THE APPLICATION OF INJURY PREVENTION PROGRAMMES IN PROFESSIONAL FOOTBALL FEATURE / JACK HUGHES Good runs in several cup competitions, including reaching subsequent EFL trophy finals, as well as entering the League One play-offs in each of the last two seasons, has seen Portsmouth play a record number of games. 62 games in 2018-19 was on course to be matched in 2019-20, having played 50 games before COVID-19 put halt a to the season after their game with Fleetwood on March 10th. Maximising availability has been one element behind the club’s success that has driven this relentless schedule. Without the same level of resources, staff, or international breaks to afford the players the same recuperation as teams in the top two tiers, Portsmouth have instead invested significant time into improving the basics.
“Like most league one clubs, we are a small performance team, so Bobby Bacic (Head Physiotherapist), Jeff Lewis (First Team Sports Scientist) and myself (First Team Physiotherapist), work closely on a daily basis to support the needs of the players. A lot of the things we do are in house as we are unable to use the various external performance monitoring systems that are available now”. One part of this has been the development and implementation of an ‘Injury Prevention Exercise Programme’ that reflects the real-world demands of professional football and the constraints that come with operating in such a hectic schedule. “With the bulk of the research being conducted on amateurs, guidance for practitioners wishing to implement IPEPs in the professional game did not really exist. Moreover, first-hand experience of
the contextual differences between the research and real-world practices led me to explore ways that I could take this research and apply it to our environment. The aim of the research was, therefore, to make recommendations towards implementing a “best practice” IPEP that were based on a review of the literature, as well as reflecting the current thinking from within professional football generally. Anecdotal experiences and the experiences shared by many of the games’ leading practitioners underlie the recommendations, so whilst some of the findings are not necessarily novel, hopefully the piece gives some much-needed real-world context to the IPEP research base and plugs the gap that currently exists in terms of guidance for practitioners wishing to implement IPEPs in professional football”.
football medicine & performance What is already known on this topic? University of South Wales Library
41 potentially relevant articles identified by title and abstract, plus manual search of reference lists Study Aim – What can this study add?
Final texts presented across chapters 3-5
Figure 1: Summary of Project Rationale and Study Aim.
Methods The PICO (Population, Intervention, Comparison and Outcome) (Schardt et al. 2007) tool was used to establish directed research questions (Table 1) that were drawn down from a ‘clinical problem’, as seen in the evidence-based practice cycle (Strauss et al. 2011). To answer these questions, this project took on the form of a research-based analysis and synthesis (Silverman, 2006), but also utilised theory derived thoughts and practices from within professional football.
What are the current perceived barriers to IPEP implementation and compliance from those working in professional football?
What strategies can be used to improve implementation of and compliance to IPEPs?
What considerations should practitioners make when planning and delivering their own IPEP?
Table 1: Research questions formulated to facilitate literature searches and address the project aim.
Figure two depicts the search strategy used to identify the relevant research. Critiquing tools were then selected and applied based on their construction and validity of the included items.
Figure 2: Flow diagram demonstrating pathway to and distribution of relevant texts
Summary of Literature Review Findings Barriers to Compliance Understanding the perceptions of those in professional football towards IPEPs is key to developing pertinent implementation strategies. O’Brien and Finch (2017) described barriers to IPEPs using self-report surveys sent out to players, coaches, and other support staff, including Physiotherapists and fitness coaches. The inclusion of players highlights the first important difference between scientific research and practice. Many studies implicitly focus on compliance, as they study how well participants conform to the study instructions. However, football is often more collaborative (van Reijen et al. 2016). Their inclusion of players may ultimately assist with compliance and formulating more efficacious IPEPs. McCall et al. (2016), on the other hand, surveyed the lead medical officer of 33 teams previously included in the UEFA elite club injury study (Ekstrand et al. 2011). Whilst this sample could be considered more restrictive and their thoughts may not be applicable to all clubs, the insight given from those directing injury prevention strategies at the highest level is valuable. Utilising both studies, the perceptions of those in professional football towards IPEPs were well understood and several factors that influence IPEP implementation were identified (Table 2).
The complex interactions between these findings across different settings suggests that a standardised approach to injury prevention conflicts with the need for consideration of the specific context and constraints faced by each club (O’Brien and Finch, 2017). Injury prevention practices will, therefore, likely need to vary between clubs to be successful.
Perceived barriers to implementation:
Lack of support from other staff and coach acceptance.
Uncertainty over who’s responsibility injury prevention is - leading to an overall lack of ‘club policy’ towards injury prevention.
Concerns about effect on future performance – fatigue and soreness.
Belief IPEPs are ineffective and potentially causative of injuries. Adequate exercise progression and variation, as well as exercise individualisation. Table 2: Summary of main barriers to IPEPs.
feature Implications of Findings – ‘Developing an IPEP to Combat the Barriers’ IPEP Formation No IPEP will achieve its full potential if it is not adopted, correctly executed, and consistently maintained (O’Brien and Finch, 2014). Taking note of the barriers, an IPEP that is generalisable to all professional teams and can be scaled appropriately to aid prevention at all levels is now presented. The programme is not designed to be prescriptive, nor exhaustive, but should give practitioners a framework from which to base their own IPEPs. Programme “Pillars” “Pillars” represent a programmes staple components. When attempting to mitigate injury risk, it is important to understand what injuries occur regularly and why (Buckthorpe et al. 2019). As such, the first approach to developing the IPEPs “pillars” is understanding football injury epidemiology and aetiology. The modifiable risk factors for said injuries can then be explored and accounted for. However, at the time of writing, it is unclear what the optimal type and prescription of exercises to combat these modifiable risk factors are, and so the relative importance of specific exercises to the IPEP are unknown. Taking this uncertainty, but with respect for the dose-response findings from previous FIFA11+ research (Whalan et al. 2019; Silvers-Granelli et al. 2015), perhaps the most important features for IPEPs in professional football arise from existing IPEPs. However, there may be some scope for adjustment of specific exercises. This is important, as assigning broader pillars may help to overcome issues of exercise variety and progression.
football medicine & performance Programme Delivery Pillar Considerations Potential Modifiable Programme Risk Factors Pillars for Injury Lumbopelvic Thigh – hip stability. Lumbopelvic Hamstring activation. strain injuries. Muscle Hamstring strength. Strength. Hip and Groin – Adductor Adductor strain Muscle strength. injuries. imbalance. Calf strength.
Prevention Priorities by Injury Site
Knee sprain injuries.
Lower leg – calf muscle strain/ Flexibility. Achilles tendon injuries. Ankle sprain injuries. Foot/toe injuries.
Functional Strength. Landing Mechanics. Mobility. Lower limb & spinal.
Table 3: Formulation of real-world IPEP Pillars – considering epidemiology, aetiology, modifiable risk factors and existing IPEP features.
It is accepted that each menu (Image 1) will not contain every pertinent exercise, but nor is it expected to do so. This process is intended to guide practitioners in formulating their own pillars and exercise menus, relevant to their environment. Differences in facilities, for example, may mean exercise choices differ. So, whilst IPEPs may look different in their implementation, their formulation is based on the same principles.
As found, not integrating IPEPs into ‘club policy’ is perhaps one explanation for a lack of compliance. It is, therefore, the opinion that IPEPs need to be seen ‘as part’ of training rather than ‘an addition’ to training. In this way, compliance is seen as compulsory rather than an optional extra. To reinforce this point further, the suggestion is that the IPEP is delivered daily to the whole squad as ‘the start of training’ (Table 4), but with scope for individualisation in the programme where appropriate. 10:00
Training starts: IPEP in Gym
Outdoors warm up
S&C in Gym
Table 4: Example of typical daily schedule and integration of IPEP into training.
Individualisation, targeted at the individual’s injury risk profile has been described as an essential element of an effective IPEP (Buckthorpe et al. 2019). Taking such an approach is one way that return on investment for IPEPs can be maximised. When designing a programme, it is not possible to assign equal weight to all risk factors. However, a needs analysis allows practitioners to rank the risk factors based on the individual player. By taking a focussed approach and targeting ‘high-risk’ players, this could reduce implementation ‘costs’ (Fuller 2019). Image 1 – example ‘menu’ of exercises listed under pillars.
For example, ‘the bench’ and ‘sideways bench’ are not the only core strengthening exercises. With no evidence in the wider reading to prove they are superior to other core exercises, but evidence to prove an IPEP with core exercises can be effective, it can be argued that other core exercises are appropriate. Creating a “pillar” of core training allows the practitioner to create a “menu” of additional exercises. Considering this, potential pillars for an IPEP are presented in Table 3.
Whilst it has been established that to be effective, IPEPs need to be performed consistently, it has also been made clear that injury prevention efforts should never impact on football performance negatively (Bolling et al. 2019). To this end, fixed protocols such as the FIFA11+ do not work in the dynamic environment of elite football, where fixture congestion (Ekstrand et al. 2013a) is a concern. Getting the right balance between load and load capacity requires constant adaptation based on training/game volume and the player’s fatigue levels (Bolling et al. 2019). A good example of how IPEP planning in respect of periods of increased loading can facilitate implementation is seen in the McCall et al. (2016) review.
“reducing the external load (60%)”,
“reducing the sets and repetitions (53%)”,
“reducing the frequency (50%)”,
“modifying the exercise type (20%)”, (McCall et al. 2016 pp. 2).
Utilising Microsoft Excel to store the menu of exercises, it is also possible to keep track of sessions delivered. This allows the practitioner to look back on previous sessions and draw upon strategies to challenge the players and progress the exercises. On a separate workbook to the menu, the practitioner can create a series of dropdown lists for each pillar. The lists are linked to the exercises in the menu, making them readily available to select. From here, a third workbook can be created that displays the selected exercises. The practitioner can use this sheet as their session plan and save them to facilitate tracking.
Utilising these strategies alongside a daily checklist of targets to hit in terms of programme pillars helps to ensure the key components are hit regularly, but at the same time, allow for enough flexibility to accommodate for the rigours of professional football. Table 5 outlines the authors current thinking regarding targets to hit and potential modifications in respect of fixture schedules.
Example 1 – Standard Two Game Week Match day (MD)
Non-starter – Hamstring Strength. Adductor strength.
Whole squad –
Hamstring, adductor, and calf strength – eccentric.
Day off. No IPEP.
Mobility. Lumbopelvic activation.
Starter – Whole squad
Day off. No IPEP
Hamstring, adductor, and calf strength – isometric.
Whole squad -
Adductor strength. Calf strength.
Example 2 – Congested Three Game Week MD
no IPEP. Starter – Mobility.
Non-starter – Hamstring Strength. Adductor strength. Calf strength. Functional Strength.
Day off. No IPEP.
Non-starter Mobility. Lumbopelvic activation.
Non-starter – Lumbopelvic activation. Hamstring, adductor, and calf strength – eccentric.
Lumbopelvic activation. Day off. No IPEP
Table 5: Variations of IPEP checklist targets based on playing status and di ering fixture schedule.
Starters - no IPEP.
Whole squad –
Hamstring, adductor, and calf strength – isometric. Landing mechanics.
Non-starter – Whole squad – Mobility.
Adductor strength. Calf strength. Functional Strength.
football medicine & performance
Image 2 - Exercise selection template. Image 3: IPEP print sheet showing exercises selected in selection workbook.
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Figure 3: Basis of session construction (Glasgow, 2019).
Image 4: PDF copy of session.
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football medicine & performance
Challenge One criticism of IPEPs that may be addressed using this approach is the sports specificity of the exercises (Bolling et al. 2019). It has been suggested that IPEP exercises may not be sufficiently specific to the high-speed demands of football (Ekstrand et al. 2013b). The complexity of actions required contrast with some of the isolated movement patterns and strengthening that typically occur in an IPEP (Buckthorpe et al. 2019). Practitioners should be aware of this when programming their exercises. Different directions, speeds, planes etc. (Table 6) are all ways of varying the same movement that may increase sports specificity and reduce injury risk.
Conclusions In summary, the approach to this project is not wholly evidence-based, but it is felt that this represents a pragmatic approach to IPEPs with what is currently available. It does not provide direct proof of outcomes, but the goal was to develop and share an approach that may be an important step in the journey towards identifying a best practice IPEP at all levels of football. The systematic approach was supplemented with anecdotal experiences from across professional football which has allowed for a realistic implementation plan to be developed. This project, therefore, gives valuable insight into how the delivery of IPEPs may be improved and how to better develop them in the future (Figure 4).
Progress Given the squad-based delivery method being advocated, prescribing an exercise that cannot be scaled or progressed may mean the exercise is either too easy or too hard for some individuals, resulting in diminished execution quality. Referring to the McCall et al. (2016) survey, poor exercise execution was one finding that practitionerâ&#x20AC;&#x2122;s thought may contribute to poor programme outcomes. Thus, execution quality is thought to be at least an â&#x20AC;&#x2DC;importantâ&#x20AC;&#x2122; component of an effective IPEP. The suggestion from this project is for the practitioner to initially prescribe the most basic version of the exercise and be armed with progressions for those who require it.
Bodyweight, barbell, trap bar, dumbbell, kettlebell, band, chain, weight vest, slideboard, medball, cables.
Standing, supine, prone, quadruped, side lying, seated, kneeling.
Vertical, horizontal, lateral, rotary.
Bilateral, unilateral, split, staggered.
Number of joints
Normal, concentric, eccentric, isometric, plyometric, ballistic
Ranges of motion
Deficit, normal, partial.
Kinetic chain types
Table 6: Exercise variation and specificity considerations.
Injuries are a cost and performance burden to professional football teams. Injuries also impact the players themselves, with detrimental links to long term quality of life known. Reducing injuries is therefore a high priority.
Multidimensional IPEPs are proposed to reduce injury risk by acting on the modifiable risk factors for injury.
The efficacy of IPEPs such as the FIFA11+ has been well documented, but its success is reliant on compliance. There is a clear dose-response relationship between increased compliance and decreased injuries. However, the perceptions of those working in professional football is that in its current form, the FIFA11+ is not suitable. Strategies to translate the evidence into practice are therefore required.
Considering the importance of compliance with, and the current criticisms of the FIFA11+; implementation strategies are proposed that facilitate effectiveness and overcome barriers. Utilising these, a simple framework for an integrated IPEP is proposed that may improve applicability to professional teams but can also be scaled to aid prevention at all levels of football.
Figure 4: Flow chart depicting key messages to arise from the project.