The official magazine of the Football Medicine & Performance Association

football medicine & performance

Issue 31 Winter 2019/20

Feature

Karen Carney A Pioneer for the Womens’ Game In this issue Injuries in Football: It’s Time to Stop Chasing the Training Load Unicorn Cautious Return to Play Could Prevent Muscle Injuries FMPA Conference 2020 Neurodegenerative Disease Among Former Footballers

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FROM THE EDITOR The women’s game is potentially where the most interesting work is happening in football medicine and performance at the moment. As it becomes truly professional, and the performance support available grows, the limits to which these athletes can be pushed is constantly tested. The periodisation of the training week, the unique injury risk profiles and hormonal considerations are just some of the aspects which make the women’s game different from the men’s. Performance support teams should be set up accordingly, and not ‘cookie-cut’ from successful models in the men’s game. With this in mind, I am delighted that we can continue our player-centred approach by featuring Karen Carney in this edition. Karen enjoyed an unprecedented career, winning 144-caps for England, and was a key figure as the women’s game transitioned to the professional era. I am confident Karen’s insights into performance and rehabilitation will add great value to your practice. For this edition, and going forward, I am very grateful to have the support of a strong editorial team made up of practitioners from across the MDT. Connie Briggs (Physio, Tottenham), Matthew Brown (Sport Scientist, PSG), Frankie Hunter (Head of Fitness, Middlesbrough), Nirmala Perera (Physio, University of Oxford), Manroy Sahni (Doctor, Aston Villa) and Andrew Shafik (Doctor, Newcastle) have been crucial to ensuring the educational content is of a high quality, and I hope that they will be able to help the publication to continue to grow. As I am writing this, the congested festive fixture schedule looms heavily. Players are expected to produce high level back-to-back performances within a few days with little time for recovery. It’s during this time when the strength of the MDT is put to the test, and I wish you all the best of luck during this period.

Sean Carmody Dr Sean Carmody Editor, FMPA Magazine

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CEO MESSAGE There are many landmarks in our calendar which seem to lend themselves to a time of reflection – the beginning of a New Year is one of course but the end of a season and the start of another are also great opportunities to consider where we are as an association, what have we achieved and what our aims and ambitions are moving forwards. Sometimes, it also seems appropriate to reflect on the highlights of a season or `Year` gone by. One such highlight was the Mental Health Symposium which the FMPA held in March 2019 in association with the Premier League. In undertaking this event, not only did we address an area that is of growing concern to all, but it also enabled us to put forward our views as an association, on the pathway of care from a `medicine and performance` perspective. We also introduced ourselves to a new audience, examined our role and responsibilities in this arena, consolidated links with Sporting Chance Clinic and eminent practitioners in this field, began the process of establishing a position statement on behalf of the FMPA, worked collaboratively with the Premier League who kindly sponsored the event and demonstrated that, as an organisation, we can be trusted and valued as a working partner. Further, we delivered the content of this event as free access to ALL practitioners across the game via a series of video presentations hosted on the FMPA website. Finally, this event led to the Autumn edition of our magazine being entirely focussed on mental health. And, the area of mental health and emotional wellbeing continues to remain high on our agenda. With several similar projects reaching their conclusions in any given year it is clear that we are continuously developing across so many areas, all of which have far reaching consequences - and benefits - both to the FMPA as an organisation and our members. As 2020 gets underway we look forward to many more highlights to come and in particular, to seeing you all at our Conference and Awards event in May. Put the date in your diary – 22nd+23rd May 2020. Perhaps you should make attendance at this event your New Year’s resolution!

EamonnSalmon Chief Executive Officer Football Medicine & Performance Association

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CONTENTS FEATURES

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Injury Mitigation in Team Sports. Part-2: The risk management approach Colin W. Fuller

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What to do and When to do it? The Tricky Question of Specialisation in Youth Football Laura Finnegan

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Injuries in Football: It’s Time to Stop Chasing the Training Load Unicorn Franco M. Impellizzeri, Aaron J. Coutts, Maurizio Fanchini, Alan McCall

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Training the Semi-Professional Footballer Daniel Bernardin, Dylan Mernagh

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Karen Carney A Pioneer for the Women’s Game Sean Carmody

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Wrist Injuries in Goalkeepers Raj Bhatia, Adam Esa, Sam Haines

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Neurodegenerative Disease Mortality Among Former Professional Soccer Players – Summary Emma Russell

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Job Insecurity: Reducing Its Negative Effect on Your Wellbeing Caroline Marlowe

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FMPA Register

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ABOUT

Cautious Return to Play Could Prevent Muscle Injuries in Professional Football Håkan Bengtsson, Jan Ekstrand, Markus Waldén, Martin Hägglund

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Generalised Joint Hypermobility – Why should it be screened for within a football setting? Adam Johnson

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FMPA Conference 2020

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Understanding and Developing Relationships in the Modern Football Hierarchy Dr Daniel Parnell, Professor Barry Drust

Football Medicine & Performance Association 6A Cromwell Terrace, Gisburn Road, Barrowford, Lancashire, BB9 8PT T: 0333 456 7897 E: info@fmpa.co.uk W: www.fmpa.co.uk FMPA_Official Officialfmpa fmpa_official LinkedIn: Football Medicine & Performance Association FMPA_Register FMPARegister fmpa_register Chief Executive Officer Eamonn Salmon eamonn.salmon@fmpa.co.uk

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Contributors Colin W. Fuller, Franco M. Impellizzeri, Aaron J. Coutts, Maurizio Fanchini, Alan McCall, Håkan Bengtsson, Jan Ekstrand, Markus Waldén, Martin Hägglund, Adam Johnson, Dr Daniel Parnell, Professor Barry Drust, Laura Finnegan, Daniel Bernardin, Dylan Mernagh, Raj Bhatia, Adam Esa, Sam Haines, Emma Russell, Caroline Marlowe

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COVER IMAGE England’s Karen Carney during the FIFA Women’s World Cup Third Place Play-Off at the Stade de Nice, Nice. Richard Sellers/PA Wire/PA Images

Football Medicine & Performance Association. All rights reserved. The views and opinions of contributors expressed in Football Medicine & Performance are their own and not necessarily of the FMPA Members, FMPA employees or of the association. No part of this publication may be reproduced or transmitted in any form or by any means, or stored in a retrieval system without prior permission except as permitted under the Copyright Designs Patents Act 1988. Application for permission for use of copyright material shall be made to FMPA. For permissions contact admin@fmpa.co.uk

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INJURY MITIGATION IN TEAM SPORTS PART-2: THE RISK MANAGEMENT APPROACH FEATURE / COLIN W. FULLER Introduction Part-1 of this series1 reviewed models used for developing sports injury mitigation programmes. Three major weaknesses were identified in the ubiquitous sequence of prevention (SoP); namely, the model focussed on reducing numbers of injury rather than injury burden, ignored associated injury management issues, and has not been operated in real-world situations. It is surprising, therefore, that SoP has provided the focus for sports injury mitigation research when there is an alternative, proven model available. Risk management has been embedded within UK health and safety legislation since publication of the Health and Safety at Work etc Act 1974. Section 2 (General duties) of this Act states “It shall be the duty of every employer to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all his employees.” Regulation 3 (Risk assessment) of The Management of Health and Safety at Work Regulations 1992 clarifies how this duty should be completed: “Every employer shall

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make a suitable and sufficient assessment of the risks to the health and safety of his employees to which they are exposed whilst at work.” The risk management approach was discussed in Royal Society reports in 19832 and 19923. Fuller4 discussed the implications of the risk management approach for sport in 1995 and published a sport-specific risk management model in 20045,6. The aim of this paper is to discuss the risk management model in the context of injury mitigation. Risk Management (RM) Model The sport-specific RM model, with players presented as the stakeholder of interest, is summarised in Figure 1: the original research papers should be consulted for a detailed explanation of each aspect of the model5,6. There are three important general features of the RM model that should be noted: Injury mitigation interventions are not automatically mandated in RM: the need for risk mitigation is determined by

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whether stakeholders consider current risk levels acceptable or unacceptable; Situations should be reviewed when new risks are identified, new information about existing risks becomes available or stakeholder perceptions about existing risks change; The model is underpinned by quality management principles. Risk factors and the context of risk The complex way that risk factors define situational context has been described as7: “Risk must always be placed in a particular context. The context of risk is related to the stakeholders, the location, the equipment, the process, the weather, the time of day, the organisation, and the sector in which the risk occurs. In addition to the physical context, one must also consider the cultural, social and political context of the risk, as these aspects also affect the decision-making process of risk assessment.” Context is therefore of paramount importance and to ignore it during the development of injury mitigation procedures would be a mistake.

football medicine & performance

Player-specific factors

Facilities, equipment, activities, setting, etc

Figure 1. Sports injury risk management model (adapted from Fuller (2007))

Risk factors Preventive interventions

Epidemiology

Risk estimation

Risk mitigation

Stakeholders’ risk perceptions

Therapeutic interventions Risk evaluation

Unacceptable level of risk

Acceptable level of risk

Communicate information to sports community

Fuller described the importance of context in sport-related situations as6: “the risk experienced by each athlete is affected by his/her intrinsic risk factors and by the way in which these personal factors interact with the sports environment”. It is essential, therefore, that the specific context for which an injury mitigation programme is intended and the context in which the programme was examined be stated, so that application boundaries are transparent. In the RM model, risk factors are grouped into two sets, which together define the overall context. Factors such as athletes’ gender, body mass, joint flexibility, previous injury and risk-taking behaviour are included within the ‘playerspecific’ set, while factors such as laws of the game, weather, equipment and game activities are included within the ‘facilities, equipment, activities and setting’ set, as they impact on all players. Risk assessment Risk assessment is the cornerstone of RM and epidemiological studies within the risk assessment process provide the evidence to support RM decisions. An important outcome from epidemiological studies should be the identification of causation factors in general terms, such as acute/gradual onset and contact/non-contact activities, and in specific terms, such as whether the player was running, tackling or kicking the ball when injured. Clearly, injuries sustained in unpredictable events are likely to require different mitigation approaches to injuries sustained in controllable events. In order to evaluate injury mitigation procedures, pre- and post-intervention levels of incidence, severity and nature of injuries are minimum requirements. Evaluating injury mitigation procedures based on incidence alone does not provide sufficient information: the RM approach also entails measuring injury severity to determine whether there has been a reduction in injury burden5-10.

Risk mitigation (injury burden reduction) If the risk assessment process indicates a level of injury risk that stakeholders consider unacceptable then mitigation measures that might reduce the level of risk to an acceptable level should be identified and evaluated. The RM model defines injury burden by two parameters: incidence and severity of injury. Therefore, teams have two strategies available for risk mitigation (Figure 1); viz., preventive (reducing number of injuries) and therapeutic (reducing severity of injuries). Unfortunately, SoP has focussed attention on the prevention of injuries and opportunities to reduce injury burden through other strategies have been largely overlooked. There are, in addition to preventive measures, many therapeutic interventions that could be explored, such as timely removal of players from the pitch when first injured11 and developing player-specific12, sportspecific13 and injury-specific14 treatment and rehabilitation protocols. If an injury mitigation intervention does not reduce the risk to a level that is acceptable to stakeholders, revised or new mitigation processes are examined in the repeating RM cycle. When injury risk has been reduced to acceptable levels, the cycle follows a different course and takes researchers, governing bodies and clubs down the risk communication route to ensure that all relevant personnel are made fully aware of the mitigation procedures being adopted. Several governing bodies, including FIFA15, have adopted this approach. Conclusions The risk management model does not suffer from the weaknesses associated with the SoP model. This opens new possibilities for improving the quality of risk mitigation research, which will be discussed in Part-3 of this series.

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1. Fuller CW. Injury mitigation in team sports. Part-1: a review of current dogma. Football Med Perform Assoc J 2019;30 (Autumn). 2. Royal Society. Risk assessment – a study group report. Royal Society; London: 1983. 3. Royal Society. Risk: analysis, perception and management. Royal Society; London: 1992. 4. Fuller CW. Implications of health and safety legislation for the professional sportsperson. Br J Sports Med 1995;29:5-9. 5. Fuller CW, Drawer S. The application of risk management in sport. Sports Med. 2004;34:349-56. 6. Fuller CW. Managing the risk of injury in sport. Clin J Sport Med. 2007;17:182-7. 7. Fuller CW, Vassie LH. Health and Safety Management. Principles and Best Practice. Harlow; FT Prentice Hall: 2004. 8. Drawer S, Fuller CW. An economic framework for assessing the impact of injuries in professional football. Safety Sci 2002;40:537-56. 9. Fuller CW. Injury risk (burden), risk matrices and risk contours in team sports: a review of principles, practices and problems. Sports Med 2018;48:1597-1606. 10. Fuller CW. Assessing the return on investment of injury prevention procedures in professional football. Sports Med 2019;49:621-629. 11. Fuller CW. “Recognize and remove”: a universal principle for the management of sports injuries. Clin J Sports Med 2018;28:377-381. 12. Fuller CW, Walker J. Quantifying the functional rehabilitation of injured football players. Br J Sports Med 2006;40:151-157. 13. Della Villa S, Boldrini L, Ricci M, Danelon F, SnyderMackler L, Nanni G, Roi GS. Clinical outcomes and return-to-sports participation of 50 soccer players after anterior cruciate ligament reconstruction through a sport-specific rehabilitation protocol. Sports Health 2012;4:17-24. 14. Mendiguchia JE, Martinez-Ruiz E, Edouard P, Morin J-B, Martinez-Martinez F, Idoate F, Mendez-Villanueva A. A multi-factorial, criteria-based progressive algorithm for hamstring injury treatment. Med Sci Sports Exerc 2017;49:1482-1492. 15. Fuller CW, Junge A, Dvorak J. Risk management: FIFA’s approach for protecting the health of football players. Br J Sports Med 201;46:11-17

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football medicine & performance

INJURIES IN FOOTBALL: IT’S TIME TO STOP CHASING THE TRAINING LOAD UNICORN FEATURE / FRANCO M. IMPELLIZZERI, AARON J. COUTTS, MAURIZIO FANCHINI, ALAN MCCALL Training on the edge To reach or maintain top levels of human performance sometimes we need to “train at or near the limits of human capacity”. Athletes and coaches might deliberately accept an increased injury risk as a trade-off for the performance benefits. In contrast, this is often seen very differently by upper management, supporters and media. On one side they want the best performance, on the other side they do not want to accept the risks inherent to the process leading to such a performance. Indeed, they can be very quick to point fingers when an injury occurs. This has raised the pressure and stress on support staff within football teams. We are not saying that this absconds staff of any responsibility, but these responsibilities have been exaggerated by the idea that there are effective ways (including tools) to control negative effects of pushing performance limits i.e. injury. In the past few years this has been fuelled by part of the scientific community (in good or in bad faith). What we contend is the belief that injuries can be well controlled for in

the practical setting and there are scientific ways in which we can reduce the risk of them occurring. Of course, there are evidence-based approaches and principles, but the effects of these methods should be superior to the effect of the uncontrollable and unpredictable factors to be appreciated and visible in the real setting. In the modern view of injury, the role of contextual factors and multifactorial nature of their occurrence is becoming increasingly acknowledged.1, 9 In this article we focus on the suggestion that training load metrics can provide ‘magical’ figures to stop injuries from occurring. What we want to show is that the training load can just provide information to allow the coach to do his/her job better (i.e. informed decision making). However, metrics should not be used to determine if the training is too much, too low, or if the progression is just right or even wrong. Data itself does not mean anything and it is only with the expert knowledge and experience that can give meaning to these numbers. Scientists should stop giving these magical numbers

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powers that they just don’t have. We should acknowledge and highlight that injury occurrence is a complex phenomenon and, given its multifactorial nature, it is difficult to identify a single cause. We can work on the factors potentially having some links with injury mechanisms. However, even considering these factors, there are still too many influencing variables outside of our control and difficult to quantify. And rarely, even if advisable, we can work on all relevant contextual levels (socio-cultural, environmental, individual)(Figure 1).1 So when we implement some interventions we should hope for the best, but prepare for the worst. This article is intended to be contentious and thought-provoking, but at this point we believe it is needed. It is necessary to face and accept reality and stop chasing this training load unicorn. We have written this article from a sport science and coach perspective. From the sport science perspective we briefly explain why the studies trying to find an association between

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Care structure Popularity of sport Socio economic position

Country

Association Governance Policy Budget Sports

Athlete Socio-cultural level

Beliefs Perceptions Attitude

Individual level

INJURY

Environmental / policy level

Level Culture Social Structures

Figure 1. A socioecological model of sports injuries incorporating context at multiple levels. Reproduced with permission [Bolling et al. Context Matters: Revisiting the First Step of the ‘Sequence of Prevention’ of Sports Injuries. Sports Medicine, 48(10):2227-2234, 2018]

training load and injuries are weak and/or biased. From a coach perspective we believe that we should accept the uncertainty of the job, taking our responsibilities without jumping on dogmas that are used to protect positions (“I was working within the sweet spot so it is not my fault”) or to create the illusion of control to face our cognitive dissonance. No one responsible, all responsible Sacking specific staff members because of higher injury occurrence assumes managers have identified the causes of injury occurrence. Whilst this is theoretically possible, it is extremely unlikely or quite difficult to do. The first big assumption is assuming that the increase in injuries is not due to random variation. The second idea is that the higher injury rate is due to a specific factor, which is most of the time assumed to be the physical training, while it in fact may be due to other contextual factors. We all know that sometimes the change in staff is just a way to show supporters that the management is doing something to address a situation to take away pressure from coaches and/or players for poor performance. In that case, even if questionable, communication should be handled appropriately because being fired and blamed for an increase in injuries can ruin careers and reputations. In reality, the increase in injury occurrence over one or few seasons cannot be attributed to a specific cause.

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A resilient and robust player is likely the result of a process starting early. Pretending that a practitioner within a few weeks or even a few seasons can compensate what has not been done for years is quite unrealistic. For example, it is becoming a widespread idea that players who have poor running technique have an increased injury risk. Although we don’t have strong evidence on that, it is reasonable since poor technique (as well as any factors altering it like an injury, complaint etc.) can have an effect on load distribution on tissues. Addressing this would mean to start working and investing in this direction earlier in the development of a career, that is work done within the youth academies. Inviting an expert in sprinting and sprint mechanics may be a useful start, but the definitive step is a systematic investment in this direction rather than brief or one-off interventions. Similarly, recruiting a player with previous injuries means recruiting someone supposed to be at higher risk of reinjury. As science and medical staff we are there to inform upper management and coaches of potential injury risks when signing new players. Once the decision is taken, key stakeholders should be aware of the implications and risks. Congested match periods can be another factor increasing the injury risk, as a minimum because matches have a higher risk of injuries.6 Indeed, it is logical that an increase in exposure to matches will increase the risk of injury. But these matches and the

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revenue generated are what fuel all of the stakeholders working in the football industry. Hence reducing the number of matches is not easy when people realise the financial consequences of doing so. Currently, we have to acknowledge this risk and accept it without blaming or attributing the fault to others. Not sleeping enough, resting adequately, eating well etc. are also factors that can influence injury risk and hence these are also responsibilities of the players that, however, cannot be forced to change (maybe they should be educated earlier in their career, e.g. academies). It is clear that the causes of injuries are really multifactorial and not only related to the training completed or planned. This is for example what is shown in more modern and realistic multifactorial (at least conceptually) injury models.1, 9 By appreciating this multifactorial nature, it becomes clear that training load is just one component and treating it as this magical unicorn is clearly delusional. Even more so given these magical metrics, supposedly related to injury risk, have been developed using suboptimal methodological criteria and over-interpreted. Role of training load monitoring in injury prevention More than 15 years ago we introduced in the scientific literature the concepts of internal and external load to identify measurable components of the training process (Figure 2).10, 11 The assessment of

football medicine & performance

Structure specific strength

PERFORMANCE (INJURY)

PLAN

Training program

DETERMINANTS

Structure specific stress and strain TRAINING TARGETS

Application of TRAINING PRINCIPLES

EXTERNAL LOAD

INTERNAL LOAD

IMPLEMENTATION

Training load monitoring

PROCESS CONTROL

TRAINING OUTCOME

Figure 2. Simplified model of the training process,10, 11 adapted to injury prevention

these components allows to understand whether the external load has achieved the planned psychophysiological response (internal load) and whether that load has induced the expected adaptations (indirectly assessed by measuring the training outcomes). A variation of this model accounting for biomechanical factors has also been proposed.20 This can help evaluating the efficacy of the training. However, before considering if a training program is effective or not effective, the coach and the staff need to know whether the athlete has done what was planned. This is the main goal of training monitoring. The development of a training program should be based on understanding the determinants (e.g. limiting factors) of the performance, which are the systems targeted by training. In the context of injury prevention, these determinants are the factors related to injury risk. When programming it is the practitioner defining the load and its progression. This is done combining experience and available knowledge, but it is a subjective process and indeed it can differ from one practitioner to another. Therefore, the central part of the training process is the training plan and the practitioner or staff brains. Monitoring is just a tool to determine whether it has been implemented and executed as planned (we all know that the coaching sessions can differ from what is initially recommended). What we consider a dogma is the idea that, from an injury

prevention perspective, training load metrics coming from the monitoring system can inform us about whether the training load and its progression is right or wrong and is giving the staff indications on whether the risk of injuries is increasing or decreasing. This idea is based on two elements: one is related to study findings that practitioners believe, since published in scientific journals, should be “trusted�; and the second is that apparently some of these findings fit common and well-known training principles. We contend that the scientific publications in the field on monitoring and injury prevention are poor or with fundamental limitations, and as a consequence do not provide any scientific evidence (at best some relations that is not possible to distinguish from random and inconsistent associations). The fact that findings apparently fit the training principles is just because among all the several and diverse results available, some researchers have fished few results and popularised those fitting our beliefs and make more sense, ignoring the others (confirmation bias). Our alternative approach is more pragmatically to come back to what was done for decades that is the progression is decided by the coach who uses training principles such as overload progression and that this progression is evaluated by the coach based on athlete responses. Training load measures give the coach information about the extent to which the athlete is

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really doing what was planned, and how he/she is coping with the load so that the training can be adjusted (not only in terms of load but also contents). This is because the available evidence is not strong enough to use new metrics to understand whether the load is too much or too low. The evaluation of the adequacy of training load is based on a more holistic evaluation that consider various training components including the nature of the training stimulus completely ignored in the scientific studies. Training load-injury studies: the biggest fishing expedition ever Sport science should provide an objective appreciation of problems and an unbiased attempt to address them. But sport scientists are also humans and bias cannot be avoided. However, this bias can be limited and most of the research methods have been developed exactly for this aim. The idea that you are applying findings coming from studies and therefore they should be evidence based is not correct. Studies can be good and bad. Being published itself is not a guarantee of study quality and strength of the findings. The review process leading to publication, despite it represents the best approach available at the moment, is not perfect. For this reason, the methodology of the studies (risk of bias) should be evaluated and if insufficient then findings should not be considered or interpreted within the limit of the study. This should be, for example, the role of a good sport scientist working within

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feature (not arbitrary estimated). The one and four weeks, used for the acute and chronic load, are approximation of these time decays, that correspond to the time needed to dissipate the training effects. In other words, the time decays have nothing to do with the time windows for the calculation of an average. The parameters of the model are calculated for each individual and do not use the same values for all of the athletes. Finally, it is an additive model and not a ratio like the ACWR. Therefore, in no way can it provide a framework or a relevant reference model. In addition, the use of the ratio between acute and chronic is another problem well-known by statisticians for a long time5. Ratios add unnecessary noise and the ACWR in particular does not properly normalise the acute by the chronic neither mathematically nor conceptually.15 However, the domino effect is that other researchers have tried (and are still trying) to develop new metrics without any conceptual framework and rationale underpinning them17 they are just numbers without any practical meaning. Embracing these metrics just generates additional confusion.

a team or organisation. Not only searching for literature but evaluating its strength and quality. This means that other than specific knowledge in the sport area, good knowledge on research methods and statistics is paramount. The first critical aspect we warn practitioners is related to the nature and goal of the studies. Even if the studies would be methodologically sound (but they are not), they are all descriptive in nature with just a few ‘failed’ attempts to create predictive models. Indeed, no studies have tried to establish a cause-effect relation between training load and injuries in team sports. Predictive models, even if appropriately developed and their predictive validity demonstrated, can be useful but are not deemed to provide causal associations. This means that manipulating the features included in the model cannot change the likelihood of a future event (unless there is cause-effect relation that should be purposely examined). To check this is the case, just read the aims section of any paper to see whether the researchers have tried to establish a causal relation and how. Although experimental studies are the gold standard for cause-effect, there are methods developed to use observational data for causal inferences and these should be explicitly reported in the papers.18 Whilst these methods do not guarantee a cause-effect, they do provide higher level of evidence than studies just running correlational/regression analysis until they do not find something. Just for this fundamental reason, no recommendations on how to manipulate the training load to change injury occurrence can be provided.

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There are other methodological problems suggesting some of the observed associations can be just artefacts and spurious, questioning their relevance even from a pure descriptive perspective for creating theories or principles. The first problem is conceptual. Associations that have been reported in the literature with new metrics that lack any biological, physiological or mechanical explanation connecting them with injury mechanisms. Injury occurs because the stress and strain experienced by a tissue structure exceeded the tissue structure strength. Training load metrics and indicators (in relation to injuries) should reflect these two components: tissues structure strength or structure stress and strain. A conceptual framework on the mechanical causes of injuries has been recently presented14 (https://osf.io/ preprints/sportrxiv/vzxga/). No studies in football have presented plausible reference for conceptual frameworks associating the training load measures to these mechanical causes of injuries. Most studies just used what provided by companies and devices. The only attempt to reconcile metrics such as acute (last week), chronic load (last 4 weeks) and their ratio (acute:chronic workload ratio, ACWR)7, 8 is the Banister model. Liberally adapting this famous model ‘acute load’ was used as indicator of fatigue and ‘chronic load’ of fitness. However, this model was created for performance (mainly endurance sports) and not injuries. Additionally, the model has no physiological explanation (it is a mathematical model). This model is additive and combines two equations that use training load adjusted using time decays calculated from the data

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Without delving too deep into technical details (these will be addressed soon in purposely prepared scientific publications), among the methodological problems of the literature there are suboptimal statistical analyses (e.g. not accounting for the recurrence of injuries), low sample size, overfitting, selective reporting, p-harking, poor handling of missing data, etc. In addition, there are the poor practices favoured by the lack of a reference conceptual framework, which gives the researchers too many degrees of freedom, i.e. they can choose and select whatever they want increasing the risk of false discoveries. Just by manipulating one feature such as the selection of the number and the reference categories typical in some statistical analysis, it has been shown that it can generate at least 42% of false discoveries.4 Indeed, it is typical to classify metrics such as ACWR in categories. In soccer, some studies have used 3,13 others 416 and others 63 categories. The very high false discoveries were obtained just varying one feature of the analysis! Well, there are unfortunately, several other features that have been modified without any justification: data trimming methods, selection of metrics, training load measures, time windows for calculating the averages (from one day to weeks), time lag between training load calculation and injury occurrence, missing data handling, etc. Last but not least, even injury definitions are not consistent among studies: contact, combination of contact and non-contact, match-loss, both training and match-loss injuries, complaints requiring medical attention, complaints or injuries requiring a training session modification, combination of upper and lower body injuries and often unspecified severities/days lost. With these premises it is clear that the area is very prone

football medicine & performance to false discoveries and confirmation bias: if you torture the data long enough, they will confess whatever you want them to! Even the famous U-shape ACWR model has been created using inappropriate methods. Indeed, a retraction request was unsuccessfully submitted, citing that the model was purely “illustrative”. The errors were not questioned but just the “illustrative” nature (the letter and the review process documents can be found here: https://osf.io/preprints/sportrxiv/ gs8yu/).12 Unfortunately, although illustrative and developed with flawed methods, this model was published more than seven times in scientific journals including two consensus statements, one of which was from the International Olympic Committee (IOC).2, 19 The latter IOC presenting the model as validated and a request of clarification is still pending (https://bjsm.bmj.com/ content/50/17/1030.responses).19 And we are sure most of the readers know this famous figure but not the errors it contains. And that’s why a retraction was deemed necessary. So once again we advise practitioners not to have faith in this model also because the practical implications are worrying. Indeed, if the model would be right (luckily it is not), it would indicate that tapering and recovery weeks increase the risk of injuries (i.e. ACWR <0.8). Would you bet your job on this? If you do, it is at your own risk. To those saying that these studies raised the attention on training load, we remind that this is well-known among coaches, fitness trainers and sport scientists for at least the past half-century (overload progression and various periodization strategies); but we concede this may not be the case for other practitioners who are perhaps not familiar with basic training methodology. Conclusion: take the red pill By acknowledging that training load metrics cannot be used to identify whether the load is appropriate, or whether the progression is increasing the risk of injuries, our only solution is to come back to what was done for decades. That is to say, working on how to develop a training plan that defines the progression based on expert knowledge and ”best practice”, eventually adjusting the progression in relation to the athlete tolerance and response. Practitioners should ideally work on the components causally related to injuries: tissue structure, strength and strain. In other words, the good practitioner will use his/her knowledge, experience and skills to solve training program design problems to guide the athlete. This approach should be used to assist the players not only to cope but to thrive with ‘training on the edge’ and achieve those top levels of human performance needed for competitive advantage.

According to the training process framework,10 it is possible to have information about training efficacy. Training load monitoring can help to quantify overload progression to see if what was done was coherent with what was planned, including the progression that it is not defined by any magical metric but is planned and decided by the practitioner (expert knowledge). In rehabilitation or return to train and play, having historical records of training load, we can know the training load that players should be able to tolerate when re-integrating. The role of the support staff is to provide the coaches with the information necessary so that they can make an informed decision. Furthermore, we should always remember that, in the practical setting it is difficult to act on all contextual factors even if in an ideal world it would be the desired approach. This means we should downsize our expectations because we are trying to optimise only few factors out of all those that can potentially influence injury risk. Whatever we do is just an attempt driven by subjective decisions, and as such we should accept the uncertainty and the risks inherent in this attempt, which are largely unavoidable. Researchers and

1. Bolling C, van Mechelen W, Pasman HR, Verhagen E. Context Matters: Revisiting the First Step of the ‘Sequence of Prevention’ of Sports Injuries. Sports medicine (Auckland, N.Z.). 2018;48:2227-2234.

scientific journals should be careful in the messages they popularise because they can create or fuel dogmas. And once a dogma enters into daily practice, challenging it is an immense work and not always successful. The exaggerated role of training load and associated metrics in injury reduction is an example. Likewise, practitioners should be careful not to jump on the unicorn-chasing bandwagon just because a metric has been published and popularised. As practitioners we probably need to educate senior management and coaches that preventing injuries is not as simple as what it has been made out to be or what many salespeople are claiming, even those coming in as so-called saviours to performance teams with their misleading sales pitches. If someone in your team or wanting to come into your team proclaims that they have the magical system to prevent all injuries the well-known saying, ‘if it sounds too good to be true, then it probably is’ should be heeded! This article is an attempt in this direction, and we hope it can sensitise stakeholders on this important issue. Is this too much to ask? Welcome back to the real world of training for performance!

11. Impellizzeri FM, Rampinini E, Marcora SM. Physiological assessment of aerobic training in soccer. J Sports Sci. 2005;23:583-592.

2. Bourdon PC, Cardinale M, Murray A, et al. Monitoring Athlete Training Loads: Consensus Statement. Int J Sports Physiol Perform. 2017;12:S2161-S2170.

12. Impellizzeri FM, Woodcock S, McCall A, Ward P, Coutts AJ. The acute-chronic workload ratio-injury figure and its ‘sweet spot’ are flawed. SportRxiv,. 2019;

3. Bowen L, Gross AS, Gimpel M, Bruce-Low S, Li FX. Spikes in acute:chronic workload ratio (ACWR) associated with a 5-7 times greater injury rate in English Premier League football players: a comprehensive 3-year study. Br J Sports Med. 2019;

13. Jaspers A, Kuyvenhoven JP, Staes F, Frencken WGP, Helsen WF, Brink MS. Examination of the external and internal load indicators’ association with overuse injuries in professional soccer players. Journal of science and medicine in sport. 2018;21:579-585.

4. Carey DL, Crossley KM, Whiteley R, et al. Modeling Training Loads and Injuries: The Dangers of Discretization. Medicine and science in sports and exercise. 2018;50:2267-2276.

14. Kalkhoven J, Watsford M, Impellizzeri FM. A conceptual model and detailed framework for stressrelated, strain-related, and overuse athletic injury. 2019;

5. Curran-Everett D. Explorations in statistics: the analysis of ratios and normalized data. Adv Physiol Educ. 2013;37:213-219.

15. Lolli L, Batterham AM, Hawkins R, et al. The acute-to-chronic workload ratio: an inaccurate scaling index for an unnecessary normalisation process? Br J Sports Med. 2018;

6. Ekstrand J, Hägglund M, Waldén M. Injury incidence and injury patterns in professional football: the UEFA injury study. British Journal of Sports Medicine. 2011;45:553-558.

16. Malone S, Owen A, Newton M, Mendes B, Collins KD, Gabbett TJ. The acute:chonic workload ratio in relation to injury risk in professional soccer. Journal of science and medicine in sport. 2017;20:561-565.

7. Gabbett TJ. The training-injury prevention paradox: should athletes be training smarter and harder? Br J Sports Med. 2016;50:273-280.

17. Moussa I, Leroy A, Sauliere G, Schipman J, Toussaint J-F, Sedeaud A. Robust Exponential Decreasing Index (REDI): adaptive and robust method for computing cumulated workload. BMJ Open Sport & Exercise Medicine. 2019;5:e000573.

8. Gabbett TJ, Hulin BT, Blanch P, Whiteley R. High training workloads alone do not cause sports injuries: how you get there is the real issue. Br J Sports Med. 2016;50:444-445. 9. Hulme A, Thompson J, Nielsen RO, Read GJM, Salmon PM. Towards a complex systems approach in sports injury research: simulating running-related injury development with agent-based modelling. Br J Sports Med. 2018; 10. Impellizzeri FM, Marcora SM, Coutts AJ. Internal and External Training Load: 15 Years On. Int J Sports Physiol Perform. 2019;14:270-273.

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18. Rothman KJ, Greenland S, Lash TL. Modern Epidemiology. 3rd. Philadelphia: Lippincott Williams & Wilkins; 2012. 19. Soligard T, Schwellnus M, Alonso JM, et al. How much is too much? (Part 1) International Olympic Committee consensus statement on load in sport and risk of injury. Br J Sports Med. 2016;50:1030-1041. 20. Vanrenterghem J, Nedergaard NJ, Robinson MA, Drust B. Training Load Monitoring in Team Sports: A Novel Framework Separating Physiological and Biomechanical Load-Adaptation Pathways. Sports Medicine. 2017;47:2135-2142.

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football medicine & performance

CAUTIOUS RETURN TO PLAY COULD PREVENT MUSCLE INJURIES IN PROFESSIONAL FOOTBALL FEATURE / HÅKAN BENGTSSON, JAN EKSTRAND, MARKUS WALDÉN, MARTIN HÄGGLUND Håkan Bengtsson: PhD from the Division of Physiotherapy, Department of Medical and Health Sciences, Linköping University and member of the Football Research Group.

The UEFA Elite Club Injury Study is an injury surveillance study initiated by UEFA in 2001 to increase the safety of football players. To date, more than 50 clubs have contributed to the study by collecting data about injuries and football exposures in their teams. The study is conducted by the Football Research Group and led by professor Jan Ekstrand.

Jan Ekstrand: Professor from the Division of Community Medicine, Department of Medical and Health Sciences, Linköping University and founder of the Football Research Group. Chief Medical Officer at Aspetar Orthopaedic and Sports Medicine Hospital, Qatar. Markus Waldén: PhD from the Division of Community Medicine, Department of Medical and Health Sciences, Linköping University and member of the Football Research Group. Consultant orthopaedic surgeon at the Department of Orthopaedics, Hässleholm Hospital, Sweden.

Muscle injuries are commonly accepted as one of the biggest challenges in football medicine being the most frequent injury type in the sport. Since 2001, the injury landscape in professional European football has been studied in the Union of European Football Associations (UEFA) Elite Club Injury Study (ECIS). Through ECIS, information about more than 17 000 injuries has been collected and almost 40% of these injuries have been muscle injuries.1 Over this period of time, at least between 2001 and 2014, the hamstring muscle injury burden has increased with 4% per season.2 Since the intensity of professional football also have increased it has been argued that the increase in muscle injury rate could be a response to the increased load that players are exposed to due to the increasing intensity of the game.

Martin Hägglund: Professor from the Division of Physiotherapy, Department of Medical and Health Sciences, Linköping University and member of the Football Research Group.

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17

mental feature health

Extensive load could be a cause of injuries. Recent years has seen a significantly improved understanding about the relationship between player loads and injuries in football, especially with regard to muscle injuries, and several studies have been published analysing such possible associations. The rationale behind these possible associations is that high load may cause player fatigue which in turn may lead to players being more injury prone. Data collected for ECIS has shown that injuries are more common during the last 15 minutes within each match-half compared to earlier in the halves indicating that players may be more injury prone as they are fatigued during a game.3 In addition to in-game fatigue there has also been studies indicating that players may accumulate fatigue if they are not given enough time to recuperate between matches. Several studies have shown remaining signs of fatigue more than 72 hours following a game of football, or other physically demanding exercises designed to mimic the demands of a game.4 In addition, in ECIS the muscle injury risk has been shown to be 20% lower when players were given six days or more between two games compared to when games were separated by three days or less, i.e. playing one game versus two games per week.5 One of the most topical issues with regard to player load and injuries is arguably the relationship between players’ long term and short-term load, often referred to

as the acute to chronic workload ratio.6 It has been hypothesised, and to some extent confirmed in studies,7,8 that players who spike their workload and thus are exposed to high acute to chronic workload ratios are more likely to suffer injuries. It has also been hypothesized that players who are returning to playing football following an injury absence may be at an increased risk of new injury partly due to the fact that they have not been able to be properly accustomed to the high loads associated with playing professional football during their rehabilitation process.9

Players who spike their workload and thus are exposed to high acute to chronic workload ratios are more likely to suffer injuries.”

Re-injuries and subsequent injuries – A big concern. Re-injuries, defined as “an injury of the same type and at the same site as an index injury within the preceding year” are frequent in professional football, comprising 17% of all injuries. Interestingly, almost 80% of these reinjuries occur within two months after return to play from the previous injury. This could be considered an indication that players are allowed to return to football to soon following their injury absences to be properly prepared for the physical demands that they are exposed to as they return to team trainings and matches.10 In addition to the high risk of re-injuries, players who have been recently injured have also been shown to have an increased risk of other subsequent injuries.11, 12

4%

Muscle injury risk

3%

2%

1%

0% 0-1

2

3

4

5

6

7

8

9

10

Completed training sessions before first match Figure 1. The black line represents the risk of sustaining a muscle injury in the first match after an injury absence showing a 13% decrease in injury risk for each additional training session that was completed before the match. The dotted line represents the average risk of sustaining a muscle injury during a match in professional football.

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football medicine & performance

1. Ekstrand J, Krutsch W, Spreco A, van Zoest W, Roberts C, Meyer T, Bengtsson H. Time before return to play for the most common injuries in professional football: a 16-year follow-up of the UEFA Elite Club Injury Study. Br J Sports Med 2019 doi: 10.1136/ bjsports-2019-100666. 2. Ekstrand J, Waldén M, Hägglund M. Hamstring injuries have increased by 4% annually in men’s professional football, since 2001: a 13-year longitudinal analysis of the UEFA Elite Club injury study. Br J Sports Med. 2016;50(12):731-7. 3. Ekstrand J, Hägglund M, Waldén M. Injury incidence and injury patterns in professional football: the UEFA injury study. Br J Sports Med. 2011;45(7):553-8. 4. Silva JR, Rumpf MC, Hertzog M, Castagna C, Farooq A, Girard O, Hader K. Acute and Residual Soccer Match-Related Fatigue: A Systematic Review and Meta-analysis. Sports Med. 2018;48(3):539-83. 5. Bengtsson H, Ekstrand J, Waldén M, Hägglund M. Muscle injury rate in professional football is higher in matches played within 5 days since the previous match: a 14-year prospective study with more than 130 000 match observations. Br J Sports Med. 2018;52(17):1116-22 6. Gabbett TJ. The training-injury prevention paradox: should athletes be training smarter and harder? Br J Sports Med 2016;50:273–80.

The return to play process – Better safe than sorry? Based on ECIS data it has recently been shown that the overall injury rate for players in their first match as they return to play following an injury absence is 87% higher compared to the general match injury rate over a season. The increase in muscle injury risk is even more pronounced, with the muscle injury rate being 158% higher in the first match after an injury absence compared to the general muscle match injury rate. While these findings may be discouraging, it was also shown that injury rates in the first match after injury absences could be reduced if players were allowed to complete more training sessions before their first match.13 For each additional team-training session that players were allowed to complete before they played their first game their muscle injury risk in that game dropped by 13%. This presents an opportunity to possibly reduce the number of subsequent injuries, especially subsequent muscle injuries, following injury absences by simply allowing players to complete more team trainings before they are allowed to take part in any competitive games. As seen in figure 1 players who had completed six training sessions or more before their first match could play that match with only limited increase in muscle injury risk in comparison to the general

risk in match play. Also shown in figure 1 is that the biggest reduction in muscle injury risk was seen following the first four training sessions showing that a significant reduction in muscle injury rate could be reached by allowing four training sessions before the first game.13 Conclusion Muscle injuries are the most common injury type in professional football and the rate of muscle injuries seems to be increasing, possibly due to an increased intensity of the game. Several risk factors, such as previous injuries or extensive physical load, has been associated with increased risk of injury in several studies. One of the reasons why players seem to be at a significantly increased risk of injury in their first match after an injury absence could be that they have not been accustomed to the load associated with competitive match-play during their rehabilitation. It is therefore plausible that increasing the amount of full team training sessions before players are allowed to return to match play after an injury absence, thereby increasing their chronic load, could be an efficient way to reduce the number of muscle injuries in a professional football team.

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7. Bowen L, Gross AS, Gimpel M, Bruce-Low S, Li FX. Spikes in acute:chronic workload ratio (ACWR) associated with a 5-7 times greater injury rate in English Premier League football players: a comprehensive 3-year study. Br J Sports Med. 2019 doi: 10.1136/ bjsports-2018-099422. 8. Delecroix B, McCall A, Dawson B, Berthoin S, Dupont G. Workload and non-contact injury incidence in elite football players competing in European leagues. Eur J Sport Sci. 2018 Oct;18(9):1280-7. 9. Blanch P, Gabbett TJ. Has the athlete trained enough to return to play safely? The acute:chronic workload ratio permits clinicians to quantify a player’s risk of subsequent injury. Br J Sports Med2016;50:471–5. 10. Hägglund M, Waldén M, Ekstrand J. Injury recurrence is lower at the highest professional football level than at national and amateur levels: does sports medicine and sports physiotherapy deliver? Br J Sports Med. 2016;50(12):751-8. 11. Nordström A, Nordström P, Ekstrand J. Sports-related concussion increases the risk of subsequent injury by about 50% in elite male football players. Br J Sports Med. 2014;48(19):1447-50. 12. Waldén M, Hägglund M, Ekstrand J. High risk of new knee injury in elite footballers with previous anterior cruciate ligament injury. Br J Sports Med. 2006;40(2):158-62. 13. Bengtsson H, Ekstrand J, Waldén M, Hägglund M. Few training sessions between return to play and first match appearance are associated with an increased propensity for injury: a prospective cohort study of male professional football players during 16 consecutive seasons. Br J Sports Med 2019 doi: 10.1136/bjsports-2019-100655.

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GENERALISED JOINT HYPERMOBILITY WHY SHOULD IT BE SCREENED FOR WITHIN A FOOTBALL SETTING? FEATURE / ADAM JOHNSON What is Generalised Joint Hypermobility? Generalised Joint Hypermobility is a term that is used to describe the capability of joints to move beyond their normal limits. Patients who are deemed “hypermobile” are the ones who have excessive levels of joint mobility. Adam Johnson First Team Performance Physiotherapist Brighton & Hove Albion Football Club @PreventionPhys

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Generalised Joint Hypermobility (GJH) is usually a hereditary condition, however, it may also be acquired as a result of sporting performance through activities requiring excess mobility, such as ballet. To be classified as having GJH there must be five or more joints involved. Acquiring hypermobility through athletic performance in one joint only (for example, knee hypermobility) would not be enough to be classified as having generalised joint hypermobility. The more appropriate term to use would be “localised joint

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hypermobility”, as per the Ehlers Danlos Society’s definition. GJH is a part of a wide spectrum of hypermobility disorders (Figure One). GJH, accompanied by musculoskeletal manifestations, provides a diagnosis of generalised hypermobility spectrum disorder. This may also potentially encompass Elhers Danlos Syndrome. If an athlete is suspected to have GJH, it is important to understand the screening tests that can be used. Figure One: The Hypermobility Spectrum taken from https://www.ehlers-danlos. com/what-is-hsd/ Key To Figure: G= Generalised, P= Peripheral, L= Localised, H= Historical, JH= Joint Hypermobility, HSD= Hypermobility Spectrum Disorder, hEDS= Hypermobile Ehlers-Danlos Syndrome.

football medicine & performance

Type

Beighton score

Musculoskeletal involvement

Asymptomatic GJH

Positive

Absent

Asymptomatic PJH

Usually negative

Absent

JH typically limited to hands and/or feet

Asymptomatic LJH

Negative

Absent

JH limited to single joints or body parts

G-HSD

Positive

Present

P-HSD

Usually negative

Present

JH typically limited to hands and/or feet

L-HSD

Negative

Present

JH limited to single joints or body parts

H-HSD

Negative

Present

Historical presence of JH

hEDS

Positive

Possible

How do we screen for Generalised Joint Hypermobility? The most commonly utilised hypermobility screening tool is the Beighton Scale. This tool encompasses a battery of tests that assess the range of movement in the little fingers, thumbs, elbows, knees and lumbar spine flexion. The Beighton Scale provides a score out of nine, with a score of 5 or greater seen as a positive indicator of GJH in pubertal men and women up to the age of 50 (JuulKristensen et al., 2017). The cut off score used to define a hypermobility changes with age, with children requiring a higher score of 6/9, and subjects over 50 requiring 4/9. The Beighton Scale has been widely used within published literature, and forms one criterion of the wider assessment for Hypermobility Spectrum (Figure One). The screen is easy and quick to perform and requires no specialist equipment. It has also been deemed valid and reliable (JuulKristensen et al., 2017). On the other hand, if we are looking at footballers specifically, then only one element of the Beighton Scale assesses lower limb laxity, and this is only in a single plane of movement. The Lower Limb Assessment Score (LLAS) (Ferrari et al., 2005) may therefore be a more appropriate tool to use when screening footballers for GJH. The LLAS includes twelve multi-planar assessments of the hip, knee, ankle and foot. A recent study has now validated the LLAS within a football setting (Johnson, Ward & Simmonds, 2019), and suggested that a cut off of 4/12 is appropriate for an adult footballing population.

Why is screening for Generalised Joint Hypermobility important in football? The first high quality epidemiological study which aimed to address this question within an elite football environment was completed by Collinge & Simmonds (2009). The study recorded injury rates and rehabilitation periods in a second-tier first team squad. The injury rates between the hypermobile and non-hypermobile players were then compared. The study identified that the hypermobile group presented with very similar rates of injury through the season when compared to the nonhypermobile group (6.2 vs 6.3 injuries per 1000hrs respectively). Despite these similar rates, the hypermobile group demonstrated a greater number of training days missed (71 vs 31 days) as well as a greater number of competitive games missed (12 vs 5 games) over the course of the season. The authors concluded that although the hypermobile players were not more prone to injury, they were perhaps prone to more significant injuries. It is important to note that these findings were not statistically significant. A larger cohort study performed by Konopinski et al. (2016) looked at three different second-tier clubs injury rates over the course of a season. Their study reported a slightly greater risk of injury within the hypermobile populations at the three clubs, however, this finding was also deemed to be “suggestive but not conclusive”. This lack of statistically significant findings within the two studies highlights the need for further research into the influence of hypermobility and football injuries. Furthering work in the area utilising the Lower Limb Assessment Tool may also provide different, and more specific, answers to the current questions.

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Notes

In reading this article, there may now be more awareness that current research has identified that approximately a quarter of football squads would be classed as “hypermobile” (when using a 5/9 Beighton Scale cut off). This is a large percentage of athletes within football squads for whom it is not yet fully understood how to best manage. It may be that hypermobile players potentially require more proprioceptive input, or strengthening through extreme ranges than the non-hypermobile athlete, in order to help reduce their risk of injury. However, until further research is done in the area, we cannot simply make assumptions surrounding their management.

Collinge & Simmonds (2009). Hypermobility, injury rate and rehabilitation in a professional football squad- A preliminary study. Physical Therapy in Sport, 10, 91-96. Ferrari, J., Parslow, C., Lim, E. & Hayward, A. (2005). Joint hypermobility: The use of a new assessment tool to measure lower limb hypermobility. Pediatric Rheumatology, 23, 413-420. Johnson, Ward & Simmonds (2019). The Lower Limb Assessment Score. A Valid Measure of Hypermobility in Elite Football? Physical Therapy in Sport, 37, 86-90. Juul-Kristensen et al. (2017). Measurement properties of clinical assessment methods for classifying generalised joint hypermobility- A systematic review. American Journal of Medical Genetics Part C (Seminars in Medical Genetics), 175C, 116-147. Konopinski et al. (2016). The effect of hypermobility on the incidence of injury in professional football: A multi-site cohort study. Physical Therapy in Sport, 21, 7-13.

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2020 “The 2020 FMPA conference will take a critical look at the MDT; the Past, Present and Future. The last 10 years have seen a proliferation in the field of Sports Science and Medicine; for the better? As each individual discipline strives for recognition amongst a landscape of opinions, how do we create clarity amongst the inevitable chaos? How is it best achieved? The term interdisciplinary team is frequently used but how does this truly look? More importantly, how does this truly work? Calling on experts across world leading institutions, a wide-ranging assembly of MDT speakers will discuss best practice, challenges faced and what the future holds for want-to-be world leading performance and medicine departments.”

Knowledge is power and strength comes from working together

Confirmed Speakers: James Morton, Professor of Exercise Metabolism, Liverpool John Moore's University Steve Kemp, Lead Men’s Physiotherapist, The FA Dr Gil Rodas Font, FC Barcelona Luke Jenkinson, Head of Sports Science & Academy Medicine, Derby County FC Thomas O’Malley, Head of Physiotherapy, Wigan Warriors Rugby League Club Mark Leather, Senior Lecturer in Sports Medicine & Therapy, University of Central Lancashire Matthew Portas, Lead Physical Performance – Education, The FA Daniel Ransom, Academy Psychologist, Manchester United FC Awaiting Confirmation, Sports Therapy Frankie Hunter, Academy Head of Sports Science and S & C, Middlesbrough FC Professor Warren Gregson, Head of Sports Science, Qatar Football Association Further speaker/details of individual presentations to be announced

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UNDERSTANDING AND DEVELOPING RELATIONSHIPS IN THE MODERN FOOTBALL HIERARCHY FEATURE / DR DANIEL PARNELL & PROFESSOR BARRY DRUST Over the past two decades, football has developed into a hyper-commercialised multimillionpound industry involving a range of stakeholders including investors, global media, sponsors and supporters. One strategy aimed at creating more sustainable football operations, embraced in European football but received more reluctantly in English football, is the recruitment of a Sporting Director. Sporting Directors in football are strategically adopted to broadly protect an owner’s investment and provide a competitive advantage. Undoubtedly, there have been both early successes and failures associated with the position in the sport, yet for many in the game we are now beyond the time when the role is simply a transient trend. As a result we can expect to see Sporting Directors become more popular and mainstream across the game in the United Kingdom over the next few years. Given the importance of this

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role in overseeing all sporting strategy, inclusive of performance (sport science and medicine) it is important to consider this context and how individuals working in professions allied to sport and exercise science and medicine may be able to further strengthen these relationships. Despite more and more clubs adopting this strategy, the role of the Sporting Director remains shrouded in mystery. Such uncertainty is partly associated with the inconsistency in both the title and the roles and responsibilities associated with the job. As a result the role of the Sporting Director is somewhat ambiguously understood externally by fans and media and internally by club employees. Broadly, the Sporting Director can be described as a senior executive with a sports-specific management remit. The role Sporting Directors are often responsible for the overall performance of all sporting

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departments. This extends from the first team, Under-23s, academy, and scouting, through to the medical and sport science department. The Sporting Director regularly assumes a board level position and is responsible for the delivery of the strategic plan for the club to achieve its sporting aims. A number of key aspects of the role includes: Support the first team and head coach; Employ the best talent to assume leadership over the various sporting departments; Manage the movement of players in and out of the club; Oversee the performance of all sporting departments including medical and sport science. Despite this, each club approaches the role in a unique fashion and it is often unclear what the exact role a Sporting Director is undertaking. As such, the lack of clarity surrounding the role has prompted

football medicine & performance

speculation and concern by stakeholders in the game. Our recent research on the Sporting Director outlined some interesting findings related to the title and job role of Sporting Directors (Parnell and colleagues, 2018). Sporting Directors explained that some stakeholders assumed they had control of recruitment: “Titles in the football industry can be confusing but providing that the functions and responsibilities are clearly understood within all of the football structure of the club then the title becomes less important.”. “The biggest challenge is that the industry gains a better understanding of the role. Boards and Owners appear to have difficulty understanding […]. More help for the Board/Owner to understand the requirements will be necessary to achieve this”. (Director of Football) This can have a consequence for both external and internal relationships: “…If the press and fans, or even just the lads in the academy think you have an influence on recruitment [i.e., transfer in and out of players], when you don’t, then basically your head is on the line. At my last club, because no-one really knew who was in charge of transfers, it ended up with other clubs and agents [i.e., intermediaries] getting caught between me, the Chairman and the first team manager. It was a bit embarrassing and not good for business. This stuff has to come from the top and needs to be communicated”. (Head of Football Operations) The majority of those in football leadership positions highlighted that the role was most important to them, rather than just achieving the Sporting Director title. This is important, as some may seek to attain the Sporting Director title given the kudos associated with the role and the implications that this may have on their employability: “If you have the title, regardless of role, it means that you [your CV] are on the table for any new jobs at that level” (Director of Football) “Once you have the title, then you are immediately on the radar of recruitment companies. It’s a lot riskier for them to put someone in [recommend someone for the job] who has never had the title, than someone who has” (Director of Football)

Therefore, those working in the game must look beyond the title and focus explicitly on the role. One previous senior football leader outlined:

have highlighted potential issues. This is especially true of medical and sport science departments in elite football environments, where multiple stakeholders are involved:

“There are many titles and yet there is little consistency in job descriptions. In my case I am Vice Chairman of Football. I believe my job description is more important than the title. I also believe I am by definition the true Sporting Director…

“What strikes me is the number of people with a stake in a player’s health and wellbeing. Naturally, we all want the best possible support for players. However, we now have a situation where players have their own doctor and in some case whole support team.

[…] The Sporting Director ‘Directs the Sport’ and that should be everything to do with the sport. Using and selling players, hiring and firing managers and coaches, setting targets and objectives within the culture, values and philosophy of the club and providing guardianship of that culture and those values. Where sports performance is concerned the true Sporting Director is the ultimate decision maker and holds responsibility and accountability for that performance. I think many incumbents of the role under this or any of the other titles rarely have this full level of responsibility. They are rarely Board Level Directors and most often the big decisions regarding players and coaches and budgets are made by other Executives ( CEO’s) or Owners / Chairpersons. Big decisions aren’t made by inexperienced or non-sporting directors. (Vice Chairman of Football) Given this, there is no surprises that there is considerable vagueness regarding the roles and responsibilities of those within the role. This can have consequences internally across the club. Role ambiguity can also create confusion with the fans and media. This creates a number of concerns given the evidence that suggests poor communication and/or blurred lines with respect of roles and responsibilities can trigger stress, role duplication and repetition, which can result in the failure of the organisation to achieve its strategic aims and objective and nodoubt the overall performance of the people and organisation. Interestingly, in performance environments, leaders must consider the implication of confusion in role. The lack of clear identity, shared visions, and behaviours, may result in an environment or ‘team’ of individuals, with multiple and variable motivation who may be more focussed on performance irrelevant and self-interested agendas, than a performance focused common purpose (see Cruickshank and Collins, 2015; Drust, O’Boyle and Gillett, 2018). Ultimately, this lack of clarity has the potential to cause internal communication challenges when the organisational structure is not clear and roles and responsibilities are undefined. This could be especially the case as medical and science departments continue to grow. Current Sporting Directors in elite football

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I am sure this is done with the best intentions, and is sometimes led by the player and other times by their intermediaries. But this has meant dealing with sport science and medical staff is becoming a huge headache, whether it’s related to training, contracts, loans or teamselection - it impacts an organisation’s decision-making and performance. In an efficient organisation, you would expect to consult with one voice as part of a collaborative management, but we just haven’t got that.” (Sporting Director) What can be done? Get to know people. This seems the most obvious recommendation to many, yet in the fast-paced, busy world of football, this simple notion can be missed. We recommend that those in the game explore the wider context of club structure, people and their roles and responsibilities. This will help identify misunderstanding, dualrole, duplication and gaps. Get channels for communication. The importance of communication is often undervalued within any organisation. People simply don’t know how important it is for creating flows of information and innovation, whether its new ideas, new ways of doing things, or making sure the strategy is put into practice on a day-to-day basis. Create methods to flatten the organisational structure through within group, across group and across hierarchy communication channels.

Cruickshank, A., and Collins, D. (2015). Illuminating and applying “the dark side”: insights from elite team leaders. Journal of applied sport psychology, 27(3), 249-67. Drust, B., O’Boyle, A., and Gillett, M. (2018) Managing Performance in elite professional football. In: The Routledge Handbook on the Business of Football, edited by Simon Chadwick, Daniel Parnell, Paul Widdop, and Christos Anagnostopoulos. Chapter 12. Parnell, D., Groom, R., Widdop, P., and Ward, S. (2018). The Sporting Director: Exploring Current Practice and Challenges within Elite Football. In: The Routledge Handbook on the Business of Football, edited by Simon Chadwick, Daniel Parnell, Paul Widdop, and Christos Anagnostopoulos. Chapter 13.

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football medicine & performance

WHAT TO DO AND WHEN TO DO IT? THE TRICKY QUESTION OF SPECIALISATION IN YOUTH FOOTBALL FEATURE / LAURA FINNEGAN What is specialisation? Consensus at the American Orthopaedic Society for Sports Medicine (AOSSM) was that early sports specialization, or early single-sport specialization, be defined by the following 3 criteria: (1) Participation in intensive training and/or competition in organized sports greater than 8 months per year (essentially year round) (2) Participation in one sport to the exclusion of participation in other sports (limited free play overall) (3) Involving prepubertal (seventh grade, US, Year 8-England, S1Scotland or roughly age 12 years) children (LaPrade et al., 2016). Vealey and Chase (2016) suggest that specialisation involves an investment in a single sport through systematic training and competition, typically including yearround participation in that sport, to pursue proficiency and enjoyment in a signature activity. The opposite of specialization is diversification, which is an investment in a broad range of sports and activities. Although we tend to view specialization and diversification dualistically, as categorical opposites, in reality they are on a continuum representing the degree to

which athletes specialize or diversify (see figure 1). Research has shown that a common development pattern for elite athletes was to narrow their number of activities to focus on their main sport in the specializing years but remained involved in a couple of other sporting activities for relaxation and cross-training during the off-season (Baker et al., 2003).

Diversification

A growing trend across youth sport has been a push for exclusive specialisation, in which athletes discontinue all other sports and most other extracurricular activities, to train and compete in one sport.

Specialization

Overspecialization

Narrowing of focus and investment

Figure 1 Specialisation continuum (Vealey & Chase, 2016)

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feature When and why is it an issue? Overspecialization occurs when children, often controlled by parents or coaches, pursue expertise and extrinsic rewards in one sport through year-round systematic training and competition, and sacrifice their psychological development and well-being as well as participation in most all other activities typical of kids their age (Vealey & Chase, 2016). The consensus statement of the American Medical Society for Sports Medicine (DiFiori et al. 2014) on overuse injuries and burnout in youth sports contends that a variety of physical and mental health concerns can be attributed to early sports specialization. It can isolate the young athlete from their peers (i.e. removal from school teams) and can increase the potential for burnout as a result of stress (Wiersma, 2000). Athletes who began training at a younger age and invested more hours per year training at ages 12 and 13 were more likely to drop out of sport (Wall &Côté, 2007). Athletes who specialize before the age of 12 may also have a greater risk of physical injury (LaPrade et al., 2018). Merits of early diversification Advocates of achieving elite performance through sampling more sports and activities through an athletes’ early development stage (early diversification), claim that it may lead to the same senior skill level without these negative consequences (Côté & Hancock, 2015). Footballers can diversify early and still attain elite status as an adult Elite athletes in a variety of sports have achieved elite sport status after engaging in early diversification (or sampling) in their childhood years (typically until around age 12) (Côté, 1999; Baker et al., 2003; Gulbin et al., 2010). A study of German footballers found that the German National Team players differed from amateurs in more nonorganised leisure football in childhood, more engagement in other sports in adolescence, later specialisation, and in more organised football only at age 22+ years (Hornig, Aust & Güllich, 2016). Retain a broader sense of identify Exclusive specialization at a young age can restrict children to a unidimensional selfconcept, which has been linked to burnout and psychological dysfunction (Coakley, 1992). Christensen and Sørensen identified how players struggled to balance the competing demands of school and sport. The perceived necessity to dedicate “100 percent” to football meant that players experienced a premature identity closure, in favour of sport. Research has shown that a strong athletic identity is associated with higher commitment and achievement in sport, but can also be problematic when coping with an injury or managing the transition out of sport (Clarke et al., 2018). Jones, Glintmeyer and McKenzie (2005) have recommended that coaches should help to develop athletes with multiple identities by encouragement to remain engaged with extracurricular activities, thus reducing this reliance on solely a footballing identity (figure 2).

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Finnegan et al., (2020) found that in a long term developmental study of youth footballers, the availability of switching between football codes (Gaelic football v association football) and teams (e.g. club v school) allowed for a greater sense of confidence building by allowing the players to go back into another team with less expectations and pressure. These enhanced perceptions of self-worth and increased motivation were then brought back into their academy environment to advance their development. Recommendations: Try and reverse the ‘race to the bottom’ Minimal ages to compete in competitions and tournaments produce a trickle-down effect on youth sport. Younger competitive structures often fuels the pressure on kids to specialise early (e.g. ‘international elite under

9’ competitions, Müller, et al., 2018) and can lead to a footballing ‘fear of missing out’ on the next superstar. Brian Jones (former Aston Villa academy manager) notes “Aston Villa spend a fortune looking at boys from six onwards – with the best will in the world I wouldn’t know if a six, seven, eight-year-old is going to play in the Premier League in 10 or 12 years’ time. It’s ludicrous.” (Green, 2009). An outdated belief in reaching a mythical 10,000 hours combined with the competitiveness between clubs can often fuel this drive for earlier specialisation. Parental pressure can also enhance the drive for earlier specialisation, as intuitively it seems to make sense that the more hours their child spends purely playing football the better for their development, but as we’ve seen above that isn’t always the case. Education for parents can be key in this regard.

Figure 2 Multidimensional Identity versus Unidimensional Identity (Vealey & Chase, 2016)

School, achivement, particularly art and science

Drawing

Hip-Hop dance

Tennis

Camping with family

Multidimensional identity

Tennis

Unidimensional identity

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football medicine & performance Figure 3 Qualified Education and Training Support (Myer et al. 2015)

Baker, J. (2003). Early Specialization in Youth Sport: a requirement for adult expertise? High Ability Studies, Vol. 14, No. 1, 85-94, DOI: 10.1080/13032000093526.

Mastery of Fundamental Movements

Psychosocial

Clarke, N.J., Cushion, C.J. & Harwood, C. (2018). Players’ understanding of talent identification in early specialisation of youth football. Soccer and Society, DOI: 10.1080/14660970.2018.1432388. Coakley, J. (1992). Burnout among adolescent athletes: A personal failure or social problem? Sociology of sport Journal, 9(3). 271-285. DOI: 10.1123/ssj.9.3.271

Neuromuscular

Program Variation

Progressive Exercises

Visual Motor

Neurocognitive

Conclusion There are athletes who choose to narrowly specialize in one sport because it is their passion, they enjoy it, and they choose to spend their time focusing on that sport. Professional Golfers’ Association (PGA) star Rickie Fowler’s mother recalls her son’s devotion to golf: “When he was 7, he told me, ‘Mom, I don’t want to play baseball or do gymnastics anymore. Just golf. I want to be a pro.’ And he worked on it every day. He sacrificed his social

Côté, J. (1999). The influence of the family in the development of sport, The Sport Psychologist, 13,395 – 416 DiFiori, J.P., Benjamin, H.J., Brenner, J, et al. (2014). Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine. Br J Sports Med. 48:287–288. Doi: 10.1136/bjsports-2013-093299 Finnegan, L., McArdle, J. Littlewood, M. & Richardson, D. (2020). “The Talent Is Out There” Talent Development In Irish Football: A Study Of Organizational Structure And Practice. PhD (submission 2020). Liverpool John Moores University.

Structured Recovery

Player welfare Children who participate in more hours per week than their age, for more than 16 hours per week in intense training, and who are specialized in sport activities should be closely monitored for indicators of burnout, overuse injury, or potential decrements in performance due to overtraining (Jayanthi, 2011). Youth who specialize in a single sport should plan periods of time to enhance diverse motor skill development and reduce injury risk factors (Myer, 2016) (figure 3). Des Ryan (Head of Sport Medicine and Athletic Development, Arsenal FC Academy) notes that “categorically the research has shown that early specialisation is bad, in terms of participation later on and injuries…but excellence takes time and we need that time with them and that will lean towards specialising early” (2018). Arsenal encourage multi-sport participation from younger age groups, progressively becoming narrower until 16 when the players specialise. They provide encouragement to engage in other sports, have a physical literacy programme, programme of cooperative games and provide sessions of multi-sport activities (periodised over the year, varied and often linked to coach goals i.e. session on finding space may utilise sports that emphasise that skill). With players from the U9 to U11 age groups mainly focusing on functional competence, fundamental movement skills, and multisport content (Ryan et al., 2018).

Côté J. & Hancock D. J. (2015). Evidence-based policies for youth sport programmes. Int. J. Sport Policy Polit. 8 51–65. 10.1080/19406940.2014.919338

life. No parties. No vacations. Didn’t go to football games. I was a little worried back then. He actually allows himself a little bit more fun now. But either way, he loved it” (Diaz, 2014, p. 108). An issue can arise when adults see these examples and assume that early, exclusive specialization is the pathway for all kids to take (the ‘Tiger effect’). We forget that the passion and commitment must be inside of the young athletes, and the choice to specialize and train to the exclusion of most other pursuits is theirs (Vealey & Chase, 2016). Côté and Erickson (2015) emphasise that one can specialise in a single sport-specific domain and sample through different experiences of the same sport domain (e.g., in case of football: playing and practising with your club, playing beach soccer with friends, playing in a park, school, and playing on your own). Ford found that still elite football players had twice as many average hours per year in soccer play activity between 6-12 years of age compared with the ex elite. For every elite performer that specialised early in football there is 100x the number who were not successful doing exactly the same thing. We should be more aware of the existence of a survivorship bias when designing youth development pathways. Various pathways can lead to expertise in football (i.e. early specialisation, early diversification and early engagement) with key recommendations being to derive an appropriate balance between domain-specific deliberate practices (i.e. team practice), participation in domain specific play (e.g. fun football activities that foster motivation, decision-making skills, enhance movement patterns) and external activities to enhance perceptions of identity (Jones et al., 2005; Ford et al., 2009; Finnegan et al. 2020) all while being cognisant of player agency, choice and well-being.

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Ford, P.R., Ward, P. Hodges, N.J. & Williams, M.(2009) The role of deliberate practice and play in career progression in sport: the early engagement hypothesis, High Ability Studies, 20:1, 65-75, DOI: 10.1080/13598130902860721 Green, C. (2009). Every Boy’s Dream. London; A&C Black Publishers. Gulbin, Oldenziel, K.E., Weissensteiner, J.R. & Gagne, F. (2010). A look through the rear view mirror: Developmental experiences and insights of high performance athletes. Talent Development and Excellence, 2(2):149-164. Hornig, M., Aust, F. & Güllich, A. (2016). Practice and play in the development of German top-level professional football players. European Journal of Sport Science, 16, 96-105. Doi: 10.1080/17461391.2014.982204. Jayanthi N, Dechert A, Durazo R, Luke A. (2011). Training and specialization risks in junior elite tennis players. J Med Sci Tennis. 16:14–20. Jones, R. L., Glintmeyer, N., and McKenzie, A. (2005). “Slim Bodies, Eating Disorders and the Coach-athlete Relationship.” International Review for the Sociology of Sport, 40(3): 377-391. doi:10.1177/1012690205060231 LaPrade, R. F., Agel, J., Baker, J., Brenner, J. S., Cordasco, F. A., Côté, J., … Provencher, M. T. (2016). AOSSM Early Sport Specialization Consensus Statement. Orthopaedic journal of sports medicine, 4(4), 2325967116644241. doi:10.1177/2325967116644241 Müller, L., Gehmaier, J., Gonaus, C., Rascher, C. & Müller, E. (2018). Maturity Status Strongly Influences the Relative Age Effect in International Elite Under-9 Soccer. Journal of Sports Science and Medicine, 17, 216-222. Myer, G.D., Jayanthi, N., DiFiori, J.P., et al. (2016). Sports specialization, part II: alternative solutions to early sport specialization in youth athletes. Sports Health. 8:65–73. Ryan, D. (2018). ASCA Podcast #22. Retrieved from: https://soundcloud.com/user-183248915/asca-podcast22-des-ryan Ryan, D., Lewin, C., Forsythe, S. & McCall, A. (2018). Developing World-Class Soccer Players: An Example of the Academy Physical Development Program From an English Premier League Team. National Strength and Conditioning Association, 40(3), 2-11. Vealey, R. & Chase, M. (2016). Best Practice for Youth Sport. Champaign, Il.: Human Kinetics. Wall, M. & Côté, J. (2007). Developmental activities that lead to dropout and investment in sport. Physical Education and Sport Pedagogy. 12, pp. 77–87. doi: DOI: 10.1080/17408980601060358 Wiersma L. (2000) Risks and benefits of youth sport specialization: perspectives and recommendations. Pediatr Exerc Sci. 12:13–22.

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football medicine & performance

TRAINING THE SEMI-PROFESSIONAL FOOTBALLER FEATURE / DANIEL BERNARDIN & DYLAN MERNAGH Outside of elite football, players feel that “nobody cares about them” and there is “a lack of professional support”. They “want to play at the highest level they can” and to do this, they “want to train like a pro”.

At the professional level people care about you and look after you, at the semi-professional level, no one seems to care.”

FSCR (Football Strength Conditioning & Rehabilitation) is a dedicated team of practitioners working within professional football. Our story started when a player who was at a professional academy as an 18-year old dropped down into non-league and wanted to find a way to continue to train like a professional. Our research found limited options except for expensive personal trainers with no elite football experience. This is when we realised that the semi-professional footballer was getting limited or poor support to help them be the best they can be, and FSCR was established to fulfil this need. Football is the world’s game with many players aspiring to reach the highest levels, with the Premier League now being a coveted destination. Unfortunately for the vast majority of those participating in football, they are more likely to be hit by a meteorite than make it as a professional footballer. It is estimated

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that less than 0.02% of those players playing within an academy setting will go on to have a full-time career in the game, with the numbers even lower for those outside of the academy set up. As a company our mission is to provide elite Strength, Conditioning and Physiotherapy support to all players’ in a results driven environment that allows every player to train like a pro. Strength & Conditioning (S&C) Our Strength & Conditioning programme aims to cover all the basics of athletic development and injury prevention. We know there are a myriad of physical factors that influence football performance and no single attribute is going to make the difference. However, by providing a well-rounded strength and conditioning programme to these players we hope to help bridge the gap to the physical qualities seen at the professional level. Currently we deliver one strength and conditioning (S&C) session per week and that session is on a Wednesday as most semi-pro clubs will train Monday, Tuesday and Thursday. If they have a mid-week game (Tuesday)

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feature the players have the option of coming in for an active recovery session which will include light aerobic work on the bike, upper body (stimulates growth hormone to aid recovery), soft tissue mobilization (foam rolling/mobility or sports massage) and contrast therapy. Due to the players’ training schedule and the fact most players have a full-time or part-time job alongside football, we only recommend one S&C session per week. Due to the financial constraints of working with this target market we provide group strength and conditioning sessions which reduces the cost for each player. We provide one coach to every six players and each programme or phase lasts six weeks. Players are only progressed onto the next phase when they have completed their current programme. We spend time teaching the players how to read their programmes correctly (exercise order, rest periods and exercise tempo), how to select their loads appropriately, how to progressively increase load weekly or reduce load if they are tired. They are expected to record all their weights and their rating of perceived exertion (RPE) for each session. With a very limited amount of contact time we had to build a programme that covered a lot of bases but was focused on achieving results. We know that there are certain key characteristics and key factors that can distinguish between successful and less successful players and teams. For example, a key characteristic for footballers is speed, which includes acceleration, maximal speed and agility. Research shows speed is a key physical requirement during the more crucial moments of the game including winning possession, scoring or preventing an opposition goal1. Similarly, a key factor in the success of a player or team regardless of level, is injury2. From an individual’s perspective decreasing the risk of injury is of paramount importance especially for the semi-professional as injury can often bring their career to a crossroads which may result in them leaving the game or not being paid, the harsh reality of their situation. For these reasons our strength and conditioning programme incorporates multiple factors that cover key characteristics and factors identified. All our S&C sessions are 60 minutes in length and include the following categories in sequential order; mobility, movement skills, speed and power, strength and muscle robustness. Mobility (10mins): One area that is severely avoided by most footballers regardless of their level is mobility. We know mobility is a key factor in reducing the risk of injury and we have a three-step process that begins with isolated mobility and progresses through to dynamic mobility. 1.

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Soft Tissue Mobilization: Includes both myofascial release (foam rollers, hockey balls) and a dynamic stretching routine led by our coaches. This includes all the key muscle groups of the lower limb and thoracic spine.

2.

Joint Mobilization: Here we focus on mobilizing the hip and knee joints which are often stiff in most footballers. We utilise mobilization with movement techniques that incorporate elastic bands and focus on ankle dorsi-flexion, hip extension, hip flexion and hip internal rotation.

3.

Global Mobilization with a Constraints Led Approach: This aims to create a situation where the player must complete a task that requires mobility to achieve it. Here we use hurdle circuits that challenge the players mobility and coordination that are progressed in difficulty with each training phase.

Movement Skills (10 mins): As mentioned earlier high-speed actions; acceleration, maximal speed and agility are key physical requirements for success in football. Therefore, developing a players’ movement skills is paramount to improving their football performance. Our aim is to build a foundation of

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general movement patterns that are specific to football that with time become stable and automated allowing players to be more effective, efficient and reactive with their movements in game situations. Our movement skills are broken down into three movement classifications as described by Ian Jefferies3 and six key movement patterns. We typically focus on two key movement patterns per phase. Movement Classification 1. 2. 3.

Initiation: Movements that are used to start or change direction Transition: Movements that are used as preparation for subsequent actions Actualization: Movements that decide the success of the action or moving to a given position as quickly as possible

football medicine & performance Key Movement Patterns 1. 2.

3. 4. 5. 6.

Athletic start position (front, side, back, acceleration and change of direction) Running gait: (acceleration and max velocity) Deceleration (stopping) Side shuffling and cross-stepping Cutting (direction change) Backpedalling and drop-stepping

Speed & Power (10mins): Alongside the development of movement skills it is important to improve speed & power. We improve speed and power through the utilisation of plyometrics. Our plyometric process is built upon three categories: the plyometric contraction, the direction of force and the plyometric movement. Players are progressed from basic level plyometrics to more advanced methods over time. We typically programme two plyometric exercises per phase and include one linear and one lateral or rotational exercise. Plyometric Pathway 1) A. B. C. D. E.

Plyometric Contraction: Non-counter movement Unloaded counter movement Counter movement Continuous Drop jump

2) A. B. C.

Direction of Force: Linear Lateral Rotational

3) A. B. C.

Plyometric Movement: Jump Bound Hop

Strength (20 mins): Strength is the foundation to all physical qualities in football and is required to improve agility, speed and power. Our aim is to build a foundation of general strength through compound movements typically split between five key exercises and their variations. This is further broken down into kettle bell, dumbbell, barbell, cable, special bars and alternative resistance variations. This provides several years of strength training progressions for the semi-pro player. We typically programme two strength exercises, one knee dominant (Split Squat and Step Up) and one hip dominant (Deadlift and Romanian Deadlift) exercise per phase.

2) A. B. C. D.

Deadlift Trap Bar Deadlift Sumo Deadlift Traditional Deadlift Snatch Grip Deadlift

3) A. B. C. D.

Step Up Controlled Step Up Controlled Triple Jumpers Step Up Pistol Squat Dynamic Step Up

4) A. B. C. D.

Romanian Deadlift Bilateral RDL Unilateral RDL Landmine RDL Snatch Grip RDL

5) A. B. C.

Pull Ups Supinated Grip Pull Ups Pronated Grip Pull Ups Wide Grip Pull Ups

Muscle Robustness (10 mins): Our muscle robustness programme focuses on the three most frequently injured muscle groups in football, the hamstrings, quadriceps and the adductors4. Our aim is to alter the angle at which peak-torque is produced, improve isolated endurance capacity, and reduce the risk of delayed onset of muscle soreness (DOMS) via isometrics held at long muscle lengths for 15-30 seconds5. Avoiding the risk of DOMS is important when you don’t have any input into the semi-pro players’ training and game schedule. We utilise many different variations of Hamstring Bridges, Reverse Nordics and Adductor Bridges and will programme one exercise for each muscle group in a tri-set with no rest between exercises. We have been providing S&C sessions for semi-pro players for 18 months now and have seen the positive impact it has had on the players. We have expanded our services to include physiotherapy

By building a team of practitioners that believe in the FSCR mission we have been able to provide footballers of all levels, in this instance semi-professional, with invaluable knowledge and experience from a range of different professional clubs. Having first-hand knowledge into the day to day requirements of the players at the highest levels allows our team to provide meaningful support to those semi-professional players trying to play at the highest level they can. For more information, check out FSCR’s social media account on Instagram @footballscr_ or get in touch via email info@footballscr.com

1. Little, T., & Williams, A.G. (2005). Specificity of acceleration, maximum speed, and agility in professional soccer players. Journal of Strength and Conditioning Science, 19 (1), 76-78. 2. Hägglund, M., Waldén, M., Magnusson, H., Kristenson, K., Bengtsson, H., Ekstrand, J. (2013). Injuries affect team performance negatively in professional football: an 11-year follow-up of the UEFA Champions League injury study. British Journal of Sports Medicine, 47 (12), 738-742. 3. Jefferies, I. (2008). Movement training for football. UKSCA Journal, 14-23. 4. Ekstrand, J., Hägglund, M., Waldén, M. (2011). Injury incidence and injury patterns in professional football: the UEFA injury study. British Journal of Sports Medicine, 45 (7), 553-558.

Key Exercises 1) A. B. C. D.

and rehabilitation for the semi-pro player. Where we believe we can make the biggest difference is in accurate diagnosis and reducing injury recurrence. Our rehabilitation strategies also include pitch re-integration and clear return to play criteria.

5. Philippou, A., Bogdanis,G., Nevil, A., Maridaki, M. (2004). Changes in the angle-force curve of human elbow flexors following eccentric and isometric exercise. European Journal of Applied Physiology, 93, 237-244.

Split Squat Front Foot Elevated Split Squat Neutral Split Squat Rear Foot Elevated Split Squat Bulgarian Split Squat

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feature

KAREN CARNEY A PIONEER FOR THE WOMEN’S GAME FEATURE / SEAN CARMODY

football medicine & performance

On a rain-soaked afternoon in October 2008, Karen Carney collected her kit and took herself down to the park near her family’s home in Birmingham. Fallen leaves crunched against the ball as she glided between the invisible opposition, occasionally needing to play beyond dogs who had strayed from their owners’ leashes. This wasn’t the behaviour of some obsessive adolescent intent on earning a shot at the big time, at achieving farfetched dreams. By the time Karen took to her local park she was 21, had scored eight goals for England and won the quadruple with Arsenal. Her time studying sport science at Loughborough had given her the knowledge to design those solo sessions and prepare her for her next adventure. The ‘all-in’ mentality which has defined Carney’s life to date led her to set her sights on America, and the opportunity to become a full-time professional footballer; “I had been interviewing for office-based jobs, but it’s not what I wanted to do. I had the support of my parents. They said give football a go for 6 months, and if it didn’t work out, well at least I tried”. It did work out though, and Carney went on to play for the Chicago Red Stars thirty-eight times before returning to Birmingham City in 2011. Eyes and Ears “I’ve gone on the record and said I’ve suffered with depression – quite bad, destructive behaviours. I was really fortunate that I was able to get the right help at the right time.” -

Karen Carney, speaking at a charity event in October 2019.

Professional sport is a cruel, unforgiving environment. The transient highs of trophy wins and supporter adulation are quickly punctured by injury and the mundanity of long-term rehab. Karen admits she was “stuck in a rut” towards the end of her time in Chicago. Injury had stalled her progress, and conflict between club and country on how best to manage the injury left her feeling isolated. These feelings in a foreign country, away from family and friends, can precede trying times for footballers and Karen was not immune. Her experiences as an injured player exposed her to some of the best care in football. It was not complex science or extensive knowledge that impressed upon Carney, but the human aspect of rehabilitation. She recalls one particular physio who made a significant impact on her and supported her through one of the most difficult times of her career; “What he did for me wasn’t from any book. He took the time to get to know me, showed that he cared. It was all eyes and ears”.

Edge “I’ve maxed out in every area. I’ve gone for every percentage gain I could be to be the best that I can be. It’s just time.” Long before The Game Changers came along and propelled ‘veganism’ into the athletic vernacular, Karen Carney had begun to adhere to a strictly plant-based diet. Prolonged periods out with injury and a sense that her career was approaching its twilight years led her to research methods that would allow her to maintain an edge over other footballers; “The hardest thing is to get to the top and then stay there. As you get older, you see younger players coming through the ranks, and you try different things to enhance, or even preserve, what you have”. This resembles the mindset of other elite performers such as Tom Brady and Serena Williams who adopted vegan diets later on in their highly successful careers. This studious approach to health and performance stemmed from academic experiences gained during her career. Following her undergraduate degree, Karen went on to complete a masters where her dissertation focussed on the influence of a coach on match day; “A coach only really has a small number of opportunities to influence performance on the day of a match, either through their substitutions or how they communicate during team talks. Who coaches the coaches? For the study we videoed the coach giving team talks, then they sought to improve their contributions by using reflective practice”. The longevity and success of Carney’s career is a living example of Professor David Lavallee’s research which suggests that studying may boost athletic performance, and prolong playing careers; “It made me feel more rounded as a person, that football was not my only identity, which helps when it comes to retirement”.

“We have the option of some players going to training early to practice: we call it individual development plans .. There was only one player that went in early yesterday, and that was Karen Carney. A player that was two days away from kicking her last ball still went down to the pitch early to practice before everyone else got there. That’s not something you can teach. That is something that you’re born with and that’s within you.” -

England Head Coach Phil Neville speaking about Karen Carney before her last ever game for England

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Her approach to recovery also set her apart from her peers. As women’s football veered towards professionalism, Karen, a self-confessed introvert found herself looking to take on more media opportunities to allow her to re-invest in her career. She purchased full-body recovery systems with the thought that “if I could train well during the day, and recover well in the evening, well then I could go on and make World Cup squads”. Before her final season in football, an individual intensive warmweather training camp in Dubai made a pleasant change from her solo sessions in Birmingham’s local parks, but the steeliness and determination from her younger years remained unchanged. Transition “It's worrying when you come out of professional sport. It's all you've ever known and all you've ever done. You have to get used to not going into the training ground and being peppered by people every single minute of every single day. It's quite daunting.” -

Karen Carney commenting on her retirement.

Bobby Barnes, a former professional footballer now working with The PFA, spoke at the recent FIFPro Conference about the reality check that retiring from football brings; “I didn’t even know how to register with a GP”. Four months into her retirement, Carney admits to similar dismay about the “outside world” and not being able to enjoy the access to services that she had as a professional footballer. Nevertheless, she has a sense of excitement for what the future may bring, and is enjoying getting stuck into interests away from football alongside her work in punditry. Vegan cookery lessons and a half-marathon have stoked the flames of her inquisitive and competitive nature for now, but will there come a time when she needs to re-immerse herself deeply in the sport? Not for the time being, her journey in football gave her a lifetime of rewards and memories, but its all-consuming nature gives her pause for thought when it comes to a career in coaching. Karen Carney was capped 144 times for England, a feat that is likely to be surpassed by few. Her career is extraordinary in modern sporting terms; from the amateur days, travelling two hours each way to train with Arsenal while studying for a degree, to competing in a home Olympics, she has been instrumental in bringing the women’s game to where it is today. Young girls can dream of becoming footballers because of Karen Carney.

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football medicine & performance

WRIST INJURIES IN GOALKEEPERS FEATURE / RAJ BHATIA, ADAM ESA & SAM HAINES

Mr Raj Bhatia BSc(Hons), MBChB,FRCS, FRCS(Tr & Orth), MD Consultant Hand & Orthopaedic Surgeon

INTRODUCTION Approximately 25% of all sports-related injuries involve the hand or wrist [1]. These incidents are on the increase, not only due to the increasing physical demands athletes face but also due to the increased activity level noticed amongst the general population [2].

goalkeepers. As poorly treated or undiagnosed injuries can be catastrophic and career ending for them. We will focus on the commonest injuries and discuss our preferred treatment options, to reduce non-playing time and increase functional recovery.

Lower limb injuries predominate in Football players and therefore much of the published literature focuses on the lower limb, with data on the upper limb being sparse. However in goalkeepers hand and wrist injuries are the most common upper limb injuries, and goalkeepers are five times more likely than outfield players to sustain such an injury [3]. Goalkeepers require a high level of hand and wrist function in their role and injuries to these sites leads to a longer nonplaying period than outfield player.

BASIC ANATOMY The wrist is a complex joint that is made up of two carpal rows, the distal ends of the radius and ulna and the bases of the metacarpal bones. Stability is provided by the osseous anatomy and ligaments and these work in concert to provide movement in different planes. The ligaments can be divided into intrinsic and extrinsic. The most important intrinsic iigaments are the Scapholunate and lunotriquetral of which the Scapholunate is the most commonly injured.

This article follows on from our previous article discussing hand injuries in goalkeepers [4]. We now turn our attention to acute wrist injuries in players, more specifically

The triangular fibrocartilage disc (TFC) attaches to the base of the ulnar styloid and to the ulnar head of the distal radius. It forms part of the triangular

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39

feature fibrocartilage cartilage complex (TFCC). The TFCC supports the carpus, absorbing and transmitting axial force across the ulnar aspect of the wrist, as well as stabilizing the distal radio-ulnar joint (DRUJ). The TFC is particularly prone to injury. Falling on an outstretched hand following a collision or direct impact of the football against the hand and wrist can lead to fracture, joint injury, ligament injury or a combination of injuries. FRACTURES Distal radius fractures In a study assessing the epidemiology of sports related distal radius fractures, football accounted for 50% of the fractures [5]. Furthermore playing football on synthetic pitches increased the likelihood of a distal radius fracture by a factor of five. In another study investigating professional football players, wrist fractures were the seventh most commonly reported upper limb injury, representing 17% of all wrist injuries. These players lost an average of 42 days playing time, or about one third of the season [6]. Non-operative treatment can be considered in the non-displaced, extra-articular fracture or the stable, reduced fracture. However, the risk of re-displacement persists and this often means a prolonged period in cast and a delayed return to playing. In a professional football player we believe open reduction and internal fixation of the fracture using a volar locking plate (Fig 1a,b) should be considered as long as the risks of surgery are fully explained. Following surgery we commence physiotherapy two weeks later when the wound has healed. An outfield player can play after 2 weeks with a splint. For a goalkeeper we would wait six weeks before allowing impact on the wrist.

Fig 1a. Comminuted intrarticular distal radius fracture

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For all multi-fragmented, displaced fractures we would recommend immediate fixation with a locking plate. Ulnar Shaft Fracture Ulnar fractures are often called nightstick fractures as they classically result from warding off an overhead blow (nightstick being the colloquial name for a policeman’s baton in the USA). Goalkeepers can sustain these injuries when colliding with a post or colliding with an outfield player with the outer aspect of their forearm. These injuries are classically mid shaft and transverse and have a slightly increased rate of non-union. In the majority of cases, these fractures show no significant shortening or angulation. Unlike other forearm fractures, the proximal and distal radio-ulnar joint is intact. This injury can be managed in a ulnar gutter splint and or functional brace. For displaced, shortened or angulated nightstick fractures, open reduction and internal fixation with a plate is required [7].

important to remember that goalkeepers are particularly prone to scaphoid fracture when stopping a shot as this is the same as falling on an outstretched hand. On examination the player may or may not be tender in the anatomical snuff box, however axially loading the thumb could re-produce the pain. We recommend radiographic scaphoid views and if these do not show a fracture then an MRI scan should be obtained. All acute proximal pole fractures should be treated with percutaneous fixation because of high rates of non-union in this fracture pattern. Waist and distal pole fractures can be treated in cast for 8-12 weeks, however this can lead to increased wrist stiffness and longer time off playing. We would recommend operative fixation of all acute scaphoid fractures with a headless compression screw (Fig 2). This enables early physiotherapy and return to football.

Scaphoid fracture The scaphoid is the most commonly injured carpal bone, with the incidence of scaphoid fractures increasing among both elite and amateur footballers [8]. Scaphoid fractures can be notoriously difficult to diagnose clinically and on X Ray and are often missed. This can lead to non-union and subsequent arthritis, termed scaphoid non-union advanced collapse (SNAC). This occurs due to poor retrograde blood supply to the bone principally the proximal pole. When treating professional footballers one must maintain a high index of suspicion. Clinically the player may only complain of mild non-specific pain and may not remember a fall or collision. It is

Fig 2. Fixation scaphoid waist fracture with headless compression screw

Fig 1b. Fracture fixed with volar locking plate, enabling early motion

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football medicine & performance

SOFT TISSUE INJURIES Scapholunate ligament injury The scapholunate ligament sits between the scaphoid and the lunate bones in a horseshoe fashion tightly binding these bones together and is important in carpal stability. Injuries to this ligament usually occur after a fall, typically the wrist is extended ulnar deviated and supinated, although the player never remembers how they fell. An X Ray can show a gap between the scaphoid and lunate (Fig 3). However, the radiographs can be normal and a diagnosis of wrist sprain is usually made [9]. Treatment of acute, scapholunate ligament injuries have better outcomes than chronic injuries [10]. Therefore if a player complains of dorso-central wrist pain and the Xrays are normal, then one has to be highly suspicious of a scapholunate ligament injury. MRI can be utilized to help with diagnosis, but is not always accurate and may not define the extent of the injury. We find a wrist arthroscopy to be the best modality for evaluation of intrinsic wrist ligament injuries, and this remains the gold standard [11]. Arthroscopy allows the grade of the ligament injury to be defined and concomitant injuries such as triangular fibrocartilage injuries and joint cartilage damage to be assessed and debrided if necessary. Partial stable scapholunate ligament injuries as defined by arthroscopy can be

treated with physiotherapy and the player can play once the wounds have healed (5-7 days). He/She may require a splint for up to 4 weeks whilst playing. Unstable Scapholunate injuries require open repair and a goalkeeper can be out of action for up to 3 months. If a scapholunate ligament injury is missed the player will continue to complain of pain, weakness, clicking in the wrist and inability to take load on the wrist. Goalkeepers will have pain when shot stopping. If the situation is left undiagnosed this will lead to early arthritis in a predictive pattern termed scapholunate advanced collapse or SLAC wrist Lunotriquetral ligament injury Lunotriquetral ligament injury is not as common as scapholunate injury but similarly under-diagnosed. After acute injury the player will complain of pain and swelling in the dorsal and ulnar aspect of the wrist. Xrays can be normal in the acute phase. MRI may be helpful in diagnosis, but arthroscopy remains the gold standard for diagnosis and treatment. Arthroscopic assisted reduction and percutaneous pinning with Kirschner wire fixation is our preferred treatment choice in complete lunotriquetral ligament tears [12]. Triangular fibrocartilage tears (TFC) A TFC tear often occurs following a fall on a pronated extended wrist, which leads to

Fig 4. TFC tear at arthroscopy

impaction of the carpus on the ulnar and damage to the intervening TFC. The player experiences pain on the dorsal ulnar aspect of the wrist. The pain is exacerbated by wrist rotation and gripping, actions which are important in goalkeeping. Radiographs are normal and MRI is commonly used to confirm diagnosis. However MRI sensitivity and specificity for TFC tears can be as low as 80% [13]. TFC tears which are diagnosed on MRI scan should be treated initially with rest and immobilization as well as taking nonsteroidal medication. Should symptoms not settle within 4 weeks then we would recommend a steroid injection. In players with persistent ulnar sided wrist pain we would recommend wrist arthroscopy for evaluation and debridement or repair of the tear. Central tears of the TFC are not amenable for repair as the central portion of the disc is avascular (Fig 4). Only peripheral tears are amenable to repair as they are in the vascular zone, but are much less common. Triangular fibrocartilage complex injury (TFCC) Isolated TFC tears are not to be confused with injury of the TFCC. The TFCC is a complex structure composed of the TFC, as well as the dorsal and palmar radioulnar ligaments, the ulnar collateral ligament and the extensor carpi ulnaris sheath. A greater force is required to injure the TFCC and therefore TFCC injuries are not as common as isolated TFC tears. TFCC injuries can lead to DRUJ instability or dislocation.

Fig 3. Gap between scaphoid and lunate indicative of Scapholunate ligament injury

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An acutely subluxed or dislocated DRUJ needs to be reduced immediately and held in place with k wires for up to 6 weeks. Sometimes the DRUJ cannot be reduced closed because the extensor carpi ulnaris tendon can become interposed in the joint and then an open surgical approach is required.

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football medicine & performance

Chronic DRUJ instability is often due to damage to a number of components of the TFCC. The players can experience pain over the DRUJ, weakness in grip, snapping of the distal ulnar and loss of forearm rotation. Treatment usually takes the form of reconstruction of the dorsal and palmar radioulnar ligaments using a free tendon graft. Injuries to the TFCC and consequent instability of the DRUJ are debilitating injuries for goalkeepers leading to a prolonged time away from football. CONCLUSION Given the greater susceptibility of football players and especially goalkeepers to developing wrist injuries, we advise having a high index of suspicion for ligamentous injuries and occult fractures. The aim is accurate and timely diagnosis as acute repair of the injured ligament or fixation of bone is preferred, owing to improved recovery times, less pain and more predictable outcomes. The goal of any treatment is to stabilise the wrist and expedite return to preinjury functional level. As previously discussed in our article looking at hand injuries, a database of such injuries amongst this elite group of athletes would serve to guide future research and provide a more evidence based approach in management of amateur and professional football players.

Lead Author: Mr Raj Bhatia BSc(Hons), MBChB,FRCS, FRCS(Tr & Orth), MD Consultant Hand & Orthopaedic Surgeon Institute: Bristol Hand & Wrist Clinic Spire Bristol Hospital Bristol BS6 6UT Website: www.bristolhandsurgery.co.uk Email: raj.bhatia@icloud.com

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1. Amadio PC. Epidemiology of hand and wrist injuries in sport. Hand Clin 1990 (6); 379-381

8. Fowler J, Hughes. Scaphoid fractures. Clinics in Sports Medicine. 34(1); 37-50

2. Avery, D. M., Rodner, C. M., & Edgar, C. M. (2016). Sports-related wrist and hand injuries: a review. Journal of orthopaedic surgery and research, 11, 99

9. Paci, G. and Yao, J. (2015). Surgical Techniques for the Treatment of Carpal Ligament Injury in the Athlete. Clinics in Sports Medicine, 34(1), pp.11-35

3. Ekstrand J et al. Upper extremity injuries in male elite footballers. Knee Surg Traumatol Arthrosc. 2013, Jul 21(7); 1626-32

10. Rohman, E., Agel, J., Putnam, M. and Adams, J. (2014). Scapholunate Interosseous Ligament Injuries: A Retrospective Review of Treatment and Outcomes in 82 Wrists. The Journal of Hand Surgery, 39(10); 2020-2026

4. Haines and Bhatia. Hand Injuries in Goalkeepers. Football Medicine & Performance. 2018(25); 15-17 5. Lawson CM, Hadjucka C, McQueen MM. Sports fractures of the distal radius epidemiology and outcome. Injury 1995, Jan 26(1); 33-36 6. Court-Brown, C., Wood, A. and Aitken, S. (2008). The epidemiology of acute sportsrelated fractures in adults. Injury, 39(12), pp.1365-1372 7. Ali, Mohammed & I. Clark, D & Tambe, Amole. (2019). Nightstick Fractures, Outcomes of Operative and Non-Operative Treatment. Acta Medica (Hradec Kralove, Czech Republic). 62. 19-23

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11. Andersson, J., Andernord, D., Karlsson, J. and FridĂŠn, J. (2015). Efficacy of Magnetic Resonance Imaging and Clinical Tests in Diagnostics of Wrist Ligament Injuries: A Systematic Review. Arthroscopy: The Journal of Arthroscopic & Related Surgery 2014, 31(10);1-7 12. Osterman A, Seidman G. The role of Arthroscopy in the treatment of L-T injuries. Hand Clinic 1995, 11; 41-50 13. Blazar, Chan et al. The effect of observer experience on magnetic resonance imaging interpretation and localization of triangular fibrocartilage complex lesions.J. Hand Surg (Am) 2001.

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NEURODEGENERATIVE DISEASE MORTALITY AMONG FORMER PROFESSIONAL SOCCER PLAYERS – SUMMARY FEATURE / EMMA RUSSELL

Emma Russell FIELD study PhD student University of Glasgow

Background to the FIELD study Neurodegenerative disease in football is an area of research which has, until recently, been largely ignored. This is despite the concerns regarding the risk of neurodegenerative disease in football, which has been driven by the growing recognition of a specific type of neurodegenerative disease, called chronic traumatic encephalopathy (CTE). Recognition of the pathology in postmortem studies of boxers, American football players, and football (soccer) players has attracted wider attention and made headlines across the globe. CTE is thought to occur as a direct result of repetitive head injury, which occurs frequently in football, as well as in a variety of other contact sports.

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Prior research has investigated neurodegenerative disease in contact sport athletes, such as American footballers, and boxers. An association between participation in contact sport and neurodegenerative disease is well documented, but often study sample sizes are low, and/or there’s lack of an appropriate comparison group. Regarding football, there is a paucity of robust studies investigating neurodegenerative risk.

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feature What these results do/ do not tell us This study is the first of its kind to provide robust data regarding risk of neurodegenerative disease in football. However, the study does not inform us about causation. While head impacts have been proposed as a potential causative agent, this conclusion cannot be drawn from the results generated by this study. This study was a starting point in this field of research, and further studies are required to both corroborate these findings, and to further research the cause of these elevated neurodegenerative deaths in former professional football players.

The FIELD Study The FIELD (Football’s InfluencE on Lifelong health and Dementia risk) study is a retrospective cohort study, aiming to better understand the influence of football on long-term health. By using electronic health records, we have been able to obtain death certification, and prescription information for 7,676 former professional footballers, and 23,028 matched population controls. Population controls were matched on a 3:1 basis, they were all male, and were matched on year of birth and degree of social deprivation (using Scottish Index of Multiple Deprivation (SIMD) quintiles). Study Results Neurodegenerative disease During follow up, 1,180 former footballers died (15.4%), and 3,807 (16.5%) of the general population comparison group died. Neurodegenerative disease mortality was higher in the cohort of former footballers when compared with the matched general population control cohort. Overall, neurodegenerative disease was around 3.5 times greater in former footballers, this was after adjusting for the competing risks of death from heart disease and cancer. We found risk to vary between subtype of neurodegenerative disorder; with risk being greatest for Alzheimer’s disease – which was around 5 times greater in former footballers. Risk was around 4 times greater for motor neurone disease, 3.5 times greater for nonAlzheimer’s dementia, and 2 times greater for Parkinson’s disease. Dementia-related prescriptions were also found to be more commonly prescribed within the former footballer cohort.

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Player position One suggested risk factor for late neurodegenerative disease in former athletes is exposure to repetitive head impacts, which occur in football through heading the football, and/or player-toplayer collisions. It was thought that goalkeepers may have a lower risk of exposure to head injury when compared with outfield players. However, the incidence of neurodegenerative deaths was not different in goalkeepers when compared with outfield players. Nevertheless, prescriptions for dementia medications were less common among goalkeepers. Overall mortality Although neurodegenerative deaths were greater in former footballers, results show a reduction in mortality due to other common illnesses. Ischaemic heart disease and lung cancer related deaths were significantly reduced, highlighting some of the health benefits than can result following a career in sport. Former professional footballers were also seen to be living longer, on average, around 3 and a half years longer. We also see a reduction in those dying prior to the age of 70. Conclusions Overall, we found an increase in deaths due to neurodegenerative disease in our population of former professional footballers, but a reduction in deaths due to other common diseases, such as ischaemic heart disease and lung cancer. We also found an increase in prescriptions for dementia related medications in our former professional footballers.

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It is important to note that this study focused on former footballers who played at a professional level, and therefore these results are not directly applicable to all levels. This research does not allow us to speculate on the risks of playing football at an amateur and/or casual level. At this stage in the research, it is too early to draw conclusions regarding neurodegenerative disease in other sports, and in different levels of play of sport given the diverse mechanism of movement and contact. CTE, formerly known as dementia pugilistica, is not coded in International Classification of Diseases (ICD) 9 or ICD-10, and therefore we cannot directly comment on the prevalence, either as a primary or secondary cause of disease, of CTE within our footballer cohort. The future of football and football research Following the insights provided by this study, we hope to see better concussion management in sport, and stricter concussion guidelines, not just for football but for all sport. Reducing risk of unnecessary head injury and head impact should be something that is endorsed. We have also demonstrated a variety of wider potential health benefits gained following an active career in football, such as reduced incidence of heart disease and lung cancer. Regular sport participation can be of great benefit to many aspects of health. For this reason, we believe participation in sport and regular physical activity should still be greatly encouraged. The study was funded by both the Football Association (FA), and the Professional Footballers’ Association (PFA), as well as by an NHS Research Scotland Career Researcher Fellowship. The study was published online in the New England Journal of Medicine (NEJM) on 21st October 2019. The full study is available to read on the NEJM website.

football medicine & performance

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football medicine & performance

JOB INSECURITY: REDUCING ITS NEGATIVE EFFECT ON YOUR WELLBEING A 2019 FMPA Survey showed job insecurity to be the overwhelming issue that most concerns FMPA members about their working/professional environment. Stress literature suggests that job insecurity, the perceived probability and perceived severity of losing one’s job, can be as stressful as losing your job. This is because the lack of control and anticipation of not being able to meet your social and economic needs makes it difficult to live in the present and to plan for the future. Further, job insecurity and redundancy can lead you to question what you know about yourself and the world. Job insecurity is potentially, therefore, a risk to wellbeing. Indeed, large-scale across-sector surveys frequently link job insecurity with greater risk of poor health, whilst research also suggests a doubling of the risk of mental health conditions, such as depression and anxiety. Cautious application of the sport transition literature also suggests that the perceived severity of job insecurity and potential loss, and thus the risk to health, might be greater for those who have only worked within, or had a long-term career in, football. Despite this, denial or avoiding to prepare for potential job loss is both common and understandable. You might feel that any preparations would threaten your/others’ perception of your commitment, or seem pointless within football’s unpredictable environment. Alternatively, the thought of working for a different club or outside of football might be difficult. Consequently, the ‘wait and see’ strategy may be helpful if it maintains a sense of control or reduces the loss of time or energy in long-term insecurity situations. But research warns that this approach may not be so helpful in the long-term. So How Should I Cope with Job Insecurity? Everyone perceives and experiences job insecurity differently. This, the lack of research specific to football support professionals or similar employment situations, makes it difficult to give strong recommendations of what to do to reduce job insecurity stress. However, honest consideration of the following evidencedbased strategies will help you find the balance that suits your situation.

Reality Check: Is your job really under threat? Gain information and give honest consideration to the probability of job loss, and the severity of specific life consequences. Be Career Aware: Remember; careers rarely progress upwards in a linear fashion, progression often requires change, and every change can be a crisis, a relief and/or a positive. Expect your career to take a series of steps, some forward - small and large, some backwards, some within your control, others not. Regardless of the reasons and direction of travel, consider each step and role as an opportunity to gain and enjoy new experiences, and to develop new personal and professional skills. If you’ve got a career dream, keep working on it. Develop Competency. Know about the latest professional skills and what’s in demand. Keep your skill base up-to-date and take on new responsibilities. Don’t underestimate the benefit of developing strong, transferable personal skills, e.g., time management, social skills, coping. Also, broaden your understanding of what other jobs and careers are available both in and out of football, and how your skills can be applied. Know and Be Confident in Who You Are: Know what makes you you; your personal beliefs and values. E.g., is it important that you have integrity, work hard, be positive? Ensure that you live by your values. Let them underpin your confidence, guide your decisions, help you face new challenges. Others will notice and value you for it. Further, if you have gone straight from playing into a support career, exploring other roles and social settings can help this process and provide a broader sense of self and identity. Grow Your Network: Optimise and use those who can provide advice, and listening, emotional and logistical support. Address Specific Redundancy Concerns. E.g.; if you are worried about financial consequences, seek financial advice and manage your current funds wisely. If you have a partner/family, discuss concerns that may affect them, with them.

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Are you in a position of knowledge or control over the employment of others? If so, do what you can to promote their sense of security. Most specifically, prioritise open communication and work to maintain their trust. This might not solve their job insecurity, but it will help reduce the psychological health risk. If Made Redundant … This life change can bring many daunting, challenging, (maybe positive), anticipated and unanticipated consequences. Use Networks: If you have set good impressions and nurtured your network, let people know you are available and ask if they can help. Moving Forward: Aim to come to terms with what’s happened. Negative thoughts and feelings of being sacked or negative situations endured whilst in post can dominate and prevent you from moving on effectively. Gain Support: Emotions associated with grief are often experienced, i.e., denial, anger, bargaining and depression. Don’t ignore or be embarrassed by them. Instead, acknowledge and work through them appropriately with friends, trusted colleagues or professional services. Restory: Look for the positives in what happened. If possible, accept. Develop a story that you can live with and move on. FMPA Support: Remember, full members who have exited a club can access a range of support including immediate advice, and legal, networking and marketing support. Remember: Careers progress in various ways. Appropriate preparation helps you; be resilient, enjoy and work optimally in your current post, and face any changes with confidence.

N.B. Previous ‘Football Medicine and Performance’ articles will help with the above, i.e., ‘How to Thrive with a Little Help from My Friends’ (Issue 29, Summer 2019) and ‘Getting Back in the Driving Seat’ (Issue 30, Autumn 2019).

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REGISTER “The quicker way to access practitioners” Our marketing team are constantly looking at ways in which the FMPA Register can be quickly accessible to the end user. On the back of this we have created a video which gives users a step by step guide on how to download the FMPA Register Menu page and save it to the home screen on their device. This will give instant access to practitioners listed on the FMPA Register with just one click on the App! Whether you are a practitioner working in private practice, available for professional consultancy to football clubs or seeking employment. It has never been easier to be sourced!

The FMPA Register is different to any other directory around. Our team actively market each practitioner to their specified audience.

STEP 1

We are in the process of informing grassroots clubs, players, colleagues and professional football clubs about this quick and simple process to download to the App to their home screen. They will have access to practitioners at their fingertips!

Add to your home screen

The FMPA Register - supporting you to ensure you are quickly and easily accessed.

Visit fmpa.co.uk/fmpa-register STEP 2 STEP 3

You’re ready to start accessing skilled practitioners from within professional football on the FMPA Register! DOWNLOAD OUR APP TODAY!

Anglea Walton Angela Walton Project Manager

PC

PROFESSIONAL CONSULTANCY TO FOOTBALL CLUBS When your club is in need of a consultant, search an extensive list of experienced practitioners and contact them directly on the FMPA Register. www.fmpa.co.uk/fmpa-register

Not yet created a listing on the FMPA Register? Scan the QR code

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Search for a practitioner on the FMPA Register Scan the QR code

info@fmpa.co.uk

THE MULTIDISCIPLINARY TEAM FIGHTING FOR ORDER AMONGST THE CHAOS

2020 SPONSORED BY:

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