MedicineMatters18E8.0:Anglais 12.03.10 14:00 Page1 MEDICINE Matters

APRIL 2010 – No.18 IN THIS ISSUE

SWEDISH SMÖRGÅSBORD

SCIENCE – MAKING A DIFFERENCE IN MODERN FOOTBALL?

MEDICAL STAFF AND REFEREES

THE FEMININE FACTOR

PUBLISHED BY UEFA’S FOOTBALL DEVELOPMENT DIVISION MedicineMatters18E8.0:Anglais 12.03.10 14:00 Page2

A FANTASTIC IMPRESSUM This issue of Medicine Matters is being compiled EDITORIAL GROUP Andy Roxburgh in the aftermath of the fifth UEFA Medical Symposium, Graham Turner staged in Stockholm in February. After so many years PRODUCTION in football medicine, it is unusual for me to be so André Vieli enthusiastic about an event. But this one was very, Dominique Maurer Atema Communication SA, very satisfying for two reasons. Gland, Switzerland Printed by Artgraphic Cavin SA, Grandson, Switzerland ADMINISTRATION David Gough Firstly, I was enthusiastic about ship among colleagues who Frank Ludolph the quality of the presentations face the same challenges. Credit Evelyn Ternes and the fact that they addressed for this must go to the UEFA UEFA Language Services genuine problems in modern-day staff and the Swedish national football medicine (as opposed association who created, around to sports medicine), such as the the symposium, an ambience prevention of sudden deaths, the which was perfect for listening, study of injury patterns, the epi- discussing and learning. I went demiology of lesions and, I would home with an exceptionally say, a remarkable session led by good feeling and with a clear the former top referee Markus view of the issues which currently Merk who, despite the difficulties concern team doctors and, for endemic to the job, made it clear that matter, the UEFA Medical that he felt the referee’s prime Committee which, with five new duty is – like ours – to protect the signings in the line-up, made health and safety of the players. its first appearance of the COVER There was not a single presentation 2009–11 campaign in Stockholm. Philipp Lahm (Bayern Munich) that failed to teach me something. It is always good to combine up against Juan Vargas (Fiorentina) the input and fresh ideas from in the UEFA Champions League Secondly – and equally importantly new colleagues with the accu- round of 16. The physical intensity of top-flight football necessitates – I was impressed by the fantastic mulated wisdom of those first-rate medical care. collegiate atmosphere in Stockholm. who have been members of the Photo: Pollex/Bongarts/Getty Images There was an ambience of friend- committee for many years.

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EDITORIAL

UEFA BY DR MICHEL D’HOOGHE Chairman, UEFA Medical Committee COLLEGIATE ATMOSPHERE

It was also a good idea to mix European national associations that dardised football-specific quali- doctors from 52 of UEFA’s member do not have a medical committee. fications is a viable project or not. associations with colleagues from I believe that it is a prime obligation the top clubs who are participating to create one and to give it admin- I underline the term ‘football- in our ongoing injury study and istrative, financial and political sup- specific’. Stockholm was not ‘just who, day in, day out, are working port. The creation of an anti-doping another medical congress’. It was, at the stadium or the training unit is also an absolute must. from start to finish, a football- centre. It was an excellent blend specific event. Medical matters and one which reinforced my view In Sweden, we also looked at crit- were always related directly to the that, at elite level, the ‘team doc- ical subjects which are of special game of football. It led to an in- tor’ doesn’t really exist any more. interest to me – and, I believe, to vigorating variety. In a single day, The medical care of a squad of my colleagues in football medicine. topics ranged from an in-depth players has become so complex that For instance, we could do worse look at doping controls and their a single person cannot be a ‘master than to look very carefully at our accuracy to various perspectives of all trades’. These days, we are own roles and establish criteria on how medicine can best serve talking about a ‘medical team’ which will help us to define exactly the player and, bearing in mind which needs to communicate effi- what qualifications are required that, in the women’s game, Ger- ciently with the coaching and man- by a doctor who sits on the bench many cannot seem to stop winning agement staff and which, to be during matches and who may, in titles, it was appropriate that efficient in terms of enhancing per- addition to more routine occur- Dr Ulrich Schneider should address formance, must be fully integrated rences, have to deal with challeng- the specificities of women’s foot- into the daily life of the group. ing emergencies. Two of my col- ball. UEFA’s technical director, Andy leagues on the Medical Committee, Roxburgh, also contributed two Of the many issues raised during Mehmet Binnet and Mogens motivational presentations on the the symposium, several will be Kreutzfeldt, are to be credited for ‘team behind the team’ and the mentioned in the following pages. some excellent groundwork in future of football. Amidst all that, So I will not try to touch on all of this area. The evidence provided the discussion sessions emphasised them now. However, some of them by their pilot study will, I am sure, that, even if we have come a long are fundamental. I was informed, be invaluable when it comes to way in football medicine, there for example, that there are still five deciding whether establishing stan- is still a lot of work to be done.

MEDICINE MATTERS/3 MedicineMatters18E8.0:Anglais 12.03.10 14:00 Page4 SWEDISH SMÖRGÅSBORD

For the average visitor to Sweden, the smörgåsbord is the typical buffet-style meal of various hot and cold dishes. It might not be stretching the imagination too far to claim only 45 of 1,728 tests last season falling that the participants at the recent medical symposium short of the mark (2.6%), with 78% in Stockholm were offered football medicine’s equivalent. of those occurring during out-of-com- The menu for the three-day event was certainly petition testing. varied – so much so that maybe the best thing to do No fewer than 81% of therapeutic use is pick up a fork or a handful of cocktail sticks, walk around exemptions were due to asthmatic con- the smörgåsbord table and take a few tasters. ditions, with Nordic countries providing the lion’s share of TUE (therapeutic use exemption) applications.

Anti-doping programme This may not be the tastiest of dishes but it has become, over the years, the team doctors’ staple diet. Dr Jacques Liénard, a long-standing member of UEFA’s Med- ical Committee, reported that, over the last decade, the number of tests con- ducted under UEFA auspices has risen from 208 to 1,748 per season and that 15 years of in-competition controls have uncovered 29 positive cases in 10,419 tests – a figure of 0.28%. As Dr Michel D’Hooghe commented, “the costs of the testing programme are considerable, but the results demonstrate that there is no doping culture in football”. Sportsfile

Dr Jacques Liénard, member of the Anti-Doping Panel, at the symposium in Stockholm

One codicil to the figures is that 9 of Among the match-related issues was the 29 tested positive for cannabinoids the draw conducted in the doping con- and 2 for cocaine. Only 11 were attrib- trol room 15 minutes before the end utable to anabolic agents, glucocor- of the game – the general opinion ticosteroids, Beta-2 agonists or, in one being that this should be attended by a case, diuretics susceptible to be used team administrator, in preference to as masking agents. leaving the bench medically unguarded while the team doctor is inside. In Stockholm, the focus was therefore on procedural details rather than ‘dop- Out-of-competition testing also pro- ing culture’. The new requirements in duces some logistical hiccups, largely terms of the specific gravity of samples related to the implementation of the have revealed that the digital refrac- ‘whereabouts’ ruling. Let’s imagine tometer is the best provider of reliable the two doping control officers ringing UEFA-Woods readings. The increase in the volume of the bell at the gates of a training The equipment for a doping control samples from 75 to 90ml resulted in ground, only to be told that, on the

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Former referee Markus Merk was on hand to present the referees’ point of view. Sportsfile

previous evening, the coach had decided the referee frustrates the team doctor developed a relationship of mutual – bearing in mind the team’s workload by putting the brakes on his desire to trust and respect. Looking at the other and the climatic conditions – to give the get onto the pitch. And there was side of the coin, however, it can be bad players a day off. On the one hand, debate about the best procedures for news for a doctor who has been per- there are understandable demands for dealing with the treatment of blood forming efficient work at a club, the sanctions in such a case to be severe injuries – another area of potential only to be ousted by the newcomer. (in order to pre-empt abuse) while, on antagonism between referee and doc- the other hand, how easily is the coach tor. Markus had the last word: “If the It raises questions about career path- going to be persuaded not to change his doctor is called onto the pitch, it is ways for the football doctor. Is it best plans on the remote chance of a doping to treat the player – not to argue with to be attached to a club? Or is it more control? In the current environment, it is the referee about his decisions!” viable to become attached to a coach? therefore essential for clubs to fine-tune Similarly, is the fitness coach to be their communication procedures so that The team behind the team considered a member of the coaching information can be passed as rapidly The importance of the team doctor and staff? Or part of the medical team? as possible to the doping control unit. his relationship with the coach was one of the core themes in Stockholm. By Stress fractures Referees and injured players extension, it generated exchanges of These are such a rare occurrence that Markus Merk, the former elite referee views on the increasing tendency for clubs asked UEFA to collate data which who handled the 2003 UEFA Champions coaches to take members of the medical could be used to draw comparisons and League and EURO 2004 finals, was in staff with them when they move to a offer pointers towards best practice. Stockholm to discuss injuries. “The different team. It is an understandable The incidence in elite male football players’ most important capital is their move for coaches and doctors who have is 0.04 stress fractures per 1,000 hours health,” he said, “and our priority is to protect and safeguard it.”

He also made the interesting point that, in a way, the referee is the first to assess an injury. “Our duty involves assessing the injury risk attached to certain types of situation. The 1990 World Cup was the first event to highlight this by look- ing at the dangers of the tackle from behind. Awareness has risen steadily since then and there is increasing pres- sure on today’s referee in terms of as- sessing fouls and injuries. We sometimes don’t get as much help as we would like. For example, how many winning teams get ‘injuries’ near the end of the match? We want to allow play to flow, so we have to make instant assessments before we react to a fallen player.”

The theme was picked up in a couple of the discussion groups. Apart from debate on how far the punishment should be influenced by the referee’s assessment of the severity of the injury, Empics Sport there was a look at situations where It is up to the referee to judge how serious an injury is and to act accordingly.

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greater interchanges of information aimed at allowing the visiting medical team to know, in advance, what facili- ties, equipment and hospital access they can expect when they arrive on-site, along with some key contact numbers and addresses.

What’s more, there’s more to a team than its players. Any doctor who has travelled to a medium- or long-duration tournament may be able to endorse the thesis that the other members of the

Sportsfile delegation give as much work to the medical staff as the squad of players. Prof. Mats Börjesson, member of the Swedish FA’s medical committee Let’s imagine that one of the administra- tors or security staff is taken ill. How much does the team doctor know about of exposure and, in a squad of 25, the to access or even accreditation prob- him or her? Hence the suggestion that, medical team can be expected to en- lems; the extremely limited possibility taking into full account all the confi- counter one every three seasons. Within of exploiting motorised transport; the dentiality issues, some sort of medical the context of rarity, it’s interesting to chance that the casualties might be passport accompanies every member of note that the risk of this type of injury is multiple; potentially dangerous environ- the travelling party so that the team double during pre-season. mental conditions; and, even if all that doctor has foundations on which to is surmounted, there might be a patient build a response to illness or accident. Stress fractures generally affect youn- who is reluctant to leave the stand ger players, with 80% of injuries in- and miss the action. Hence the need to The UEFA team volving the under-26 age group. Fifth draw up a coherent medical action Last but not least, Stockholm provided metatarsal fractures became topical plan and brief the appropriately trained the scenario for the first meeting of the when they affected elite players, and personnel on how to implement it. UEFA Medical Committee, which has the team doctor can expect to deal with been re-structured for the 2009-11 44 muscle injuries for every metatarsal The flying doctor period. The committee’s chairman, injury. A study based on 30 MT5 frac- How can you guarantee the team doctor Dr Michel D’Hooghe, welcomed five tures revealed that, of the 18 operated a comfortable away trip? You eliminate new members: Dr Ian Beasley from Eng- players, the average absence was the niggling worries that he or she land, Dr José Henrique da Costa Jones 87 days against 63 days for non-oper- carries on to the plane. Insurance, for of Portugal, Dr Ioannis Economides ated players. However, there were four example. How many policies include of Greece, Dr Andrea Ferretti of Italy cases of non-union in each group – in the small print a clause about cover- and Dr Juan Carlos Miralles of Andorra. which meant that the incidence is one ing only the work performed on home For the record, there were 16 items on in three if the non-surgical option territory? Is enough attention paid the agenda for their first get-together, is preferred. to this aspect when age-limit teams are covering many of the issues which made on the road? the symposium such an enriching event. Medical action plans Cardiac arrests and sudden death are, These were among the questions to Some of the other dishes on the Stock- unfortunately, topical issues. But, in emerge from the discussion groups, holm smörgåsbord will undoubtedly Stockholm, the subject was put into a where a chorus of voices called for appear in future issues… broader context. Prof. Mats Börjesson, cardiologist and member of the Swedish association’s medical committee, started by reviewing the importance of reaction times to cases of cardiac arrest and then used a wider lens to focus on the stands as well as the pitch. He com- mented on a survey of 190 European clubs which, even though the study was completed in a single season, revealed widely differing degrees of arena safety.

He also invoked a series of observations made by one of the members of his au- dience: Luís Serratosa, head of medical services at Real Madrid CF. Between them, they pinpointed potential difficul- ties in dealing with medical emergencies in the stadium: the need to navigate large crowds, often with no clear land- Sportsfile marks; the frequent existence of barriers The UEFA Medical Committee

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SCIENCE – MAKING A DIFFERENCE IN MODERN FOOTBALL? BY DR PAUL BALSOM, PERFORMANCE MANAGER AT THE SWEDISH FOOTBALL ASSOCIATION AND HEAD OF SPORTS SCIENCE AT LEICESTER CITY FC, IN COLLABORATION WITH GARY PHILLIPS, HEAD OF EXERCISE SCIENCE AT THE FOOTBALL ASSOCIATION

During the symposium in Stockholm, Paul Balsom twice appeared on stage alongside his former ‘boss’, Lars Lagerbäck, head coach of the Swedish national team for over a decade. The first time was to discuss the importance The high-tempo of the modern game, in addition to an increase in the num- and the mechanisms of the ‘team behind the team’. During ber of matches per season,is placing the second, dedicated to ‘the future of football’, Paul, to increasing physical and mental de- his credit, had only a momentary expression of panic, when mands on the player. The speed of play asked to summarise, in two minutes, the role of science in and power exhibited by the player is the future of top-level football. Afterwards, we offered Paul greater than ever before. An English Premier League game was recently the possibility to be more expansive on the pages of described as “an intense athletic experi- Medicine Matters. This is the result… ence”. In the last ten years, statistics have shown that, at the highest level, players in all positions now record more increasing the availability of players overall and high-speed distance totals for training and selection, and assist in than ever before. establishing a player’s “readiness to perform”. Adopting a systematic “sci- On average, 16 of the 2008/09 UEFA entific” approach to performance Champions League teams had 230 issues has the capacity to inform and training sessions and 59 matches over enhance decision-making, improve the season. This equated to 23 training game understanding and positively sessions and 5.8 matches per month affect risk management. Such insights with an average 4:1 training/match have the potential to positively influ- ratio. In 2007/08, Glasgow Rangers had ence both the coaching process and a 68-game campaign lasting from resultant coaching behaviours. 31 July to 24 May, with an average of Sportsfile

Dr Paul Balsom

Today, professional football is a result- driven industry where winning is the science of being totally prepared. JW Orchard is among those to have sug- gested that “the importance of med- ical/sports science staff in overall team success may be currently undervalued.”

Sports and medical science can create an understanding of training impact through the quantification of training loads and advise in the design of indi- vidualised multidisciplinary preparation programmes (physical, nutritional, psy- chological and technical), taking into consideration inter-individual variability and adaptation capacities. Planned Getty Images and structured interventions can min- Glasgow Rangers (Kyle Lafferty, in blue, pictured here in the imise the incidence of injury and illness, Scottish Cup Final against Jackie McNamara of Falkirk) have a packed programme.

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Sir Alex Ferguson and his assistant, Mike Phelan, have the support of an extensive medical team at Manchester United. Empics Sport

4.4 days between matches. If five inter- required, particularly in the area nutrition, preparation and prevention, national breaks totalling 59 days are of sports science. Medical information, and important work by the psycholo- excluded, the average was 3.8 days nutrition and preparation of players gist to achieve mental balance. between matches. In the final month of for top-level games have reached the season, they played 9 games in another level.” Sir Alex’s current To be effective, sports science and 24 days. Add to this the confounding backroom staff at Manchester United medical practitioners must be able to variation in kick-off times (from 12.00 includes five physios, a doctor, an influence key decisions with respect to 20.45) and it was hypothesised optometrist, a podiatrist, a strength to injury-reducing or performance- that the amount of travel and number coach, three fitness coaches, two enhancing aspects such as training of international players in their squad video analysts and two assistant loads (duration and intensity), train- impacted negatively on the club’s coaches. ing content (e.g. gym-based versus ability to achieve domestic and Euro- on-field activities), recovery strategies, pean performance goals. In the UEFA injury study conducted by training/team selection based on needs Prof. Jan Ekstrand and his team dur- (considering the requirement to rest In response to these trends, the physi- ing the 2008/09 season, the clubs with players, etc). This is where the core val- cal development of the modern foot- the most favourable injury statistics ues, beliefs and leadership qualities of baller has needed to adapt. Higher lev- were asked to give subjective opinions the modern-day coach become critical. els of strength and power are required about why they had such good results. to be more ‘explosive’ and increased Several highlighted the importance It can be argued that the job descrip- resilience to physical impact, increased of good collaboration between the tion of the head coach of a modern aerobic and anaerobic power/capacities medical/sports science team and the professional football team can be are necessary to produce intensive phys- technical staff. compared to the CEO of a business, ical efforts more frequently, and a who commands overall responsibility greater ability to produce, reduce and Other reasons highlighted: the role of for a company’s operations. Sir Alex stabilise force in a coordinated manner assistant coaches in implementing a Ferguson puts his longevity down to is imperative to execute complex techni- sound mentality of training, rigour in developing management skills as cal and locomotory actions at even adhering to prevention/treatment much in common with running large higher speeds. Mike Forde, perform- protocols, players who have minor companies as with work on the foot- ance director at Chelsea FC, noted that complaints or imperfect condition be- ball pitch. He is no longer the one-man the primary aim of the support staff ing allowed to rest, players monitored band who did everything. With a is to make sure that the players are before games to identify fatigue, hundred players and staff under his technically, tactically, mentally and the role of the fitness coach in help- control, he has become a master physically prepared to cope with the ing to prevent muscle strains, individ- of overseeing a giant operation at a demands of the modern game. ualised programmes with focus on club valued at £1 billion.

In the “team behind the team”, medical and sports science practitioners are now well established at most professional football clubs. In a recent interview with UEFA’s technical director, Andy Roxburgh, Sir Alex Ferguson was asked how, in the last 25 years, the ingredi- ents for success had changed. “They have changed in terms of the backup

The medical symposium in Stockholm

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At Chelsea, Carlo Ancelotti has a scientific coordinator to help him to prepare his team. Getty Images Koepsel/Bongarts/Getty Images

“It would be impossible to work in the head coach is essential for this role to oped on objective decision-making same way as I did in 1986,” said Sir Alex. be successful. All information gathered rather than subjective opinion. The per- “It’s too big a beast now to be hands-on by the medical and sports science prac- formance decisions made by the sup- with everything. Delegating is essential. titioners is filtered in order to provide port team need professional accept- I’ve learned at this level you need good the coach with an executive report. ance. Key decisions such as when the people around you. I trust them and Bruno Demichelis, the scientific coordi- player can return, should NOT be rely on them. There must be about nator at Chelsea FC, describes his role tainted by the opinion of the coach. 40 people who report to me now, quite as “assisting the coach in order to apart from the players.” coor dinate all the activities that sup- Is sports and medical science having an port the team and individual players to impact on the game today? Undoubt- Ric Charlesworth, in his book The help them reach their highest perform- edly yes. Greater resourcing, integration Coach: Managing for Success, writes ance levels.” He is one of three assis- and application of the multidisciplinary “a manager must optimise athletes’ tant managers, alongside Ray Wilkins approach will see the support team pro- capacities with a training, learning and and Paul Clement, a trend envisaged vide greater performance insights as counselling regime. His task is not sim- to become more prevalent in the technology develops and both the inter- ply a scientific one for the subtleties. forthcoming decade and crucial to pretation and communication of knowl- Nuances of coaching are best learned by ensure that programmes are devel- edge improves. experience and wide consultation. The coach must absorb scientific data and apply them to the best effect using judgement and finesse.”

Modern management demands the cre- ation and integration of an athlete- focused/coach-centred holistic, multidis- ciplinary support team to implement a support infrastructure which allows for the systematic development of tal- ent. The task is to develop and coordi- nate a programme of sports science and medical services for players – its objec- tive to provide the right opportunities (facilities, training and competition) and support (sports medicine/science) for the right people (coaches/athletes) at the right time. When operating opti- mally, these support systems have the potential to underpin high perform- ance, maximise the talent of the athlete and provide the coach with detailed information on individuals and the group in order to help them make more informed coaching decisions.

The growth in the number of medical and sports science practitioners in foot- ball has led to the emergence of a ‘scientific coordinator’ or ‘performance

manager’. A good relationship with the Images Baron/Bongarts/Getty

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for medical assistance is recognised. The presentation in Stockholm by Markus Merk highlighted Beware the player who is not moving the need for collaboration between referees and medical following a challenge. staff in terms of assessing and treating injuries. It offered the The cautioning of a player should perfect cue for Medicine Matters to feature an abridged not be the priority: the medical staff version of an article by Mike Healy, head of medical education need to be called on first. at The Football Association, entitled: There must also be an understanding that observed life-threatening or limb-threatening injury warrants im- mediate access. There are cases where the medical profession would respectfully ask the referee not to MEDICAL be too pedantic about ‘entering the field of play without permission’.

Serious injury STAFF AND What should be considered a ‘serious injury’? Evidently, players who are unconscious, have impaired breath- ing or are bleeding severely. These REFEREES are ‘time-critical’ injuries which require immediate medical atten- Teaming up to care for the players tion. Fractures, dislocations and head or spinal injuries similarly need prompt attention. Referees have a duty of care to the Stopping the game players and pre-game confirmation Law 5 states that a referee should stop Severe bleeding, if not controlled that the playing conditions, the play- the match if, in his/her opinion, a quickly, will cause a player to go into ing area, the ball and the player’s player is seriously injured and ensure shock and possibly lose consciousness. equipment comply with the laws, and that the player is removed from the The bleeding may also conceal a are not a potential source of injury, are field of play. This is down to a referee’s potentially serious open fracture of testimony to this fact. individual interpretation and ability to the lower leg. Those managing an discriminate between serious and non- open wound must wear disposable Pre-match briefing serious injury. This is not always easy. protective gloves. Bloodstained cloth- Pre-match dialogue between referee ing must be changed before a player and medical staff can be useful to review The abiding principle in medical prac- is allowed to return to play and any the protocol related to entering the tice is ‘first: do no harm’. Delaying blood on the field of play should field of play and to ensure that any in- treatment may cause harm. Referees be dispersed. jury is managed efficiently and does not have a duty to permit medical staff on unduly delay the restart of the game. the field as soon as a player’s need No head injury is trivial. Delayed in- jury response is potentially cata- strophic. It is important that referees do not measure severity only by un- consciousness. A player may sustain a fractured skull or a spinal injury as a result of a blow to the head and yet remain conscious. But players who are rendered unconscious, no matter how short the timeframe, should not be allowed to return to the match. The use of smelling salts on uncon- scious players, which prompts a vio- lent neck movement, may result in spinal trauma. Referees should also be aware that the use of chewing gum entails a risk of choking or air- way compromise.

Manhandling players There is widespread misunderstand- ing that an unconscious or concussed player may have ‘swallowed his Empics Sport Empics tongue’ and must be immediately The referee checks to see how badly the player is injured. moved into the ‘recovery position’

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Arsenal’s goalkeeper Vito Mannone receives treatment on the field during a Premier League match against West Ham. PA Wire / Wire PA Images PA

(on their side with their head back). ability of a player to return to play. should be allowed to do so, as it is a Both misconceptions need to be dis- Treatment is only applied once part of a functional assessment process. pelled. Players do not swallow their this process is complete. Serious Stretcher-bearers, typically called on at tongues; the relaxed tongue simply falls injuries clearly take longer to assess. the same time as the medical staff, back and obstructs the airway. An ob- need to understand their supporting structed airway can be managed by Referees sometimes fail to appreciate role. They must not intervene, man- appropriate head positioning. Putting that a physiotherapist’s use of hands handle players or attempt to put them a player in the ‘recovery position’ does does not necessarily constitute treat- on a stretcher until asked to do so by not mean a player will recover! What’s ment. And – a point which also applies the medical staff. more, moving an injured player may to some of the other issues raised – unwittingly cause them further harm. referee observers should not pre-judge Conclusion a delay as poor referee control. There are many ways in which a ref- Referees should avoid touching or eree can safeguard the health of the moving an injured player and should On-field treatment players and contribute to the quality of discourage manhandling by team- Injury treatment is considered to be medical care for an injured player. The mates before being medically assessed, any intervention, e.g. ice application default position should be that Law 18, ‘normal’ breathing is confirmed, and or strapping of a joint, which takes ‘the law of common sense’, should pre- potential spinal injury excluded (the place after an injured player has been vail and that referees, in partnership risk could be permanent paralysis assessed. In most instances it is safe to with the medical staff, should always of the player). The referee has a duty have the player leave the field of play. act in the best interests of the players to hasten the arrival of the medical However, in cases of serious injury, and ensure that prompt medical atten- staff responsible for the ‘duty of care’. a player should not be moved until tion is permitted and administered. pre-hospital treatment has been On-field management administered and the injury/condition of injured players is stabilised. A referee should allow an injured player to be medically assessed before The emergency management of a being removed from the field of play. player who is unconscious, not breath- To do this, referees need to be able ing normally or has a suspected or to differentiate between the ‘assess- obvious spinal injury or fracture, may ment’ and ‘treatment’ of an injury. take several minutes. Airway manage- ment, oxygen administration, immo- The standard ‘on-field’ musculo-skele- bilisation of the spine and fracture sta- tal injury assessment process has the bilisation all take time. This is where following stages: i) questioning the the medical staff are grateful for the player, confirming responsiveness and referee’s patience. the site of injury; ii) a look at the site of the injury; iii) gentle palpation Removal of injured players around the area of the injury; iv) active The referee is responsible for ensur- movement of the injured/involved ing that an injured player is safely joint by the player; v) passive move- removed from the field of play, but ment of the injured/involved joint by the ultimate decision on removal and the physiotherapist; and vi) resistance the method of removal is for medical tests of the muscles working over the staff alone. The referee should be injured/involved joint. The process is ready to accept expert opinion rather designed to assess the integrity of the than harass medical staff or insist that / Wire PA Images PA bony structures, ligaments, muscles a player gets onto a stretcher. Players If the injury looks serious, the referee and tendons and to confirm the suit- who are able to walk off the pitch allows the doctor onto the field.

MEDICINE MATTERS/11 MedicineMatters18E8.0:Anglais 12.03.10 14:00 Page12 THE FEMININE

Dr Magnus Forssblad, chairman of the Swedish FA’s medical committee, addresses the symposium.

One of the presentations made during the symposium in Stockholm was by Dr Ulrich Schneider, medical consultant to the German national team which, as their rivals will not wish to be reminded, is THE dominant force in European women’s football – a fact highlighted by their fifth successive victory at the Women’s EURO 2009 finals staged in Finland. In medical terms, the fact that Germany has set benchmarks on the field of play is possibly less relevant than the figure of over 1 million registered female players, which provides a broad base for data gathering and analysis. Sporstfile

Even though Germany is one of the more recent phenomenon – a fact 2008, whereas the growth rate in the continent’s frontrunners, organised which may have a bearing on certain masculine game was 2.45%. This sort women’s football is still a relatively medical parameters. This means that of statistic, even though the figures young discipline. The first women’s growth rates are more spectacular vary considerably from country league match in Germany, for in- than in the men’s game. In Germany, to country, is a clear indicator of the stance, was not played until 1990 and, the audience in Stockholm was told, rapidly increasing need to provide in a majority of other member associ- women’s football experienced a proper medical care for female play- ations, league football is an even growth of 21.27% between 2000 and ers. Dr Schneider’s presentation on the specificities of women’s football was therefore thought-provoking.

He started by examining workloads. A survey among German national team players revealed that they played between 22 and 45 club matches a season (at an average of 32.5) plus between 1 and 20 for national teams (at an average of 10.6). The average match-play workload was therefore 43 games and could, in an extreme case, stretch as far as 65. Training units ranged from 4 to 12 per week at an average of 6.4 – all of which adds up to figures easily comparable with phys- ical loadings in the men’s game.

In terms of workload during matches, Dr Schneider commented that analysis based on the German national team against top-class opposition revealed an average distance covered of 10,507 metres, with midfielders averaging 11,784 – again, figures comparable

Getty Images with the men’s game. However, run-

MEDICINE MATTERS/12 MedicineMatters18E8.0:Anglais 12.03.10 14:00 Page13 FACTOR

Prof. Jan Ekstrand is in charge of UEFA’s injury study. Sportsfile

ning patterns differ substantially, with On the other hand, Dr Schneider onship final round in Finland, where only 260 metres covered at sprint revealed that the sort of eating disor- the average height was 169cm and speed (179 metres at speeds between ders or menstrual dysfunctions preva- the weight 62kg. 21 and 24km/h and 81 at speeds of lent in other sporting disciplines are 24+), and a further 765 metres covered not endemic to the footballing popu- A few minutes before Ulrich Schnei- in the 17–21km/h speed range. High- lation. Indeed, the percentages are der stepped on to the stage in Stock- speed running therefore represents three or four times lower – and sub- holm, Magnus Forssblad, chairman of 0.77 of the total distance covered. stantially less frequent than in society the Swedish FA’s medical committee, at large. The anthropometric data he national team doctor and orthopaedic Interestingly, comparisons were made presented indicated that the under-20s surgeon, had asked a rhetorical ques- between the two members of an at- are now taller and heavier than their tion with regard to medical skills and tacking partnership. One covered ‘senior’ team-mates – which made ethics. “We might be skilled, inter- 11,115 metres during the game, 372 of for some interesting comparisons ested and capable surgeons when per- them (3.3%) at 21km/h or more. The with data related to the squads at the forming ACL reconstructions,” he said, other ran a lower distance (10,466 2009 European Women’s Champi- “using high-tech methods, latest graft metres) but covered 494 (4.7%) at high speed. Comparing top-level per- formances, the distances covered at sprint speed in men’s football are approximately 50% higher than at the elite end of the women’s game.

Having said that, the figures pre- sented by Dr Schneider in Stockholm indicated that performance levels in the women’s game are increasing. Between 2006 and 2009, the mean time for explosive sprinting over 5 me- tres decreased from 1.11 to 1.05 sec- onds (compared with 0.95 in the men’s game). Over 30 metres, the time has been lowered from 4.45 to 4.35.

Recent studies of heart rates during elite women’s games have demon- strated a high degree of consistency over the 90 minutes, with readings reaching 87% of maximum values.

Studies have also revealed that anae - mia is an issue to be addressed in the medical care of female players, with Hb and Ferritin readings – even among national team players – quite often dropping to levels which are consider- ably below normal and which can Images Baron/Bongarts/Getty place considerable restrictions on per- Studies have demonstrated the high level formance. of consistent effort of Germany’s women’s team.

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Women’s youth teams are also monitored closely from a medical point of view. UEFA-Woods

choice and increasing percentages at risk in women’s football is between to produce fractures, whereas the of double-bundle technique, but can 15 and 20, with an absolute peak be- doctor working with a women’s team we honestly recommend a 15-year-old tween 17 and 19. Dr Schneider offered is more likely to deal with contusions. girl to return to football?” plausible explanations for the high But that might be changing.” incidence of ACL ruptures: anatomical The italics don’t reflect a change of factors (such as increased Q-angle, His suspicion can be backed by figures Magnus Forssblad’s tone, but rather an smaller intercondylar notch in the from the Women’s EURO 2009. At the unspoken question: why had he cho- femur), hormonal influences on knee 2005 finals in England, there had been sen a 15-year-old girl as an example? joint stability, or muscle strength and no fractures. In Finland, the number Dr Schneider was to throw light on neuromuscular activation patterns of contusions was lower (six), but it by referring to the high incidence of (e.g. hamstring to quadriceps ratio). there were four fractures – hinting anterior cruciate ligament injuries in that the mass and velocity equation women’s football. A season-long study at the top end of the women’s game in the German league had produced However, statistics related to other might be evolving. Contusions a figure of 2.2 ACL ruptures per types of injury hint at an evolution and fractures jointly accounted for 1,000 hours of match play and a sur- within women’s football. Dr Schneider 36% of the injuries. vey among national team players had referred to studies which revealed revealed that 23% had suffered an a peak of injuries at under-15 level, UEFA’s injury study conducted in Fin- ACL rupture in the past – most of which then dropped steadily until the land provided positive information in them at tender ages. age of 19. The same studies showed that the tournament registered a an approximate equilibrium between clear trend towards lower incidences This dovetailed with a survey con- contact and non-contact injuries ducted by UEFA during the Women’s (52 to 48%), with 52.6% of the non- EURO 2009 as part of the ongoing contact variety occurring during run- injury research project. A study based ning (30.5%) or abrupt changes of on 10 of the 12 squads revealed that direction (22.1%) – followed by shoot- 4.9 players per team had suffered ing (15.8%), jumping (11.6%) or im- an ACL rupture – representing 22% pact from the ball (10.5%), with the of all the players at the finals. For remaining 9.5% down to various the record, there was one ACL rup- other types of incident. Of the con- ture during the tournament – and it tact injuries, 70.6% were the result occurred during training. of a tackle deemed to be legitimate, 22.5% were derived from foul By contrast, a similar study among play and 6.9% were due to collisions. the eight finalists at the Women’s Under-19 Championship final One of the salient features was that round played in Belarus a month contusions provided 27.3% of thigh before the tournament in Finland injuries, 13% of those related to the had revealed an average of 0.5 per knee and 9.3% of the ankle injuries. squad (3% of the total). “The traditional notion,” commented Professor Jan Ekstrand, “is based on Magnus Forssblad, however, referred mass and velocity. So the parameters to data collected between 2005 and of the men’s game are more likely 2010, which revealed a contrast be- tween patterns of men’s and women’s ACL ruptures. Whereas the ‘peak Sweden v England in the Women’s period’ for the men was between the EURO 2009, which was the subject of

ages of 20-25, the age group most a medical study Sportsfile

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Dr Ulrich Schneider, medical consultant to the German women’s national team Sportsfile

of injury. During the 19-day, 25-match At the same time, UEFA’s injury studies and playing helping to generate event, 27 injuries were recorded – at the finals of its Women’s Under-19 hardened tissues. Projecting into the 19 of them during match play. The Championships have also revealed future, Dr Schneider suggested in highest injury rate was recorded dur- an interesting pattern. After a slight Stockholm that female players will ing the 18-match group stage, though upturn at the 2007 finals in Iceland, need to be equipped for more high- the three severe injuries (entailing an the incidence of injury has headed intensity running and that preventive absence of four weeks or more) were steadily downwards. strategies aimed at reducing the inci- all sustained during the knockout dence of knee and ankle injuries phase of the tournament – and all It is dangerous to jump to conclusions. in the higher-risk age groups will three were knee-joint lesions in non- But it could be legitimate to debate need to include specific training on contact situations. Of the other 24, whether one of the statistics presented aspects such as proprioceptive coordi- 15 (55% of the total) entailed absences by Dr Schneider might be part of the native exercising, lower-extremity of up to three days and only six explanation. He pointed out that, landing skills, plyometrics and the im- resulted in absence of over one week. in the year 2000 in Germany, 25.3% provement of muscle balance. A total of 85% of the injuries were of the registered female players traumatic. Another salient feature was were under-16s. By 2008, this had Bearing in mind that Germany is at that, whereas 20–25% of injuries in the risen to 32.5%. the top of the women’s ladder, the men’s game affect the thigh, the advice is of special interest to national women’s tournament registered only It could be argued that if girls are associations on the rungs below them, 11% and of minimal severity. playing football from earlier ages, where girls may be starting to play their limbs receive a more complete their football at later ages, and where In injury studies, ‘down’ is a good footballing education than those who doctors have a role to play in helping word. At the Women’s EURO 2009, come into the game at – literally and them to avoid the physical pitfalls down went the incidence of severe figuratively – secondary education which, in recent years, have become injuries (2.5 per 1,000 hours compared stages, with the extra years of training apparent in the women’s game. with 5.6 at EURO 2005 and 9.5 at the men’s EURO 2008) and down went the overall incidence of injury (22 per 1,000 hours of match play compared with 36 at EURO 2005).

The incidence of injury in training was also very low, at 3.3 per 1,000 hours, yet provided 30% of all the tourna- ment’s injuries and 38% of those which entailed an absence of over a week. In this sector, comparisons with 2005 are dangerous, given that the finals in England were played in June, whereas the event in Finland was staged in late August / early September. The 2009 training schedules had high rest- and-recovery components and the number of sessions during the group phase ranged from three to eight – something logical bearing in mind that Sportsfile some contestants were in mid-season,

Sportsfile others in pre-season. The Danish women’s team in training during the Women’s EURO 2009

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