÊÎÊ* ÞÃi>ÊV>ÀÌ>}iÊ >ÃÊ«>ÀÌ>ÞÊÃÃvi`° neither a valid identification document, nor a reliable UÊ -Ì>}iÊ{Ê* ÞÃi>ÊV>ÀÌ>}iÊ >ÃÊV«iÌiÞÊÃÃvi`° birth certificate, or they simply do not want to give their correct age. If possible, further sub-classification of stages 2 and 3 into a, b, and c modified according to Kellinghaus et al were per- Today, age diagnostics of living individuals is well estab- formed. lished in forensic sciences as well as in competitive sports, to ensure that athletes are competing fairly and with suf- Between February and June 2011, T1 gradient echo 3D ficient health protection. However, age estimations in this FFE sequences of the whole pelvis were performed with field should not rely on imaging methods that include a 3.0 T MR system (Achieva, Philips) and an 8 elements exposure to radiation. Thus, determination of skeletal age SENSE cardiac coil. Multi-planar reconstructions allowed a is significantly complicated. Moreover, especially for U-20 simultaneous view of multiple dimensions. competitions, novel morphological criteria are sought, as Ossification stages were determined for both the right and the skeletal maturation of hand and wrist bones is com- the left pelvic side. MR assessments were done by one plete well before the age of 20 years. examiner, who was unaware of the age of the individuals before and during the examinations. Results are expressed The iliac crest apophysis has recently been shown to be of as minimum, maximum, mean ± standard deviation, and value in forensic age estimation settings using convention- median with lower and upper quartiles. Comparison of left al projection radiography as well as sonography [20, 21]. versus right side was done by means of Wilcoxon test. Sig- In an anthropological approach, Coqueugniot and Weav- nificance was assumed at p \ 0.05 (exact, two-sided). er demonstrated that complete fusion between the apoph- ysis and iliac bone occurs at the age of 22 years in women and 20 years in men. Therefore, the present pilot study Results addresses the question of whether the investigation of this skeletal region by means of a modern cross-sectional tech- In all subjects examined (n = 152), a reliable MR assess- nique, such as the magnetic resonance imaging (MRI), ment of the apophyseal iliac crest ossification was possible might serve as an additional criterion for age diagnostics on both pelvic sides. The ossification stages 1 to 4 were in U-20 soccer competitions. demonstrated in (Fig. 5.4.2.1 a–c). A determination of sub-stages according to Kellinghaus et al did not appear feasible because of movement artefacts, the relatively large F-MARC PROJECTS | OTHER RECOGNISED MATTERS 165
Fig. 5.4.2.1 Ossification stages of the iliac crest apophysis visualized by means of magnetic resonance imaging. Each panel shows a right pelvic side in a coronal view. a Stage 2: The ossification center of the apophysis has ossified. There are no osseous connections between ossification center and iliac wing. b Stage 3: The ossification center has partially fused with the iliac wing. The inner part of the former physeal cartilage has ossified. The arrow demonstrates a thin osseous bridge in the outer part between ossification center and Os ilium. c Stage 4: The physeal cartilage has completely ossified
Stage n Min-max Mean ±SD Median; LQ; UQ The key point of the study were summarised as follow:
2 1 18.1-18.1 18.1 18.1; -; - 1. There is a growing demand for establishing radiation- 3 32 18.1-22.6 19.5±1.3 19.1; 18.5; 20.6 free imaging techniques for age diagnostics in living 4 119 18.0-22.9 20.8±1.3 20.9; 19.7; 21.9 individuals. Min age minimum, Max age maximum, SD standard deviation, 2. This is the first study investigating the iliac crest LQ lower quartile, UQ upper quartile apophysis for the purpose of age estimation by means of Tab. 5.4.2.1 Statistical parameters (expressed in years) a modern cross-sectional imaging method. 3. Major ossification stages, known from forensic X-ray and complex anatomy of the iliac crest and its surrounding studies of the iliac crest, could be visualised by MRI structures, as well as an insufficient image resolution. The and revealed increasing age medians with increasing statistical parameters according to the four-stage classifica- stages. tion were presented in Table 5.4.2.1. 4. Sub-classification of stages 2 and 3 according to Developmental differences between the right and the left Kellinghaus et al. did not appear feasible. pelvic side were only found in 14 cases and were not statis- 5. Since the statistical parameters obtained in this study tically significant (p = 0.013). In these cases, the pelvic side did not allow for further differentiation in the cohort showing the more advanced development was chosen for considered, examinations should be done in a larger evaluation. cohort aged between 10 and 20 years. Within the five age groups investigated, ossification stage 1 was not found. Only one case showed stage 2 and can therefore not be considered as representative. Both stage 3 and stage 4 were observed between 18 and 22 years. The means steadily increased by about one year from stage 2 (18 years), via stage 3 (19 years), to stage 4 (20 years).
What we learned from the studies Duration: 2011 MRI of the iliac crest is a suitable method in age diagnos- Country: Germany tics of living individuals. However, it does not represent an Cooperation: University Hospital Muenster, Germany applicable criterion for age estimations in U-20 soccer play- Reference: Dvořák ers. Wittschieber D, Vieth V, Timme M, J, Schmeling A (2014). Magnetic resonance imaging of the iliac crest: age estimation in under-20 soccer players. Forensic Sci Med Pathol 10(2):198-202 166 OTHER RECOGNISED MATTERS | F-MARC PROJECTS
5.5 Cartilage Injury in the Football Player
Why we conducted these studies
Football is a high-impact contact sport, which may trig- ger significant acute and chronic joint contact forces with potential detrimental effects on the joint surface. Due to the limited spontaneous regeneration of articular cartilage, injuries often lead to significant symptoms under the con- tinued high demands of football ultimately resulting in the players’ inability to play. Besides loss of playing time, progressive articular cartilage degeneration and osteoar- thritis have been found in up to 32% and present a major cause for disability and retirement from the sport. Sharing a deep concern for cartilage injuries in football, F-MARC and the International Cartilage Repair Society (ICRS) col- Fig. 5.5.1:The ‘spectrum of care” paradigm for the management of laborated on research projects devoted to cartilage issues articular cartilage injury and degeneration in football (soccer) players in football.
prevention; (2) surgery; (3) cartilage supplementation, Aims of the studies and (4) rehabilitation (Fig. 5.5.1).
UÊ*ÀÛ`iÊ>ÊV«Ài iÃÛiÊÛiÀÛiÜÊvÊÌ iÊVÕÀÀiÌÊ knowledge of cartilage injury pathophysiology, epide- Results miology, and etiology UÊi«Ê>`Û>ViÊÌ iÊÃViViÊ>`ÊÕ`iÀÃÌ>`}ÊvÊ>ÀÌVÕ- Steinwachs, Engebretsen, and Brophy established the lar cartilage injury and degeneration in the football scientific evidence base for cartilage injury and repair in player and to investigate options for future treatment the athlete. These injuries and the inherent risk of the and prevention methods of articular cartilage in foot- game create an overall prevalence of knee articular carti- ball lage lesions of 36% and up to 72%. The football player UÊ/ÊÀi`ÕViÊÌ iÊV`iViÊvÊV>ÀÌ>}iÊÕÀÞÊ>`ÊÀÃÊvÊ with articular cartilage injury is often faced with a signif- osteoarthritis in football players of all ages and skill icant challenge because of the high demands placed on levels the normal, repaired, and regenerated tissue by the game over time. The doctors showed that cartilage defects in athletes could be treated with microfracture, osteochon- How we collected the data dral autogenic or allogenic tissues but that the ultimate challenge is the quality of the repair tissue, as this must A number of studies were conducted by researchers closely resemble and function like normal hyaline carti- worldwide to investigate the issue of articular cartilage lage. injury in football players. Research findings were pre- sented in 12 scientific papers and jointly published as Mithoefer and Steadman investigated a case series supplement in the journal Cartilage in 2012. While all of professional, injured football athletes, concluding studies made individual contributions to the illumina- that the microfracture technique followed by appropri- tion of the subject, they may be subsumed under the ate rehabilitation provides restoration of the knee joint “spectrum of care” paradigm. This paradigm has been function and may thus allow for a high rate of return to formulated for the management of articular cartilage play. However, the doctors also pointed to the issue of injury and degeneration in football players with the aim deterioration of clinical results in some cases after two of facilitating and accelerating an injured athlete’s return years. to play. The paradigm rests on four cornerstones: (1) F-MARC PROJECTS | OTHER RECOGNISED MATTERS 167
Panics, Hangody, Baló, Vásárhelyi, and Gál estab- about a third of professional players and diagnosed four lished that autologous osteochondral mosaicplasty in to five years earlier. competitive elite and recreational football players is a good alternative procedure to repair cartilage damage with best results in younger athletes with smaller lesions. What we learned from the studies
Mithoefer, Peterson, Saris and Mandelbaum dem- The probability of developing osteoarthritis in football onstrated that articular cartilage repair with autologous players is five to 12 times more frequent than in the gen- chondrocyte implantation especially in elite football eral population. Factors determining a successful return players often allows for successful return to play with to football after articular cartilage repair of the knee excellent durability at 5 years and beyond. However, the include player age, time between injury symptoms and doctors also pointed out that the disadvantage of this treatment, competitive level of participation, defect size, technique lies in the long time for tissue maturation and and repair tissue morphology. Sports and exercise par- consequent return to play. ticipation after cartilage repair may facilitate joint resto- ration, functional recovery, and fitness levels. Promoting Görtz, Williams, Gersoff, and Bugbee described oste- the “spectrum of care” paradigm for the management ochondral allograft reconstruction as an increasingly of articular cartilage injury in football players as well as popular treatment option for osteoarticular lesions in encouraging players and coaches to actively incorporate athletes. These allografts provide mature and immune- the “FIFA 11+” programme into their training prac- privileged hyaline cartilage on an osseous scaffold that tice are therefore promising moves towards a reduction serves as an attachment vehicle. This is rapidly replaced of articular cartilage injuries and their consequences in via creeping substitution, leading to reliable graft inte- football. It must be noted, however, that not all players gration that allows for simplified rehabilitation and will return to football after articular cartilage repair. accelerated return to sport. The next step in the FIFA/ICRS initiative will be to investigate how this progression of osteoarthritis can be Bekkers, de Windt, Brittberg, and Saris provided a delayed, with research s. a. presented by Zaslav et al in critical review of the “state of cartilage repair” in foot- their evaluation of new frontiers for cartilage repair and ball athletes as well as a critical review of the best avail- protection leading the way. able evidence for cartilage surgery and treatment selec- tion. They furthermore evaluated specific patient profiles for professional and recreational athletes and proposed a treatment algorithm for the treatment of focal cartilage lesions in football players.
Hambly, Silvers, and Steinwachs pointed out that the evidence base for rehabilitative practice after articular cartilage repair is increasing but remains sparse in areas. Articular cartilage repair may allow return to sport but rehabilitating time scales can be lengthy.
Kirkendall and Garrett developed a strategy based on the available evidence and clinical practice guidelines that includes a regiment of patient education, self-man- agement, weight control, and exercise supported by indi- Duration: 2012 vidualised pain management strategies. Countries: International Reference: Lee and Chu revealed that the probability of develop- Mandelbaum B, Mithoefer K, Peterson L, Saris D, Dvořák ing osteoarthritis in soccer players is 5 to 12 times more J (2012). Cartilage Issues in Football (Soccer): An Executive frequent than in the general population. It is higher than Summary of the Fédération Internationale de Football for most elite athletes and responsible for retirement in Association (FIFA)/ International Cartilage Repair Society (ICRS) Initiative. Cartilage 3(1 Suppl): 6S-10S 168 IMPROVING STANDARDS OF CARE | F-MARC PROJECTS
6 Improving Standards of Care 6.1 Football Medicine Manual and Website
6.1.1 Football Medicine Manual In spring of 2003, the preparations for the F-MARC Football Medicine Manual started. Our objective was to create a single and practically orientated resource for the Background medical care of the football player. In order to improve the standards of care for the millions of players world- In our continuous effort to protect the health of play- wide that have no access to the sophisticated medical ers worldwide, F-MARC had realised that FIFA mem- services available to elite players, the Football Medicine ber associations were in need of a comprehensive educa- Manual had to primarily address those who take care of tional tool that dealt with all medical aspects of football. the players at grassroots level (Fig. 6.1.1.1). While the information was mostly published, anyone interested had to go to multiple sources in sports medi- As a first step, the main focus and individual topics of the publication needed to be identified. Following F-MARC’s research strategy, prevention was clearly one of the most fundamental concerns. Therefore, after addressing the epidemiology of injuries and risk man- agement in football, one chapter was dedicated to injury prevention, but also to nutrition and doping control in order to demonstrate the comprehensive F-MARC definition of prevention. According to our findings on the frequency and characteristics of injury in football, the treatment and rehabilitation as well as return-to- play considerations of the most relevant injuries were described in individual chapters. Finally, the diagnosis, treatment and return-to-play issues of diseases being important in football were explained. The next step was to identify the respective experts for the different topics. A list of individuals was developed not only to encompass the breadth of football medicine, but also to ensure comprehensible and practically orien- tated reporting on research findings to those members of the medical profession less exposed to scientific lit- erature (Fig 6.1.1.2). In an intense workshop, the iden- tified experts created drafts of their respective chapters, and then presented the drafts to their peers to react, to criticise and to complement on. One year later, a smaller group of the original authors gathered to edit the manu- script and finalised the English version. Football medi- cine colleagues from around the world were then asked to translate the Football Medicine Manual into the other three FIFA languages of French, German, and Span- ish. Since then, the manual has also been translated into Arabic, Czech, Japanese, Mandarin, Polish, and Russian with more language versions being prepared.
However, the body of knowledge in football medicine continuously grows, not least because of the initiatives Fig. 6.1.1.1 Cover of the first edition of the F-MARC Football and activities by F-MARC. In June 2008, preparations Medicine Manual for a completely revised second edition of the F-MARC cine, identify and then modify the findings so that they Football Medicine Manual started. We reviewed the became more applicable to football. content of the first edition and asked the authors of the first edition for an update of their chapters. We further F-MARC PROJECTS | IMPROVING STANDARDS OF CARE 169
assessed the need for information on additional topics that had accumulated in the meantime, and new authors were identified as needed. After editing of the original English drafts, the new edition was published at the FIFA network conference in October 2009 explicitly organised and dedicated to demonstrate the importance of medical issues to the presidents or general secretaries and one physician of all FIFA member associations. Print copies of the F-MARC Football Medicine Man- ual in English, French, Spanish and German are avail- able to any sports physician and member association on request, and also distributed at F-MARC conferences and courses. Member associations who are interested in translating and publishing the manual in their individual language can enter into an agreement with FIFA that entitles them to translate and publish a specified number of copies within their language region. A pdf-file is avail- able as a download from the football medicine extranet of F-MARC.
Fig. 6.1.1.2 Cover of the second revised edition of the F-MARC Football Medicine Manual
Duration: 2003 - ongoing Countries: International Cooperation: International References: Dvořák J, Junge A (eds) (2005). F-MARC Football Medicine Manual, FIFA, Zurich Dvořák J, Junge A, Grimm K (eds) (2009). F-MARC Football Medicine Manual, second revised edition, FIFA, Zurich 170 IMPROVING STANDARDS OF CARE | F-MARC PROJECTS
6.1.2 Emergency Medicine Manual What the manual offers
The Football Emergency Medicine Manual compris- Why we conducted this project es four chapters, each of which offers valuable insights and guidance on different aspects of football emergen- Large-scale football tournaments are cheerful celebra- cy medicine in the scope of mass football events (Fig. tions of the world’s most popular sport. However, mul- 6.1.2.1): tiple casualty management may be needed when such mass gatherings take place, and that there is a demand (1) A thorough introduction in chapter one identifies for a structured football emergency medicine educa- and explains the need for football emergency medicine, tion for all health care providers involved. The Football and presents a structured approach to planning. Accord- Emergency Medicine Manual, published in the forefront ing to this approach, there are eight matters to be con- of the 2010 FIFA World Cup™ in South Africa, reflects sidered in the planning and organisation of medical ser- FIFA’s dedicated and comprehensive approach to the vices for football events of different sizes and at different protection of players, spectators and actors involved, or levels of play nationally and internationally: (a) Constit- present, in mass football events. Written for and from uents; (b) Locations; (c) Conditions to cover; (d) Juris- the perspective of the team and event physician to facili- diction; (e) Duration; (f) Services; (g) Personnel; and (h) tate their work, the manual carefully addresses matters to Facilities. be considered in the planning and organisation of medi- cal services for mass football events, and offers scientific (2) The second chapter provides an overview of the basic advice as well as hands-on guidance for a variety of inci- principles of multiple casualty management in football; dents that may occur on, or around, the pitch. of the principles of football stadium mass gathering medicine; and of emergency medical logistics at FIFA competitions. Furthermore, the basics of managing life- Events leading to the publication of the FIFA threatening incidents are conveyed for acute instances Emergency Medicine Manual such as acute cardiac arrest, acute anaphylaxis, acute hypoglycaemia, acute generalised seizure, and acute In 2004, upon its nomination as host of the 2010 FIFA potential spinal injury. Key definitions, checklists, step- World Cup™, South Africa and its Local Organising by-step explanations and helpful advice in the form of Committee carried out an analysis, which revealed that memo boxes are provided as well, thus allowing readers the country would have to manage not only large num- to immediately apply the newly acquired knowledge to bers of constituents, but also an extensive geographical their medical practice. A risk classification of football area and a range of conditions. Also, it became obvious matches presented under the headings “low”, “moder- that there would be overlapping and common interests ate”, and “high” aids the reader in gauging the degree between the sports medical and emergency medical staff of risk prior to a football match. Furthermore, advice operating during the upcoming World Cup, and that regarding the minimal standards in medical mass gather- football medical practitioners would have to be able ing services, as well as regarding the recommended num- to “convert” from sports practitioners to “emergency” ber and qualifications of health care providers in football practitioners in case this was needed. The introduction stadium mass gathering are given, and detailed sugges- of a preparatory education programme in the form of tions concerning the necessary equipment are made. a three-day Football Emergency Medicine course was a first step taken as a consequence of these insights. In a (3) Chapter three outlines the possible spectrum of next step, and with the support of FIFA and F-MARC, medical emergencies on the pitch. It gives detailed guid- it was then agreed to write a specific manual that would ance for team and event physicians on how to handle the provide prospective event physicians with the required most frequent life-threatening injuries and incidences on knowledge and skills enabling them to function with the pitch, musculoskeletal injuries requiring emergency confidence in the positions assigned to them during the treatment and facial injuries. In this context, reference World Cup: the idea for the Football Emergency Medi- should be given to sudden cardiac arrest (SCA), which is cine Manual was born. known as the most important cardiac emergency in foot- ball, potentially leading to sudden cardiac death (SCD). SCD during a football match should be avoided at all F-MARC PROJECTS | IMPROVING STANDARDS OF CARE 171
costs, and the most effective way of preventing SCD is a cardiovascular screening through a thorough pre-sea- son or pre-competition medical assessment (see chapter 4.1). The most definite and effective form of treatment for SCA on the pitch is defibrillation within one to three minutes. The Football Emergency Medical Manual offers valuable advice on the diagnosis and treatment of concussion and SCA, as well as on a number of other potentially life-threatening injuries.
(4) The fourth chapter looks at environmental factors such as weather, altitude, pollution and aeroallergens, and explains which effects different playing environ- ments may have on the condition of players and teams. Because of the particularities of geographic locations, visiting national teams may be confronted with playing situations that are not only at different altitude, but also under different environmental conditions such as heat, cold and different relative humidity, as compared with their home country. The Football Emergency Medicine Manual lists risk factors, gives advice on how impair- ment and illnesses due to, e. g. heat, can be prevented, and outlines signs and symptoms of conditions induced by environmental factors and how they should be treat- ed.
Fig. 6.1.2.1 The FIFA Emergency Medicine Manual Availability and distribution
In order to disseminate the knowledge compiled in the Football Emergency Medical Manual, print copies are made available in English, French, Spanish, and Ger- man to any sports physician and member association on request. Furthermore, the manual is distributed at F-MARC conferences and courses.
Duration: 2004 - 2009 Countries: South Africa, Switzerland Cooperation: Department of Emergency Medicine of the University of Witwatersrand, Johannesburg, South Africa Reference: Dvořák J, Grimm K (eds) (2009). F-MARC Football Emergency Medicine Manual, FIFA Zurich 172 IMPROVING STANDARDS OF CARE | F-MARC PROJECTS
6.1.3 First Aid Manual Players should always be approached and managed by the “ABCDE (Airways-Breathing-Circulation-Disabil- ity-Expose/Examine)” approach. Why we conducted this project This approach is applicable for assessing all injuries you encounter on entering the football or training This booklet is designed for use by coaches and non- field of play for player injuries and is not just applica- medically qualified First Aiders working within foot- ble to Basic Life Support (BLS). ball around the world and specifically in the developing The aim of the First Aider is to ensure what is known countries. It is a short and practical guide to dealing with as the 3Ps: injuries and illnesses, mainly on the field of play, both Preserve Life - Prevent deterioration of the player’s in training and in matches (Fig. 6.1.3.1). It provides a health situation - Promote Recovery comprehensive guide to immediate first aid management of player injuries and illnesses from critical to minor. UÊ Wounds and bleeding The intentions have been to provide a “holistic” view This chapter focuses on the ability to recognise that of first aid because of the limited medical resources that bleeding (external/ internal) is taking place and on may exist. It also advises on appropriate return to play how to stop it. It is one of the most important aspects guidelines for a wide range of conditions and advises of first-aid casualty survival. on equipment the First Aider should carry to all events The assessment of the severity of the bleeding and the when dealing with players (Fig. 6.1.3.2). management of a wound centres on: This manual may be of use to those therapists and doc- - Control of bleeding tors just starting out in their football medical careers. - Prevention of infection - Prevention of further complications
What the manual offers UÊ Soft tissue injuries This chapter describes signs and symptoms of a soft This manual outlines firstly the roles, duties and respon- tissue injury, which can be very similar to those of a sibilities of the First Aider under any circumstances and fracture (broken bone). A fracture must be ruled out level of resources. It recommends the “best first aid prac- by careful evaluation before continuing to manage the tice within the limited resources of a developing coun- injury. This may require the player being first seen by try”, if it is not possible to practice at this level, do the a doctor or therapist. best you can whilst you slowly increase the standard of For treatment of soft tissue injuries use the P.R.I.C.E. first aid practiced. In order to achieve this, each of the (Protection, Rest, Ice, Compression and Elevation) following points should be followed by the First Aider in regime. charge of training or a match: (a) Scene safety, (b) pro- viding a safe environment – hygiene and hand washing, UÊ Bone injuries (c) content of a first aid kit, (d) clean water, (e) injury This chapter focuses on the signs and symptoms of recording and (f) prevention. bone injury. All fractures, even if only suspected, should be immediately referred to the hospital for Secondly, the First Aid Manual comprises six chapters, investigation and management. each of which offers practical insights and guidance for A fracture can be classified into different types: (1) any First Aider to dealing with different aspects and lev- “Closed”, (2) “Open”, (3) “Complicated” and “Green- els of injuries and illnesses. stick fracture”. Signs and symptoms of fractures are: UÊ Assessment of the unresponsive casualty and basic Ê Ê UÊ*>Ê>ÌÊÌ iÊÃÌiÊvÊÌ iÊÕÀÞÊV>ÊLiÊÃiÛiÀiÊÊ life support pain). This chapter describes the approach and management Ê Ê UÊ7i>iÃÃÉÃÃÊvÊ«ÜiÀ of the many potential causes of a player becoming Ê Ê UÊLÀ>ÉÕ>ÌÕÀ>ÊÛiiÌ unresponsive on the field of play. The most common Ê Ê UÊ-Üi} causes are: Sudden Cardiac Arrest, Asphyxia (Chok- Ê Ê UÊ ivÀÌÞÉÀÀi}Õ>ÀÌÞ ing), Shock, Head Injury, Heat Exhaustion, Epilepsy, Ê Ê UÊ Ài«ÌÕà Diabetes, Fainting. F-MARC PROJECTS | IMPROVING STANDARDS OF CARE 173
UÊ Injuries to the head and neck This chapter focuses on the potential head and neck injuries. It is important to have an awareness of the potential problems that can occur to a player who suf- FIRST AID MANUAL AND fers an injury to the head and/or neck. It is important RELATED HEALTHCARE
ISSUES FOR FOOTBALL that you deal with all known or suspected spinal inju- FOR USE BY FIRST AIDERS AND COACHES ries (fractures) and dislocations quickly and correctly. Proper immobilisation and player management may mean the difference between complete recovery and lifelong paralysis, or even death. Injuries to the head and neck can be very serious and occasionally fatal. A neck injury should be considered for: Ê Ê UÊ>ÞÊÕÀÞÊVVÕÀÀ}Ê>LÛiÊÌ iÊV>ÀÊLiÆ Ê Ê UÊ>ÞÊ i>`ÊÕÀÞÊÜÌ ÊÃÃÊvÊVÃVÕÃiÃÃÆ Ê Ê UÊ>`ÊÜ iÀiÊ>LÀ>ÊyiÝÊÀÊiÝÌiÃÊvÊÊ the neck has occurred; or Ê Ê UÊ>ÊV>à ÊvÊ i>`Ã]ÊÀiÃÕÌ}ÊÊÌ iÊ«>ÞiÀÊÊ having an altered level of consciousness. Fig. 6.1.3.1 The First Aid Manual UÊ Medical emergencies that may occur in football This chapter outlines “other” conditions that might require first-aid attention that are not a direct result of football participation but are conditions that the play- er may suffer from (such as asthma, diabetes, epilepsy, heart disease) during football training or matches.
It is advisable when working as a First Aider in a team environment, that for every new player signing, and also at the start of each season, First Aiders ask the players to complete a questionnaire asking about their previ- ous medical history and illnesses so that they are aware of any underlying medical conditions the players might have as well as previous injuries that they have suffered. If the players are below the age of 16, the parents may need to complete the form.
Availability and distribution Fig. 6.1.3.2 A basic first aid kit for a first Aider to cover a football match In order to disseminate the knowledge compiled in the Duration: 2011 - 2014 Football First Aid Manual, print copies are made avail- Countries: UK, South Africa able in English to any sports physician and member Cooperation: Exercise Medicine Centre for Sports Medicine, association on request. Furthermore, the manual is dis- University of Nottingham, UK; Department of Emergency tributed at F-MARC conferences and courses. Medicine of the University of Witwatersrand, Johannesburg, South Africa Reference: Hodgson L, Kramer E (2015). First Aid Manual and Related Healthcare Issues for Football - with special regard to first aiders and coaches. Official publication of the Fédération Internationale de Football Association (FIFA), Zurich, Switzerland 174 IMPROVING STANDARDS OF CARE | F-MARC PROJECTS
6.2 Consensus Statements and Recommendations
6.2.1 Recommendations for Diagnosis and UÊ VÕÃÃÊÃÊ>ÊLÀ>ÊÕÀÞÊ>`ÊÃÊ`iwi`Ê>ÃÊ>ÊV«iÝÊ Treatment of Concussion in Sport pathophysiological process affecting the brain, induced by biomechanical forces. There are several common features that incorporate clinical, pathologic and biomechanical A revision and update of the recommendations devel- injury constructs that may be utilised in defining the nature oped following the first (Vienna 2001), second (Prague of a concussive head injury. 2004) and third (Zurich 2008) International Consen- UÊ VÕÃÃÊ>ÞÊLiÊV>ÕÃi`ÊiÌ iÀÊLÞÊ>Ê`ÀiVÌÊLÜÊÌÊÌ iÊ sus Conferences on Concussion in Sport is based on the head, face, neck or elsewhere on the body with an “impul- deliberations at the fourth International Conference on sive” force transmitted to the head. Concussion in Sport held in Zurich in November 2012. UÊ VÕÃÃÊÌÞ«V>ÞÊÀiÃÕÌÃÊÊÌ iÊÀ>«`ÊÃiÌÊvÊÃ ÀÌ At each conference, a number of experts in the field were lived impairment of neurological function that resolves invited to address specific issues of concussion in sport spontaneously. such as epidemiology, basic and clinical science, injury UÊ VÕÃÃÊ>ÞÊÀiÃÕÌÊÊiÕÀ«>Ì }V>ÊV >}iÃÊLÕÌÊ grading systems, cognitive assessment, new research the acute clinical symptoms largely reflect a functional dis- methods, protective equipment, management, preven- turbance rather than structural injury. tion and long term outcomes. At the conclusion of each UÊ VÕÃÃÊÀiÃÕÌÃÊÊ>Ê}À>`i`ÊÃiÌÊvÊVV>ÊÃÞ`ÀiÃÊ conference, a small group of experts drafted a document that may or may not involve loss of consciousness. Resolu- describing the position reached by those in attendance at tion of the clinical and cognitive symptoms typically fol- the meeting. These consensus documents were then co- lows a sequential course. published in different journals of sports medicine. Fur- UÊ VÕÃÃÊÃÊÌÞ«V>ÞÊ>ÃÃV>Ìi`ÊÜÌ Ê}ÀÃÃÞÊÀ>Ê ther, a practical tool for physicians was developed, aid- structural neuroimaging studies. ing in the systematic assessment of a player with a head injury at the sideline, whether at the recreational, elite or professional level. Return to play guidelines
The new 2012 Zurich Consensus Statement is designed One of the critical issues in “Concussion Management” to build on the principles outlined in the previous docu- are the “Return to Play (RTP)” guidelines, which were ments and to develop further conceptual understand- already a focal point at the Prague Conference. The cor- ing of this problem using a formal consensus-based nerstone of the most updated concussion management approach. is physical and cognitive rest until the acute symptoms resolve, and then a graded programme of exertion prior This consensus paper is broken into a number of sec- to medical clearance and RTP follows (Tab. 6.2.1.1): tions In the case of complex concussion, rehabilitation will 1. A summary of concussion and its management, with be more prolonged and return to play decisions will be updates from the previous meetings; more cautious. Such complex cases should be managed 2. Background information about the consensus by physicians with a specific expertise in the manage- meeting process; ment of concussion injury. 3. A summary of the specific consensus questions The Sport Concussion Assessment Tool (SCAT) was discussed at this meeting; developed as part of the conclusions of the second con- 4. The consensus paper should be read in conjunction sensus conference. This tool represents a standardised with the SCAT3 assessment tool, the Child SCAT3 method of evaluating players after a suspected concus- and the CRT (designed for lay use). sion in football. SCAT2 was created following the third consensus meeting and has two forms – a sideline assess- ment form for team doctors and coaches and a more What we learned from the meetings detailed medical evaluation form (Fig. 6.2.1.1). A future SCAT test battery (ie. SCAT3) should include At the fourth conference in Zurich 2012, a panel discus- an initial assessment of injury severity using the Glasgow sion was held regarding the review of the definition of Coma Scale (GCS), immediately followed by observing concussion and its separation from mild traumatic brain and documenting concussion signs. Once this is com- injury (mTBI). Minor revisions were made to the “Defi- plete, symptom endorsement and symptom severity, as nition of Concussion”, which is defined as follows: well as neurocognitive and balance functions, should be F-MARC PROJECTS | IMPROVING STANDARDS OF CARE 175
Tab. 6.2.1.1 Graduated return to play protocol assessed in any athlete suspected of sustaining a concus- Pocket CONCUSSION RECOGNITION TOOL™ sion. It is recommended that these latter steps be con- To help identify concussion in children, youth and adults ducted following a minimum 15 minute rest period on the sideline to avoid the influence of exertion or fatigue on the athlete’s performance. Although it is noted that RECOGNIZE & REMOVE this time frame is an arbitrary one, the expert panel Concussion should be suspected if one or more of the following visible clues, signs, symptoms or errors in memory questions are present. agreed nevertheless that a period of rest was important 1. Visible clues of suspected concussion Any one or more of the following visual clues can indicate a possible concussion: prior to assessment. Loss of consciousness or responsiveness Lying motionless on ground / Slow to get up It was further agreed that the SCAT3 would be suitable Unsteady on feet / Balance problems or falling over / Incoordination Grabbing / Clutching of head for adults and youths aged 13 and over and that a new Dazed, blank or vacant look Confused / Not aware of plays or events tool (Child SCAT3) be developed for younger children. 2. Signs and symptoms of suspected concussion Presence of any one or more of the following signs & symptoms may suggest a concussion:
- Loss of consciousness-Headache Duration: 2001 - ongoing - Seizure or convulsion - Dizziness -Balance problems - Confusion Countries: International - Nausea or vomiting - Feeling slowed down -Drowsiness - “Pressure in head” -More emotional-Blurred vision Cooperation: Concussion in Sport Group - Irritability- Sensitivity to light - Sadness-Amnesia References: - Fatigue or low energy- Feeling like “in a fog“ - Nervous or anxious- Neck Pain Aubry M, Cantu R, Dvořák J, Graf-Baumann T, Johnston K, - “Don’t feel right” - Sensitivity to noise - Difficulty remembering - Difficulty concentrating Kelly J, Lovell M, McCrory P, Meeuwisse W, Schamasch P, © 2013 Concussion in Sport Group Concussion in Sport Group (2002). Summary and agreement
3. Memory function statement of the First International Conference on Concussion Failure to answer any of these questions correctly may suggest a concussion.
“What venue are we at today?” in Sport, Vienna 2001. Recommendations for the improvement “Which half is it now?” “Who scored last in this game?” of safety and health of athletes who may suffer concussive inju- “What team did you play last week / game?” “Did your team win the last game?” ries. Simultaneous publication in Br J Sports Med 36(1): 6-10
Any athlete with a suspected concussion should be IMMEDIATELY REMOVED FROM PLAY, and should not be returned to activity until they are assessed and Clin J Sports Med 12(1 Suppl): S 6-11 medically. Athletes with a suspected concussion should not be left alone and should not drive a motor vehicle. McCrory P, Johnston K, Meeuwisse W, Aubry M, Cantu R, It is recommended that, in all cases of suspected concussion, the player is referred to a medical professional for diagnosis and guidance as well as return to play decisions, Dvořák even if the symptoms resolve. J, Graf-Baumann T, Kelly J, Lovell M, Schamasch P (2005). Summary and agreement statement of the 2nd RED FLAGS If ANY of the following are reported then the player should be safely and immediately removed from the field. If no qualified medical professional is International Conference on Concussion in Sport, Prague available, consider transporting by ambulance for urgent medical assessment: 2004. Simultaneous publication in Br J Sports Med 2005;39(1 - Athlete complains of neck pain- Deteriorating conscious state - Increasing confusion or irritability- Severe or increasing headache - Repeated vomiting- Unusual behaviour change Suppl):i78-86 and in Clin J Sport Med 15(2): S 48-55 - Seizure or convulsion- Double vision Dvořák - Weakness or tingling / burning in arms or legs McCrory P, Meeuwisse W, Johnston K, J, Aubry
Remember: M, Molloy M, Cantu R (2009). Consensus Statement on - In all cases, the basic principles of first aid (danger, response, airway, breathing, circulation) should be followed. Concussion in Sport: the 3rd International Conference on - Do not attempt to move the player (other than required for airway support) unless trained to so do - Do not remove helmet (if present) unless trained to do so. Concussion in Sport, Zurich 2008. Br J Sports Med;43(1 Suppl):i76-90 from McCrory et. al, Consensus Statement on Concussion in Sport. Br J Sports Med 47 (5), 2013 th © 2013 Concussion in Sport Group Concussion in Sport- 4 International Consensus Conference in Zurich 2012. Supplement of the Br J Sports Med 2013;47, (5 Fig 6.2.1.1 The SCAT3 pocket card Suppl) (for details see Bibliography) 176 IMPROVING STANDARDS OF CARE | F-MARC PROJECTS
6.2.2 Nutrition for Football Get the right amount of energy It’s not just making the right choices. The volume of food is important. The demands of training mean the Why we held this meeting player will eat a large volume of food. The hard part is matching the calorie intake with the energy output. Eat Whenever highly talented, motivated and well trained too much and body weight increases. Eat too little and players meet in competition, the margin between victory body weight decreases leading to poor performance, ill- and defeat is small. Attention to detail can make that nesses and injury. vital difference. Diet affects performance, and the food Choose the right foods to meet energy needs that we choose in training and competition will affect The bulk of the diet should be carbohydrates and there how well we train and play. While the basic components are different kinds of carbohydrates. The nature of the of nutrition are a constant, food selection and prepara- carbohydrate influences how fast it is taken in by the tion varies considerably around the world. Therefore, cells. There is an interaction of the type of carbohydrate F-MARC convened a consensus group of experts in the and the time from the last and to the next exercise ses- field to meet in Zurich in September 2005 to discuss the sion. Optimal recovery strategies need to consider not state of the art and the body of knowledge in nutrition only choosing carbohydrates, but what type of carbohy- and performance in football in order to prepare infor- drate and when it is eaten in relationship to training and mation material that would improve the health and per- matches. formance of players worldwide. This group presented A varied diet supplies adequate protein papers about the vital topics of nutrition and sports per- Carbohydrates are the primary source of energy for exer- formance, which were then discussed by all experts. cise. But after physical work, the body needs to repair damaged tissues and adapt for the next workout. Repair “The food and drink that players chose to consume can and adaptation occur in the cells and require protein. affect how they perform in sport and help them to stay fit Most diets consumed by athletes contain sufficient pro- and healthy. All players should choose food wisely to help tein so eating more protein is not necessary for most achieve their goals in sport.” players. Even a well thought out vegetarian diet will be FIFA President Joseph S. Blatter adequate to meet protein needs. Energy needs are met with a varied diet of nutrient- rich foods What we learnt from the meeting Athletes who pay attention to their diet tend to focus an unreasonable amount of attention just on carbo- Diet affects performance hydrates. A varied diet also included vegetables, fruits, A diet rich in carbohydrates supports the running beans, legumes, cereals, lean meats, fish and dairy prod- demands of the game. The player who has chosen a ucts. Only with a wide selection of foods will the player nutrient-rich diet with plenty of carbohydrates will run realise intake of all the necessary vitamins and minerals. farther and faster late into the game, execute skills accu- Excluding any food group in an attempt to regulate calo- rately, make better decisions and prevent injuries. ries intake is discouraged. Every player is different Hydration is important for performance There is no single diet plan that will meet the needs of Fluid intake before, during and after exercise is critical, every player in every circumstance. Training demands, especially in hot environments. When temperatures are match and travel schedules, injuries and more require extreme or when sweat losses are high, food and drinks considerable flexibility in food selection. are needed in order to replace vital fluids and salts. Small A good diet will support consistent training amounts of dehydration will affect performance and the The greatest emphasis on nutrition and performance player needs to be aware of the role dehydration plays is usually directed at match performance, but a sound in performance and work to keep sweat losses to a mini- nutrition plan has it greatest impact on training. The mum. well-fuelled player will be able to handle more intense The indiscriminate use of dietary supplements is dis- training that will improve fitness while reducing the risk couraged of illness or injury. In addition, the foods chosen affect When a player makes good choices from all food groups, the adaptive processes by the body. there is little need to add supplements to their diet. This is especially important in players who might be com- F-MARC PROJECTS | IMPROVING STANDARDS OF CARE 177
peting at a level where doping controls are taken. A substantial fraction of supplements contain unlabelled ingredients that might trigger a positive doping test and end up with painful sanctions.
Nutrition in lay terms
The members of the consensus group published their findings in the Journal of Sport Sciences in 2006 (Fig. 6.2.2.1). The level of detail and scientific depth was clearly beyond the level of understanding of the football family. A working group therefore synthesised the infor- mation and prepared an easy-to-read lay summary of the conference in the booklet “Nutrition for Football” (Fig. 6.2.2.2). This summary is available in English, Spanish, German and French and posted on FIFA.com as a free download. This booklet also contains special messages for the elite player, the semi-professional, the amateur, females, the young player, the referee and suggestions for eating while travelling. From this, the football family now has an accessible summary of the importance of nutrition in football performance and health.
Fig. 6.2.2.2 “Nutrition for Football. A practical guide to eating and drinking for health and performance”
Duration: 2005 - 2006 Countries: International Cooperation: Prof R. Maughan, Loughborough University, UK and all international experts participating References: Fig. 6.2.2.1 Supplement: “Nutrition and Football” Nutrition for Football. A practical guide to eating and drinking for health and performance (2006). FIFA, Zurich, Switzerland FIFA/F-MARC Consensus Conference 2006. Nutrition and football: J Sports Sci;24(7 Suppl) (for details see Bibliography) 178 IMPROVING STANDARDS OF CARE | F-MARC PROJECTS
6.2.3 Medical Issues of the Female Football Player
Why we conducted this project
FIFA staged the first FIFA Women’s World Cup™ in the People’s Republic of China in November 1991. Ever since then, the standards of play had risen, new youth competitions at world level were created, professional leagues were established in various countries, public interest grew and women’s grassroots football continu- ously broadened. In 2007, according to the Big Count survey, there were some 26 million girls and women who played football in over 180 countries.
When F-MARC did their first review of the literature on injuries, it became clear that the body of knowledge with regard to women’s football was scarce. In FIFA’s view however, it went without saying that in terms of medical research and instruction, women’s football deserves the same attention as the men’s game. F-MARC conducted several studies that added to what was known on injuries and their prevention in the female player. Prior to the FIFA Women’s World Cup China 2007™, we wanted to establish and update the current evidence of football Fig. 6.2.3.1 Supplement “Women’s Football” medicine in women and asked experts worldwide for their contributions. The scientific supplement covered all aspects of injury causation, incidence on different sur- faces and of course prevention, particularly addressing ACL tears and head injuries, and nutrition, as well as the problem of the female triad in football (Fig. 6.2.3.1).
Female football medicine in laymen terms
Following the strategy of translating scientific information into an easily comprehensible language that had proved successful with the nutrition booklet, F-MARC created a new publication for the female player, adding information on bone health and specific women’s issues. From this, the female player can now learn everything they need to know about e.g. their specific risk of ACL tears and how to prevent them, what to eat prior to and after a match or how to protect their bones. The booklet was published and distributed on occasion of the FIFA Women’s World Cup 2007™ (Fig. 6.2.3.2) and is available in English, Spanish, German and French and posted on FIFA.com as a free download. F-MARC PROJECTS | IMPROVING STANDARDS OF CARE 179
Fig. 6.2.3.2 “Health and Fitness for the Female Football player”
Duration: 2006 - 2007 Countries: International Cooperation: Schulthess Clinic and University of Zurich, Zurich, Switzerland; University of Nottingham, UK; Loughborough University, UK; Santa Monica Orthopaedic Sports Medicine and Research Foundation, US; National Collegiate Athlete Association and Indiana University, Indiana, US; University of North Carolina, Chapel Hill, US; Duke University, Durham, US; Oslo Sports Trauma Research Center and Norwegian School of Sports Sciences, Oslo, Norway; University of Melbourne, Australia References: Health and Fitness for the Female Football player. A guide for players and coaches (2007). FIFA, Zurich, Switzerland Women’s Football (2007). Supplement of the Br J of Sports Med 2007;41(1 Suppl) (for details see Bibliography) 180 IMPROVING STANDARDS OF CARE | F-MARC PROJECTS
6.2.4 Playing Football at Different High Recommendations on playing at different Altitudes altitude
For players ascending from sea level to low altitude, a Why we conducted this project short acclimatisation period of three to five days may be useful to approach peak performance as from 1500m Whenever a team needs to compete in a location that is and above. In players ascending from sea level to mod- either at considerably higher or lower altitude than their erate altitude, an acclimatisation period of one to two home address, they will note differences in their perfor- weeks at the location of the match is recommendable to mance. If they have been travelling from low to high approach peak performance. In players ascending from altitude, they may also suffer from health impairments sea level to high altitude, an acclimatisation period of such as headache impaired sleep and nausea. The inter- at minimum two weeks at the location of the match is national match schedule often does not allow for extend- required to achieve peak performance. ed stays at one spot in order to enable acclimatisation. +ÕiÃÌÃÊÀi>Ìi`ÊÌÊ i>Ì ]Ê«iÀvÀ>ViÊ>`Êv>ÀÊ«>ÞÊ Acute Mountain Sickness (AMS), High Altitude Pulmo- under these circumstances had been a matter of intense nary Edema (HAPE) or High Altitude Cerebral Edema debate within the football family for a long time. (HACE) do not occur below 2000m. HAPE and HACE are life-threatening diseases that can, however, be easily The FIFA Sports Medical Committee and F-MARC treated by supplemental oxygen and descent. therefore invited twelve international experts to a meet- ing in Zurich from 25-27 October 2007. The major At moderate altitude, the risk of AMS for players liv- focus of the meeting was the current body of knowledge ing at sea level or low altitude is low and the illness on hypoxia, athletic performance, and playing football at usually mild, HAPE and HACE hardly ever occur. At different altitude. All experts prepared an overview arti- high altitude, the risk of AMS is considerable for play- cle on their respective subject. According to the results of ers living at sea level or low altitude and the illness can the discussion at the meeting, the individual articles were be more severe. Without proper treatment AMS may reviewed and published in a scientific supplement, pro- progress to HACE. HAPE may occur, particularly above viding a unique summary of what is known on playing 4000m. The risk of AMS for players living at sea level football at different altitude (Fig. 6.2.4.1). or low altitude depends on their individual susceptibil- ity, the degree of acclimatisation, the rate of ascent and the intensity of exercise. AMS symptoms such as mild What we learnt from the meeting headache, loss of appetite, impaired sleep or dizziness do not prevent a healthy player from playing, but might still The experts agreed on a new classification of altitude, impair performance. the rationale being based on the effects of hypoxia on exercise performance and health: Staged ascent will prevent severe high altitude illnesses in players from near sea level or low altitude when playing UÊi>ÀÊÃi>ÊiÛiÊäxää® a match or competition at high altitude. For each 300 - UÊÜÊ>ÌÌÕ`iÊxääÊqÊÓäää® 500m above 2000m, one day of acclimatisation should UÊ`iÀ>ÌiÊ>ÌÌÕ`iÊÓäääÊqÊÎäää® be spent at an intermediate moderate altitude. In suscep- UÊ } Ê>ÌÌÕ`iÊÎäääÊqÊxxää® tible individuals, AMS can be prevented by drugs such UÊiÝÌÀiiÊ>ÌÌÕ`iÊxxää® as acetazolamide or glucocorticosteroids, but these are both prohibited substances in sports. Players living at sea level or low altitude will have to cope with a reduction of their performance when playing at moderate and high altitude which continually increases Limitations of the findings with the level of altitude. Highly trained players suffer higher reductions in performance than untrained indi- Most studies on sports at high altitude involved indi- viduals. vidual athletes in specific sports which cannot always be generalised for team sports such as football. When play- ing at different altitude not only the absolute level of F-MARC PROJECTS | IMPROVING STANDARDS OF CARE 181
altitude, but also the difference between the starting (liv- ing) level and the playing level are of importance. There is a high individual variability in the adaptation process to altitude, which has to be considered when analysing the performance of an entire football team. Further, studies with sufficient statistical power are seldom avail- able as regards elite players and studies on recreational athletes or untrained subjects may not be relevant for the elite athlete. Further, while we have a fairly good knowledge about performance and training at moderate to extreme altitude with regards to aerobic exercise, little is known about intermittent high intensity exercise such as playing football. Finally, it is important to understand the influence of environmental conditions such as heat, cold and humidity on the health and the performance of players.
Fig. 6.2.4.1 Supplement “F-MARC Consensus Meeting: Football and Altitude”
The organisers of the consensus meeting on football at different altitude, (Dr M. D’Hooghe, Prof. P. Bärtsch, Prof. B. Saltin, Prof. J. #UNŪ¨J)
Duration: 2007 - 2008 Countries: International Cooperation: Prof. Bengt Saltin, Denmark, Prof. Peter Bärtsch, Germany, and all experts participating Reference: Experts of the consensus meeting on football at different altitude 2008 in Zurich F-MARC Consensus Meeting: Football and Altitude (2008). Supplement of the Scand J Med Sci Sports 18(1 Suppl) (for details see Bibliography) 182 IMPROVING STANDARDS OF CARE | F-MARC PROJECTS
6.2.5 Playing Football in Hot Environments Results
The capacity to exercise is considerably reduced in hot Why we supported these studies as compared to cool environments, most likely due to a combination of what is called a “central fatigue” induced Today’s international competition schedules in foot- by the brain and reduced oxygen delivery to the mus- ball require elite players to perform throughout the year cles by limitations in heart function. In the heat, body and world. In addition to dealing with the challenges of temperature rises. This is aggravated by exercise since long-distance travel and multiple time-zone crossings, muscle function leads to further heat production. The extreme environmental conditions at the destination body needs to dissipate this heat to keep its equilibrium, may pose considerable additional challenges to players which in the heat mainly happens through sweating. and support staff. The issue is further complicated by With low wind speed and high humidity, sweating may the fact that the host team is acclimatised to the respec- be impaired, increasing the risk of heat illness. Different tive environment and therefore does not experience the degrees of heat illness are observed, ranging from heat stress of travelling or climate change, possibly leading to syncope over heat exhaustion to heat stroke, all related a performance advantage. to increasingly higher body temperature.
In 2008, the FIFA Medical Committee and F-MARC There are large inter-individual differences in heat toler- were mandated by the FIFA Executive Committee to ance among players, meaning that one player may suffer study the different environmental conditions football heat exhaustion before another does have any symptoms. players may be exposed to while training or playing foot- Further, a number of substances may reduce a player’s ball. This was meant to include a review of the literature, ability to cope with heat stresses, as they are used in carrying out new research where necessary, and devel- medications for allergies, colds, sleep or hyperactive dis- oping recommendations for organisers of competitions orders. As continuous body temperature measurements and match officials who have to deal with matches being are not feasible, the best approach to individual risk played in extreme conditions. Heat is one of three envi- assessment is a pre-participation examination. ronmental conditions raising most concerns in relation Environmental factors influencing the ability to cope to performance issues and the health of players, together with high temperatures are most importantly high with high altitude and cold. humidity, which impairs sweating, but also wind speed and direct sun radiation. Therefore, environmental risk cannot be properly assessed by dry air temperature meas- Aims of the study urements alone. The currently best method to assess heat illness risk is to measure the Wet Bulb Globe Tempera- UÊÛiÃÌ}>ÌiÊÌ iÊivviVÌÃÊvÊ`ÀÞÊÛiÀÃÕÃÊ Õ`Ê i>ÌÊV`- ture (WBGT), a composite of air temperature, humid- tions ity, wind speed and sun radiation. Special devices are UÊÃÃiÃÃÊLiÃÌÊ«À>VÌViÊvÀÊ>VV>ÌÃ>ÌÊÌÊ ÌÊiÛÀ- available for measuring the WBGT at the spot. Where ments and develop evidence-based recommendations these are not readily available, WBGT may be calculated based on a formula derived from shaded dry bulb tem- perature and humidity. How we collected the data A natural protection mechanism against heat illness is The proceedings of a conference on sporting activi- to reduce exercise intensity. In football, this is reflected ties in extreme heat conditions organised and hosted in less sprinting, less high-intensity running and small- LÞÊ-* /,ÊqÊ+>Ì>ÀÊ"ÀÌ «>i`VÊ>`Ê-«ÀÌÃÊ i`- er distances covered during the second half of matches. cine Hospital, a FIFA Medical Centre of Excellence in Preventive measures further include adequate hydration Doha, together with a number of studies investigating to avoid fluid losses of more than 2% of body weight, the impact of hot environments when playing football which needs to be practised by each individual player. supported by F-MARC formed the base for a position Further strategies are half-time cooling measures, or the statement by international experts on playing football in introduction of additional fluid breaks. hot environments. F-MARC PROJECTS | IMPROVING STANDARDS OF CARE 183
What we learnt from the studies or to the match. This was first practiced at the final of the Men’s Olympic tournament in Beijing, and thereaf- The capacity to exercise is markedly reduced in hot envi- ter introduced by the FIFA administration as an impor- ronments, with high humidity posing further physiologi- tant measure to protect players’ health at all FIFA com- cal strain on the body. The combination of exercise and petitions. hot environments increases the risk of heat illness and heat stroke.
Recommendations for players UÊ ÀÊiÕ} ÊvÕ`ÊÌÊÀiÃÌÀVÌÊL`ÞÊ>ÃÃÊÃÃÊÌÊÊ <2% of pre-exercise mass UÊ ÌÊi>ÃÌÊ£ÓÊÜiiÃÊvÊ>VV>ÌÃ>ÌÊ>ÀiÊÊ Ê recommended for players from different climates before playing in hot environments
Recommendations for organisers (Table 6.2.5.1) UÊ *iÀvÀÊ«Ài«>ÀÌV«>ÌÊÃVÀii} UÊ >ÀivÕÞÊLÃiÀÛiÊ>ÌÀÃÊ`Û`Õ>ÃÊi°}°ÊÃViViÊÊ trait, cardiovascular disease) and signs and symptoms Ê >ÌÊÓnc Ê7 / UÊ ÌÀ`ÕViÊ>``Ì>ÊvÕ`ÊLÀi>ÃÊ>`Ê«ÀÛ`iÊÊ Ê i`V>ÊVÛiÀ>}iÊvÊÎäc Ê7 /Ê UÊ ,iVÃ`iÀÊÃÌ>ÀÌ}ÊiÛiÌÊvÊÎÓc Ê7 /
WBGT (C°) Comments
Unrestricted < 22 Normal activity
Low risk 22-28 Monitor fluid intake
Observe signs and symptoms Fig. 6.2.5.1: Supplement “Exercise in Hot Environments: From Basic High risk 28-30 Watch at-risk individuals Concepts to Field Applications”
Additional fluid breaks added Very high risk 30-32 Medical coverage mandatory
Stop play >32
Tab. 6.2.5.1: Recommendations for preventive measures based on WBGT Further research is required to assess use of different cooling strategies, the influence of acclimatisation on performance, the impact of heat on decision-making and the risk for spectators from different climates.
Practical impact on football practice: Based on a study Duration: 2011 - 2012 in Turkey, which had shown that the critical rise in Countries: International body temperature occurs after 30 minutes into the first Cooperation\ÊÊÊëiÌ>Àq+>Ì>ÀÊ"ÀÌ «>i`VÊ>`Ê-«ÀÌÃÊ half, with no major increases thereafter, F-MARC pro- i`ViÊëÌ>]Ê >]Ê+>Ì>À posed the introduction of an additional cooling break at References: exactly this time for official FIFA matches with WBGTs Exercise in Hot Environments: From Basic Concepts to Field higher than 31C°, based on measurements by the FIFA Applications (2010). Supplement of the Scand J Sport Med Sci Medical Officer responsible for the medical services pri- 20(3 Suppl) (for details see Bibliography) 184 IMPROVING STANDARDS OF CARE | F-MARC PROJECTS
6.3 FIFA Regulations
6.3.1 Gender Verification Regulations large it may be. In this regard, it has to be further noted that among healthy men, the actual levels of circulating testosterone and also their determination of muscle mass Background and strength vary considerably.
The division of athletes into male and female catego- Finally, as all these individuals have grown up with a cer- ries is widely accepted practice throughout sports. The tain gender identity, suddenly challenging this identity rationale behind this separation is that there are sex dif- may potentially disrupt their concept of life. Doing so ferences resulting from differences in testosterone and through publicly exposing them without respecting their oestrogen levels. Testosterone, the major male sex hor- gender identity means a humiliation and trauma that mone (androgen), increases muscle mass and strength, should be prevented at any cost. bone size, mineral and haemoglobin content. Based on numerous studies demonstrating the performance The FIFA Medical Committee and F-MARC therefore enhancing capacity of testosterone, the use of artifi- decided to develop a proposal on gender verification cially produced androgens (and of drugs which raise the regulations in football based on current standards of best body’s natural androgen levels) in sports is prohibited. practice in medicine and science. The previous use or current exposure to androgens is considered as criteria for unfair competition in general. Objectives While this argumentation might appear straightforward and the differences between men and women obvious, UÊ ÃÕÀiÊ>ÊiÛiÊ«>Þ}Êwi` there are a number of important considerations if we UÊ*ÀÌiVÌÊÌ iÊ«ÀÛ>VÞÊ>`Ê`}ÌÞÊvÊ«>ÞiÀà are to ensure a level playing field for all players, but also, and at least as importantly, protection of the dignity and privacy of the individual. Major stipulations
Deliberate cheating by men masquerading as women to The FIFA Gender Verification Regulations apply for all gain an advantage in football is nowadays highly unlikely FIFA competitions and consequently have been adopted and, moreover, would be easily revealed. A by far larger by the FIFA confederations. They major responsibility and much more complicated problem is constituted by on the FIFA member associations to prevent exposure of individuals having what is, albeit controversially, called players at an international level. “disorders of sexual development”. This term includes a broad variety of conditions where the sex of a person For FIFA men’s competitions, only men are allowed to cannot easily be defined due to either a discrepancy play. For FIFA women’s competitions, only women are between the sex as defined by their chromosomes as allowed to play. Each FIFA member association shall opposed to their bodily characteristics, an ambiguity of ensure the correct gender of all their players by actively their chromosomal sex itself, an underdevelopment of investigating any perceived deviation in secondary sex their adrenal glands leading to hormone disturbances, characteristics and by keeping complete documenta- and several other conditions. In all these conditions, the tion of the findings. A gender verification procedure concerned individual is, rightly or wrongly, or out of may only be requested by either the player concerned, a ignorance, assigned a sex at birth defining the person´s FIFA member association, the appointed FIFA Medical gender identity. To complicate matters further, all these Officer or the FIFA Chief Medical Officer. The formal conditions occur to a different degree, rendering correct requirements for requesting a gender verification proce- sex assignment even more difficult. dure are strictly regulated, but one of the most impor- tant points is that in case of an unfounded or irrespon- While all these conditions represent constellations differ- sible request, the FIFA Disciplinary Committee may ent from what is normally found in women and men, impose sanctions on the requesting body/person. there is no scientific evidence as to whether a perfor- mance advantage actually exists, respectively results, if If a request for initiating a gender verification procedure the concerned person participates in sports. There is also is accepted by FIFA, the respective team doctor and no evidence to define, if such advantage existed, how player have to provide the medical documentation estab- F-MARC PROJECTS | IMPROVING STANDARDS OF CARE 185
lishing the gender of the player. If further investigations are justified based on these files, the player shall undergo an examination by an independent expert. If the gender is confirmed as being consistent with the one declared, the case is closed without possibility of appeal. If the gender found is considered inconsistent with the one declared, the case will be deferred to the FIFA Discipli- nary Committee. If further investigations seem required, the case is referred to an expert panel.
An expert panel to investigate a gender verification case may include, but is not limited to, a gynaecologist, an endocrinologist and a genetic expert. They have to be provided with the whole documentation to evaluate the same for completeness and ask for further information as necessary. Their task then is to conclude on the consist- ency or inconsistency of the gender of the player with the one declared. If considered consistent, the case will be closed with no possibility of appeal. If considered inconsistent, the case will be referred to the FIFA Disci- plinary Committee.
Conclusions
The major objective of the FIFA Gender Verification Regulations is to raise awareness of the complexity of gender verification matters and to sensitise all involved parties of the potentially traumatising effect of ques- tioning the sex of a player as not being consistent with the gender the player identifies with. All FIFA member associations should aim to comprehensively address any unclear or suspicious cases prior to promoting a player to national and international level.
References: The FIFA Gender Verification Regulations entered into force on 1 June 2011, prior to the FIFA Women´s World CupTM (available from: http://www.fifa.com/mm/document/footballdevelopment/medi- cal/01/45/42/02/genderverification_efsd.pdf 186 IMPROVING STANDARDS OF CARE | F-MARC PROJECTS
6.4 FIFA Medical Centres of Excellence UÊ«iiÌ}Ê>`ÊV>LÀ>Ì}ÊÜÌ ®Ê>««i`Ê}- ing and novel research and development within the framework and long-term strategy of F-MARC. Why we are conducting this project UÊ `ÕV>Ì}Ê>`ÊÌÀ>}ÊÌ iÊiÝÌÊ}iiÀ>ÌÊvÊVV>Ê specialists and scientists committed to football medi- When football players are injured, all they care about is cine. returning to action as soon as possible. This is not always wise, and a doctor who enables players to do that is not necessarily the best choice. A better option would be to Duties and benefits find a doctor who will allow players to come back just at the right time in their recovery process to make sure In order to achieve this, FIFA Medical Centres of Excel- they can enjoy playing for many more years – and at lence will: their personal best level of performance. This already implies that optimum care for football players requires UÊ-iÀÛiÊ>ÃÊ>ÊvwV>ÞÊÊ>VVÀi`Ìi`ÊÀiviÀÀ>ÊViÌÀiÊvÀÊ experience not only in state-of-the-art diagnosis and football players treatment of injuries, but also in aftercare and preven- UÊ-iÀÛiÊ>ÃÊ>ÊV>Ê>ÃÊÜÌ ÊÊ>`Ê , tion. However, the term “football medicine” coined by UÊ*>ÀÌV«>ÌiÊÊivviVÌÛiÊVÕV>ÌÊ>`Ê«i- F-MARC means much more than that. Doctors trained mentation of the F-MARC mission and the practical in this highly specialised field also offer their expertise in application of scientific results. football-specific health assessment including mental and UÊÕVÌÊ>ÃÊ>ÊÀi}>ÊViÌÀiÊ>`ÊÀiÃÕÀViÊÊÌ iÊ psychological strategies and diet, as well as comprehen- worldwide network of FIFA Medical Officers and sive advice on doping matters. FIFA Doping Control Officers as needed. The problem for players, parents, and coaches however, UÊ `ÕVÌÊ`i«i`iÌÊ>`ÊV>LÀ>ÌÛiÊÀiÃi>ÀV ÊÃÌÕ`- is finding these truly qualified football medicine experts. ies with F-MARC and other centres, and become a FIFA therefore intends to officially accredit established team player in the global research strategy in football centres that have demonstrated medical, educational medicine. and research expertise and have a history of commit- UÊ/Ê«ÀÛ`iÊi`ÕV>Ì>Ê>VÌÛÌiÃÊvÀÊVÕÌiÃÊ ment to football. By recognising these elite centres, play- within the framework of the different FIFA and ers worldwide will know which centres they can turn F-MARC educational programmes in football medi- to when the need for specialised services is required. In cine. addition, FIFA will recognise established clinics that have demonstrated expertise in the care and prevention To achieve this, the FIFA Medical Committee and of football-related injuries and illnesses. F-MARC started an exacting accreditation process for FIFA Medical Centres and FIFA Medical Clinics of Excellence. A comprehensive application has to be sub- Vision and Aims mitted and is reviewed by the respective F-MARC evalu- ation group. FIFA Medical Centres and Clinics of Excellence will promote injury prevention and the improvement of Centres have to submit standardised annual reports on physical and mental health and well-being of the football their achievements that will be reviewed by F-MARC. player by: Accreditation is valid for five years, when the centre has to reapply to maintain its status as a FIFA Medical Cen- UÊÃÌiÀ}ÊV>LÀ>ÌÛiÊÀi>Ìà «ÃÊÜÌ Ê`Û`Õ>Ã]Ê tre of Excellence. The FIFA Medical Centres of Excel- institutions and organisations to improve player health lence will generally be open to everyone and will offer and support the mission of FIFA and F-MARC. a football-specific diagnostic service, as well as therapy, UÊ*ÀÛ`}ÊÃÌ>ÌiÊvÊÌ iÊ>ÀÌÊVV>Ê>>}iiÌÊvÊ with second opinions on specific illnesses and injuries football medicine issues including surgical and non- forming a key part of the service. surgical expertise in musculoskeletal medicine for rec- reational through elite professional players of all ages Since 2005 until the end of 2014, 42 FIFA Medical and genders. Centres of Excellence have been accredited worldwide so far (Fig. 6.4.1). F-MARC PROJECTS | IMPROVING STANDARDS OF CARE 187
FIFA Medical Centres of Excellence
Zurich ’05 Cape Town ’08 Sao Paulo ’09 Brugge ’10 Melbourne ’12 Pachuca ’12 Tokyo ’13 Auckland ’07 Doha ’08 Algiers ’10 Budapest ’10 Lyon ’12 Porto ’12 Kobe ’14 Johannesburg ’07 Oslo ’08 Durham ’10 Rome ’10 Barcelona ’12 Innsbruck ’13 Madrid ’14 Kawasaki ’07 Regensburg ’08 Guadalajara ’10 Stockholm ’10 Brasilia ’12 St. Georges Park ’13 London ’14 Munich ’07 Bologna ’09 Prague ’10 Cardiff ’12 Clairefontaine ’12 Murcia ’13 Poznan ’14 Santa Monica ’07 Saarbrücken ’09 Zeist ’10 Bangkok ’12 Istanbul ’12 New York ’13 Warsaw ’14
Fig. 6.4.1 World Map of the FIFA Medical Centres of Excellence
1. Schulthess Clinic Zurich, CH 29. ‘Centre Technique National de Football’ Medical Centre, Clairefontaine, FRA 2. UniSports Sports Medicine, Auckland, NZ 30. Acibadem Fulya Orthopedics and Sports Medicine Clinic, Istanbul, TUR 3. Centre for Exercise Science and Sports Medicine, Johannesburg, RSA 31. Intermédica, Medical SA Ideas de CV, Pachuca, MEX 4. St Marianna University School of Medicine, Kawasaki, JPN 32. Clínica Espregueira-Mendes (Clínica EM), Porto, POR 5. Orthopädische Klinik, Munich, GER 33. OSM Research Foundation, Innsbruck, AUT 6. Santa Monica Orthopaedic and Sports Medicine, Santa Monica, USA 34. The Football Association Sports Medicine & Sports Science Department, St. 7. UCT/MRC Research Unit for Exercises Science and Sports Medicine Cape George’s Park, UK Town, Cape Town, RSA 35. Ripoll y de Prado Sport Clinic, Murcia, ESP 8. ASPETAR – Qatar Orthopaedic and Sports Medicine Hospital, Doha, QTR 36. Hospital for Special Surgery, New York, USA 9. Oslo Sports Trauma Research Center, Oslo, NOR 37. Juntendo University Hospital, Tokyo, JPN 10. University Medical Centre, Regensburg, GER 38. Kobe University Graduate School of Medicine, Hyogo Prefectural 11. Isokinetic Medical Group, Bologna, ITA Rehabilitation Centre, Center Hospital, Kobe, JPN 12. Institut für Sport- und Präventivmedizin, Universität des Saarlandes, 39. Clinica CEMTRO, UCAM-Universidad Catolica San Antonio, Clínica Saarbrücken, GER Traumatológica, Madrid, ESP 13. Instituto de Ortopedia e Traumatologia da FMUSP, Sao Paulo, BRA 40. Fortius Clinic, London, UK 14. Clinique Chahrazed – Département Médecine et Traumatologie du Sport, 41. Rehasport Clinic sp. z.o.o., Poznan, POL Algiers, ALG 42. Carolina Medical Center, Warsaw, POL (FIFA Medical Clinic of Excellence) 15. Duke University Medical Center, Durham, USA 16. Sport Med ‘Clinica de Medicina del Deporte’, Guadalajara, MEX (FIFA Medical Clinic of Excellence), 17. Department of Orthopaedics of the 1st Faculty of Medicine of Charles University and Teaching Hospital na Bulovce, Prague, CZ 18. Royal Netherlands Football Association Sports Medical Centre, Zeist, NED 19. Bruges – Roeselare AZ St-Jan av, Department Sports Medicine, Brugge, BEL 20. Uzsoki Hospital, Budapest, HUN 21. Villa Stuart Sport Clinic, Institute of Sport Medicine – CONI – FMSI, Rome, ITA 22. Capio Artro Clinic, Stockholm, SWE 23. Cardiff Sport and Exercise Medicine Centre, Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, UK 24. Bangkok Hospital Medical Center (BMC), Bangkok, THA 25. Olympic Park Sports Medicine Centre Pty Ltd, Melbourne, AUS 26. Albert Trillat Centre, Croix-Rousse Hospital, Centre Orthopédique Santy, Lyon, FRA Duration: 2005 - ongoing 27. FC Barcelona, Medical Services, Barcelona, ESP 28. HOME – Hospital Ortopédico e Medicina, Especializada, Brasilia, BRA Countries: International Cooperation: International 188 THE FIGHT AGAINST DOPING IN FOOTBALL | F-MARC PROJECTS
7. The Fight against Doping in Football
7.1. FIFA’s Approach to the Fight against following their Hippocratic Oath as well as their profes- Doping in Football sional and ethical values.
Fuelled by some prominent cases, the debate on dop- Definition of doping ing in amateur and professional sport raised public awareness of a problem that had not been fully appre- Doping is any attempt either by a player themselves, or ciated during the rapid development of various sports at the instigation of another person, such as their man- disciplines in previous decades. Prior to the 2014 FIFA ager, coach, trainer, doctor, physiotherapist or masseur, World Cup™, FIFA introduced a completely new etc. to enhance mental and physical performance not approach in the fight against doping with the implemen- physiologically or to treat ailments or injury – when tation of the biological profile (or so-called passport). this is medically unjustified – for the sole purpose of FIFA tested all the players from every team prior to the taking part in a competition. This includes using (tak- competition in unannounced controls. During the com- ing or injecting), administering or prescribing prohib- petition, two players from each team were tested after ited substances prior to or during a competition. These each match for blood and urine. Additional controls stipulations also apply for out-of-competition testing of were performed under certain circumstances. With this anabolic steroids and peptide hormones, as well as to procedure, FIFA was one of the first international sports substances producing similar effects. federations to introduce such a passport, including blood and urine parameters, in a major competition. Other prohibited methods (e.g. blood doping) or manipulation of the samples collected, are likewise clas- sified as doping. The detailed definition as related to the Aims of doping controls and the anti-doping anti-doping rule violations are presented in the annually policy updated FIFA Anti-Doping Regulations.
UÊ1« `Ê>`Ê«ÀiÃiÀÛiÊÌ iÊiÌ VÃÊvÊëÀÌ UÊ->vi}Õ>À`ÊÌ iÊ« ÞÃV>Ê i>Ì Ê>`ÊiÌ>ÊÌi}ÀÌÞÊvÊ Statistics the player UÊ ÃÕÀiÊÌ >ÌÊ>ÊV«iÌÌÀÃÊ >ÛiÊ>ÊiµÕ>ÊV >Vi The confederations and/or member associations that come under FIFA’s umbrella carry out their own doping FIFA introduced doping controls in 1970 to ensure that controls at the competitions they stage. Also National the results of matches played as part of its national and Anti-Doping Organisations (NADOs) are allowed to international competitions were a fair reflection of the conduct testing of national players (in- and out-of-com- ability of those taking part. The FIFA Medical Commit- petition), as well as of players from other countries com- tee has the overall responsibility for not only implement- peting within that nation’s borders. Urine and/or blood ing doping controls at all FIFA competitions but also samples collected must, however, be analysed at WADA- for the harmonisation with confederations and member accredited laboratories. These laboratories send reports associations. It is supported by the FIFA Doping Con- on any “chemically positive” A samples – so called trol Sub-Committee, and since 2007, by the TUE advi- Adverse Analytical Findings (AAFs) or Atypical Findings sory group. The administrative management of the dop- - to the member associations, FIFA Anti-Doping Unit ing controls is overlooked by the FIFA medical office, for management and to WADA for information. and since May 2009, by the FIFA Anti-Doping Unit. Once the FIFA Anti-Doping Unit receives a positive A sample result, follow-up information is required by the Over the years, F-MARC has developed a worldwide member association and/or confederation in question to network of specialists, who are involved in the educa- be informed on the results of the B sample and particu- tional process within the confederations and member larly the respective disciplinary committee decision. If associations as well as in the practical approach for the the information is not provided, the FIFA Disciplinary domestic, international and FIFA competitions. The Committee takes appropriate action. physicians play the key role in FIFA’s long-term strategy Between 1994 and 2013, 11,086 doping tests were per- of prevention and education in the fight against doping, formed at FIFA competitions (Tab. 7.1.1). Of these, 13 samples tested positive: five samples of anabolics, two of F-MARC PROJECTS | THE FIGHT AGAINST DOPING IN FOOTBALL 189
automatically, although the positive cases counted in numbers did not increase compared to previous years. Tab. 7.1.1 FIFA statistics of positive doping cases in football world- The relatively low incidence of positive doping samples wide. particularly for the truly performance enhancing drugs nandrolone, one each for ephedrine, cannabis, tuamino- such as anabolic steroids and hormones (2011 0.06%, heptan, methylhexanamine and dexamethasone account- 2012 0.04%, 2013 0.05%) and stimulants allows FIFA ing for an incidence of 0.12%. Doping tests conducted to state that there is no evidence for systematic doping in during confederations’ and associations’ competitions football. However, this does not mean that doping does are the responsibility of the organisers. not exist in football. The total number of football samples analysed per year allows the calculation of incidents for the positive sam- ples in total and for the calculation of the most com- Harmonisation within the confederations and monly detected prohibited substances. In this respect, member associations FIFA developed its own database to keep track of records on the samples being reported as positive. This allowed In 1999, a comparative study of the doping control control of the management of these samples within the regulations issued by the confederations showed a high different confederations and member associations. level of agreement as far as the lists of prohibited sub- Over the last nine years (2005–2013), 258,494 doping stances and methods were concerned. This was primarily tests were performed in football, worldwide. Accord- because the Confederations simply decided to adopt in ing to the FIFA doping control database, 808 sam- the FIFA Anti-Doping Regulations. ples (0.31%) tested positive and, of these, 111 samples A detailed survey of the doping control regulations (0.04%) were positive for anabolic steroids and hor- issued by national football associations however revealed mones. Over the years, cannabis have accounted for some differences in the procedure and the inclusion of about 40% of positive test results. In addition, other certain individual substances in the categories of prohib- stimulants (e.g. cocaine, diuretics) accounted for 46% ited drugs. Following this comparative study, F-MARC (Fig. 7.1.1). During 2013 WADA increased the level and the FIFA Medical Committee proposed to the FIFA for reporting of cannabis in players from 15ng/mL to Executive Committee that the doping control regula- 150ng/mL with a direct impact of positive results found. tions of all member associations were harmonised, and In 2013 only 17% tested positive for cannabis (data not that they would automatically adopt the list of prohib- yet finalised). The data for 2014 are still to be final- ited substances and methods. ised, but so far there is a strong indication of a further Following the FIFA Executive Committee recommen- decrease of positive cannabis tests. Due to the decrease dation, the FIFA Congress ratified this decision at their of the use of the substance cannabis, the remaining sub- Ordinary Congress in May 2002. This again paved the stances counted in percentage increases in the statistics way for the decision of the FIFA Extraordinary Congress 190 THE FIGHT AGAINST DOPING IN FOOTBALL | F-MARC PROJECTS
Ê iViLiÀÊÓääÎÊÊ >É+>Ì>ÀÊÌÊiÝÌi`ÊÃ>VÌÃÊ of specially trained physicians who act as FIFA Doping by the FIFA Disciplinary Committee of member associa- Control Officers (DCO). With regard to medical con- tions (being expelled) for all international matches fol- fidentiality and the necessity for specific knowledge in lowing the same method of individual case management. the field, FIFA exclusively appoints physicians (MDs) to In 2009 it was further decided to establish a new admin- perform this task. istrative body, the FIFA Anti-Doping Unit to coordi- The FIFA doping control procedure is straightforward nate the activities of the different departments involved and transparent leaving no place for cheating or wrong- and ensure and survey implementation of the WADA doing when all steps are performed in the presence of Code in 2009 at all levels of the organisation. With the representatives from both teams. implementation of the new World Anti-Doping Code in FIFA DCOs have all attended instructional seminars 2015 and the FIFA Anti-Doping Regulations 2015, fur- conducted by F-MARC and the FIFA Anti-Doping ther measures and procedures were institutionalised to Unit in order to secure “unity of doctrine”. The DCOs, ensure that all FIFA member associations comply with as members of the FIFA network, are located around the the WADA Code. world. A new education and training scheme was devel- oped and presented to the FIFA Medical Committee at the beginning of 2009 and has been implemented since Prohibited substances prescribed for medical that time. reasons – Therapeutic Use Exemption (TUE)
In a player who has a medically confirmed pathologi- FIFA-WADA cooperation cal condition, drugs containing prohibited or partially prohibited substances could be permitted in exceptional On 4 February 1999, the Lausanne declaration on Dop- cases if: ing in Sport called for an independent International Anti-Doping Agency to be established. The aim was to UÊ/ iÊ«>ÞiÀ½ÃÊ i>Ì ÊÜÕ`ÊLiÊ«>Ài`ÊvÊÌ iÊ«À L- coordinate the various programmes necessary to realise ited drug were withheld the objectives of all stakeholders in the fight against dop- UÊ Ê«iÀvÀ>ViÊi >ViiÌÊVÕ`ÊÀiÃÕÌÊvÀÊÌ iÊ ing. prohibited substance being administered as medically From the beginning, the medical and legal representa- prescribed tives of FIFA developed a close collaboration with the UÊ Ê«iÀÌÌi`ÊÀÊ«À>VÌV>Ê>ÌiÀ>ÌÛiÊ`ÀÕ}ÊÃÊ>Û>>LiÊ representatives of the World Anti-Doping Agency in place of the prohibited substance (WADA). On 21 May 2004, at the 54th Ordinary FIFA Congress in Paris, FIFA, the IOC and WADA signed In such a situation, a player or their doctor must sub- a declaration regarding the collaboration in the fight mit a formal application, requesting a so-called “thera- against doping following a warranty that WADA would peutic use exemption” for the respective substance. The respect the autonomy of the international federations FIFA TUE Advisory Group was created in 2007 as the (Fig. 7.1.2). body responsible for granting all TUE approvals within FIFA however always strongly opposed the sanctioning FIFA. As the International Standard for Therapeutic system of WADA of two years for every doping viola- Use Exemptions (ISTUE) 2015 is an extensive docu- tion, independent of factors such as the substance, fault, ment that leaves options for the Anti-Doping Organisa- intention, age of the player, individual circumstances, tions (ADOs) to define by themselves, FIFA developed etc. FIFA and WADA both asked the Court of Arbitra- its own document which clarifies all TUE issues that tion for Sport (CAS) for a legal opinion on their differ- remained unresolved after the ISTUE 2015 came into ent views. CAS explicitly confirmed FIFA’s practice of force. The FIFA TUE policy ensures a clear and consist- individual case management when sanctioning doping ent approach to medication use in football. offences. In addition, CAS noted that FIFA’s princi- ple of individual case management complied with the WADA Code. At the same time, CAS ruled that FIFA’s FIFA network of Doping Control Officers provisions with regard to the fight against doping and the sanctioning of doping offences were, to the greatest In cooperation with the confederations and member possible extent, in line with the WADA Code. associations, FIFA has established a worldwide network F-MARC PROJECTS | THE FIGHT AGAINST DOPING IN FOOTBALL 191
The new World Anti-Doping Code
The revision process for the 2015 Code began at the end of 2011 and, following three phases of consultation over a two-year period, and with 2,000 changes submit- ted, the revised Code was unanimously approved on 15 November 2013 at the World Conference on Doping in Sport in Johannesburg, South Africa. One of the key changes was the implementation of a new period of ineligibility of four years for presence, use or attempted use, or possession of a prohibited sub- stance or prohibited method. Further, associating with a banned person or a person convicted or found in a criminal, disciplinary or professional proceeding to have Fig. 7.1.1 FIFA statistics of positive samples 2010-2013 (For 2013, engaged in conduct which would have constituted a vio- analysis of data is not yet finalised; 15 pending cases, incl. T/E lation of anti-doping rules if Code-compliant rules had ratio); (S1=Anabolic Agents, S2=Peptide Hormones, Growth Factors & Related Substances,S3 = Beta-2 Agonists, S4 = Hormone been applicable to such person is sanctionable. and Metabolic Modulators, S5 = Diuretics and other Masking FIFA adopted these changes in its new Anti-Doping Agents, S6 = Stimulants, S7 = Narcotics, S8 = Cannabinoids, S9 = Glucocorticosteroids) Regulations 2015. Duration: ongoing WADA considered all these concerns and introduced Countries: International changes in the final version of the 2009 Code. The 2009 Cooperation: FIFA Medical Committee, FIFA Doping WADA Code demonstrated that harmonisation was Control Sub-Committee, FIFA TUE advisory group, FIFA preferable to uniformity in the interest of the athletes. Legal Department, FIFA Anti-Doping Unit Laboratoire suisse Flexibility was granted when sanctioning a player, so d‘Analyse du Dopage, University of Lausanne, Switzerland that all relevant criteria could be taken into account. References: FIFA’s fight against doping in football (2006). Supplement of On 29 February 2008, FIFA and WADA signed a let- the Br J Sports Med 40(1 Suppl) (for details see bibliography) ter of intent and declared that the fight against doping Strahm E, Sottas PE, Schweizer C, Saugy M, Dvořák J, Saudan must be continued through all possible means in order C (2009). Steroid profiles of professional soccer players: an to safeguard the objectives of FIFA and WADA. On 30 international comparative study. Br J Sports Med 43(14):1126- May 2008, FIFA President Joseph S. Blatter and WADA 1130 President John Fahey ratified Version 3.0 of the Code at Dvořák J, Budgett R, Saugy M, Vernec A (2014).Drawing the the ordinary FIFA Congress in Sydney. map to implement the 2015 World Anti-Doping Code. Br J Sports Med 48(10):800 Dvořák J, Baume N, Botre F, Broséus J, Budgett R, Frey WO, Geyer H, Harcourt PR, Ho D, Howman D, Isola V, Lundby C, Marclay F, Peytavin A, Pipe A, Pitsiladis YP, Reichel C, Robinson N, Rodchenkov G, Saugy M, Sayegh S, Segura J, Thevis M, Vernec A, Viret M, Vouillamoz M, Zorzoli M (2014). Time for change: a roadmap to guide the implementa- tion of the World Anti-Doping Code 2015. Br J Sports Med 48(10):801-6 Vernec AR (2014). The Athlete Biological Passport: an integral element of innovative strategies in antidoping. Br J Sports Med 48(10):817-9 Zorzoli M, Pipe A, Garnier PY, Vouillamoz M, Dvořák J Fig. 7.1.2 Formal agreement between FIFA and WADA signed at the 54th Ordinary Congress in Paris 2004 by IOC President Dr. Rogge, FIFA (2014). Practical experience with the implementation of an ath- President Blatter, WADA President Pound lete’s biological profile in athletics, cycling, football and swim- ming. Br J Sports Med 48(10):862-66 192 THE FIGHT AGAINST DOPING IN FOOTBALL | F-MARC PROJECTS
7.2 Comprehensive Information for longer at the top of the list of prohibited compounds Laymen detected at WADA-accredited laboratories. Canna- bis might be considered as having an indirect impact on performance by reducing anxiety before a match or “Make the game doping free” is the aim of the anti- increasing relaxation after a match. However, regular doping strategy of FIFA. Not only is the integrity of the use can alter behaviour, concentration and motivation. game at stake, but so too is the need to protect the play- Cocaine is the most powerful naturally occurring stim- ers’ health and keep them from the harm that can result ulant of the nervous system and is highly addictive. It from doping. Football players who compete in FIFA has no performance enhancing effect on running times World Cups™ are ambitious professionals and FIFA or endurance. The addictive nature of the drug can lead wants to ensure their support in the fight against doping a player to redirect their energies away from sport and whilst demonstrating respect for the privacy and dignity towards how to obtain their next dose. Both drugs are of each player. easily detected in urine.
FIFA first conducted doping tests in 1970. The impor- tance of the fight against doping is however not con- Stimulants fined to just the doping control room at the stadiums of major competitions or the no-advance-notice testing. It Of concern in this category are amphetamines and is the responsibility of everyone within the football fam- ephedrine. Amphetamines are known enhancers of per- ily to stand up against those who would seek to upset formance with established, and potentially dangerous, the competitive integrity of the game through chemical side effects. Ephedrine is perceived to be a performance means. In FIFA’s view, the key to keep the game doping enhancer, but any performance benefits are inconsistent free is education and knowledge. And this does not only and probably of little consequence. Some recent fatalities apply to the physicians, everyone plays a position in this in athletes taking ephedrine have prompted associations game. Coaches are highly influential and can have enor- to take a closer look at tightening restrictions on ephed- mous authority over their players. The role of a player’s rine. parents cannot be discounted as they are the player’s primary role model and connect with their children on the most basic level every day. Finally, most players get Anabolic agents information about many aspects of life from their peers – their teammates. The more players become aware of Synthetic derivatives of testosterone are known perfor- the dangers of cheating, both from a football perspective mance enhancers that have been used in many sports as well as the health perspective, the less doping we will and are generally banned in sports. Anabolic-androgenic see in our sport. steroids enhance protein synthesis, improve high inten- sity performance, speed up recovery, but can also affect While it is important for physicians to further their the psychological and emotional state of the player. Dos- understanding of the more technical aspects of doping ing schedules and drugs of choice are largely empirical and detection of doping, most members of the football and well above what is used for therapeutic use in medi- family would find the reports in the F-MARC scientif- cine. Complex analytical methods are required to detect ic supplement on doping hard to understand. To meet the presence, amount, and relationships of compounds. their needs, F-MARC decided to prepare a booklet that There is concern about 19-norandrosterone that has includes the pertinent information in easily understand- been identified in some food supplements in amounts able language. sufficient to trigger a positive doping test for nandrolo- ne. Uninformed players may unwittingly ingest this banned substance because the compound might not be Recreational and social drugs listed on the label. Avoiding nutritional supplements is the best way to avoid innocent ingestion of such com- The vast majority of positive doping tests are for recrea- pounds. tional and social drugs. Cannabis and cocaine account for more than 80% of all positive tests in football. Due to increasing the threshold limit of cannabis, it is no F-MARC PROJECTS | THE FIGHT AGAINST DOPING IN FOOTBALL 193
Erythropoietin with this class of medicine. The medical literature does not support the indiscriminate therapeutic use of glu- Increasing the oxygen carrying capacity of the blood is cocorticoids for most musculoskeletal injuries nor has it a proven aid in endurance sports. Initially, blood dop- been proven that glucocorticoids are an effective perfor- ing involved removal and reinfusion of an athlete’s own mance enhancer. blood. The introduction of recombinant erythropoietin (rhEPO) offered an alternative method of improving endurance. It can be expected that in future, each abuse What we have learnt from experience of EPO will be detected. A long-term follow-up with repeated tests over time is probably the best way to tar- The FIFA Medical Committee believes that doping get abusers. controls and sanctions are an effective part of combat- ing doping when applied over the long term in a com- prehensive programme. The education and informa- Human growth hormone tion of players is however just as important. Physicians, who must follow their own professional ethical codes, Banned since the early 1990s, human growth hormone are integral components of the anti-doping strategy (HGH) is abused for its potential as an anabolic com- designed to create a drug-free environment through edu- pound. While the abuse of HGH became more preva- cation that will improve the overall health of players. lent with the availability of recombinant HGH, there are FIFA fully acknowledges its responsibility to reach out few studies that show a significant effect on performance to the players and fans. when used alone. Some athletes, however, use HGH as part of a drug cocktail combined with other anabolic agents. The basic physiology of HGH and the similarity with the recombinant version makes detection difficult.
Beta-2 agonists
Inhaled beta-2 agonists are used to treat exercise-induced asthma and are prohibited for use in non-asthmatic ath- letes because of a potential ergogenic effect. The pub- lished incidence of asthma in the population is about 5%, but the incidence in athletes has been reported to be between 10 and 20%. A review of 20 clinical trials on the use of beta-2 agonists failed to show a consistent enhancement of performance in athletes. Since WADA added thresholds for formoterol, salbutamol and salme- terol, positive test results for these substances decreased.
Duration: 2006 Glucocorticoids Countries: International Cooperation: Martial Saugy, Laboratoire suisse d‘Analyse This class of compounds has unchallenged therapeutic du Dopage, University of Lausanne, Switzerland; Michel potential for treating numerous inflammatory and other D‘Hooghe, Bruges, Belgium; FIFA Medical Office, Zurich, diseases and is a first line therapy for the treatment of Switzerland asthma. Sports medicine physicians have used gluco- Reference: corticoids for numerous situations such as muscle inju- Dvořák J, Grimm K (eds) (2006). The Fight against Doping in ries, tendon injuries, musculoskeletal inflammation and Football. A comprehensive introduction and overview. FIFA’s more. The World Anti-Doping Agency bans all oral, strategy, the relevant substances, their effects and detection. intravenous or intramuscular routes of administration Official publication of the Fédération Internationale de Football and requires a formal use exemption for athletes treated Association, Zürich, Switzerland 194 THE FIGHT AGAINST DOPING IN FOOTBALL | F-MARC PROJECTS
7.3 Research Projects
7.3.1 Nandrolone Excretion after Exercise How we collected the data
For the excretion part of the project, we recruited 22 Why we conducted this study volunteers who ingested two 25mg doses of [13C]nan- drolone at 24 hour intervals that were followed up with While there are numerous classes of agents that can urine specimens for five days. The “13C” means that enhance almost every aspect of sport, the use of anabolic specific carbons within the steroid structure were an steroids probably dominates the doping landscape. Ana- isotope of carbon that can be measured and traced. The bolic steroids have legitimate clinical uses such as in the labelled metabolites were identified and measured by gas treatment of anaemia, osteoporosis, selected cancers and chromatography–mass spectrometry at an IOC-certified as hormone replacement therapy. Of all the anabolic laboratory. steroids on the market, nandrolone (Deca-Durabolin®) is one of the most widely used because of its potent For the exercise project, all football players from the anabolic properties. In the body, nandrolone is broken first and second divisions of the Swiss Football National down into two easily detectable metabolites: 19-andros- League (n=358) submitted urine samples after a match terone (NA) and 19-noretiocholanolone (NE) which are as a part of normal doping controls. A group of ama- excreted in the urine. A test is positive if the urine level teur players (n=137) submitted urine samples before and of NE is above 2ng/ml (males) or 5ng/ml (females). If after match play. We used a cut-off of 0.2ng/ml for pres- the number of positive tests is an indication of use by ence of nandrolone metabolites, a value much more sen- sportsmen, one might conclude that its use is increasing. sitive that the official cut-off for a positive test. Shortly after 1997, when a number of sportsmen in France tested very close to the cut-off limit for nan- drolone, a debate was raised about the capability of the Results human male body to produce these metabolites without any intake of nandrolone or related compounds. A num- The pattern of excretion (called kinetics) of the metabo- ber of specialists argued that exhaustive exercise could lites varied a great deal from person to person (interindi- increase nandrolone production in the body or exercise- vidually) leading to considerable variation in the ratio of induced dehydration could lead to a greater concentra- NE:NA. For example, norandrosterone varied between tion of nandrolone metabolites in urine, leading to a 1180 and 38,661ng/ml and noretiocholanolone varied false-positive test. Of all the outcomes of testing for from 576 to 12,328ng/ml. At the end of the five-day performance enhancing drugs, a false-positive is particu- iÝVÀiÌÊ«iÀ`]ÊÌ iÊ \ ÊÀ>ÌÊÜ>ÃÊÃiÌiÃÊ£Ê larly troublesome and unfortunate. An athlete who has and followed no consistent pattern over the excretion not taken something illegal could be punished for doing period (Fig. 7.3.1.1). While most of the nandrolone was nothing wrong and suffer public censure for having test- excreted within 20 hours, some subjects still had levels ed positive. With the 1998 FIFA World CupTM about to consistent with a positive test for nandrolone for 100 start in France, FIFA was very concerned and wanted to hours. There were concerns regarding urinary concentra- protect football players from such mishap by investigat- tion from exercise also being a factor in the results. ing the changes of nandrolone with exercise. None of the amateurs examined had evidence of any nandrolone metabolites before exercise. After match play, just over 6% of the professionals and a similar Aims of the study percentage of amateurs showed presence of nandrolone metabolites (Tab. 7.3.1.1). UÊ iÌiÀiÊÌ iÊÌiÀ`Û`Õ>ÊÛ>À>LÌÞÊÊ>`À- ne excretion patterns and kinetics after the administra- Professional Amateur tion of labelled nandrolone to healthy volunteers players players
UÊ`ÊÕÌÊvÊÌÀ>ViÃÊvÊ>`ÀiÊiÌ>LÌiÃÊVÕ`ÊLiÊ Absence of NA 336 129 detected in the urine of football players after a match Presence of NA 22 8
Tab. 7.3.1.1 Level of player and presence or absence of NA (cut-off for presence or absence of urinary NA = 0.2 ng/ml) F-MARC PROJECTS | THE FIGHT AGAINST DOPING IN FOOTBALL 195
4.0 4.0
3.0 3.0
2.0 2.0
1.0 1.0 NE/NA ratio B NE/NA ratio A
0.0 0.0 0 24 48 0 24 48 Time (h) Time (h)
350 350 NE NA 300 300
250 250
200 IS 200
150 NA 150 IS NE 100 100
Abundance (x 1000) 50 Abundance (x 1000) 50
0 0 14.00 15.00 16.00 17.00 18.00 19.00 20.00 14.00 15.00 16.00 17.00 18.00 19.00 20.00 Time (min) Time (min)
Fig. 7.3.1.1 NE:NA ratios (top) for two volunteers after the oral administration of two doses of nandrolone and corresponding chromatograms (bot- tom) obtained by GC-MS from spot urines collected at 50.5 h (A) and 54 h (B) after the first nandrolone dose (t0).
What we learned from the study
After match play, a small percentage of the players showed presence of nandrolone metabolites. The ori- gin of these metabolites in the urine after activity is unknown, however three hypotheses might be consid- ered. First, an endogenous production of nandrolone metabolites might actually have taken place. Second, nandrolone metabolites could have been released from the fatty tissues after intake of nandrolone, some relat- ed compounds or some contaminated nutritive supple- ments. Finally, the sportsmen could have taken some- thing just before or during the football game. Duration: 2002 - 2004 Doping control regarding steroids continues to be an Country: Switzerland evolving process as more is learned about excretion and Cooperation: Laboratoire suisse d‘Analyse du Dopage, the factors that can influence results. The value of using University of Lausanne, Switzerland a single cut-off as the criteria for a positive test would References: need to be further to be investigated. Baume N, Avois L, Schweizer C, Cardis C, Dvořák J, Cauderay M, Mangin P, Saugy M (2004). 13C-Nandrolone Excretion in Trained Athletes: Inter-individual Variability in Metabolism. Clinical Chemistry 50(2):355-64 Robinson N, Taroni F, Saugy M, Ayotte C, Mangin P, Dvořák J (2001). Detection of nandrolone metabolites in urine after a football game in professional and amateur players: a Bayesian comparison. Forensic Sci Int 122(2-3):130-5 196 THE FIGHT AGAINST DOPING IN FOOTBALL | F-MARC PROJECTS
7.3.2 Testosterone Variability – the Influence for the study. More specifically, samples from 57 Afri- of Ethnicity on Steroid Profiles of can players (Uganda, South Africa), 32 Hispanic players Football Players (Argentina), 32 Asian players (Japan) and 50 Caucasian players (Switzerland, Italy) were taken. All samples were analysed to determine the T/E ratio and analyse the ster- Why we conducted this study oid profile and isotopic ratio of testosterone metabolites. A new method for detection and quantification of ster- When looking at the statistics of adverse analytic fin- oid conjugates in urine samples was used in addition to dings (AAFs) reported by the WADA-accredited labora- already established methods. tories during the last years, it becomes obvious that tes- tosterone accounts for a high proportion of these cases. This does not reflect the actual use of endogenous ste- Results roids in sport, in particular not in football, but rather indicates that currently used parameters for the detection No sample showed an absolute steroid concentration of steroids are leading to false positive results. This rep- higher than the respective threshold defined by WADA. resents one of the most important problems internation- / ÀiiÊÃ>«iÃÊ£°Ç¯®Êà Üi`Ê>Ê/É À>ÌÊ{]ÊLÕÌÊÌ iÊ al sport federations face nowadays. Previous studies with above-mentioned IRMS did not reveal evidence for volunteers receiving testosterone had shown considerable exogenous steroid use. Significant differences of the T/E- variability between individuals regarding the diagnostic ratio were observed between all ethnic groups. Based results of testosterone abuse. on the results, ethnic-specific T/E-ratio thresholds were developed (Africans 5.6; Asian 3.8; Caucasian 5.7; His- Recently, the World Anti-doping Agency Code 2009 panic 5.8). was adopted establishing the need of submitting a sam- ple to isotopic ratio mass spectrometry (IRMS), if the Defining a unique and non-specific threshold to indicate urinary T/E ratio value is equal to or greater than four anabolic steroid abuse is not fit for purpose in doping (previously at six). If such IRMS does not readily indi- control. Individual steroid profiling in players would cate exogenous steroid intake, the result is reported as allow individual reference values (endocrinological pass- inconclusive and further longitudinal studies can be per- port) to be identified. It was also shown that the thresh- formed. While longitudinal studies to investigate elevat- old value of four lies considerably below the ethnic-spe- ed T/E ratios are very costly, there is no strong scientific cific threshold values in all but the Asian players. evidence supporting the following decisions of discipli- nary committees. F-MARC therefore sees a clear need to conduct further investigations in individuals showing different metabolism speed in order to identify more val- id biomarkers of steroid abuse.
Aims of this study
UÊÛ`Êv>ÃiÊ«ÃÌÛiÊÀiÃÕÌÃÊÜ iÊVÕÀÀiÌÞÊÕÃi`Ê«>À> meters are measured including consequences with regard to costs, time etc. UÊ*ÀÛ`iÊëÀÌÊ>ÕÌ ÀÌiÃÊÜÌ ÊivwViÌÊÌÃÊÌÊÌ>iÊ their decisions based on scientific data in case of an altered steroid profile
How we collected the data
About 117 urine samples were provided by senior male players from different ethnic populations specifically F-MARC PROJECTS | THE FIGHT AGAINST DOPING IN FOOTBALL 197
Duration: 2007 - 2008 Countries: Switzerland, Italy, Uganda, South Africa, Argentina, Japan Cooperation: Martial Saugy, Laboratoire suisse d‘Analyse du Dopage, University of Lausanne, Switzerland, team physicians of the respective teams Reference: Strahm E, Sottas PE, Schweizer C, Saugy M, Saudan C (2009). Steroid profiles of professional soccer players: an international comparative study. Br J Sports Med 43(14): 1126-1130 198 THE FIGHT AGAINST DOPING IN FOOTBALL | F-MARC PROJECTS
7.3.3 Quantification of Clenbuterol at Trace Aims of the study Level in Human Urine UÊ iÛi«Ê>`ÊÛ>`>ÌiÊ>Ê1* q - -É -ÊiÌ `Ê for the quantification of clenbuterol in urine samples Why we conducted this study at the low pg/mL range UÊ««ÞÊÌÊÀi>ÊÕÀiÊÃ>«iÃÊvÀÊ£nÊ i>Ì ÞÊ>iÊ Clenbuterol is part of the β2 agonists family, a class volunteers collecting urines over six days after a single of compounds firstly designed for the antiasthmatic intake of clenbuterol-enriched yogurts at three dose properties and tocolytic effect in human and animals. levels 1, 5 and 10μg The administration of clenbuterol-like drugs has other physiological effects such as increase of aerobic capacity, blood pressure and oxygen transportation, stimulation How we collected the data of the central nervous system and has an impact on the body fat metabolism rate. The anabolic properties given During the method-development part of the study, by the marked increase of skeletal muscles in parallel to clenbuterol was extracted from urine samples by liq- the decrease of the body fat mass has forced the World uid–liquid extraction (LLE) using tertbutyl-methyl Anti-Doping Agency (WADA) to put clenbuterol in the ether (TBME), allowing a 66 times concentration fac- class S1.2 (other anabolic agents) of the Prohibited List. tor for the target analyte. Samples were then analysed by Because there is no threshold level for clenbuterol in the UHPLC–MS/MS with a linear gradient of acetonitrile anti-doping regulations, any of the concentration found in nine minutes only. This simple and rapid method was in urines of athletes would lead to an adverse analytical validated in compliance with authority guidelines and finding, leading theoretically to a sanction of the athlete. showed a limit of quantification at 5pg/mL and a linear- Nowadays, clenbuterol has been banned for therapeutic ity range from 5pg/mL to 300pg/mL. use in humans but is sometimes employed as a growth- During the clinical study part conducted in 2011 in promoting agent in food-producing animals. The use Cyprus after approval by the Cyprus National Bioeth- of this compound for cattle and bovine breeding is well ics Committee, the method was applied to real samples regulated in the United States of America by the FDA from 18 volunteers. Spiropent® syrup containing clen- and in Europe. Despite these rules, there are still some buterol hydrochloride was used to enrich yogurts at 1, countries where, after used of clenbuterol for the promo- 5 or 10μg/yogurt. After ingestion, the volunteers were tion of animal growth, residues of this compound can asked to collect urines over six days. Urine samples were be found in the meat. Consumption of such contami- analysed with the UHPLC–MS/MS method and the nated meat could therefore lead to the presence of traces amount of clenbuterol excreted was plotted versus col- of this forbidden substance in human urine and then to lection time with the aim of investigating the elimina- an anti-doping rule violation for an athlete. Moreover, tion profile in urine. WADA has introduced since 2004 the strict liability rule in the World Anti-Doping Code meaning that athletes are responsible for themselves and should be cautious Results about any substances entering their body, which could cause a doping offence. In 2011, FIFA faced several The WADA recommendations in terms of Minimum adverse analytical cases containing traces of clenbuterol. Required Performance Limits (MRPL) for clenbuter- The urine samples were collected from athletes living ol were adjusted down to 200pg/mL on the 1 Janu- in Mexico or having stayed in this country for a certain ary 2013. The development of the method was there- period of time. A warning was also published on the fore focused on sensitivity issue in order to detect and WADA website in November 2011 saying that sufficient quantify clenbuterol in urine samples in the low pg/mL evidence has been collected to demonstrate this risk in range. some countries. The method developed herein is simple and rapid and Considering these problems and the above-mentioned was validated in compliance with authority guidelines cases, the development of rapid and robust analytical ÜÌ Ê>Ê "+Ê>ÌÊx«}É °Ê->ÌÃv>VÌÀÞÊÌÀÕiiÃÃ]ÊÀi«i>Ì>L- methods for the detection of urinary traces of clenbuter- ity and intermediate precision results were obtained. No ol is of high interest for anti-doping laboratories. sample carry-over was observed in the analytical system. Clenbuterol showed acceptable stability in urine samples F-MARC PROJECTS | THE FIGHT AGAINST DOPING IN FOOTBALL 199
(long-term and freeze–thaw stability) and in extracted samples (post-preparative stability) for the purpose of the study. Urine samples from the 18 volunteers collected over six days after clenbuterol were analysed with the devel- oped method. The urinary pharmacokinetic profiles are illustrated in Fig. 7.3.3.1. These profiles showed that maximum levels of clenbuterol in urine appeared approximately four hours after administration (Tmax). Maximum excretion values (Cmax) during this time period were approximately 1.2 ± 0.3ng clenbuterol/mg creatinine (1.2 ± 0.4ng/mL) after a single dose of 10μg, while trace levels (approx. 5pg/mL) of this compound can still be found in urine samples up to six days after administration. Cmax for 5μg and 1μg administered doses were 0.5 ± 0.1ng clenbuterol/mg creatinine (0.6 ± 0.2ng/mL) and 0.1 ± 0.05ng clenbuterol/mg creati- nine (0.2 ± 0.1ng/mL), respectively. As depicted in Fig. 7.3.3.1, a high inter-individual variability was observed in the pharmacokinetic profiles due to the urine matrix (diuresis, flow, and pH). However, the urinary elimina- tion half-life was quite long for clenbuterol leading to VViÌÀ>ÌÃÊ>LÛiÊ "+Êx«}É ®ÊÕÌÊ£{äÊ ÕÀÃÊ (six days) after oral intake. This was first valuable infor- mation to deter clenbuterol misuse in sports. The dose– response relationship was nevertheless difficult to evalu- ate in urine matrix and therefore blood samples analyses would be important complementary information for this topic in the future of the fight against doping. Fig. 7.3.3.1 Pharmacokinetic profiles of clenbuterol in urine after administration of a single dose (1, 5 or 10 μg) of clenbuterol-enriched yogurts to 18 volunteers: (a) 1 μg; (b) 5 μg and (c) 10 μg. Dotted gray What we learned from the study lines (---) correspond to the mean concentrations measured for each time point. Solid lines correspond to the mean concentration and The rationale of this study was to better understand the 95% confidence intervals for the pre-defined standardized collection times T = 2, 4, 8, 24, 48, 72, 96, 120 and 144 h. pharmacokinetic of elimination from the human body of doses of clenbuterol similar to the ones, which can be ingested through contaminated food. The analytical results showed an important inter-individual variability in the excretion profiles as already observed for many pharmaceutical compounds. Thus, the determination of a possible urinary threshold level for clenbuterol based only on urinary excretion profiles must be carefully set to avoid any false positive cases. In addition, collection and Duration: 2012 use of alternative matrices such as serum could represent Country: Switzerland complementary information to urine matrix. Therefore, Cooperation: Swiss Laboratory for Doping Analyses (LAD), a multi-parameters approach using more sophisticated University of Lausanne, Switzerland data treatment (e.g. correlation between blood and urine Reference: concentrations) as well as the deep insight of phase I and Nicoli R, Petrou M, Badoud F, Dvořák J, Saugy M, Baume N II metabolism of clenbuterol would be of high interest to Óä£Î®°Ê+Õ>ÌvV>ÌÊvÊViLÕÌiÀÊ>ÌÊÌÀ>ViÊiÛiÊÊ Õ>Ê document appropriately and interpret each case of clenb- urine by ultra-high pressure liquid chromatography-tandem uterol misuse in anti-doping testing in the future. mass spectrometry. J Chromatogr A 1292: 142-150 200 THE FIGHT AGAINST DOPING IN FOOTBALL | F-MARC PROJECTS
7.3.4 Profiling of Steroid Metabolites after 12 targeted steroid metabolites quantified in this study Transdermal and Oral Administration of in more than 500 urine samples was evaluated with Testosterone respect to both route of T administration based on indi- vidual threshold levels.
Why we conducted this study Aims of the study The screening of endogenous anabolic androgenic ster- oids (AAS) for doping control purpose is routinely UÊ iÛi«Ê>`ÊÛ>`>ÌiÊ>Ê1* q+/" -ÊiÌ `Ê implemented by assessing the steroid profile in urine. for the quantification of 12 steroid metabolites in Monitoring ratios between precursors or biosynthetic urine samples metabolites of testosterone (T) helps to distinguish an UÊ««ÞÊÌÊÀi>ÊÕÀiÊÃ>«iÃÊViVÌi`Ê>vÌiÀÊ/ÊÌÀ>Ã`iÀ- exogenous intake from physiological levels. The most mal and T undecanoate (TU) administration from 19 sensitive biomarker is the T glucuronide (TG) to epites- healthy male volunteers having different UGT2B17 tosterone glucuronide (EG) TG/EG ratio, which cut-off genotypes (del/del, ins/del and ins/ins). Evaluation of is set at 4 for suspicion of T or precursor administration. the variation of the 12 targeted steroid metabolites in Despite the high specificity of this parameter, the sensi- the 500 plus urine samples collected during the study tivity of this test suffers from the short detection window and the high inter-individual variability due to natural elevated TG/EG ratios or genetic polymorphisms [2–5]. How we collected the data The majority of steroids are biotransformed into phase I and II metabolites (glucuro- and sulfo-conjugates) to During the method development part of the study, the facilitate their excretion in urine. Among the UDP-glu- target analytes were extracted from urine samples by curonyl transferases (UGT), the UGT2B17 is the most solid-phase extraction (SPE) on Oasis HLB cartridges important isoform involved in T glucuronidation and 30 mg in the 96-well plate format to extract selectively is highly subjected to polymorphism. Moreover, today’s glucuro- and sulfo-conjugated AAS from urine samples doping habits consist in low-doses and topical route of (TG, EG, testosterone sulfate (TS), epitestosterone sul- administration, according to testimony of top-level ath- fate (ES), androsterone glucuronide (AG), androster- letes, to avoid peak concentration excretion. Then, the one sulfate (AS), etiocholanolone glucuronide (EtioG), current TG/EG ratio threshold and other steroid profile etiocholanolone sulfate (EtioS), dehydroepiandrosterone parameters might not be sufficiently sensitive to detect glucuronide (DHEAG), dehydroepiandrosterone sulfate low doses and transdermal T route of administration. To (DHEAS), dihydrotestosterone glucuronide (DHTG) avoid this limitation, subject-based monitoring approach and α-diol-3-glucuronide (5αββ-AdiolG). was proposed by setting individual basal threshold lev- ->«iÃÊÜiÀiÊÌ iÊ>>ÞÃi`ÊLÞÊ1* q+/" -Ê els instead of population reference limit as suitable tool with a linear gradient of acetonitrile in 25 minutes. for steroid profiling, as proposed for the future Athlete This method was validated in compliance with author- Steroidal Passport (ASP). With the perspective of using ity guidelines and showed limits of quantification and multiparametric indicators to reinforce the steroid pro- linearity ranges from 1 to 200ng/mL for TS and ES, 2 file detection ability, the research of novel biomarkers to 100 and 500ng/mL for 5αββ-AdiolG and DHTG, or minor metabolites is expanding to improve current respectively, 5 to 500ng/mL for TG, EG and DHEAG, detection windows of AAS doping. 50 to 3,000ng/mL for AS, DHEASand EtiosS, and 500 to 8,000ng/mL for AG and EtioG. In this study, a new generation quadrupole time-of- During the clinical study part conducted in 2012 in flight mass spectrometer coupled to ultra-high pressure Switzerland after approval by the Human Research Eth- µÕ`ÊV À>Ì}À>« ÞÊ1* q+/" -®ÊÜ>ÃÊiÛ>- ics Committee Vaud, the method was applied to real uated for its ability to assess the steroid metabolism after samples from a cohort of 19 volunteers. Control sam- T administration. For that purpose, urine samples from ples (C) were gathered during the first week. Kinetics a clinical trial protocol, collected after T transdermal and urine and blood spots were collected at time C-t00 = 0 T undecanoate (TU) administration to 19 healthy male h, C-t01 = 2 h,C-t02 = 4 h, C-t03 = 8 h, C-t04 = 12 h volunteers, having different UGT2B17 genotypes (del/ and C-t05 = 24 h. During the second week, volunteers del, ins/del and ins/ins), were analysed. The variation of received twice 2 T transdermal systems of 2.4mg/24 h F-MARC PROJECTS | THE FIGHT AGAINST DOPING IN FOOTBALL 201
Fig. 7.3.4.1 Principal component analysis (PCA) biplot combining samples distribution (scores) and analytes’ contributions (loadings) for the 12 tar- geted steroids. (A) Transdermal T patch administration and (B) oral TU pills intake. Empty ◊,i and Δ correspond to the control samples from the del/ del, ins/del and ins/ins UGT2B17 genotype, respectively. Full t, l and p are related to samples exposed to transdermal or oral T for the del/del, ins/ del and ins/ins UGT2B17 genotype, respectively. X represents the contributions of the targeted steroids. The variables were represented by PC1 and PC2 on the biplot. on Monday and Wednesday. The patch system (P) was As samples collected at different time points constituted stuck on the shoulder and removed after 48 h. During homogeneous clusters, no chronological trend could be that time urine and blood were taken at times P-t00 = highlighted on the PCA biplot for control and transder- 0 h, P-t01 = 2 h, P-t02 = 4 h, P-t03 = 8 h, P-t04 = 12 mal data. Therefore, T patch administration could not h, P-t05 = 24 h and P-t06 = 48 h. Time points P-t07 reveal a detectable influence on the steroid profile sug- = 60 h, P-t08 = 72 h and P-t09 = 96 h were collected gesting that the induction of the phenomenon was after the application of the second patch. Apart from too small. The effect of the treatment was confounded the mentioned collection times, all the urines produced with the biological variability and could certainly be were gathered during 48 hours after the application of attributed to the low dose and bioavailability as well the first patch. During the two following weeks, the as the slow kinetic release of topical system. Neverthe- first morning urine as well as a blood sample was col- less, three clusters could be clearly distinguished, corre- lected on Mondays. Following a wash-out period of sponding to the three UGT2B17 genotypes and indicat- two weeks, two TU tablets of 40mg were taken orally }Ê>Ê}À>`>ÌÊvÊÃÌiÀ`ÊiÛiÃÊ`iÉ`iÊÊÃÉ`iÊÊÃÉ by the volunteers on Monday and Wednesday. During ins). This observation suggests that the basal level of the the fifth week, urine and blood specimens were collected steroid profile is closely related to the UGT2B17 geno- after oral pill ingestion (O) at the same time points to type and correlates with the TG/EG level in urine. The those of T patch administration (O-t01-09). Blood tests PCA biplot of samples from volunteers exposed to oral included one EDTA tube of 7mL and two serum tubes TU and controls revealed a different picture. While no of 4.5mL. In this study, blood samples were only used effect of this high dose could be highlighted for the del/ for genotyping but frozen at -20 °C for future studies. del UGT2B17 genotype, a clear trajectory was revealed UGT2B17 and UGT2B15 genotyping was conducted for the inserted heterozygotous and homozygotous indi- and genotypes were well balanced with 5 del/del, 7 ins/ viduals by linking the time points. Del/del individuals del and 7 ins/ins genotypes for UGT2B17 and 5 YY, 4 remained apparently unaffected by the treatment, as the DD and 10 YD for the rs1902023SNP of UGT2B15. samples were clustered with controls, but time points 2, Urine samples were then analysed with the UHPLC– 4, 8 and 12 h post-dose of ins/del and ins/ins genotypes +/" -ÊiÌ `° were clearly separated from the control samples follow- ing a chronological trajectory. By these means, an acute excretion state, starting from 2 h to 12 h after TU pill Results intake could be distinguished from a basal level, and the analysis of the variables’ contributions indicated TG/ Two principal component analysis (PCA) models were EG, TG, DHTG and 5αββ-AdiolG as compounds driv- calculated to assess the trends related to both T admin- ing the trend highlighted after TU pill administration. istration routes compared to control urines (Fig 7.3.4.1). 202 THE FIGHT AGAINST DOPING IN FOOTBALL | F-MARC PROJECTS
Fig. 7.3.4.2 TG/EG, DHTG and EtioS excretion profiles. Subjects 01, 13 and 15 are depicted with the individual threshold (bold line) after transder- mal T and TU oral administration.
ROC curve analysis was performed to evaluate the over- individual thresholds were set up, to avoid the influence all accuracy of the measured parameters for the discrimi- of ethnicity and genotyping on the reference limit, as nation between control and T administered subjects. proposed for the forthcoming ASP approach. For that purpose, true positive rate (sensitivity) and The usefulness of each marker after transdermal and oral false positive rate (1-specificity) were assessed at differ- administration of T was evaluated by setting subject- ent thresholds. Transdermal testosterone administration based thresholds. Detection time was defined as the time ROC curves were built for each targeted steroid from after T administration when the measured concentration the control and the patch group. The most relevant was higher than the individual threshold, assuming that markers of the steroid profile were TG and the TG/EG the administration of T will increase the levels of the ratio. Regarding topical T application, TG and TG/ metabolites (Fig. 7.3.4.2). EG were poorly predictive. ROC curves of all the oth- er compounds had very low discrimination power. The Only a few markers revealed detection ability based poor sensitivity could be attributed to the low dose and on individual threshold after transdermal testos- bioavailability of the topical route, as well as the geno- terone administration. While the concentration of typicUGT2B17 diversity included in the study. Oral EG, DHEAG and ES never rose beyond the indi- testosterone administration ROC curves of 5 biomarkers vidual threshold, the best markers were TG, the TG/ from the steroid profile, including the TG/EG, present- EG ratio and the AG/EG ratio. Individual thresholds ed good accuracy indices after TU administration. As were reached for 13 volunteers out of the 19, and the expected, TG and TG/EG provided the best discrimina- effect was less pronounced for the del/del genotype, as tion power but parameters such as AG as well as DHTG expected. The elevation of those markers after T patch showed also satisfactory performance indices. From the administration followed the slow-kinetic release of the sulfo-conjugated steroids, EtioS revealed also appropri- topical route with detection time mostly between eight ate accuracy. To assess the pertinence of each biomarker, hours and 24 hours after T patch administration. The F-MARC PROJECTS | THE FIGHT AGAINST DOPING IN FOOTBALL 203
other targeted steroids quantified in the urinary samples erences, as found in the ASP, implemented with novel were not notably modified after T patch administra- biomarkers (hydroxy-, sulfo-conjugated) would thus be tion. While the classic biomarkers used to screen for T the most adequate tool to screen for T misuse. Eventu- misuse were not able to detect low T transdermal dose ally, the blood matrix collected during this clinical trial administration, the longitudinal follow-up of these will constitute invaluable complementary information to markers based on subject-based thresholds presented reveal T doping as a future perspective. In addition, as higher detection ability predominantly at time 24 hours an untargeted acquisition over the entire selected mass after patch application. However, most of the parame- À>}iÊÜ>ÃÊ«ÃÃLiÊÜÌ ÊÌ iÊ+/"Ê>ÃÃÊëiVÌÀiÌiÀ]Ê ters remain below the individual threshold for the indi- unknown markers could be extracted. In the future, the viduals bearing the del/del genotype. Regarding subject- predictive ability of these markers will be investigated based detectability after TU pill administration, the with respect to T transdermal and oral administration, most relevant biomarkers were glucuro-conjugated ana- without necessity to re-analyse the samples. The selec- lytes including TG, AG, EtioG, 5αββ-AdiolG, DHTG, tion of untargeted metabolites is promising for a broader as well as the ratios TG/EG and AG/EG. However, TG, steroid profiling on fresh and well-structured clinical 5αββ-AdiolG, DHTG, TG/EG and AG/EtioG ratios study samples. could not detect exogenous intake of TU by individu- als bearing the del/del genotype. For all of the elevated markers and in accordance with several studies, the detection window ranged from two hours to 12 hours, with an excretion peak between four hours and 12 hours and returned to the baseline level 24 hours after pill intake. Based on individual threshold strategy, the inte- gration of multiple parameters in a longitudinal follow- up could enhance the detection ability and discrimina- tion power between confounding factors, individual biological variability and oral TU intake doping.
What we learned from the study
While UGT2B17 polymorphism was highly linked to TG excretion in this study, the UGT2B15 polymor- phism could not be highlighted to influence specific metabolites excretion. Therefore, due to the complexity to integrate those data, longitudinal follow-up of indi- viduals was the strategy of choice. This is particularly important because classical criteria based on the uri- nary steroid profile are not adequate to reveal T misuse via topical route and the detection of administration of Duration: 2012 - 2013 high oral dose is limited to short time post dose. Based Country: Switzerland on this approach, transdermal T application consisting Cooperation: Swiss Laboratory for Doping Analyses (LAD), in low dose and slow-releasing kinetic could be detect- University of Lausanne, Switzerland ed at several time points by following TG or the ratios References: TG/EG and AG/EG. After 80mg oral TU ingestion, the Badoud F, Boccard J, Schweizer C, Pralong F, Saugy M, Baume sulfo-conjugated analyte EtioS was revealed as a promis- N (2013). Profiling of steroid metabolites after transdermal and ing biomarker, especially for individuals having a deleted oral administration of testosterone by ultra-high pressure liquid UGT2B17 genotype. Additionally, hydroxy metabolites chromatography coupled to quadrupole time-of-flight mass were highlighted as potential long-term detection mark- spectrometry. J Steroid Biochem Mol Biol 138C: 222-235 ers of TU. The results confirmed this hypothesis, with Kuuranne T, Saugy M, Baume N (2014). Confounding factors an increase of this marker after TU intake even for indi- and genetic polymorphism in the evaluation of individual ster- viduals bearing the del/del genotype. Subject-based ref- oid profiling. Br J Sports Med 48(10): 848-855 204 THE FIGHT AGAINST DOPING IN FOOTBALL | F-MARC PROJECTS
7.3.5 Influence of Multiple Injections of ed at a concentration above this value, considering that Human Chorionic Gonadotropin (hCG) over production of hCG could become from tumor cells. on Urine and Serum Endogenous It is therefore complex to put forth doping with hCG in Steroids Concentrations male athletes using only the urinary matrix.
In 1979, the urinary ratio between testosterone and LH Why we conducted this study to detect doping with testosterone was first presented. The value of this urinary T/LH ratio was confirmed by The attractive characteristic of testosterone as a doping additional studies either as a more reliable marker for agent is its endogenous production by the human body testosterone abuse or for additional information to the making the identification of an exogenous intake much more generally used T/E ratio in urine. As hCG mis- more complex. The urinary steroid profile, including use has an impact on endogenous testosterone and LH absolute concentrations of testosterone related com- production, this T/LH ratio should also be a marker of pounds as well as ratio between testosterone and its hCG abuse. epimere epitestosterone (T/E ratio) and other ratios of various androgens, is of central importance in doping In this study, we aimed to evaluate the effect of three controls. However evaluation and quantification of ster- intramuscular injections of rhCG on urine and serum oids in urine are subjected to variations. In particular, concentrations of LH, hCG and androgens to put for- treatment with hormones such as luteinising hormone ward additional markers to direct urinary hCG detection (LH) and human Chorionic Gonadotropin (hCG) are and serum T/LH ratio for gonadotropin abuse in sports. forbidden by WADA due to their physiological roles linked to testosterone metabolism in the body. There is unequivocal evidence that hCG in males causes testos- Aims of the study terone to be produced and released. Hence, sportsmen could use hCG to boost endogenous testosterone pro- UÊ iÛi«Ê>`ÊÛ>`>ÌiÊ>Ê -ÊiÌ `ÊvÀÊÌ iʵÕ>Ì- duction but also to compensate a prolonged use of ana- fication of eight steroid metabolites in urine samples bolic steroids disrupting the regulation of steroids pro- UÊ««ÞÊÌÊL}V>ÊÃ>«iÃÊViVÌi`Ê>vÌiÀÊÌ ÀiiÊ Ê duction in the human body. injections at days 0, 2 and 4 from ten healthy male volunteers. Evaluation of serum LH, hCG and T and A mixture of hCG forms are found in the urine matrix, urinary LH, hCG and steroid profile variations which has a significant impact on the recognition of samples by the multiple hCG immunoassays tests avail- able on the market. Hence, an immunoassay sensitive to How we collected the data the whole pool of hCG forms seems to be fit for pur- pose in the fight against doping. Another concern about During the method development part of the study, T, E, the quantification of urinary hCG is the setting of the androsterone (A), etiocholanolone (Etio), 5α-androstan- decision limit above which an atypical finding could be 3α,17β-diol (5α-diol), 5β-androstan-3α,17β-diol considered. Indeed, as direct hCG quantification is now (5β-diol), dehydroepiandrosterone (DHEA) and dihy- considered as the only value to deter doping with hCG, drotestosterone (DHT) were extracted from urine sam- a cut-off value should be evaluated for each immuno- ples by liquid-liquid extraction (LLE) using tertbutyl- assay as no standard tests are imposed by the WADA. methyl ether (TBME) and derivatised prior to injection, Commercially available assay has been validated for resulting in a 20 times concentration factor for the quantitative serum hCG measurement whereas only analytes. Samples were then analysed by GC-MS with qualitative estimation of urine hCG concentration was a suitable temperature programme to selectively sepa- possible. As urine is currently the mostly used biologi- rate the target compounds in 14 min. This simple and cal matrix for anti-doping tests, the lack of immunologi- rapid method was validated in compliance with author- cal tests allowing an exact measure of urinary hCG is the ity guidelines and showed a limit of quantification and first difficulty to detect hCG doping. Secondly, and even linearity ranges from 0.5 to 450ng/mL for T and E, 100 if the Minimum Required Performance Limit (MRPL) to 8,000 for A and Etio, 2 to 450 ng/mL for 5α-diol and imposed by WADA is fixed at 5mIU/mL, this does not 5β-diol, 2 to 180ng/mL for DHEA, and 1 to 180ng/mL mean that an adverse analytical finding should be report- for DHT. F-MARC PROJECTS | THE FIGHT AGAINST DOPING IN FOOTBALL 205
Tab. 7.3.5.1 Design of the clinical study on hCG administration.
Serum T, LH and hCG as well as urine LH and hCG the successive injections while the rest of the individu- were measured by immunoassays with an IMMULITE als presented stabilisation. It is known that when hCG is 2000 machine, using T, LH and hCG kits. The sample intra-muscularly administered, the maximum plasmatic analyses were conducted in duplicate and the mean value level is reached between two and six hours. Further- was considered for result evaluations. more, hCG is eliminated in two phases with a first of During the clinical study part conducted in 2010 in 8–12 hours and a second of 23–37 hours, principally in Switzerland after approval by the Human Research the kidney. As a consequence, the inter-individual vari- Ethics Committee Vaud, the method was applied to ability observed in the excretion through urine is more healthy male volunteers (n = 10). Three HCG injec- important than in serum. The concentrations observed tions (2000 I.U. Choriomon®) were performed at days in the spot urines were comparable to serum levels for 0, 2 and 4 between the hours of 7.00 and 8.00 just after eight individuals, but two other subjects presented very urine and serum collection. Other urine and serum col- low levels of urinary hCG. lections were scheduled as described in Tab. 7.3.5.1. Basal levels of the molecules of interest were determined The mean level in all subjects of serum T increased 12 on four samples (B1–B4 and U1–U4). After the third hours after the first injection and increased some more hCG injection, every spot urine were collected for 48 after 24 hours. Likewise, the mean value increased 24 hours (8–25 samples depending on the subject). Serums hours after the second injection. Twelve hours after the were aliquoted and kept frozen at −20 °C until analy- last injection, the mean serum concentration was slight- sis. Serum LH, hCG and T were measured 4 months ly decreased. Interestingly, the mean testosterone level after collection. Urine samples were divided in several in serum was significantly decreased twelve days after vials and frozen at −20 °C prior to analysis within two the last injection dose compared to the basal level. It is months. This protocol was approved by the Ethical important to note that at the basal level, the circadian Commission for the Clinical Research of the Faculty of influence on T production was significant with a high- Biology and Medicine (University of Lausanne, Laus- er value on morning blood samples than evening. The anne, Switzerland). same difference was observed on the two last samples collected in the morning and the evening 12 days after the last injection. Results The serum LH level decreased along the study due to All subjects responded to the hCG injections by an the negative feedback on the hypothalamopituitary axis increase of hCG levels in serum and urine. Twelve (HPA) performed by T up regulation. The average LH hours after the first injection, nine subjects presented the basal level remained stable 12 hours after the first injec- maximal serum concentration of hCG. One individu- tion and decreased after 24 hours and further on after al still presented an increase between 12 and 24 hours 48 hours. The average LH concentration remained low whereas the others presented a decrease in hCG level. 24 hours after the second injection and 12 hours after In four individuals, an accumulation was observed after the last injection. Twelve days after the last injection, the 206 THE FIGHT AGAINST DOPING IN FOOTBALL | F-MARC PROJECTS
Fig. 7.3.5.1 T/LH ratio follow-up along the study in serum (a) and in urine (b) (mean ± standard error of the mean (SEM))
LH level among volunteers was not significantly differ- samples collected on mornings and evenings. In order to ent from the basal concentrations measured before the compare A/Etio levels along the study, morning values first treatment. were compared to morning basal values and evening val- ues to evening basal values. This ratio was significantly As a consequence, the T/LH ratio in serum was sub- increased from 12 to 24 hours after the first injection, jected to a major increase due to hCG administration at 12 hours and 24 hours after the second injection and (Fig. 7.3.5.1). The average basal ratio value was 4.6 and 12 hours after the last injection with a maximal value increased to 6.3 after 12 hours and 13.3 after 24 hours. observed 12 hours after the last injection. If the elimi- At the second injection time, the T/LH ratio was of 24.9 nation kinetic is similar to T for the other steroids, the and increased to 44.3 after 24 hours. A large inter-indi- recovery of basal values 12 days after the study was dif- vidual variation was observed on the T/LH ratio mainly ferent regarding the steroid. While E followed the same due to the T response to hCG injections. Three individ- significant tendency as T, i.e. to be below the basal level, uals presented a decrease of the T/LH ratio between the A, Etio, DHT, 5α-diol, 5β-diol and DHEA were not second injection and 24 hours later essentially due to a significantly different from basal values 12 days after the rapid tendency to recover basal LH levels. Twelve hours last hCG injection. after the last injection, the influence on the T/LH ratio was still important. And as a consequence of the low Regarding urinary LH, the profiles were not significantly T level 12 days after the last hCG injection, the T/LH influenced by the hCG treatment during the whole pro- ratio was significantly below the basal value. tocol, however unpredictable fluctuations were observed. Nevertheless, the T/LH ratio in urine was studied as an Urinary T excreted under its glucuro-conjugated form alternative to the T/E ratio to deter hCG administra- adjusted to specific gravity presented essentially similar tion, particularly in UGT2B17 deleted individuals. The pattern to serum except that the inter-individual vari- hCG injections affected the T/LH ratio by an increase ability was much higher. Two subjects presented a ster- of up to 110 times when the maximum T/E increase in oid profile typical of individuals devoid in UGT2B17 UGT2B17 del/del subjects is of 1.9 times. with an average basal T glucuronide level in urine sig- nificantly inferior. Only for individuals with inserted Relative serum T/LH (absolute values corrected by the UGT2B17, the T increase in urine was significantly individual basal values) as biomarker of hCG adminis- delayed compared to serum 24 hours after the first injec- tration presented the highest discriminating power, fol- tion, at the second injection time and 24 hours after the lowed by T in serum and T in urine. Due to the difficul- second injection. The excretion patterns of the steroid ty to measure low concentration of LH in urine, the T/ profile were similar to T with differences in the accu- LH ratio in urine was prone to outliers’ events in some mulation after the successive injections of hCG. This cases. In order to satisfy anti-doping requirements, the explains for instance the non-significant variation for the cut-offs were defined for a maximal specificity. T/E. It is important to note that a significant difference in basal values of the A/Etio ratio was observed between F-MARC PROJECTS | THE FIGHT AGAINST DOPING IN FOOTBALL 207
What we learned from the study
The hCG pharmacokinetic observed in all subjects was, as expected, prone to important inter-individual varia- tions. Using ROC plots, level of T and T/LH ratio in both blood and urine were found to be the most relevant biomarker of hCG abuse, regardless of inter-individual variations. This study showed the crucial importance of reliable quantification methods to assess low differences in hormonal patterns. In regard to these results and to anti-doping requirements and constraints, blood togeth- er with urine matrix should be included in the anti- doping testing programme. Together with a longitudinal follow-up approach it could constitute a new strategy to detect hCG abuse, applicable to further forms of steroid or other forbidden drug manipulation.
Duration: 2010 - 2011 Country: Switzerland Cooperation: Swiss Laboratory for Doping Analyses (LAD), University of Lausanne, Switzerland Reference: Strahm E, Marques-Vidal P, Pralong F, Dvořák J, Saugy M, Baume N (2011). Influence of multiple injections of human chorionic gonadotropin (hCG) on urine and serum endogenous steroids concentrations. Forensic Sci Int 213(1-3): 62-72 208 FOOTBALL FOR HEALTH | F-MARC PROJECTS
8. Football for Health 8.1 Prevention of Non-Communicable Diseases
8.1.1 Prevention of Risk Factors for Non- training on performance, muscle adaptations and health Communicable Diseases profile follow.
Why we conducted these studies Physical demands during small-sided games
Football’s worldwide governing body (FIFA) attaches Football practice organised as small-sided games for two particular importance to health. In 1994, an independ- to 14 players provides a marked physiological response ent research unit was established, the FIFA Medical even for youngsters, elderly and untrained individuals. Assessment and Research Centre (F-MARC), with the objective of developing the scientific basis to protect the health of all players and promote football as a health- Effect of regular participation in small-sided enhancing leisure activity. The focus of ‘‘Football for games on performance and muscle adaptations Health’’ is not only on players’ health, but also on the health of society as a whole. Football’s popularity gives Football training for 12–16 weeks carried out as small- it the potential to play a unique role in awareness and sided games two to three times (one hour) a week of prevention of diseases – and at very low costs. FIFA/F- untrained middle-aged male and female players without MARC has clear goals: to protect the health of the 265 prior experience with football, led to e.g.: million active participants worldwide and to promote UÊ >Vi`Êi>ÊL`ÞÊ>ÃÃÊ>`Êi}ÊÕÃViÊ>ÃÃ football as a safe and healthy leisure activity contributing UÊ >Vi`Ê>Ý>Ê`Þ>VÊ >ÃÌÀ}ÊÕÃViÊ to an improvement in health of the general population. strength UÊ «ÀÛi`Ê«ÃÌÕÀ>ÊL>>Vi Thus, 12–16 weeks of football training is sufficient Aims of the studies to induce a variety of performance enhancements and muscular adaptation, which can be maintained, and UÊÛiÃÌ}>ÌiÊ i>Ì Ê>`ÊwÌiÃÃÊLiiwÌÃÊvÊÀi}Õ>ÀÊ«>À- some further elevated if training is continued even at a ticipation in small-sided football games of various age reduced frequency. groups over a period of up to 16 months UÊ>ÞÃiÊÌ iÊivviVÌÃÊvÊvÌL>ÊÌÀ>}ÊvÀÊ>Ê« ÞÃ- ological, medical, social and psychological perspective Health benefits of regular participation in football practice
Method Football training for 12–16 weeks carried out as small- sided games two to three times (one hour) a week for The results of a two-year multi-centre study in Copen- untrained middle-aged men and pre-menopausal wom- hagen and Zurich include studies of different age groups en, without prior experience with football, led to e.g.: analysed from a physiological, medical, social and psy- UÊ ,i`ÕVÌÃÊÊÀiÃÌ}Ê i>ÀÌÊÀ>ÌiÊ>ÃÊÜiÊ>ÃÊLÌ ÊÃÞÃÌVÊ chological perspective. The main groups investigated and diastolic blood pressure were middle-aged, former untrained, healthy men and UÊ ÜiÀ}ÊvÊv>ÌÊ>ÃÃ women, elderly, children and hypertensive patients. UÊ VÀi>Ãi`Êi}ÊLiÊiÀ>ÊVÌiÌ Each group was carrying out regular football training Regular football practice has considerable positive effects organised as small-sided games two to three times a week on the health profile of middle-aged women and men, for 12–16 weeks. particularly for those exhibiting mild-to-moderate hypertension.
Results Social and psychological effects A summary and interpretations of the main findings divided into an analysis of the physical demands during The psychological effects of football training organised training of various groups and the effect of a period of in small groups of 10–20 participants, most of whom F-MARC PROJECTS | FOOTBALL FOR HEALTH 209
were untrained and had no particular prior experiences ferent ages with proper control groups are warranted to or skills, were as follows e.g.: obtain evidence-based recommendations for using foot- UÊ ÊÀiÜ>À`}Ê«ÃÞV }V>ÊÃÌ>Ìi]Ê`ÕÀ}ÊvÌL>ÊÌÀ>- ball in the early treatment of obesity and related co-mor- ing bidities in childhood. UÊ `iÀ>ÌiÊÀ>Ì}ÃÊvÊ«iÀViÛi`ÊiÝiÀÌÊ>`ÊÜÊÃVÀiÃÊ for worry UÊ ÌL>ÊÌÀ>}ÊÃÊvÕÊ>`Ê>ÊÀiÜ>À`}Ê>VÌÛÌÞÊÜÌ Ê What we learned from the study the social capital and health promotion The studies demonstrated that carrying out regular foot- ball training organised as small-sided games two to three Comparison of football training and endurance times a week, causes significant cardiovascular and mus- running cular adaptations, including muscle growth and elevated muscular strength independent on the level of training, Regular recreational football training was compared with lack of experience with football, gender and age. The endurance running in a number of studies using physi- effects can be maintained for a long period even with ological, psychological and sociological methods. Most a reduced frequency of training to one to two times of the results and adaptations were the same for football for one hour a week. Recreational football, therefore, and running, but in a number of areas football training appears to be an effective type of training leading to per- exceeded that of endurance running, e.g. formance improvements and significant beneficial effects UÊ Ài>ÌiÀÊÛ>À>ÌÊÊ i>ÀÌÊÀ>ÌiÊ>`Ê>>iÀLVÊiiÀ}ÞÊ to health, including a reduction in the risk of cardiovas- turnover cular diseases, falls and fractures. In a number of aspects, UÊ VÀi>ÃiÊÊÕÃViÊ>ÃÃÊ>`ÊiiÛ>ÌÊÊ6"2max football training appears to be superior to running train- UÊ ÌÛ>Ìi`ÊLÞÊÌ iÊ>VÌÛÌÞÊ>`ÊvÕÊ>`ÊLi}ÊÌ}iÌ iÀÊ ing. Football training can also be used to treat hyperten- in the group sion and it was clearly superior to a standard treatment strategy of physician-guided traditional recommenda- tions. Effects of lifelong participation in football The supplement papers reveal that football is a motivat- practice for the elderly ing activity that promotes social interactions and has the potential to facilitate adherence to an active life style. Elderly men (63-78 years) exposed to lifelong football The supplement offers scientific evidence that football had superior muscle force characteristics and better pos- can be promoted as a health-enhancing leisure activity. tural stability compared with untrained age-matched individuals, and the same levels as untrained young men. A higher rate of force development in the football- trained elderly could be attributed to qualitative neuro- muscular and tendinous factors, such as motor unit fir- ing rate and tendon stiffness, rather than quantitative factors such as muscle size.
Effects of regular participation in football Duration: 2008 - 2010 practice for children and youngsters Countries: Denmark, Switzerland Football training has been demonstrated to enhance Cooperation: Department of Sport and Exercise Sciences, intermittent exercise performance, coordination and University of Copenhagen, four Danish University Hospitals, maximum oxygen uptake of children and teenagers. In Swiss Federal Institute of Technology in Zurich, Schulthess addition, for obese children, regular participation in Clinic, Zurich football training is at least as efficient in improving the References: physical capacity, health-related fitness parameters and Football for Health - Prevention of Risk Factors for Non- self-esteem as a standard exercise programme. Long-term communicable Diseases (2010). Supplement of the Scand J Med studies of children and youngsters playing football at dif- & Sci Sports 20(1 Suppl) (for details see Bibliography) 210 FOOTBALL FOR HEALTH | F-MARC PROJECTS
8.1.2 Prevention and Treatment of Aims of the studies Non-Communicable Diseases across the Lifespan UÊ-Õ««ÀÌÊÌ iÊVÌÕi`Ê«ÀÌÊvÊvÌL>Ê>ÃÊ>Ê health-enhancing leisure activity that improves social behaviour Why we conducted these studies UÊÕÃÌvÞÊÌ iÊ«iiÌ>ÌÊvÊÌ iʺʣ£ÊvÀÊ Health” programme, backed and approved by the On the occasion of the FIFA World Cup™ in South 2013 FIFA Congress, as a global health initiative Africa in 2010 and in the same journal, a special issue was dedicated to the prevention of risk factors for non- communicable diseases through playing football. The 13 Method original papers concluded that football, the most popu- lar team sport in the world, is associated with positive The team of international researchers has thoroughly motivational and social factors that may facilitate com- investigated numerous groups of inactive subjects across pliance and persistence with the sport and at the same the lifespan in a prospective controlled manner. These time contributes to the maintenance of a physically studies, which include groups of children aged 9-13, active lifestyle (8.1.1). adult women and men up to the age of 80, have pro- duced impressive results that cannot be ignored by pub- The original studies demonstrated that carrying out lic health policy-makers around the globe. football training on a regular basis, two to three times a week, caused significant cardiovascular and muscular adaptation, including muscle growth and elevated mus- Results cle strength, irrespective of the level of training, experi- ence of the game, gender, and age. Football conducted as small-sided games affects fitness and health of untrained individuals across a wide range The results of extensive scientific studies have been sim- of lifespan. The intermittent nature of football and high plified in the slogan “Playing football for 45 minutes exercise intensity result in a broad range of effects. The twice a week – best prevention of non-communicable heart changes its structure and improves its function. diseases”, first presented at the 59th FIFA Congress in Blood pressure is markedly reduced with the mean arte- Nassau. In line with this, the editor-in-chief of the Brit- rial blood pressure being lowered by ~10mmHg for ish Journal of Sports Medicine, Karim Khan, promoted hypertensive men and women training two to three the slogan “The exercise pill – time to prescribe it”. Giv- times/week for 12–26 weeks. Triglycerides and cho- en its popularity, football might be the appropriate exer- lesterol are lowered and body fat declines, especially cise pill to prescribe and promote. in middle-aged men and women with type 2 diabetes. Furthermore, muscle mass and bone mineral density The research group from Copenhagen, under the lead- increases in a number of participant groups, including ership of Professors Peter Krustrup and Jens Bangsbo, 65–75-year-old men. The functional capacity is elevated joined forces with FIFA/F-MARC (FIFA Medical with increases in VO2max of 10–15%, and 50–100% Assessment and Research Centre) as a number of ques- improvements in the capacity to perform intermittent tions remained unanswered following the research pre- work within 16 weeks. These effects apply irrespective of sented in 2010. During the past four years, these ques- whether the participants are young, overweight, elderly tions have been investigated in a large multi-national or suffering from a disease. study covering Denmark, England, Portugal, and Brazil. Using the momentum of the 2014 FIFA World Cup The 16 original papers of the supplement describe in BrazilTM, this special issue of the journal presents 16 detail how fitness and health of each group was affected: original papers with convincing data. UÊ Þ«iÀÌiÃ\Ê/ÜÊ>ÀÌViÃÊ`iÃVÀLiÊvÌL>Ê>ÃÊ>Ê effective broad-spectrum treatment for hypertension in middle-aged Danish men (Andersen L.J. et al) and mature Faroese women (Mohr et al). UÊ /Þ«iÊÓÊ >LiÌiÃ\ÊÊÌÜÊ>ÀÌViÃÊ`iÃVÀLiÊÌ iÊ«ÃÌÛiÊ cardiovascular and metabolic effects of football for F-MARC PROJECTS | FOOTBALL FOR HEALTH 211
type 2 diabetic men in Denmark (Andersen T.R. et al. 2014a) and Brazil (de Sousa et al). UÊ 1ÌÀ>i`ÊÈx³ÊÞi>ÀÃÊ««Õ>Ì\ÊÕÀÊ>ÀÌViÃÊ«ÀiÃiÌÊ a brand-new insight into the effects of football for 65- to 80-year-old untrained men who have never played football before, describing marked improvements in heart function (Schmidt et al), physical capacity (Andersen T.R. et al) and bone strength (Helge et al) as well as elevated muscle mass for prostate cancer patients despite anti-androgen treatment (Uth et al). UÊ -iviÃÌiiÊ>`Ê« ÞÃV>ÊV«iÌiViÊvÊV `Ài\Ê Three articles cover the effects of football for 9- to 12-year-old children, showing improved cardiac func- tion after short-term school football in Denmark (Krustrup et al), enhanced self-esteem, perceived physical competence and attraction to physical activity for obese boys after short-term school football in Por- tugal (Seabra et al) and effective training through club football for recreational and elite U-10 and U-13 play- ers in Denmark using 5v5 and 8v8 matches (Randers et al). UÊ iiÃÃÊ««Õ>Ì\Êi}iÊiÌÊ>Ê`iÃVÀLiÃÊÌ iÊ«Ã- tive effects on muscles, bones and postural balance for homeless men playing street football in Denmark. UÊ 1ÌÀ>i`Ê``i>}i`Ê««Õ>Ì\Ê,>`iÀÃÊiÌÊ>Ê describes and explains the high intensity during foot- ball training for untrained men irrespective of the number of players. UÊ ÌÛ>ÌÊ>`ÊÃV>Ê>ëiVÌÃ\Ê/ ÀiiÊ>ÀÌViÃÊ`iÃVÀLiÊ the positive psychosocial benefits of football for mid- dle-aged men (Nielsen et al), elderly men (Bruun et al) and mature women (Bennike et al. 2014), covering the motivational and social aspects of football.
What we learned from the study
The supplement articles reveal that football has a great potential in the prevention and treatment of non- communicable diseases across the lifespan. Given that football is easy to organise as an intense and effective broad-spectrum type of training it shows a great prom- ise in changing the habits of untrained people all over the world, creating adherence to a physically active and Duration: 2010 - 2014 healthier lifestyle. Countries: Denmark, England, Portugal, and Brazil Cooperation: Copenhagen Research Group References: Football for Health - Prevention and Treatment of Non- Communicable Diseases across the Lifespan through Football (2014). Supplement of the Scand J Med & Sci Sports 24(1 Suppl) (see details in Bibliography) 212 FOOTBALL FOR HEALTH | F-MARC PROJECTS
8.2 ”FIFA 11 for Health”
8.2.1 Development and Evaluation in area; (2) the availability of local organisations with suffi- Different Settings cient experience to help deliver the football-based health education programme on site; (3) access to a suitable group of men/women who could be trained as instruc- Why we conducted these studies tors and coaches and who were fluent in the local lan- guage and familiar with local culture. To strengthen the The World Health Organization (WHO) has identified appeal of the programme, each health message received the major worldwide mortality risk factors, and has esti- the support of an international elite football player as mated that, by 2020, preventable non-communicable a role model to encourage children to follow the pro- diseases will be responsible for ~70% of deaths. Only gramme. 20% of chronic disease deaths occur in high-income countries, 80% occur in low and middle-income coun- The intervention consisted of 11 90-minute sessions, tries. divided into two 45-minute halves of Play Football (football skills) and Play Fair (health issues). Each ses- In 2006, FIFA recognised the unique role of football in sion focused on one specific health issue or health risk the promotion of exercise and health behaviour. Given factor. Main outcome measures for the implementa- the strong evidence that exercise is suitable as a thera- tion were: (1) health knowledge using a 20-item (South py for a wide range of diseases, and football being the Africa), and 30-item questionnaire (Mauritius; Zim- most popular sport worldwide, FIFA decided to help to babwe), implemented pre- and post-intervention; (2) reduce the burden from communicable and non-com- coaches’ attitudes towards their training using a ten-item municable diseases to its best endeavours. This led to the questionnaire (South Africa); and (3) children’s attitude development of a football-based health education pro- towards the health education programme using a six- gramme, which was named “Football for Health”, and item questionnaire designed with the Likert scale. was first implemented in South Africa in 2009. In 2010, the programme was then implemented in Mauritius and Based on the results from a pilot study, it was suggest- Zimbabwe, and received its current name “FIFA 11 for ed that a sample size of ~110 children would be needed Health”. to identify with 95% confidence and 90% power an increase in the proportion of correct responses to 80% after the intervention. It was assumed that an overall loss Aim of the studies of ~25% would occur in the follow-up so that the mini- mum initial sample size required in each group should UÊ iÛi«]Ê«iiÌÊ>`Ê>ÃÃiÃÃÊ>ÊÌiÀ>VÌÛi]ÊvÌL> be ~150 children. based health education programme for children in South Africa, Mauritius and Zimbabwe The implementation took place in 2009 in South Africa in two schools, and in 2010 as in-school intervention at 11 secondary schools on Mauritius and as an out-of- Method school intervention using local coaches in Zimbabwe. Overall, three groups of 370-395 school children aged In the initial stage, two focus groups comprising doc- 12-15 participated in the implementation. tors, researchers and representatives of government and non-government organisations from Africa met in 2007 to discuss the build-up of the programme. It was Results decided that the implementation and evaluation of the programme should follow the ten-stage process already South Africa: Average attendance levels were 89.5% for proposed by the WHO for AIDS health promotion pro- the intervention group, grade 7; 93.9% for the control grammes. Two additional health messages were added to group, grade 7; 93.4% for the intervention, grade 6. the programme: “use of bed nets” to prevent the spread There were no significant differences between the num- of malaria and dengue fever, and “respect for girls and ber of boys and girls included in each group, and no women” to reduce the spread of sexually transmitted dis- statistically significant differences in the demographic eases. It was based on three factors: (1) the prevalence data for the children. Responses to the health-related of communicable and non-communicable diseases in the statements were measured at an overall accuracy of 99.7. F-MARC PROJECTS | FOOTBALL FOR HEALTH 213
Compared with pre-intervention levels, the intervention grade 7 group showed significant increases in knowledge for nine of the 20 health statements at the post-interven- tion assessment and for 11 of the 20 statements at the three-month follow-up assessment. In the health issues, knowledge of coaches was a signifi- cant gain in the intervention group but no change was observed in the control group after their “Play Football” training programme.
In Mauritius and Zimbabwe, average attendance levels were 92.3% and 86.6%, respectively. There were no significant differences between the number of boys and girls included in the cohorts in either country. At the post-intervention stage, responses to 21 statements were significantly higher in Mauritius. On average, knowl- edge enhancement from pre- to post intervention was similar in both countries. In Mauritius, there were two statements resulting in significantly different responses between boys and girls at the pre-intervention stage – both of these related to the health message “respect girls and women”.
What we learned from the study
Results from these studies demonstrated that it was pos- sible to implement an education programme for children containing valuable health messages linked to football and to achieve significant improvements in knowledge regarding a number of health issues. Importantly, the knowledge gained was retained beyond the end of the programme. The positive outcome of these studies sug- gests a further development of the “FIFA 11 for Health” programme, and large-scale implementation in different countries and different settings.
Duration: 2007 - 2010 The results from all three countries showed that the pro- Countries: South Africa, Mauritius, Zimbabwe gramme was effective for girls and boys, and equally well Cooperation: Grassroot Soccer Inc, Cape Town, South Africa, received by girls in the different countries. It could be University of Cape Town, Cape Town, South Africa, Ministry demonstrated that new forms of partnerships for devel- of Youth and Sport, Port Louis, Mauritius oping health promotion programmes can be developed References: Fuller CW, Junge A, DeCelles J, Donald J, successfully between non-governmental organisations Jankelowitz R, Dvořák J (2010). ‘Football for and national Football Associations. The studies show Health’—a football-based health-promotion programme for that the “FIFA 11 for Health” programme can indeed be children in South Africa: a parallel cohort study. Br J Sports scaled up to accommodate large numbers of children. Med;44(8):546-554 Fuller CW, Junge A, Dorasami R, DeCelles J, Dvořák J (2011). ‘11 for Health’, a football-based health education programme for children: a two-cohort study in Mauritius and Zimbabwe. Br J Sport Med ;45:612-61 214 FOOTBALL FOR HEALTH | F-MARC PROJECTS
8.2.2 Planning a Nationwide Implementation Method
Planning Why we conducted this study Moving from a regional pilot study completed success- fully in South Africa, Mauritius and Zimbabwe to a The social and economic burden associated with com- nationwide project in Mauritius meant that additional municable diseases, such as HIV/AIDS, malaria and concepts, such as the individual, organisational and gastrointestinal diseases, is a major concern in the devel- social dimensions of the health promotion, as well as oping countries of Africa. According to WHO reports additional implementation issues had to be considered. however, non-communicable diseases, such as coronary Furthermore, given the large scale of the project, it was heart disease, hypertension, and diabetes will become an necessary to distribute lead responsibilities for various even greater problem by 2030, if no appropriate preven- aspects of the project. tive actions are taken. Since 1994, FIFA/F-MARC has been committed to Implementation research aimed at improving the health prospects of a) Pilot study football players of all levels of skill in different environ- An implementation protocol for the delivery of the ments around the world. In 2006, the centre moved its “FIFA 11 for Health” programme was developed by research focus from “Medicine for Football” to “Football F-MARC which included: (1) preparation of a manu- for Health”: the main objectives being to use the popu- al; (2) arrangements for teachers’ training courses and larity of football to encourage greater physical activity (3) a time schedule for delivering the teachers’ train- among all age groups and to deliver health education to ing courses, the interventions and the pre- and post- children in developing countries. course programme evaluation questionnaires. Schools “FIFA 11 for Health” is a football-based health educa- were recruited with the help of the local coordinator tion programme for children, developed by F-MARC, and upon assessment visits by F-MARC. Teachers from and consisting of 11 simple messages designed to address the participating schools together with football coaches the most common risk factors for communicable and from the Mauritian Football Association (MFA) were non-communicable diseases. taken through a five-day interactive training course by F-MARC.
Aims of the study b) Nationwide project A local organisation was established that could over- UÊ/Ê>``ÀiÃÃÊ«ÀÌ>ÌÊ i>Ì ÊÃÃÕiÃÊ>Ài>`ÞÊ`iÌwi`Ê see and ensure the delivery of a successful project to by the Mauritius Ministry of Health among school- ~17,000 children studying in ~200 schools. Two “zone children in Mauritius and to develop a long-term leaders” (North/South) were recruited to work with the strategy for the direction and implementation of the local coordinator at the MFA. “FIFA 11 for Health” programme within the country UÊ/ÊÃiÌÊÕ«Ê>`Ê«ÀiÃiÌÊ>ÊvÌL>L>Ãi`Ê i>Ì Êi`ÕV>- Monitoring & Sustainability tion programme, which is sustainable through capac- The efficacy of the “FIFA 11 for Health” pilot and ity-building of local stakeholders and acceptable to nationwide projects was assessed using questionnaires. government health and education departments Data analyses for the pilot and nationwide projects were UÊ/ÊiÝiÀVÃiÊ>ÊÃÌi«ÃÊvÊÀ}>Ã}]Ê«>}]Ê«i- completed by F-MARC. The sustainability of the pro- menting and monitoring requirements needed to ject was safeguarded through a cost-effective approach deliver the “FIFA 11 for Health” programme nation- using a tripartite agreement between F-MARC, the wide and to establish thereby, a case study for com- country’s football association and the appropriate gov- munity-based educators who wish to implement this, ernment departments. To safeguard an ongoing support, or similar, sport-based health education programmes F-MARC provided a reduced level of support in Mauri- in their country tius for two years beyond the first nationwide implemen- UÊ/Ê}>ÊÜi`}iÊ>LÕÌÊÌ iÊÃÃÕiÃÊÛÛi`ÊÊÌÀ>Ã- tation. ferring the ownership of the “FIFA 11 for Health” programme to national bodies F-MARC PROJECTS | FOOTBALL FOR HEALTH 215
Materials used to support the pilot and nationwide The study drew attention to issues involved in transfer- project ring the ownership of the “FIAF 11 for Health” pro- The successful implementation of a football-based edu- gramme to national bodies and showed that adapting cation programme requires the input of informative or changing individual health messages from the pro- literature and other resources. F-MARC developed a gramme may be necessary or even crucial as differing manual for the training course and provided teachers health issues may predominate in the various countries. with a summary of (1) the skills required to deliver the programme, (2) the content of each of the 11 sessions, The positive results of the measured post-intervention (3) the timings for each aspect of each session, and (4) health knowledge among children and the overall posi- health information sheets that contained additional tive response from teachers and coaches, governmental information to support the teachers when answering and non-governmental bodies shows that a football- children’s questions during session discussion periods. based health education programme such as the “FIFA Activity cards were used to highlight issues related to 11 for Health” programme is capable of attracting the the session’s health topic, and the equipment needed support and commitment of local and national stake- for implementing the interactive games in each session holders. It presents a promising tool in the fight against was distributed. Health knowledge questionnaires and communicable and non-communicable diseases as attendance records were applied to evaluate the project. defined by the WHO.
Results
The pilot study produced an 18% absolute increase in post-intervention health knowledge across the health messages, which was equivalent to a 26% relative increase against the children’s baseline knowledge level. The nationwide study produced a 14% absolute increase in the post-intervention health knowledge across the health messages, equivalent to a 22% relative increase against the baseline knowledge level.
An independent assessment of the development and implementation of FIFA’s “Football for Health” phi- losophy, which includes the “FIFA 11 for Health” pro- gramme, concluded that it fulfilled all eight components of Kotter’s model for strategic change. The implementa- tion of the “FIFA11 for Health” programme in Mauri- tius was considered to have met the objectives set out at the beginning of the project and, importantly, was con- sidered to be a success by F-MARC, the MFA and the Mauritius Government Departments of Health, Educa- tion and Sport.
What we learned from the study
This study demonstrated that it is possible to develop Duration: 2010 - 2012 and implement a large-scale football-based health educa- Countries: International tion programme, which is adaptable to different national Cooperation: Mauritius Ministry of Health Dvořák and regional settings and sustainable through the inte- Reference: J, Fuller CW, Junge A (2012). Planning gration and cooperation of local stakeholders and appro- and implementing a nationwide football based health-education priate governmental bodies. programme. Br J Sports Med 46(1): 6-10 216 FOOTBALL FOR HEALTH | F-MARC PROJECTS
8.2.3 Implementation in Five African Method Countries A prospective five-cohort study was implemented in schools in Ghana (17), Malawi (12), Namibia (11), Why we conducted this study Tanzania (18) and Zambia (11). The programme con- sisted of eleven 90-minute sessions consisting of two In 2007, the FIFA Medical Assessment and Research 45-minute halves of Play Football (football skills) and Centre (F-MARC) recognised the important contribu- Play Fair (health issues). Participants were boys and girls tion that football could make to health in the commu- aged 10–14 years: Ghana (906), Malawi (1098), Namib- nity and began developing a football-based health edu- ia (439), Tanzania (720), Zambia (651). The main out- cation programme for the children of Africa, entitled come measures recorded were children’s attendances at “FIFA 11 for Health”. The programme was intended each session, their health knowledge (30-item question- to be a medical legacy for Africa following the 2010 naire) before and after the interventions and the chil- FIFA World Cup South AfricaTM. The programme was dren’s evaluation of the programme itself by means of a designed to address risk factors associated with the most six-item questionnaire. common non-communicable diseases, such as cardiovas- cular disease, hypertension and diabetes, and communi- cable diseases, such as HIV, malaria and diarrhoeal dis- Results eases, encountered in sub-Saharan Africa. The rationale behind the development, content, implementation and Mean attendance by children during the “FIFA11 for evaluation of the “FIFA 11 for Health” programme has Health” programme ranged from 88% (Malawi) to 99% been described in detail previously. The programme was (Tanzania) of participants. The proportions of children developed following input from 14 experts working in responding correctly to each question in the pre- and areas of health, education and physical activity: the con- post-intervention health-knowledge questionnaires are tributing experts came from ten countries on three con- presented as percentage changes (absolute) in mean tinents but all had intimate knowledge and experience knowledge value for each health topic and each country of the specific problems and issues related to developing Figure 8.2.3.1. Pre-intervention questionnaire responses and delivering health-related programmes in Africa. in the five countries showed that the mean level of chil- dren’s health knowledge fell into two distinct groups, The FIFA programme was first implemented and evalu- namely, a higher-knowledge group consisting of Malawi ated in South Africa in an out-of-school project involv- (74.7%) and Tanzania (71.3%) and a lower-knowledge ing children (mean age of 13.3 years); later it was evalu- group consisting of Ghana (61.3%), Namibia (57.9%) ated in Zimbabwe in an out-of-school project involving and Zambia (57.5%). The health topics showing the children (mean age of 11.5 years) and in Mauritius in biggest differences in knowledge between the high- and an in-school project (mean age of 13.0 years). All three low-knowledge groups related to HIV/AIDS, malaria, projects resulted in significant increases in the chil- hygiene and vaccination. Post-intervention, the level of dren’s health knowledge but it was concluded that the health knowledge increased significantly (p ≤ 0.001) in programme would be more likely to achieve nationwide all countries for a large number of the 30 health-related acceptance and sustainability if it were delivered within questions (Ghana: 29; Malawi: 20; Namibia: 29; Tanza- the school curriculum in collaboration with the coun- nia: 24; Zambia: 25). Increases in the children’s overall try’s Ministry of Education and Football Federation. level of health knowledge were recorded in all countries: range: 11% (Malawi) to 25% (Namibia). Children’s overall evaluation-rating of the programme was very Aim of the study positive in all countries, ranging from 93% (Zambia) to 98% (Namibia, Tanzania). UÊ/Ê>ÃÃiÃÃÊÌ iÊivviVÌÛiiÃÃÊvÊÌ iʺʣ£ÊvÀÊi>Ì »Ê programme in increasing children’s knowledge about communicable and non-communicable diseases in five countries of Sub-Saharan Africa F-MARC PROJECTS | FOOTBALL FOR HEALTH 217
Fig. 8.2.3.1: Change in health topic knowledge (%, absolute change from baseline value)
What we learned from the study are most likely linked to the very high satisfaction rating given to the programme by the children involved, which The “FIFA 11 for Health” programme produced sig- was reflected in the high attendance levels achieved dur- nificant increases in children’s health knowledge and ing each session. The results obtained also demonstrate their awareness of disease prevention using an in-school, the contribution that international sports governing football-based health education programme. This suc- bodies can make in health education and helping to cess was most likely linked to the very high satisfaction reduce the prevalence of communicable and non-com- rating given to the programme by the children involved. municable diseases in sub-Saharan Africa. The success of the interventions also demonstrated the benefit of collaborating with the Ministries of Education in each country. Duration: 2010 - 2014 This study demonstrated that the “FIFA 11 for Health” Countries: Nambia, Tanzania, Malawi, Zambia, Ghana programme offers an effective way of engaging with chil- Cooperation: Namibia Football Association, Tanzania dren in order to increase levels of physical activity and Football Federation, Football Association of Malawi, Football to enhance health knowledge, improve understanding of Association of Zambia, Ghana Football Association health risk factors and provide guidance on prevention Reference: strategies for the major diseases in sub-Saharan Africa. Fuller CW, Junge A, Amaning J, Kaijage R, Kaputa J, Dvořák When delivered through national education systems, the Magwende G, Pambo P, J (2014). ‘FIFA 11 for Health’: programme has the potential to reach a very high pro- implementation in five countries in sub-Saharan Africa. Health portion of the target population. The results obtained Education Journal 74(1):103-119 218 FOOTBALL FOR HEALTH | F-MARC PROJECTS
8.2.4 FIFA in the Fight against Ebola simple preventative measures to help combat the spread of Ebola. “11 against Ebola” is a campaign encompass- ing 11 simple messages and featuring Ronaldo, Neymar, Why we conducted this campaign Drogba, Lahm, Xavi, Piqué, Obi Mikel, Boateng, Bale, Varane and Guardiola. Just over a year has passed since the Ebola epidemic broke out in West Africa. The Ebola disease, which is Using the umbrella slogans “Together, we can beat Ebo- transmitted through direct contact with bodily fluids, la” and #wecanbeatebola, the world stars convey the 11 was first detected in Sudan and the Democratic Repub- messages in a multi-media campaign incorporating ani- lic of Congo in 1976. The current epidemic is the most mated films, commentaries, banners, posters and images. widespread outbreak of the disease ever recorded. In total, 21,689 cases have been detected, 8,626 of which have resulted in death (WHO, 18.01.2015). There is What we learned from the campaign currently no cure – only the symptoms themselves can be treated. Due to the highly contagious nature of the In the event of an emergency, we can count on the pow- Ebola virus, taking hygienic precautions is of utmost er of football in helping to lessen people’s misfortune. importance. Ebola will only be conquered if people learn What we have also learnt is that we have to act faster, how to protect themselves from infection. be prepared and click into gear should a similar situation occur. The virus has even had an impact on football in West Africa. National championships had to be brought to a Moreover, the Ebola situation underlines the funda- halt, qualification for the 2015 Africa Cup of Nations mental philosophy of the FIFA Medical Assessment and was an organisational nightmare and the tournament Research Centre – prevention. itself was in considerable doubt until Equatorial Guinea stepped into replace Morocco as hosts. The football platform proved to be successful in dissemi- nating simple educational messages about health among children through the voice of football stars. Aims of the campaign
UÊ,>ÃiÊ}L>Ê>Ü>ÀiiÃÃÊÌ ÀÕ} ÊÌL>ÊÊÌ iÊw} ÌÊ against Ebola UÊ `ÕV>ÌiÊ«i«iÊ>LÕÌÊÌ iÊ`Ãi>ÃiÊ>`Ê ÜÊÌÊ«ÀiÛiÌÊÌÊ from spreading
How we conducted the campaign
On 22 September the concept “11 against Ebola” was presented to the FIFA Medical Committee where it was fully supported by the medical doctors and then approved by the FIFA Executive Committee on 24 Sep- tember 2014.
With the support of the African doctors, experts from the World Bank Group and top football stars, the cam- Duration: 2014 - ongoing paign was completed and presented on 17 November Country: West Africa 2014. Cooperation: African confederation, World Bank Group, Healthcare experts International football stars are supporting world govern- Reference: ing body FIFA, African confederation CAF and health- www.fifa.com/aboutfifa/organisation/the-fifa-weekly/issues/ care experts in a global information campaign promoting newsid=2512893.html F-MARC PROJECTS | FOOTBALL FOR HEALTH 219
TOGETHER, WE CAN BEAT EBOLA.
11 PLAYERS, 11 MESSAGES, REPORT UNUSUAL KNOW THE SYMPTOMS ONE GOAL ILLNESSES
Didier Drogba Neymar Jr. The “11 against Ebola” campaign brings together Chelsea FC FC Barcelona football stars and doctors from around the world HMSGDÖFGS@F@HMRS$ANK@ 2G@QDSGDRDLDRR@FDR to help reduce the chances of Ebola spreading HMXNTQBNLLTMHSX 3NFDSGDQ VDB@MAD@S$ANK@
This is a joint campaign from the world governing body of football FIFA, the World Bank Group, the M@SHNM@K ENNSA@KK @RRNBH@SHNMR NE 2HDQQ@ +DNMD Do you have a fever with a loss of appetite, headache, Please report any unusual illnesses fatigue, pain, vomiting, bleeding or diarrhoea? Know +HADQH@@MC&THMD@@MCCNBSNQREQNL EQHB@ or deaths in your community. the symptoms of Ebola.
SEEK IMMEDIATE AVOID BODY WASH YOUR HANDS MEDICAL HELP CONTACT AND DISINFECT Xavi Cristiano Ronaldo Philipp Lahm FC Barcelona Real Madrid FC Bayern Munich
Please seek urgent medical help if you Avoid direct, skin and body contact Wash your hands regularly and disinfect anything have a fever with additional symptoms. with anyone suffering from Ebola. RMSAFCB@WQSQNCARCBMPAMLjPKCB#@MJ?QSDDCPCPQ
WEAR PROPER COOK MEAT PROPERLY ALWAYS PRACTISE PROTECTION SAFE SEX
Gerard Piqué John Obi MikelMikel Jérôme Boateng FC Barcelona ChelseaChelsea FFCC FC Bayern Munich
Wear gloves and proper protective clothing if you are caring for an Ebola sufferer, and get the right instruction Cook all meat and animal products Use protection if you are having sex for the use of protective clothing. thoroughly before consumption. with anyone recovering from Ebola.
AVOID CONTACT WITH DO NOT TOUCH SEEK HELP FOR WILD ANIMALS AND BATS THE DEAD SAFE BURIALS Gareth Bale Raphaël Varane Pep Guardiola Real Madrid Real Madrid FC Bayern Munich
Wild animals and bats can carry Avoid direct contact with dead Ebola victims Please seek help from local authorities to bury the Ebola virus. Avoid them. or anyone who has died from a strange disease. any victims of Ebola or strange diseases.
11 AGAINST EBOLA 220 BIBLIOGRAPHY | F-MARC PROJECTS
9 Bibliography
Status as per April 2015
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Shirreffs SM, Maughan RJ. Water and salt balance in young male football players in training during the holy month of Ramadan. J Sports Sci 2008;26(3 Suppl):S47-54 F-MARC PROJECTS | BIBLIOGRAPHY 231
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#UNŔ¨J J, George J, Junge A, Hodler J. Warden SJ, Creaby MW, Bryant AL, Crossley KM. Age determination by magnetic resonance imaging of the wrist in ado- Stress fracture risk factors in female football players and their clinical lescent male football players. Br J Sports Med 2007;41(1):45-52 implications. Br J Sports Med 2007;41(1 Suppl):i38-43
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Rosenbloom CA, Loucks AB, Ekblom B. #UNŔ¨J J, McCrory P, D’Hooghe M. Special populations: the female player and the youth player. J Sports Sci FIFA’s future activities in the fight against doping. Br J Sports Med 2006;24(7):783-793 2006;40(1 Suppl):i58-59
Reilly T, Gregson W. Special populations: the referee and assistant referee. J Sports Sci 2006;24(7):795-801 2005
Baume N, Avois L, Sottas PE, #UNŔ¨J J, Cauderay M, Mangin P, Saugy M. Effects of high-intensity exercises on 13C-nandrolone excretion in trained athletes. Clin J Sport Med 2005;15(3):158-166 F-MARC PROJECTS | BIBLIOGRAPHY 233
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Fuller CW, Smith GL, Junge A, #UNŔ¨J J. The influence of tackle parameters on the propensity for injury in inter- Risk Factors and Incidence of Injuries in Football national football. Am J Sports Med 2004;32(1 Suppl):43S-53S Players Junge A, #UNŔ¨J J, Graf-Baumann T, Peterson L. Supplement of the American Journal of Sports Football injuries during FIFA tournaments and the Olympic Games, 1998-2001: development and implementation of an injury-reporting Medicine 2000; Vol. 28(S5) system. Am J Sports Med 2004;32(1 Suppl):80S-89S
Weston M, Helsen W, MacMahon C, Kirkendall D. #UNŔ¨J J, Graf-Baumann T, Peterson L, Junge A. The Impact of Specific High-Intensity Training Sessions on Football Ref- Football, or soccer, as it is called in North America, is the most popular erees’ Fitness Levels. Am J Sports Med 2004;32(1 Suppl):54S-61S sport worldwide. Am J Sports Med 2000;28(5 Suppl):S1-2 #UNŔ¨J J, Junge A. Football injuries and physical symptoms. A review of the literature. Am J 2003 Sports Med 2000;28(5 Suppl):S3-9 Junge A. Mussack T, #UNŔ¨J J, Graf-Baumann T, Jochum M. The influence of psychological factors on sports injuries. Review of the Serum S-100B protein levels in young amateur soccer players after con- literature. Am J Sports Med 2000;28(5 Suppl):S10-15 trolled heading and normal exercise. Eur J Med Res 2003;8(10):457-464 Junge A, #UNŔ¨J J, Chomiak J, Peterson L, Graf-Baumann T. Graf-Baumann T. Medical history and physical findings in football players of different ages Court of Arbitration in Football (CAF) - critical appreciation after FIFA - and skill levels. Am J Sports Med 2000;28(5 Suppl):S16-21 international analysis. In: Röhricht K, Vieweg K, Haas U (eds). Recht und Sport; 2003 Junge A, #UNŔ¨J J, Rösch D, Graf-Baumann T, Chomiak J, Peterson L. Psychological and sport-specific characteristics of football players. Am J Giza E, Fuller C, Junge A, #UNŔ¨J J. Sports Med 2000;28(5 Suppl):S22-28 Mechanisms of foot and ankle injuries in soccer. Am J Sports Med 2003;31(4):550-554 Rösch D, Hodgson R, Peterson TL, Graf-Baumann T, Junge A, Cho- miak J, #UNŔ¨J J. Assessment and evaluation of football performance. Am J Sports Med 2000;28(5 Suppl):S29-39 2002 Junge A, #UNŔ¨J J. Influence of definition and data collection on the incidence of injuries in Aubry M, Cantu R, #UNŔ¨J J, Graf-Baumann T, Johnston K, Kelly J, football. Am J Sports Med 2000;28(5 Suppl):S40-46 Lovell M, McCrory P, Meeuwisse W, Schamasch P, Concussion in Sport Group. Summary and agreement statement of the Junge A, Chomiak J, #UNŔ¨J J. First International Conference on Concussion in Sport, Vienna 2001. Incidence of football injuries in youth players. Comparison of players Recommendations for the improvement of safety and health of athletes from two European regions. Am J Sports Med 2000;28(5 Suppl):S47-50 who may suffer concussive injuries. Br J Sports Med 2002;36(1):6-10 Peterson L, Junge A, Chomiak J, Graf-Baumann T, #UNŔ¨J J. Junge A, Rösch D, Peterson L, Graf-Baumann T, #UNŔ¨J J. Incidence of football injuries and complaints in different age groups and Prevention of soccer injuries: a prospective intervention study in youth skill-level groups. Am J Sports Med 2000;28(5 Suppl):S51-57 amateur players. Am J Sports Med 2002;30(5):652-659 Chomiak J, Junge A, Peterson L, #UNŔ¨J J. Severe injuries in football players. Influencing factors. Am J Sports Med 2000;28(5 Suppl):S58-68
2001 #UNŔ¨J J, Junge A, Chomiak J, Graf-Baumann T, Peterson L, Rösch D, Hodgson R. Risk factor analysis for injuries in football play- ers. Possibilities for a prevention program. Am J Sports Med 2000;28(5 Robinson N, Taroni F, Saugy M, Ayotte C, Mangin P, #UNŔ¨J J. Suppl):S69-74 Detection of nandrolone metabolites in urine after a football game in professional and amateur players: a Bayesian comparison. Forensic Sci Int 2001;122(2-3):130-135 F-MARC PROJECTS | BIBLIOGRAPHY 235 236 SUPPLEMENTS | F-MARC PROJECTS
10 Supplements
2000 2005
2004 2005 F-MARC PROJECTS | SUPPLEMENTS 237
2006 2006
2006 2006 238 SUPPLEMENTS | F-MARC PROJECTS
2007 2008
2007 2008 F-MARC PROJECTS | SUPPLEMENTS 239
2009 2010
2009 2010 240 SUPPLEMENTS | F-MARC PROJECTS
2010 2011
2011 2011 F-MARC PROJECTS | SUPPLEMENTS 241
2011 2012
2011 2012 242 SUPPLEMENTS | F-MARC PROJECTS
2013 2013
2013 2013 F-MARC PROJECTS | SUPPLEMENTS 243
2013 2014
2014 2015 244 SUPPLEMENTS | F-MARC PROJECTS
10.1 Twenty years of the FIFA Medical and Research Centre (F-MARC): From “Medicine for Football” to “Football for Health”
Medicine for Football FIFA World Cup Brazil™ (Baume et al, 2015). All players were tested unannounced prior to the competi- In 1994, epidemiological data on the incidence of inju- tion, and results from the individual players were then ries during major football competitions were scarce. compared with the samples provided after each match Thus, F-MARC established an injury surveillance sys- during the 2014 FIFA World Cup Brazil™ (two play- tem at the 1998 FIFA World Cup France™, and has ers randomly selected from each team). The steroid pro- routinely implemented it in all subsequent FIFA com- files of the urine of the players were stable and consist- petitions. This database now enables comparison of the ent with previously published publications. The blood incidence and characteristics of injury between competi- parameters showed no significant differences in haemo- tions for different age, gender and skill-levels, and over globin value between pre-competition and post-match time. From the 2002 to the 2014 FIFA World Cup™, samples. The experience from Brazil documented that the incidence of injuries decreased by 37% (Junge & the implementation of biological monitoring during Dvořák 2015). Reasons for the decrease might be the the time of a footballers career is feasible, offering more better preparation of the players for the competition, information on the potential manipulation of the body the strict application of the Laws of the Game by the by prohibited substances. referees, and also the improved approach of the players towards of fair play. The use of medication has been analysed since the 2002 FIFA World Cup™. More than two thirds of adult Since the large majority of the football players around male players used medication(s) during the tournament, the world are recreational players, F-MARC developed and more than half were using non-steroidal anti-inflam- an injury prevention programme for these players based matory drugs (NSAIDs). Up to one third of the play- on scientific evidence and best practice. Bizzini and ers were using NSAIDs prior to every match. Despite of Dvořák (2015) summarised the scientific evidence of the potential side effects especially of NSAIDs, No decrease effectiveness of “FIFA 11+” in reducing injuries by up to in the use of medication was observed during 2014 FIFA 50% if performed regularly. Since 2009, FIFA has been World Cup Brazil™ (Tscholl et al, 2015). disseminating “FIFA 11+” through the network of its 209 member associations (MAs) and implementing the Following the tragic death of Marc-Vivien Foé during programme on a large scale. the FIFA Confederations Cup 2003, FIFA has been fully committed to a programme of standard research educa- Prevention is possible on the level of recreational football tion and practical implementation to prevent and man- players by implementing the “FIFA 11+” programme. age emergency cardiac arrest on the football field (Kram- However, the survey on the perception and practice of er et al, 2015). In the meantime, this strategy has been the injury prevention strategies of physicians from the routinely implemented with the aim of detecting foot- 32 participating national teams at the 2014 FIFA World ball players with a medical risk during mandatory pre- Cup Brazil™ documents the need for improvement competition medical assessment and by implementing in developing preventive strategies at top level football the international accepted guidelines for the interpreta- (McCall et al, 2015). tion of an athlete’s ECG based upon the Seattle criteria. A clear protocol has been developed and applied for on The 2014 FIFA World Cup Brazil™ was played in five the field of play for the recognition response, resuscita- different regions from temperate to tropical environ- tion and the removal of a player under sudden cardiac mental conditions. The web bulb globe temperature arrest. FIFA have introduced and distributed to all MAs (WBGT) was obtained prior to, during and after the the FIFA Medical Emergency Bag including an Auto- match while various physical and technical performance mated External Defibrillator (AED). The FIFA Sudden parameters were recorded during each match for both Death Registry has been established at the FIFA Medical teams. Nassis at al (2015) reported that top-level play- Centre of Excellence of the Saarland University to doc- ers seemed to modulate their activity patterns during ument and examine fatal events in football worldwide matches in hot and humid environments to preserve the (Scharhag et al, 2015). global match characteristics.
For the first time, FIFA implemented a new anti-doping programme and biological monitoring before the 2014 F-MARC PROJECTS | SUPPLEMENTS 245
Football for Health five regions of Brazil, and the results were equivalent to those previously obtained in sub-Saharan Africa. The effects of recreational football for prevention and treatment of non-communicable diseases from children to mature women and ageing men were summarised by Bangsbo et al, 2015. Regular football training in small- sided games for 45-60 minutes up to three times a week reduces blood pressure, lowers resting heart rate, makes favourable adaptations in cardiac structure and function, improves lipid profile, elevates muscle mass, re-uses fat mass and ultimately improves functional capacity.
The most recent nationwide implementation of the “FIFA 11 for Health” programme is presented by Fuller et al, 2015. The momentum of the 2014 FIFA World Cup Brazil™ was used to prepare the medical legacy of the World Cup in Brazil/South American continent. The programme was delivered to 128 schools in the 12 official Host Cities in five regions of Brazil, jointly with the Brazilian Football Association and the Brazil- Duration: 1994 - ongoing ian Ministry of Health, Sport and Education. The mean Countries: International increase in health knowledge was 18.4%, and almost Cooperation: International 91% of the children gave a positive evaluation of the Reference: programme. The study showed that the “FIFA 11 for Twenty years of F-MARC (2015). Supplement of the Br J Health” programme was successfully delivered across the Sports Med 49(9) (for details see Bibliography) 246 ACKNOWLEDGEMENT | FOOTBALL MEDICINE PROJECTS
11 Acknowledgement
The F-MARC-studies could and can only be conducted Football Association, Grenada Football Association, with the substantial support of a broad number of per- Fédération Guinéenne de Football Federazione Italiana sons and institutions. F-MARC would like to thank all Giuoco Calcio, Jamaica Football Federation Limited, collaborating experts, team physicians, coaches, research Japan Football Association, Liberia Football Association, assistants and people “behind the scene” who substan- Fédération Malagasy De Football, Football Association tially contributed to the success of the studies and, espe- of Malawi, Football Association of Martinique, Mauri- cially, the players for their participation in the various tius Football Association, Federación Mexicana De Fút- projects. In particular, we are extremely grateful for the bol Asociación, A.C., Myanmar Football Federation, untiring support of the following people and organisa- Namibia Football Association, New Zealand Football tions: Inc., Norges Fotballforbund, Oman Football Associa- tion, Federación Puertorriqueña De Fútbol, Schweiz- erischer Fussballverband, Sierra Leone Football Asso- FIFA ciation, Solomon Islands Football Federation, Football Federation of Sri Lanka, St. Lucia Football Association President: JS Blatter; Honorary President: J Havelange; Tanzania Football Federation, Tonga Football Associa- Chairman FIFA Medical Committee: M D’Hooghe; tion, Fédération Tunisienne de Football, Türkiye Futbol Secretaries General: U Linsi and J Valcke; Deputy Federasyonu, U.S. Soccer Federation, Football Associa- Chairmen FIFA Medical Committee: A Diakite, W tion of Zambia. Makudi and D Chung; Former and present members FIFA Medical Committee: L Peterson, N O’Hata, R Gittens, Y Zerguini, R Madero, T Graf-Baumann, L Players, Coaches, Referees and Clubs Toledo, YS Yoon, S Kannangara, HA Ahmed, T Bab- wah, G Singh, T Edwards, M Al-Riyami, H Aoki, S Alonso X, Alves D, Bale G, Boateng J, Buffon G, Capel- Fusimalohi, B Mandelbaum, C Palavicini, J V Ramath- lo F, Charisteas A, Puyol C, del Bosque V, Demel G, esele, J Chomiak, E Hermann, M Dohi, J Segajugo; Drogba D, Essien M, Eto’o S, Falcao R, Forlan D, Directors of Member Associations and Development: M Gekas T, Guardiola P, Henry T, Hernandez (Chich- Harvey, T Regenass; FIFA Refereeing Department: G arito) J, Hodgson R, Irmatov R, Klinsmann J, Lahm P, Cumming; JM Garcia-Aranda Encinar, S Denoncourt, Luis D, Luxemburgo V, Magnin L, Marta, Mascherano C Pilot, E Strelsov, M Busacca, F Tresaco-Gracia, C J, McCarthy B, Messi L, Mikel J, Miyama A, Modise P, Pilot, M Navarro, J Otero; FIFA Women´s Department: Muamba F, Nedved P, Neves T, Neymar, Pagliuca G, T Haenni, R Smith; FIFA Legal Affairs: H Tännler, M Parreira C, Piqué G, Prinz B, Rizzoli N, Ronaldo Ch, Villiger; FIFA Development Officers: H McIntosh, A Ronaldo (Fenomeno), Rosetti R, Santa Cruz R, Sawa H, Mamelodi, G Turner; FIFA Medical Office: H Boban, Scolari F, Signori G, Steinhaus B, Touré K, Valdez N, K Grimm, R Charles, S Schlumpf, A König, M Keller, P Varane R, Webb H, Xavi; FC Barcelona, Real Madrid Tobler, M Lawless, M Vaso, A Weber. C.F., FC Bayern Muenchen, Chelsea F.C., Manchester City FC, Olympique Lyon, Corinthians Sao Paulo, Fla- mengo Rio, Inter Mailand, Atletico Madrid. FIFA Member Associations
The Football Association LTD., Fédération Algérienne Collaborating experts de Football, Botswana Football Association, Confed- eração Brasileira de Futebol, Canadian Soccer Associa- Aagaard P, Abed N, Ackerman KE, Adenij O, Ahmed tion, Cayman Islands Football Association, Fotbalová +]Ê>`>ÀÊ,]ÊÃÊ ]Ê>}Ê]ÊâiÀÌÊ]Ê Asociace Ceské Republiky, Federación Colombiana De Andersen LJ, Andersen T, Anielski P, Armstrong L, Fútbol, Fédération Congolaise de Football-Association, Arroyo F, Aubry M, aus der Fünten K, Awaragi P, Aziz Federación Costarricense de Fútbol, Federashon Futbol AR, Badoud F, Bahr R, Baló E, Bandelow S, Bangsbo, Korsou, Dansk Boldspil-Union, Deutscher Fussball- Barriguete JA, Barros T, Bartagi Z, Bärtsch P, Baume Bund, Real Federación Española de Fútbol, Ghana N, Beasley I, Bekkers JEJ, Beltrami G, Bendiksen F, FOOTBALL MEDICINE PROJECTS | ACKNOWLEDGEMENT 247
Bendiksen M, Bennike S, Benson BW, Beuck S, Bianchi Klügl M, Knoepfli-Lenzin C, Kolbe J, Kramer E, Krebs F, Binnet M, Bishop JD, Bizzini M, Bjørneboe J, Black- D, Kreutzfeldt M, Krug H, Krumbholz A, Krustrup P, well J, Blair SN, Boccard J, Bomberger I, Börjesson M, Kurdak SS, Kutcher JF, Kutcher JS, Kuuranne T, Lam- Bortolan L, Botha M, Botre F, Boutellier U, Branco P, precht M, Langevoort G, Larsen MN, Lea T, Leach Brasso K, Brinkmeier P, Brito J, Brittberg M, Broad RE, Lee HH, LeiperJ, Lepers R, Leunig M, Levine B, N, Brophy RH, Broséus J, Bruun DM, Budgett R, Lindenskov A, Lislevand M, Ljungqvist A, Loland S, Bugbee WD, Bull F, Bunc V, Bungu-Kakala J, Burke Loucks A, Lundby C, Lütscher A, Lüscher T, Maddocks L, Butch A, Cantu B, Cantu R, Caplan A, Carlsen D, Maffiuletti NA, Magwende G, Mahajan V, Mak- KH, Casartelli NC, Castagna C, Castellacci E, Cas- dissi M, Malina RM., Mandelbaum B, Manniche V, tillo F, Chabane S, Chagonda E, Chalabi H, Chamari Mannion AF, Manzi V., Marclay F, Marques-Vidal P, K, Chaouachi A, Cheung K, Cheung SS, Chilvers C, Mateus-Avois L, Matheson G, Maughan R, Mayosi B, Christensen JF, Christensen KB, Chtourou H, Chu Mazzarino M., Mboup S, Mc Guinness I, McAdams T, CR, Clarke J, Clothier B, Connes P, Constantinou McCall A, McCrea M, McCrory P, McIntosh AS, McK- D, Coppo V, Corlette J, Correia L, Costello M, Coyle ay C, Meeusen R, Meeuwisse W, Meier U, Meijboom E,Cunningham K,D´Hooghe P, da Silva ME, Davis G, E, Meyer T, Midtgaard J, Millard-Stafford M, Mith- de Andrade JL, de Ceuninck M, de la Torre X, de Silva oefer K, Modena R, Mohr M, Molloy M, Moreno A, A, de Sousa MV, de Windt TS, DeCelles J, Della Villa Mortensen J, Mota J, Motaung S, Mountjoy M, Muli- S, Dellal A, Derman W,Deutsch C, Di Paolo FM, Dick Musiime F, Müller S, Müller W, Mussack T, Mykle- RW, Dolle G, Donald J, Donath L, Donati F, Dorasami bust G, Nassis GP, Nicoli R, Nielsen CM, Nielsen G, R, Draper C, Drezner J, Drust B, Dungl P, Durkin P, Nielsen HP, Nielsen JJ, Nieman D, Nilstad A, Nybo L, Durussel J, Echemendia RJ, Edouard P, Eiles M, Ekb- O’Brien C, Odendall M, Oksa J, Olsen OE, Orntoft C, lom B, Ekstrand J, Elbe AM, Ellenbogen R, Emery C, Ortega P, Ottesen LS., Özgünen KT, Pambo P, Pánics Engebretsen L, Ersöz G, Eterovic I, Evans R, Faude O, G, Patricios J, Pedrinelli A, Pedrinelli LF, Pellegrini B, Feddermann-Demont N, Felix S, Finch CF, Fitzpatrick Pelliccia A, Pereira RM, Peterson L, Petrou M, Peytavin D, Flenker U, Flores M, Frandsen C, Frandsen U, Frey A, Pfäfflin F, Pineda G, Pipe A, Pitsiladis YP, Platen P, WO, Friedmann B, Friedrich K, Fukui R, Fuller CW, Pohlig R, Powers S, Pralong F, Provvidenza C, Purcell Gál T, Gaoua N, Gardner A, Garnier PY, Garrett WE L, Putukian M, Rabin O., Racinais S, Raftery M, Rahli Jr., George J, Geraint GS, Gersoff WK, Geyer H, Geyer A, Ramkurrun J, Randers MB, Rasmussen LS, Raut- L, Gfrerer L, Gianotti S, Gittens R, Giza E, Gleeson M, enberg C, Rebelo A, Rechsteiner R, Rêgo C, Reichel Gliemann L, Gobbi A, Goldstein MA, Gore C, Görtz C, Reider B, Reilly T, Reis I, Renström P, Reuter H, S, Grantham J, Graw M, Greenhaff P, Gregson W, Richalet JP, Robinson N, Rodchenkov G, Rodrigues Grimm K, Grosse J, Grossen R, Guddat S, Günter H, AC, Roelands B, Roky R, Romiti M, Rørth M, Rösch Guskiewicz K, Gutzwiller F, Haddad M, Hägglund M, D, Rosenbloom C, Rössler R, Rufer W, Ryynänen Hambly K, Hammes D, Hänggi P, Hangody L, Hansen JAI, Saltin B, Saris D, Saudan C, Saugy M, Sawka M, L, Hansen PR, Harcourt PR, Hargreaves M, Hasler H, Sayegh S, Schamasch P, Schänzer W, Schena F, Schmalz Hawley J, Helge EW, Helsen W, Hernandez AJ, Herrera R, Schmeling A, Schmidt JF, Schmidt S, Schmidt W, CP, Herring S, Hespel P, Hewett T, Ho D, Hodgson R, Schmied CM, Schneider KJ, Schulz R, Schweizer C, Hodgson L, Holder J, Holdhaus H, Holland R, Holm Schweizer T, Schwellnus M, Scopp J, Seabra A, Segura PM, Holme I, Hoppeler H, Hornstrup T, Horton J, J, Sekajugo J, Sennhauser C, Serratosa L, Serwadda Houllier G, Howman D, Huber S, Huguet J, Hume P, D, Shewchenko N, Shireffs S, Siegenthaler U, Sills A, Hussain AW, Hutchison B, Illig C, Impellizzeri F, Insler Silva PR, Silvers H, Singh DG, Smalley M, Søgaard S, Isola V, Iverson GL, Jackman SR, Jakobsen MD, Jan- P, Soligard T, Spielvogel H, Sprumont D, Stamm H, kelowitz R, Jenoure PJ, Jensen CJ, Jochum M, Johans- Steadman RJ, Steffen K, Steffen R, Steinacker J, Stein- en L, Johnson JM, Johnston K, Jordan B, Jørgensen wachs MR, Sterk S, Stone M, Strahm E, Straumann D, NR, Kaijage R, Kang J, Kaputa J, Karli U, Karlsson J, Straume-Naesheim TM, Stray-Gundersen J, Suetta C, Kautiainen H, Keller DI, Kerper O, Kesti M, Khan K, Sundstrup E, Tahmi M, Tator CH, Terrel B, Theodosa- Khouaja F, Kilzer T, Kindermann W, King C, Kirk- kis J, Theron N, Thevis M, Thiele E, Thiele ES, Thieme endall DT, Kissick J, Kjaer M, Klameth S, Kloeck W. D, Thom C, Thomas A, Thomassen M, Thünenkötter 248 ACKNOWLEDGEMENT | FOOTBALL MEDICINE PROJECTS
T, Timme M, Tipton K, Toigo M, Tombides D, Tovar tella G, Dingiso P, Dladla S, Eenhoorn B, Etter I, Fan- G, Tscholl PM, Tschopp M, Turner M, Urwin J, Uth J, chini M, Fladberg Grøv S, Gattoni C, Gomide Leite M, van der Ende M, van Mechelen W, Vanscheidt W, Var- González M, Grasshoff G, Guzula N, Item-Glatthorn gas E, Vásárhelyi G, Verhagen E, Vernec A, Verroken J, Keller O, Knobel A, Koch F, Kollaritsch A, Konopka M., Vieth V, Viret M, Voight M, von Grebel C, Vouil- K, Lacloche AMM, Liu Yuk Pat-Agathe MJ, Lund SS, lamoz M, Vuddamalay A, Walden M, Wallace S, Wan- Lutuli M, Madondile D, Mafi lika L, Magqwaka X, der J, Watson K, Watson P, Weihe P, Weiler R, Weston Makay T, Malgas Z, Marquardt B, Martin-Schmitt S, M, Wiget C, Wikman JM, Williams AM, Williams C, Mathieu N, Mathiso N, Matiwane N, Mbaleki S, Mdle- Williams III RJ, Wittschieber D, Wong del P, Wong F, leni M, Mkhontwana N, Mkita H, Mondi G, Mondli- Wyss H, Zaslav K, Zebis MK, Zenobi-Wong M, Zer- wa X, Morf C, Mottier P, Mselele H, Müller R, Ndi- guini Y, Zidema D, Zorzoli M. weni LBM, Netto D, NeumannS, Nhokombi S, Nickel F, Okoth GT, Pfeffer R, Pfennig A, Morf C, Rodo A. Rosenheck T, Ryffel-Fehlbaum E, Sala F, Samsel T, Physicians Savoldelli A Shumane V, Sibeko N, Sidzumo L, Solem Mwikaria M, Sowamber S, Steiner R, Streng M, The- all team physicians of all FIFA competitions and the iss J, Tjongarero T, Töndury S, Troncana M, Tuali N, football tournaments of the Olympic Games, andA- Wellauer V, Wolfensberger S, Zwahlen A. guilar M, Annan P, Asanin I, Atchou G, Atravia Arias G, Babwah T, Bahtijarevic Z, Bassett D, Baumann M, Benchebha H, Benkhelifa D, Berkovskiy V, Biegel Research assistants M, Boldt J, Bonin B, Borges S, Borras G, Bouglali M, Boukhalfa R, Boumeridja M, Boumeridja S, Brjesson M, Anyango B, Aoina J, Bahorun R, Baier C, Blum J, Brukner P, Brunner U, Campos N, Celada OL, Cha- Bunce J, Cervantes G, Chong S, Dvořák D, Gaillard A, bane S, Christopoulos H, Coleman L, Colla F, Cota J, Geng H, Grasshoff G, Hanacek R, Hartenbach K, Hart- Dah C, Dawson T, Eirale C, Emmanuel A, Engmann mann M, Ilic Z, Jelassi H, Joe G, Juma Wilberforce B, M, Erhart D, Fischer V, Fousek J, Gatteschi L Geert- Karambu Muthee J, Kariuki J, Kariuki W, Karuku Gitau sema C, Goudswaard GJ, Greuter R, Gruhler R, Grzy- J, Kemboi J, Khouaja A, Kiefer J, Kolmer M, Krámek V, wocz J, Hagne C Haknchol R, Hanna C, Hasek R, Krauer S, Kreisl D, Lewis G, Lunga O, Mahler R, Mat- Holtzhausen L, Hospodar V, Hyun-Chul K, Isler A, eva R, McCammon C, McFarlane K, Meyer J, Muigai Jones JJH, Jowett A, Kaalund S, Kafunek M, Kammouai Irungu D, Musango P, Musembi Muindi S, Muthiah H, Khalifa R, Khanlari P, Knezek J, Krejci P, Krupa D, J, Mweene L, Nyangila M, O’ Riordan D, Onyango Kubes R, Lowndes S, Luiz Runco J, Makhlouf L, Mal- Okoth E, Oriko A Papác J, Purbhoo M, Rakotoarimino kus T, Marti F, Martin UP, Martinez AMartinkova D, Schmidt J, Schuler R, Sonntag C, Specker HJ, Sti- J, Mbuwi J Medina R, Mladenovic M, Montans AP, neear C, Stuart G, Wagner M, Walker K, Wambui S. Montes C, Morikawa T, Müller F, Murphy I, Mutiso V Nematswerani E, Novak Z, Onyeudo P, Paclet JP, Pan- Players, coaches, team physicians, physiotherapists, man- grazio O, Paterson G, Radames G, Robles E, Roche B, agers and representatives of all the clubs and school teams Rosetto M, Ruff P, Runco J, Russell J, Ryser J, Sadji S, that volunteered to participate in our studies. Sager M, Schläpfer M, Schneider W, Schubert J, Sekfali R, Seob Song J, Serranno Diaz J, Shimizu K, Siemssen T, Simon A, Slim M, Sward L, Titah D, Titah O, Val- Should we have forgotten to specifically name entin A, Vanecek L, Verner J, Villani D, Vogrin M, anyone of our numerous supporters, please Walter R, Zeroual T. accept our sincere apologies, and be reassured of our utmost gratefulness!
Physiotherapists, coaches and instructors
Abraham J, Abt S, Achieng Truphena V Arbini C, Baartman G, Bartsch J, Beato M, Beisert S, Beuchat A, Boendermaker B, Boodnah R, Brighenti A, Bucci M, Castellanos Ruiz E, Cobbart B, Consolini A Cora- FOOTBALL MEDICINE PROJECTS | ACKNOWLEDGEMENT 249 FIFA MEDICAL COMMITTEE | FOOTBALL MEDICINE PROJECTS
FIFA Medical Committee
Chairman D’HOOGHE Michel, Dr Belgium
Deputy Chairman CHUNG David Papua New Guinea
Members ZERGUINI Yacine, Dr Algeria MADERO Raúl, Dr Argentina PETERSON Lars, Prof. Dr Sweden BABWAH Terence, Dr Trinidad and Tobago SINGH Gurcharan, Dr Malaysia AHMED Hosny Abdelrahman, Prof. Egypt EDWARDS Tony, Dr New Zealand MANDELBAUM Bert, Dr USA PALAVICINI Carlos, Dr Costa Rica CHOMIAK )HŪ´, Dr Czech Republic AL MAADHEED Mohammed Ghanim Al Ali, Dr Qatar HERMANN Ecki, Dr Liechtenstein DOHI Michiko, Dr Japan SEKAJUGO James, Dr Uganda
Special Advisor #5.į* )HŪ´, Prof. Dr Switzerland FOOTBALL MEDICINE PROJECTS | FIFA MEDICAL ASSESSMENT AND RESEARCH CENTRE
FIFA Medical Assessment and Research Centre (F-MARC)
President D’HOOGHE Michel, Dr Belgium
Chairman #5.į* )HŪ´, Prof. Dr Switzerland
Members PETERSON Lars, Prof. Dr Sweden MADERO Raúl, Dr Argentina ZERGUINI Yacine, Dr Algeria CHOMIAK )HŪ´, Dr Czech Republic EDWARDS Tony, Dr New Zealand JUNGE Astrid, Prof. Dr Germany FULLER Colin, Dr England MANDELBAUM Bert, Dr US AHMED Hosny Abdelrahman, Prof. Dr Egypt KIRKENDALL Donald T, Dr USA BIZZINI Mario, Dr Switzerland KRAMER Efraim B., Prof. Dr South Africa SCHMIED Christian M., Dr Switzerland FEDDERMANN-DEMONT Nina, Dr Germany D’HOOGHE Pieter, Dr Belgium Impressum
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Chairman of the FIFA Medical Assessment and Research Centre (F-MARC) )HŪ´ #UNŪ¨J, Prof. Dr
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