Maturation, Playing Position and Genetic Variation
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MATURATION, PLAYING POSITION AND GENETIC VARIATION: INJURY RISK FACTORS IN HIGH-LEVEL YOUTH SOCCER ELLIOTT C R HALL A thesis submitted in partial fulfilment of the requirements of Liverpool John Moores University for the degree of Doctor of Philosophy September 2019 ACKNOWLEDGEMENTS I wish to thank all those who have helped me in completing this PhD thesis, particularly my supervisory team. It has been a privilege to work with and learn from you all, and I am extremely grateful for the opportunity. I would like to express sincere gratitude to my Director of Studies, Dr. Rob Erskine, firstly for considering me for this PhD, and secondly for the exceptional guidance and support throughout the project. The work ethic, passion and drive you have displayed has motivated me to perform to the best of my ability, and my development has been guided by your valuable knowledge and experience. I hope the faith you displayed in nominating me for this project has been in some way repaid by the work we have achieved. I would like to thank Professor Barry Drust. I feel very fortunate to have had the opportunity to work under your guidance, particularly as this project involves a sport to which you have contributed so much invaluable knowledge and passion. Importantly, you have helped me to see things differently than I did at the start of this journey, and to see the ‘bigger picture’ in academic and personal life. It is also imperative to mention your support during participant recruitment, which contributed significantly to the success of this project. I would like to thank Professor James Morton. I am extremely lucky to have had your valued input throughout my PhD in relation to this project and my own professional development. Your knowledge, ambition and enthusiasm are inspiring to both researchers and practitioners, and you have helped me to appreciate the value of being able to function as both. I would also like to thank Dr Alun Williams. It has been a privilege to have your contribution throughout the entire PhD, though particularly in 2 relation to our investigation of genetic variability. Your expertise and knowledge in the field has inspired me to study and understand key concepts of research in this area, particularly how our work may benefit real world settings, but also the limitations and ethical considerations of such research. Thank you to all fellow PGRs and students I have worked with during my PhD, and to those who contributed to the research described in this thesis. Importantly, thanks to all players, parents/guardians and staff of participating clubs. I would like to thank my parents and family for their love and support, and my friends for providing distraction when needed. I must express my love, thanks and gratitude to my girlfriend Christy, who has supported me from day one and has made sacrifices for me to complete this PhD. Finally, I would like to thank my daughter Ayla for happiness and entertainment. You showed me in your first few weeks of life that determination and persistence eventually overcomes any challenge. 3 ABSTRACT The negative impact of injury on the development of youth soccer players (YSP) means that efforts must be made to prevent and control their occurrence. Although a range of risk factors have been investigated in YSP, they remain poorly understood due to limitations with previous studies (as discussed in Chapter Two). Greater understanding of the factors affecting injury risk could help identify and improve management of ‘at risk’ players, thus improving the likelihood of them reaching their full potential of a professional contract. Accordingly, the overriding aim of this thesis was to investigate the association of potentially key risk factors with injury risk in a large cohort of high-level YSP from academies within eight professional clubs from four different countries, across two continents. For all four experimental chapters in this thesis, injuries were prospectively recorded over the course of a single season in high-level YSP to determine (i) whether the rate of these injuries varied in YSP between different nations; (ii) if maturation status, playing position and/or genetic variation were associated with injury risk in YSP. The injury audit (Chapter Three) revealed that non-contact injuries to skeletal muscle were amongst those frequently recorded, with most injuries located in the lower limb. The Under-14 (U14) and U16 age groups suffered relatively more severe injuries, with minimal differences in injury rate between nations. Thus, Chapter Three indicated that more severe injuries occurred around the timing of biological maturation, suggesting an association of maturation status with injury in YSP. When this hypothesis was tested directly in Chapter Four, maturation status (pre-, mid- and post- peak height velocity [PHV], estimated by maturity offset) 4 was indeed associated with injury risk, where soft-tissue, ligament/tendon and thigh injuries were more prevalent in post-PHV than pre- and mid-PHV, and muscle injuries were more prevalent in post- than pre-PHV. With all injuries combined, post-PHV missed more days in the season than pre-PHV. Thus, the results from this chapter strongly suggest that post-PHV are at greatest risk of injury, and miss more of the season due to injury than pre- and mid- PHV. Having identified a maturation-dependent link with injury risk in YSP, Chapter Five investigated whether there was an association between playing positon and injuries solely in post-PHV YSP (due to the greater prevalence and severity of injuries in post- vs. pre-PHV, and the fact that playing position is more firmly defined at post-PHV). Prevalence and severity did not differ between outfield positions, but relatively fewer goalkeepers suffered thigh injuries than lateral and forward players combined. These data indicate injury prevention strategies should be similar for outfield players in post-PHV, but should focus on preventing thigh injuries particularly for lateral and forward players. Finally, the results from Chapter Six showed that three single nucleotide polymorphisms (SNPs), i.e. COL5A1 rs12722, EMILIN1 rs2289360 and VEGFA rs2010963, were associated with injury prevalence in pre- and post-PHV combined, and that more SNPs were individually associated with injury risk in post- vs. pre-PHV. When combining those SNPs that were individually associated with injury risk, injured YSP demonstrated a worse polygenic profile (in terms of more ‘at risk’ genotypes) than uninjured YSP regarding non-contact and non-contact soft-tissue injuries, while pre- and post-PHV YSP had similar polygenic profiles. These data indicate a maturation-dependent influence of individual SNPs on injury, i.e. the 5 environment likely interacts with genetic predisposition for injury more so in post-PHV YSP, when the intensity of training/match-play is greater than it is for pre-PHV YSP. The results from this thesis clearly identify post-PHV as being at higher risk of injury than their biologically younger counterparts, and that injury risk is similar between countries in this under-researched and important population. The results also show that playing position in physically mature YSP has minimal influence on injury risk but that genetic variation appears to be linked with the likelihood of suffering certain injuries, as well as the severity of those injuries. These novel findings could be used to help identify and manage ‘at risk’ YSP in order to reduce the burden of injury, thus increasing the chance of talented YSP reaching their full potential of a professional playing career. 6 TABLE OF CONTENTS ACKNLOWEDGEMENTS ............................................................................ 2 ABSTRACT ................................................................................................. 4 TABLE OF CONTENTS .............................................................................. 7 LIST OF ABBREVIATIONS ....................................................................... 13 LIST OF FIGURES .................................................................................... 15 LIST OF TABLES ...................................................................................... 17 CHAPTER ONE 19 GENERAL INTRODUCTION ....................................................................... 19 1.0 INTRODUCTION ................................................................................. 20 1.1 AIMS AND OBJECTIVES OF THE THESIS ........................................ 25 CHAPTER TWO 26 LITERATURE REVIEW ............................................................................... 26 2.1 INTRODUCTION ................................................................................. 27 2.2 PHYSIOLOGICAL DEMANDS AND INJURY IN YOUTH SOCCER .... 30 2.3 THE EFFECT OF MATURATION ON INJURY INCIDENCE IN YOUTH SOCCER ................................................................................................... 34 2.3.1 Skeletal maturation in youth soccer players ................................... 34 2.3.2 The contribution of biological age to injury incidence ..................... 39 2.4 THE EFFECT OF PLAYING POSITION ON INJURY INCIDENCE IN YOUTH SOCCER ..................................................................................... 42 2.4.1 Physiological demands of different playing positions in youth soccer ................................................................................................................ 42 2.4.2 Effect of playing position on injury incidence in