Issuu

The official magazine of the Football Medicine & Performance Association

football medicine & performance

Issue 34 Spring 2021

Feature

Does Load Management Using the Acute: Chronic Workload Ratio Prevent Health Problems?

In this issue The Match Demands of Elite Women’s Football Do Niggles Matter? Defining Best Practice Nutrition - UEFA Consensus Statement FMPA Virtual Conference 2021

Legal • Education • Recruitment • Wellbeing

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CEO MESSAGE The Covid-19 pandemic has been particularly challenging for our members this past year with the implementation of the strict yet necessary medical protocol, causing huge changes to working practices. Yet some of these changes are likely to stay even as football returns to its “new normal,” since the more imaginative and innovative ideas may have inadvertently improved certain areas of practice. This has been a period of considerable change for the FMPA but one that has in fact been enlightening, creating unforeseen possibilities as we move forward. While our focus on members has always been paramount, this became even more important in the early stages of lockdown. Communication was key at a time of grave uncertainty and even fear and we had to deliver the much needed information and support that was desperately needed by our members This is why our early efforts to signpost our members to information on furlough, financial advice, employment law both written and via podcasts, legal support, and the establishment of a 24 hour mental health hotline were such a success. Our lines were open 24/7 and used not infrequently. This connection with our members also confirmed that in times of need, it is the FMPA that members turn to for clarity and guidance, reassured by the knowledge that we are fully aware of and engaged with the fabric of the football environment and have our members best interests at the core of what we do.

Such confirmation meant our focus necessarily sharpened and further strengthened our resolve to ensure that our voice is heard and respected throughout the professional game. Our forthcoming Conference will now be a virtual event this year and while we will miss the face to face contact we all enjoy, our reach will be increased substantially and go way beyond our shores as we connect with like-minded bodies in world football. Zoom meetings, rotating of staff in the office and home working are all new to us but these have bought huge benefits in terms of expediency of communication and efficiency. The FMPA magazine has made an unscheduled move to an online version only, yet this transition has been seamless and accepted by members who are perhaps more familiar with accessing all matters in a digital format. Our podcasts have been a huge success as we focus on our members and colleagues who have a message or experience or vision they are happy to share. Audiences are rising rapidly. As the vaccination process is rolled out there is now a sense of cautious optimism. This provides all of us with the opportunity to look forward and to embrace some of the changes that have, through necessity and invention, become part of our lives. Change is the law of life. And those who look only to the past or present are certain to miss the future. John F Kennedy

Eamonn S almon

Chief Executive Officer Football Medicine & Performance Association

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FROM THE EDITORS Welcome to the 34th edition of Football Medicine & Performance. Over a year into the pandemic, professional football has begun to find its feet and navigate its way with fixtures rarely postponed and European competition continuing in the Men’s and Women’s game. The ‘knock-on’ effect of this is congested schedules, with interdisciplinary teams needing to carefully manage fatigue and its impact on performance and injury risk. The most successful teams in this unusual season, may well be the teams who can recover and adapt most effectively. As well as this, there has been a great interest recently in the long-term impact of head injuries in football and the risk of dementia, with studies suggesting former footballers are three and a half times more likely to die of dementia than the general population. This has led to the parliament launching an inquiry into the link between sport and long-term brain injury to understand how best to tackle this. This will hopefully lead to more research on the topic to establish robust conclusions, with FIFA and the PFA issuing a call for research on the impact of neurodegenerative disorders on ex-footballers and in particular subgroups, which will certainly lead to evidence-based policy change. We have already seen the introduction of concussion substitutes by The International Football Association Board (IFAB), with Issa Diop of West Ham United being the first player to be replaced with a concussion substitution in the Premier League. We hope this will pave the way for changes to ensure player welfare is prioritised. Finally, we are delighted Dr Andrew Shafik will be joining Fadi and Sean as a Senior Editor. Andrew, who works in Millwall’s Academy, has done an excellent job collating the Football Medicine & Performance podcasts. The three Senior Editors will oversee the wider Education Team which will encompass representatives from most disciplines within the interdisciplinary team. We will continue in these pages to try and bring the disciplines together, recognising the role that interdisciplinary collaboration has on enhancing player performance and well-being. As ever, we hope you feel inspired and informed after reading Football Medicine & Performance. Yours in football,

Sean Carmody Dr Sean Carmody Editor, FMPA Magazine

Fadi Hassan Dr Fadi Hassan Editor, FMPA Magazine

Andrew Shafik Dr. Andrew Shafik Editor, FMPA Magazine

CONTENTS FEATURES

09 Availability equals Winnability: The effects of a Periodised Training Model on Player Availability in Elite Soccer A Case Study (Part 3) Damian Roden 18 FMPA Virtual Conference 2021 Meet the Speakers 22 Rehabilitation of an Anterior Talofibular Ligament Injury In a Professional Footballer Incorporating the Use of the Empowerband Ankle Support David Fevre MSc, Chris Wilding MSc, Rhys Daly & Chase Homer 25 Influencing Performance on Match-Day: A Specific Look at Subs, Goalkeepers and Half-Time Interventions Dr Mayur K Ranchordas

34 The Match Demands of Elite Women’s Football: Implications for Future Integrative Research Frameworks Dr Paul Bradley 40 No Time to Waste During the COVID-19 Pandemic and Beyond: Screening for Mental Health Symptoms and Disorders in Professional Football Vincent Gouttebarge 45 Do Niggles Matter? Injury Surveillance is a Key Step in the Prevention of Injuries Matt Whalan 50 Does Load Management Using the Acute: Chronic Workload Ratio Prevent Health Problems? Torstein Dalen-Lorentsen

30 Defining Best-Practice Nutrition Recommendations in Professional Football: The UEFA Expert Group Statement James Collins, Dr Alan McCall

ABOUT

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

Design Oporto Sports www.oportosports.com

Executive Administrator Lindsay Butler admin@fmpa.co.uk

Photography PA Images, FMPA

Administration Assistant Amie Hodgson amie.hodgson@fmpa.co.uk

Damian Roden, David Fevre MSc, Chris Wilding MSc, Rhys Daly, Chase Homer, Dr Mayur K Ranchordas, James Collins, Dr Alan McCall, Dr Paul Bradley, Vincent Gouttebarge, Matt Whalan, Torstein Dalen-Lorentsen

Project Manager Angela Walton angela.walton@fmpa.co.uk Marketing/Advertising Charles Whitney 0845 004 1040

Contributors

COVER IMAGE Newcastle United’s Allan SaintMaximin picks up an injury during the Premier League match at St. James’ Park, Newcastle.PA Images / Alamy Stock Photo

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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feature

football medicine & performance

AVAILABILITY EQUALS WINNABILITY: THE EFFECTS OF A PERIODISED TRAINING MODEL ON PLAYER AVAILABILITY IN ELITE SOCCER – A CASE STUDY (PART 3) FEATURE / DAMIAN RODEN INTRODUCTION In the first edition of the Football Medicine and Performance Association Magazine (issue 32), the structure and rationale behind the training model implemented during Seattle Sounders’ MLS Cup Winning Season in 2019 was discussed. It detailed the intricacies of a typical training week, how this contributed to the highest player availability in the club’s history and more importantly, how the team started and finished the season so strong. Whilst the structure of a typical week from a training and loading perspective was significant, the decision-making process and the management of individuals within the framework of the model was of equal importance. In the second edition (Issue 33), the assessment processes that were carried

out during the training week, together with the logic behind such assessments were discussed in order to determine each and every players ‘readiness to train’.

games through the various ‘readiness’ assessments, it is important to recognise how to prepare players to optimise performance and further prevent any unnecessary injuries.

In this final edition, this article discusses the rationale behind the daily ‘preparation’ of players, the type of exercises that were commonly used and the key non-negotiables of the training week. This is all carried out in an attempt to prime players for the demands of the game and ensure that critical parameters were observed to keep players healthy and available.

Given both the multi-directional nature of the game of football in addition to what happens following each training session or game and leading up to the next, preparation and more specifically preparation exercises are an essential part of performance and injury prevention.

PREPARATION TO TRAIN Having determined whether each player is primed and ready for training through testing and identified how to assess each players’ response to training and

Whenever a player performs football actions, there is a lot of stress placed on joints, ligaments, tendons and muscles so it is not uncommon for players to report inflammation, tightness or discomfort somewhere in the body after training or prior to training the following day.

FOAM FOAM ROLLER

ROLLER

FUNCTIONAL FUNCTIONAL MOVEMENT MOVEMENT

BACK BACK MOBILITY MOBILITY

PREPARATION PREPARATION TO TRAIN TO TRAIN

CORE CORE STABILITY STABILITY

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GLUTE GLUTE ACTIVATION ACTIVATION

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Although this is not always a problem, over time inflammation can restrict movement around a joint, tightness can cause muscle imbalances and changes in posture and discomfort can cause an individual to change their normal gait, running style or posture to compensate for the discomfort that they are experiencing. Similarly, whilst each individual is different and will respond to training in a different way, players often spend a significant amount of time in a seated position before training whether it be driving to work, eating breakfast or chatting with team mates in the dressing room. Spending too long in this position is not ideal for general posture, and it encourages key muscle groups to act differently to how they are required to act when performing football actions. Preparation exercises should therefore form part of a players’ daily pre-training routine with the aim of improving posture, improving mobility in some joints whilst stabilising others and stimulating the key muscle groups that are responsible for specific football actions. PREPARATION EXERCISES Before considering which exercises to use, It is important to remember that every individual is different so there is not one set of exercises for all players as each player will require a slightly different stimulus. The following categories of exercises however are those most commonly used to rectify many of the issues players will encounter in response to training and spending long periods in a seated position and will send players onto the training pitch primed and ready to perform. A library of exercises relating to each category with a full description of how they should be executed can be found at www.fitforeverygame.com. Whilst there are endless exercises that practitioners use with players it is important to understand the principles behind the exercises as opposed to the exercises themselves as each individual will often present with different needs on a daily basis.

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football medicine & performance FOAM ROLLER Given the jarring nature of the sport and the number of accelerations, decelerations, changes in direction and rotations that occur during training and games, players will undoubtedly experience tightness in muscles that will occasionally have a negative effect on their ability to move and coordinate their body fully. The use of foam rollers of all major muscle groups both immediately after training to boost recovery, and prior to training helps to increase blood flow, remove waste products from muscles, iron out knots in muscle tissue and increase mobility by lengthening the sheath that surrounds muscle fibres. The sheath known as “myofascia” if tight can inhibit muscle length particularly during explosive movements causing a sensation or even occurrence of muscle tissue damage. Ironing out knots and releasing tightness in overactive muscles will therefore increase range of movement around a joint and ultimately improve mobility. Whilst there are numerous ways to use a foam roller, the following information provide examples of some key parts of the body in which foam rollers should most frequently be used. A full series of foam roller exercises can be seen in the appendix.

THORACIC SPINE Lying on your back with the foam roller just below your shoulder blades, raise your hips off the floor. Roll up, down, hold and bend upper body slightly over roller. Then go back to the starting position and repeat.

GLUTES Sitting with the foam roller underneath your glute, with your hands either side of you to maintain posture and balance, start to move downwards on the foam roller and then move slowly upwards.

KEY CONSIDERATIONS • Activate glute & abdominal muscles before raising hips. • Maintain normal breathing throughout the exercise. • End with upwards movement to help remove any waste products

KEY CONSIDERATIONS • Alternate between a straight leg and bent leg position. • Maintain normal breathing throughout the exercise. • End with upwards movement to help remove any waste products.

IT BAND Face sideways with the foam roller positioned under your knee. Start to move upwards towards the hip and then change direction moving slowly downwards going back to start position and repeat. KEY CONSIDERATIONS • Make full use of your arms to support your body weight. • Maintain normal breathing throughout the exercise. • End with upwards movement to help remove any waste products.

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BACK MOBILITY To enable messages from the brain to travel to active muscles in order to perform football actions effectively, nerve impulses must pass seamlessly through the spinal column. For this to happen it is important to maintain a typical ‘S’ bend so that each segment (joint) of the spine and each shock absorber (disc) between each segment are lengthened and assembled appropriately. Unless a conscious effort is made to maintain healthy posture, spending too long in a seated position can cause players to ‘slouch’ placing the spine in an unnatural position where segments and discs become ‘squashed’ potentially affecting the pathway of nerve impulses. Back Mobility exercises help to lengthen and align the joints of the spine and switch on both lower back and deep abdominal muscles and should form part of every players’ daily routine. Whilst there are many variations and combinations of exercises widely used, the following information provides an example of some simple exercise that can be performed. A full series together with a description of how to perform back mobility exercises can be seen in the appendix.

BACK ROLLS Start by sitting upright with your knees close to your chest and your chin tucked in. Then begin to roll backwards, followed by rolling forwards, whilst maintaining posture and balance and avoiding any lateral movement.

SINGLE LEG SIDE STRETCHES Lying on your back, raise one of your legs straight up to 90 degrees. Then move this leg across your body and then back to the middle. Return to the starting position and repeat with opposite leg.

KEY CONSIDERATIONS • Place your hands at back of legs, behind the knees to activate your abdominal muscles and lower back muscles when your are rolling. • Bend your neck forwards and tuck your chin in to stretch neural pathways when rolling.

KEY CONSIDERATIONS • Keep both legs as straight as possible throughout movement for maximum stretch. • Ensure that your shoulder blades stay flat to the floor. • Maintain the correct position throughout the exercise.

CAT STRETCHES Position yourself on your hands and knees making sure your back is straight and your head is facing the floor. Arch your back and hold this position, then lower and straighten back to the starting position. KEY CONSIDERATIONS • Pull belly button into spine throughout movement. • Ensure hips, knees and ankles are all shoulder width apart • Maintain the correct position throughout the exercise.

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football medicine & performance GLUTE ACTIVATION The gluteal muscles are the strongest muscles in the human body. Whilst their primary role is to stabilise the hip, pelvis and knee joints and also generate force particularly when accelerating, they also play a key role together with the lower back and deep abdominal muscles (core) in keeping the spine in a stable position. Unless players make a conscious effort to activate ‘Glute’ muscles when sitting for long periods, they may switch off. Inability of the Glutes to fire makes the knee joint vulnerable, causes the hip flexors to tighten which places a greater demand on the hamstrings and can cause the lower back to bear the brunt of any explosive actions. Performing glute exercises initially in a supine position to check that they are firing correctly before performing upright and more functional exercises will help to prime players for dynamic football actions. Whilst there are many variations and ways in which glute exercises can be performed, the following information provide an example of some simple exercise that can be used to prepare players for the demands of the game. A full series of Glute Activation exercises can be seen in the appendix.

ALTERNATING SINGLE LEG BRIDGE Lying on back with your head facing up and your chin tucked in. Put your arms by side and one knee bent at 90 degrees. Raise your hips off the floor pushing through your heel. Hold this and return to start position.

SINGLE LEG LOWERS Standing on one leg, with arms across your chest, face forward and put your opposite foot in front. Bend your knee and slowly lower into single leg half squat. Return to start position and repeat with opposite leg.

KEY CONSIDERATIONS • Make sure your glutes are switched on and ‘firm’ and your hamstrings are relaxed and ‘soft’’ • Don’t allow your hips to rotate or drop. • Maintain the correct position throughout the exercise.

KEY CONSIDERATIONS • Try to stop knee joint from moving sideways by activating glute med. • Keep upper body in upright position throughout movement. • Maintain correct upper body posture throughout the exercise.

BAND SIDE WALKS Stand with your feet shoulder width apart and face forward with your arms by side. Place the band below knees and walk sideways 5-6 strides & back to start position 5-6 strides. Face the same direction at all times. KEY CONSIDERATIONS • Slightly bend your knees when your are moving. • Pull belly button into spine and switch glute muscles on at all times. • Maintain correct upper body posture throughout the exercise.

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CORE STABILITY The deep abdominal muscles commonly referred to as the ‘core’ are responsible for stabilising the body when performing football actions and changing direction effectively. Similar to the glutes, unless players make a conscious effort to activate the core when sitting for long periods, they may switch off. Performing static core stability exercises before progressing to more challenging, dynamic and functional movements will help reduce the amount of shearing and rotational forces that are transmitted through the body that will ultimately help reduce the risk of injury but also make movement more efficient. When performing core stability exercises it is important to concentrate on activating the glute muscles simultaneously as combined they will help protect the spine and maintain a healthy posture. Whilst there are many variations of core exercises widely used complete with progressions, the following information provides an example of some basic exercises that can be performed prior to performing more functional movements. A full series of core exercises can be seen in the appendix.

PLANK WITH MOVEMENT Position yourself resting on your elbows and toes. Ankles, knees and hips should in a line. Hold this position before making forwards / backwards movements followed by left / right movements avoiding any hip drop at all times.

SIDE PLANK WITH MOVEMENT Position yourself on your side with all the weight on your elbow and forearm and side of foot with opposite arm raised out straight with feet together. Hold this position before raising and lowering non weight bearing foot.

KEY CONSIDERATIONS • Pull belly button into spine throughout movement to stabilise “plank” position. • Activate the glutes to stabilise “plank” position. • Maintain the correct position throughout the exercise.

KEY CONSIDERATIONS • Pull belly button into spine throughout movement to stabilise “plank” position. • Activate the glutes to prevent your hips from rotating. • Maintain the correct position throughout the exercise.

HEEL TAPS Lying on your back with your knees raised at a 90 degree angle, slowly lower one leg and touch your heel on the floor and return to the starting position. Repeat this process with opposite leg. KEY CONSIDERATIONS • Keep your chin tucked in throughout the movement. • Do not allow your pelvis to rotate during the exercise. • Push your rib cage downwards at all times throughout the movement.

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football medicine & performance FUNCTIONAL MOVEMENT Given the dynamic nature of the game and the random, spontaneous movements that occur it is important that players prime themselves for such movements by mimicking the type of movement, the range that they will have to move through and also the intensity at which they are likely to be performed prior to entering the training pitch. Providing players have released tightness by performing foam roller exercises, mobilized their spine via a range of back mobility exercises and activated both glute and core muscles, performing functional movements will help to energize the body and fully prepare them for the demands of both training and the game. Whilst there are many functional exercises that can be used, the following information provides an example of some simple exercises that can be used. A full series of functional exercises that can be performed can be seen in the appendix.

SQUAT Stand upright with your hips, knees, and feet all shoulder width apart. Toes should be slightly pointed out and arms out for balance. Lower yourself into deep squat position and back up to start position.

MULTI-DIRECTIONAL LUNGE Stand upright with arms by side, raise one knee and lunge in different directions keeping ankle, knee and hip in line. Plant heel before toe and ensure knee doesn’t pass the line of the toes before returning to start position.

KEY CONSIDERATIONS • Make sure to hinge at the pelvis before lowering. • Activate the glutes to prevent knee joint moving inwards (valgus) or outwards (varus). • Maintain correct upper body posture with chest out and shoulders back.

KEY CONSIDERATIONS • Pull belly button into spine throughout the movement to stimulate deep core muscles. • Activate the glutes to prevent knee joint moving inwards (valgus) or outwards (varus) • Maintain correct upper body posture with chest out and shoulders back

MULTI-DIRECTIONAL JUMP AND HOLD Stand upright with arms out and jump in different directions keeping your ankle, knee and hip all in line. Ensure knee doesn’t pass the line of the toes when landing before returning to start position. KEY CONSIDERATIONS • Pull belly button into spine throughout the movement to stimulate deep core muscles. • Activate the glutes to prevent knee joint moving inwards (valgus) or outwards (varus) • Absorb force by bending ankle, knee and hip joint collectively on landing.

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LOAD MANAGEMENT It is important to recognise the need for the modern player to activate their body prior to high intensity exercise and build key movements and exercises into their daily routine. However, this must sit alongside observing trends in each player’s daily training load to ensure they are optimally prepared for each game, week after week, for the full duration of the season. As discussed in Issue 32, the structure of the periodisation model ensures that any peaks or troughs in training load are avoided. This is because each type of training is performed over two consecutive weeks, meaning that even when there is a drop or a rise in intensity when moving from one type of training week to the next, it is always within a safe ‘band’ or ‘range’. That said, it is still important to do due diligence and ensure that players are always on track. Two of the nonnegotiables when observing player response to training each week are: 1) No high intensity drop or rise from one week to the next of greater than 50%; and

football medicine & performance

2) Each player must hit between 9095% of his or her maximum speed each training week leading up to a game, an example of which can be seen in Figure 1. Whilst figure 1 is just an example of one player over the course of a season, it is evident that there are fluctuations week-onweek, largely based on variations in the high intensity distance covered each game. There is also a general increase in intensity each two week segment of each cycle (green x 2, amber x 2, red x 2) and the intensity of each week in all cycles shows an upward trend (light green compared to light green, dark green compared to dark green etc.). Lastly, it is shown that the player hit speeds above 90% each week of the season leading into each game.

ABOUT THE AUTHOR Damian Roden is one of the most highly regarded Performance Coaches worldwide having implemented his approach successfully for over 15 years in the Premier League, with National Teams and more recently in the MLS. If you enjoyed the three articles in the last three editions visit www.fitforeverygame.com and order his newly released book ‘fit for every game’

To re-emphasise what was discussed in the first edition of this article, this is one example of an approach to load management that ensures players are optimally prepared for games, with the rationale and underpinning principles behind it. Providing there is sound rationale behind the philosophy and that players remain injury free and maintain a high level of performance throughout the season, it may be argued that the correct approach is being implemented.

Total High Intensity Distance (including games)

Figure 1. Weekly Total High Intensity Distance (including games) and Weekly Maximal Speed (training) over the course of a season.

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MEET THE SPEAKERS

DR DARREN DEVANEY Psychologist Arsenal FC

LUKE JENKINSON Head of Sports Science & Academy Medicine Derby County FC

MATTHEW PORTAS Lead Physical Performance – Education The FA

Darren is the Lead for Academy Psychology at Arsenal Football Club, and has been at the club for almost 4 years. He previously worked with the England & Wales Cricket Board’s National Development Programme, where he also completed a PhD investigating the holistic support needs of elite youth cricketers. Darren is passionate about how individual player’s growth as people provides the foundation for sustainable performance, the importance of psychologically informed support systems around our players, and for the grounding of player support in sound psychological principles. Darren’s presentation will focus on how he has experienced psychology input being impactful at the level of the Multi-Disciplinary Team (MDT), as opposed to limiting input to players on a one-to-one basis.

Luke Jenkinson has been working as a Strength and Conditioning Coach in applied sport since 2009. Graduating with a 1st class degree that included strength and conditioning, while also undertaking UKSCA accreditation, Luke became Lead Strength and Conditioning Coach at Sheffield United for 6.5 years whilst also completing a Masters that looked to critique acute chronic workload.

Dr Matt Portas is a football biomechanist and has particular interests in improving movement efficiency, reducing injury risk and planning and monitoring of training load. Matt has provided consultancy to professional football for over 15 years and works for the Football Association, tutoring UEFA A licence and Physical Performance Coach courses.

Luke is currently an Associate Lecturer at the University of Derby since 2013. Luke joined Derby County Football Club in 2016, initially as Head of Academy Strength and Conditioning. In 2019 this role developed to Head of Sports Science and Academy Medicine. The role is unique in the fact that Luke is tasked at overseeing the physical development department from under 9 through to 1st team to ensure continuity through the phases. In 2018 Luke began a doctorate at Liverpool John Moores where he is currently investigating the application of isometric exercises in dynamic team invasion sports. Luke has experience of coaching athletes in a range of disciplines including soccer, cricket, field hockey, climbing and bodybuilding.

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Matt has lectured in higher education for 17 years and is a Principal Lecturer, University Teaching and Senior Fellow of the higher education academy. He has a leadership role in developing and improving effective learning environments and supporting learner transitions. For over 25 years Matt was a gymnast and then a coach within the sport of gymnastics. The experiences, coaching skills and knowledge developed in these 25 years in the sport have been invaluable in his academic career and in the roles he has fulfilled subsequently in professional football.

JAMES MORTON Professor of Exercise Metabolism Liverpool John Moores University

James is a Professor of Exercise Metabolism & Nutrition at Liverpool John Moores University (LJMU). James’ specific research interests focus on the molecular and cellular responses of human skeletal muscle to acute and chronic exercise and the impact of diet and nutrition on modulating these responses. To date, he has authored over 130 research publications in the fields of sports nutrition, physiology and metabolism as well as numerous books / book chapters on these topics. In addition to research, James also works in elite professional sport in both sports physiology and nutrition support roles. From 2010-2015, he was the performance nutritionist to Liverpool FC and also specialises in providing nutritional and conditioning support to a range of professional boxers, MMA athletes and jockeys. James was also the Head of Nutrition and Physical Performance for Team Sky between 2015 and 2019 having led the nutrition strategy for the 2015 , 2016, 2017 and 2018 Tour de France victories. He is also the Director of Performance Solutions for Science in Sport (SiS).

DR GIL RODAS Head of Medical Area, Barca Innovation Hub FC Barcelona

MARK LEATHER

Dr Rodas Font is a specialist in Medicine and Surgery at the University of Barcelona, a Doctor of Medicine and a specialist in Sports Medicine as well as a research on issues related to Sports Medicine with several publications of his own. He is an ideologist of the comprehension training scheme of the athlete in all areas of the club and for all sports, from training to its final stage. Dr Rodas Font currently directs a permanent staff of professionals in the field of high performance sports in different disciplines.

Mark Leather qualified as a physiotherapist in 1983 where he spent 4 years in the NHS before moving into professional football. He spent over 10 years in the FA Premier League including 6 years as the Head Physiotherapist for Liverpool FC whilst he dedicated over 20 years working as a Head physiotherapist for Sunderland FC, Preston North End, Burnley, Brighton and more recently, as Head of Performance and Medicine at Bolton Wanderers.

• • • • • • • • • • • • • •

Medicine and Surgery Physician , Barcelona Autonomous University 1980-86 Sports Medicine Specialist , Barcelona University 1987-89 Doctor of Medicine (PhD), Barcelona University 2002 Sport Physician at High Performance Center (CEARE). Barcelona (1987-2001) Head of Medical Department at Spanish Hockey Federation. Madrid (1993-today) Sports Physician at Spanish Olympic Committee (Barcelona 1992, Atlanta 1996, Sydney, 2000) Member of Medical Commission of Spanish Olympic Committee from 2013-today Sports Physician and Researcher at Leitat Technology Center, Terrassa (2010-today) Sport Physician in Medical Department at FC Barcelona. Barcelona (2003-today) Team Doctor of the 1st team of soccer FC Barcelona. Barcelona (2003-2007) Team Doctor 1st team of basketball FC Barcelona (2008-2015) Medical Head of Barça Sport Innovation Hub, FC Barcelona (2016-today) Medical Head Sports and Exercise Medical Unit, Clinic Hospital and Sant Joan de Déu Hospital , Barcelona (2017-today) Medical Associate Professor Barcelona University (2018-today)

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Senior Lecturer in Sports Medicine and Therapy University of Central Lancashire

Away from professional football, Mark has also worked as the Head Physiotherapist at Wigan Warriors RLFC and worked at the Commonwealth Games in 1986 and the World University Games 2007. He was formerly the Physiotherapist for the England Futsal Team, lectured for the Football Association and has acted as a Consultant Physiotherapist for IPRS a leading company in injury treatment and prevention services. Following a previous successful spell in higher education at Edge Hill University, Mark took a role at the University of Central Lancashire as Course Leader in MSc Football Science & Rehabilitation & Senior Lecturer in Sports Medicine and Therapy. Alongside this, he is the Director at Mark Leather Physiotherapy Ltd and a guest columnist for both The Times & Daily Mail newspapers commenting on sport related injuries.

PROFESSOR WARREN GREGSON Head of Sports Science, Aspire Academy

MATHEW PEARSON

FRANKIE HUNTER

Head of Performance & Research Wolverhampton Wanderers FC

Head of Fitness Middlesbrough FC

Warren is currently Head of Sports Science at Aspire Academy/Qatar FA and has worked as a consultant to a number of Premier League clubs, national football associations and key stakeholders in the game. Warren is a Professor of Exercise Physiology in the Football Exchange and Research Institute for Sport and Exercise Sciences at Liverpool John Moores University and has published over 90 scientific publications in peer reviewed journals. Current research interests include the mechanisms underpinning post exercise recovery interventions and their influence on performance restoration and training adaptation, player loading (match-play and training) and the development of strategies for monitoring player fatigue.

I have worked in elite youth and senior football for over 10 years, gaining a wealth of experience in analysis and also coaching. Currently I am Head of Performance and Research at Wolverhampton Wanderers, where I lead on the analysis provision across the first team and academy. Before this I worked as the lead first team analyst, with my main focus being on opposition analysis and match preparation, and also as the Head of Academy analysis prior to joining the first team.

Frankie is a Sport Scientist who currently works at Middlesbrough Football Club as Head of Fitness. Having graduated from The University of Hull in 2010, Frankie enrolled on a Masters by Research working with Hull City Youth Team between 2010-2012. This was later published in the International Journal of Sports Medicine in 2014 termed ‘Individualisation of Time-Motion Analysis: A Method Comparison and Case Report Series’. After completion, Frankie spent almost 3 years at Southampton starting as an Intern in the Academy and finishing as 1st Team Sport Scientist in 2014.

Career history before Wolves: Duhail Sports Club Analyst / Assistant Coach – Reserve Team 2015-2016 QFA, Qatar / ASPIRE Academy for Sports Excellence Performance Analyst / Opposition Scouting 2008 – 2015 Blackburn Rovers FC Academy Coach & Performance Analyst 2007 – 2008

Since then, roles have included Head of Science and Strength & Conditioning (Middlesbrough Football Club), Head of Science (Everton Football Club), Head of Academy Science & Medicine (Hull City) & Exercise Scientist (The FA). Frankie is hoping to start her UEFA A Coaching Licence to continue her passion of coaching and to have a greater insight into the Technical & Tactical side of the game to support her career.

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REHABILITATION OF AN ANTERIOR TALOFIBULAR LIGAMENT INJURY IN A PROFESSIONAL FOOTBALLER INCORPORATING THE USE OF THE EMPOWERBAND ANKLE SUPPORT FEATURE / DAVID FEVRE MSC, CHRIS WILDING MSC, RHYS DALY & CHASE HOMER Introduction Lateral ankle ligament injuries are common in most sports, particularly in football. The most recent studies put the incidence of such an injury in a range of 10-17% of all injuries (1,2,3) in elite soccer. The majority of these injuries are managed conservatively with a graduated rehabilitation programme before returning to play. This often involves the use of an immobilisation boot, brace or strapping with the progressive increase in load-bearing demanded throughout the specific rehabilitation stages. Recovery time for ankle sprains varies between 7 –34 days; post-surgery in more severe cases this figure is reported as 77-105 days (4) Case Report The subject is a 21-year-old professional footballer who is presently contracted to a professional English soccer team in EFL 2 for the 2020-2021 season. He primarily plays as a left-sided full-back or midfielder

and has represented his country at U-18, U-19 and U-21 level. His injury occurred in a pre-season friendly match when he came on as a substitute. Two minutes after entering the field of play, his left foot was trapped in a collision with an opponent and his fixed foot ‘rolled’ over into a plantarflexed/ inverted position. He tried to play on but 5 minutes after the injury he was substituted to prevent further damage. On initial examination, he complained of moderate pain over the anterolateral aspect of the ankle, with an effusion over the anterior/ inferior lateral malleolus. He had tenderness on direct palpation of the anterior talofibular ligament (ATFL) with mild to moderate instability on stress testing. All other ankle structures appeared normal. He was treated with ice, compression and elevation using a Cryo-cuff with ankle attachment (Picture 1) and immobilised in an immobilisation walking boot (Picture 2).

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His injury was re-assessed daily but no further stress testing of the ATFL was performed until day 5 to allow the acute symptoms to subside and repair tissue to start to form. Each day his symptoms subsided and after re-examination on day 5, the medical team were happy that the player had an isolated Grade2 tear of the ATFL. An MR (Magnetic Resonance) scan was considered but after daily discussion with the player/medical team, this was decided to be unnecessary as physically and psychologically the player was improving daily without this additional intervention. Intervention and Outcome In order to assist his rehabilitation after coming out of the immobilisation boot, the player was offered the use of a semi-rigid Empowerband ankle support (Picture 3) which is worn over the boot unlike most other ankle braces or supports and which has been designed specifically for football.

football medicine & performance

PIcture 1. Cryo-cuff

PIcture 2. Immobilisation walking boot

The player himself was very keen to use this and wore it throughout the proliferation and re-modelling phase of his rehabilitation, post immobilisation boot. Exercise therapy combined with progressive weight bearing is an essential stage in the functional treatment of acute lateral ligamentous sprain [11] and the use of the Empowerband support at all stages gave a physiological and psychological assistance as well as sports specificity to his recovery. Early active range of motion exercises were subsequently followed by strengthening exercises, proprioceptive training and functional exercises. It has been shown that external ankle support does not impede speed, agility and kicking accuracy in football players (7). Sports specific activities in the final phase progressively simulated the physical demands of football, many similar to the drills accessible on the Empowerband web site (https://www.empowerband.com).

it is unclear whether external braces are more effective than strapping as there are advantages and disadvantages for both. Taping can produce skin lesions and loses 50% of its effectiveness 15 minutes after application with intense exercise (6). However, some athletes do not like braces as they may not sit correctly in football boots and can be initially expensive. However, they are reusable, re-adjustable and need minimal expertise to apply. At present-day prices, the cost of the tape materials would be approximately £4 per strapping at a cost of more than £250 for his 32-day rehabilitation/return to training postinjury. This works out at a cost of 6 times more expensive than the Empowerband brace. It would also have necessitated application by a sports medicine professional twice a day

The player returned to full training 23 days post-injury and was back in the first-team squad as a substitute 9 days later after a full week of training with the first-team squad, where he continued to wear the Empowerband ankle support. The other common option after coming out of the immobilisation boot is to tape the ankle, twice daily for rehabilitation and training sessions. Although a recent study reported no differences in outcome 6 months after treatment with tape, semi-rigid brace, or lace-up brace [9], a significant number of studies report superior results from protection with a brace [8, 10]. There is a consensus that external ankle braces can reduce the reoccurrence by approximately 70% (5) but

Conclusion Rehabilitation of an ATFL injury is a common case for many sports’ medical professionals. For a successful return to sport, it is important that each stage of the recovery is only progressed after successful clinical outcomes have been achieved. To try and fast track the recovery process can often lead to re-occurrence of this type of injury, so any product which can assist and supplement the skills of the sports physiotherapist while helping the player both physically and mentally can only be an adjunct. In this process, the use of the Empowerband ankle support helped achieve the aforementioned goals throughout the rehabilitation programme, albeit as demonstrated in this single case study. Further similar reports using a larger number of players is necessary to assess the use of this particular ankle brace.

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PIcture 3. Empowerband ankle support

1. Waldén M, Hägglund M, Ekstrand J. Timetrends and circumstances surrounding ankle injuries in men’s professional football: an 11-year follow-up of the UEFA champions league injury study. Br J Sports Med. (2013) 47(12):748–53 2. Ekstrand J, Hägglund M, Waldén M. Injury incidence and injury patterns in professional football: the UEFA injury study. Br J Sports. (2011) 45(7):553–8 3. D’Hooghe P, Cruz F, Alkelahifi K Return to play after a lateral ligament sprain. Curr Rev Musculoskelet Med (2020) 13:281-288 4. Pearce CJ, Tourne Y, Zellers J, Terrier R, Toschi P, Silbernagel KG, et al Rehabilitation after ankle ligament repair or reconstruction (2016) Knee Sports Surg Traumatol Arthrosc 24 (4):11301139 5. Dizon JM, Reyes JJ A systematic review on the effectiveness of external ankle supports in the prevention of inversion ankle sprains among elite and recreational players (2010) J Sci Med Sport 13 (3):309-317 6. Frankeney JR, Jewett DL, Hanks GA, Sebastienelli WJ A comparison of ankle taping methods (1993) Clin J Sports Med 3 (1): 20-25 7. Putnam AR, Bandolin SN, Krabak BJ Impact of ankle bracing on skill performance in recreational soccer players (2012) PM R 4 (8) 574579 8. Petersen W, Rembitzki IV, Koppenburg AG, Ellermann A, Liebau C, Brüggemann GP, Best R. Treatment of acute ankle ligament injuries: a systematic review. Arch Orthop Trauma Surg. (2013) 133(8):1129–1141. 9. Van den Bekerom MP, van Kimmenade R, Sierevelt IN, Eggink K, Kerkhoffs GM, van Dijk CN, et al. Randomized comparison of tape versus semi-rigid and versus lace-up ankle support in the treatment of acute lateral ankle ligament injury. Knee Surg Sports Traumatol Arthrosc. (2016)24(4):978–984. 10. Kemler E, van de Port I, Backx F, van Dijk CN. A systematic review on the treatment of acute ankle sprain: brace versus other functional treatment types. Sports Med. (2011)41(3):185–197. 11. Kerkhoffs GM, Handoll HH, de Bie R, Rowe BH, Struijs PA. Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults. Cochrane Database Syst Rev. (2007)2:CD000380.

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football medicine & performance

INFLUENCING PERFORMANCE ON MATCH-DAY: A SPECIFIC LOOK AT SUBS, GOALKEEPERS AND HALF-TIME INTERVENTIONS FEATURE / DR MAYUR K RANCHORDAS While the implementation of training and preparatory practices occupies the majority of a practitioner’s workload, football matchday also provides opportunities to positively influence performance. Recently, a number of intervention opportunities relating to the practices of substitutes, goalkeepers and consideration of half-time strategies have been identified in the literature. Whilst practical and logistical constraints may often represent substantial hurdles to overcome, by considering match-day demands and responses on an individual player level, it is possible to tailor training, nutrition, and/or recovery treatments accordingly. The following article presents a commentary on how recent research focused on bespoke populations and scenarios may provide practitioners with opportunities to modify match-day protocols for enhanced performance in football players.

Substitutes Although exceptions exist (e.g., in the case of injury, or where providing playing time to certain individuals represents a key objective), substitutes are usually introduced at half-time or during the second-half of a match; a fact which presents several areas for consideration when seeking to optimise the treatment of this playing group[2-4]. For substitutions made with the aim of providing fresh energy to a team, it is vital that players entering the pitch are appropriately prepared to produce high and sustained physical outputs, with minimal risk of injury. The length of time elapsing between the end of the pre-match warm-up and eventual match-introduction has the potential to negatively affect a substitute’s ‘preparedness’[1-3] via mechanisms

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potentially linked to progressive decreases in body temperature. For this reason, ensuring that substitutes engage in adequate warm-up and rewarm-up activity (potentially in conjunction with the use of passive heat maintenance techniques) prior to pitch-entry may be of utmost importance – especially in typical weather conditions in the UK. However, despite acknowledging that a substitute entering the pitch following inadequate preparations may negatively impact upon overall team performance[4], published and empirical observations suggest that many teams allow awaiting substitutes to autonomously determine the preparatory strategies adopted between kick-off and pitch-entry[2, 4], often resulting in minimal rewarm-up activity being performed[2, 4].

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Many stadia provide limited space where substitutes can perform rewarm-up activities, and professional competitions often require club staff to remain within the technical area whilst a match is underway. Despite these substantial barriers, savvy practitioners may recognise the potential to directly influence the activities performed by substitutes during the pre-match and half-time periods (when it may also be possible to use certain areas of the pitch and/or to perform tasks involving the use of a ball or other equipment). Moreover, establishing a culture of buy-in may allow for effective player-education and/or the provision of specific recommendations surrounding the importance of pre-pitch-entry preparation. In the absence of regulatory changes to allow staff to directly lead all pre-pitchentry rewarm-ups, these strategies may represent a means by which practitioners can positively influence a substitute’s ability to deliver the desired match-impact, alongside potentially reducing injury-risk. Another striking consideration is the substantial discrepancy in match-play demands often faced by substitutes compared with whole-match players. Indeed, irrespective of the relative (i.e., per min of playing time) physical responses observed, a substitute’s shorter

match-exposure is likely to elicit lower absolute physical demands compared with if a full 90 min had been played. As preparation and recovery strategies should be determined based upon the specific demands faced by any athlete, such observations suggest a benefit to bespoke treatment of substitutes. Whilst uncertainty surrounding a substitute’s likely match-play demands (e.g., the potential requirement to play substantially longer than anticipated due to injury to a starting player) may preclude the adoption of tailored pre-match strategies (e.g., fuelling, tapering, priming, etc.), it seems logical that post-match training and recovery practices could be individualised. It is widely recognised that ‘top-up’ conditioning sessions may be beneficial to offset reductions in high-intensity loading for substitutes compared with wholematch players[4]. However, substantial variation exists with regards to the objectives and modalities adopted within such sessions, and barriers such as pitchprotection policies, travel, and scheduling considerations may often impose limit their duration and/or content. In addition, whilst some practitioners may tailor carbohydrate consumption and/or withhold cold water immersion strategies, adopting bespoke recovery strategies for substitutes appears to be relatively uncommon[4]. As

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match-play demands may vary markedly even amongst substitutes (e.g., depending upon playing time), preparation and recovery provision may require further individualisation. Goalkeepers As goalkeepers typically remain near the goal-line that they tasked with protecting, it is unsurprising that goalkeepers cover ~50% of the match distances of players in outfield positions[5]. Acknowledging that other metabolically challenging tasks such as long kicks, jumps, and dives may also be performed, these lower physical demands may necessitate unique fuelling and recovery practices. Indeed, like substitutes, goalkeepers may not require the same aggressive recovery strategies like those recommended for outfield players who play a whole match[6], even during periods of fixture congestion. White et al.[5] also documented the training demands of professional goalkeepers throughout an in-season microcycle. For practitioners seeking to appropriately manage training loads and/or prescribe nutritional strategies, it is notable that training activities that typically elicit the highest physical loads amongst outfield players did not reflect the most demanding activities for goalkeepers. Indeed, for certain goalkeeper-specific metrics such as dives

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and jumps, match-days elicited amongst the lowest loading of any day within a week. Such observations highlight how practitioners may need to consider training and nutritional periodisation individually for goalkeepers, rather than on a whole-squad basis. Half-time Nutritional Considerations The half-time period has become increasingly recognised as an opportunity to improve second-half performance via strategies such as tactical debriefing and the use of active and/or passive heat maintenance techniques. Moreover, as maintenance of blood glucose concentrations may offer benefits in terms of physical performance, decisionmaking, and/or the ability to execute soccer-specific technical skills[7], it is common practice for football players to consume carbohydrate-electrolyte beverages prior to kick-off and during half-time. Notably, most commercially available sports drinks contain 6-10% carbohydrate, of which high glycaemic index sources such as glucose and maltodextrin typically represent the primary constituents. Whilst this practice is often adopted without question, differences in the physiological responses elicited when carbohydrate is consumed at rest compared with during exercise mean that transient declines in blood glucose concentrations have been observed during the early stages of the second-half when such solutions are ingested before and during (i.e., including at half-time) soccer-specific exercise[7-9]. In a review of this area, Hills and Russell[7] proposed four modifications to current half-time practices, that may each have merit when seeking to maintain blood glucose concentrations following the resumption of match-play, and thus potentially benefit cognitive and skilled performance throughout the second-half.

Changing the amount/concentration of carbohydrate consumed • Ingesting solutions of >10% carbohydrate may afford ergogenic effects on second-half physical and skilled performance

4. Consuming carbohydrate during a half-time rewarm-up • Combining high-intensity rewarm-up exercise with carbohydrate ingestion may attenuate the exercise-induced rebound hypoglycaemic response at the onset of the second-half

This article is not intended to dictate the practices of any football team, player, or practitioner. Such specifics will be, and should be, determined by individual practitioners based upon their own priorities, resources and circumstances. However, the foregoing commentary has highlighted three emerging areas of research, the principles of which warrant deeper consideration amongst those seeking to continually evolve their practice in light of current evidence, and thus move towards ‘optimising’

the preparation of their players. Acknowledging that practical, logistical, and regulatory barriers to implementation exist, given recent advances in player monitoring techniques and the traction gained by the concept of ‘marginal gains’, the days of ‘one-size fits all’ are surely in the past.

Dr Mayur Ranchordas is a Reader in Nutrition and Exercise Metabolism at Sheffield Hallam University and provides performance nutrition consultancy to elite and professional athletes. Mayur’s research is focussed on performance nutrition strategies that can enhance performance and recovery and he also works as a performance nutrition consultant at Wolverhampton Wanderers Football Club. Twitter @Diet4Sport

1. Hills SP, Barrett S, Russell M. Spotlight on substitutes. Football Medicine and Performance Magazine. 2019:37-8. 2. Hills SP, Barrett S, Feltbower RG, Barwood MJ, Radcliffe JN, Cooke CB, et al. A match-day analysis of the movement profiles of substitutes from a professional soccer club before and after pitch-entry. PloS one. 2019;14:e0211563. 3. Hills SP, Barwood MJ, Radcliffe JN, Cooke CB, Kilduff LP, Cook CJ, et al. Profiling the responses of soccer substitutes: A review of current literature. Sports Med. 2018;48:2255-69. 4. Hills SP, Radcliffe JN, Barwood MJ, Arent SM, Cooke CB, M R. Practitioner perceptions regarding the practices of soccer substitutes PloS one. 2019;Under Review. 5. White A, Hills SP, M. H, Cooke CB, Kilduff LP, Cook CJ, et al. The movement demands of professional soccer goalkeepers in different training types and transiently throughout matchplay. J Sports Sci. 2019;In Press.

Changing the glycaemic index of the carbohydrate consumed • May promote a lower insulinaemic response, slower delivery of glucose into the systemic circulation, and may help to spare muscle glycogen

6. Ranchordas MK, Dawson JT, Russell M. Practical nutritional recovery strategies for elite soccer players when limited time separates repeated matches. J Int Soc Sports Nutr. 2017;14:35. 7. Hills SP, Russell M. Carbohydrates for soccer: A focus on skilled actions and half-time practices. 2018;10:e22.

Changing the timing of carbohydrate ingestion • Consuming carbohydrate within ~5 min prior to the onset of the second-half may elicit comparable blood glucose responses to when consumed during exercise

8. Russell M, Benton D, Kingsley M. Influence of carbohydrate supplementation on skill performance during a soccer match simulation. J Sci Med Sport. 2012;15:348-54. 9. Russell M, Benton D, Kingsley M. Carbohydrate ingestion before and during soccer match play and blood glucose and lactate concentrations. J Ath Train. 2014;49:447-53.

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DEFINING BEST-PRACTICE NUTRITION RECOMMENDATIONS IN PROFESSIONAL FOOTBALL: THE UEFA EXPERT GROUP STATEMENT FEATURE / JAMES COLLINS AND ALAN MCCALL The role and impact of nutrition on the health and performance of professional footballers is becoming more prominent within the game. Despite growing popularity and influx of research focused on football nutrition, there have been no clear guidelines for over a decade that can help practitioners make decisions that are evidence-led and practically driven. The last time the football nutrition research was collated, and recommendations given was by FIFA in 2006 (FIFA Consensus), obviously a lot has changed since then, not only in the nutrition landscape but also in the game of football itself. The physical and technical demands of the game have increased in recent years (Bush et al., 2015; Barnes et al., 2014), as well as the financial implication of winning and losing. This impacted many aspects in the sport such as training regimens, travel demands, and cultural diversity. The cultural identity has evolved with an increase in player migration moving between different countries and continents.

The Expert Group Statement Process The idea was conceived in 2016 whilst working together at Arsenal FC and we published a call for action in 2017 (Collins et al., 2017). Following conversations with UEFA at their headquarters in Nyon, they too recognised this gap and importance in providing some evidenceled recommendations for the European and indeed global football community. This is when the ‘UEFA Expert Statement on Nutrition’ project was born. Together with UEFA, we established a steering committee of Prof. Ron Maughan, Dr Johann Bilsborough, Prof. Mike Gleeson and ourselves, where the first job of the committee was to decide the key topics that should be covered; (1) match day nutrition, (2) training day nutrition, (3) body composition, (4) stressful environments and travel, (5) cultural diversity and dietary considerations, (6) dietary supplements, (7) rehabilitation, (8) referees and (9) junior high-level players.

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Altogether, 31 experts were invited to collaborate on the project coming from nine countries spanning four continents, from research and practical backgrounds working within elite teams (e.g. FC Barcelona, AFC Ajax, Australia Football, French Football Federation and the Mexican Football Association). The recommendations are aimed primarily at senior professional football players (male and female) with specific sub-sections highlighting key points for junior players and also extending to top-level referees. Importantly, the UEFA expert group statement endorses and supports a ‘food first’ philosophy (Collins et al., 2020a). The Coach’s Perspective From the initiation of this project, it was important that this project engaged coaches, an important objective of UEFA for its 55 member associations. We secured the expertise of the iconic and long-term nutrition advocate, Arsène Wenger who has championed the importance of nutrition since working at AS Monaco back in the 1980s. He produced an editorial on ‘the

football medicine & performance is to win matches and preparing the players for the match is the central component of the multidisciplinary team (coaching, science, medical, nutrition etc). Elite football teams are often exposed to congested periods of match-play and preparation includes pre-, during and post-match (i.e. preparing for the next match by recovering optimally). Pre-match (Carbohydrate and fluids) Carbohydrate (CHO) is the primary fuel for muscle during high-intensity activities and is essential when preparing players for match play. On match day (MD)-1, MD and MD+1, CHO intake should be at least 6-8 g/kg BM (body mass) to elevate muscle and liver glycogen stores. During periods of fixture congestion CHO intake should be maintained at 6–8 g/kg BM/day for the 48-72 hours between matches to promote glycogen storage. On MD itself, a CHO-rich meal should be consumed 3-4 hours before kick-off, that provides 1-3 g/kg BM, to start the match with adequate glycogen stores and to ensure no gastrointestinal problems. Liver glycogen stores can be reduced by ~50% overnight, so the pre-match meal is particularly important for early kick-off’s (those that start the match with low muscle glycogen stores, cover less high distance at much less high speed [particularly in the second half]). Figure 1

coach’s perspective’ (Wenger, 2020) to support the scientific guidelines. “We often hear from the scientific community of the importance within football, but too often the voices of coaches are not heard in the best practice guidelines when they could offer valuable insight” From Arsène Wenger editorial (http:// dx.doi.org/10.1136/bjsports-2019-101972) Additionally, much of the nutritionrelated recommendations are historically aimed at performance enhancement, but an important focus for UEFA was to balance the performance with the health aspects of professional football players. To highlight this, UEFA’s Chairman of the Medical Committee, Tim Meyer wrote a separate editorial from the team doctor perspective’ (Meyer, 2020).

“Team nutritionists and medical staff should focus intently on educating players on the various nutrients and how to include them in their daily lives. In this context, good communication between players, nutritionists and medical staff is essential” From Tim Meyer editorial (http://dx.doi. org/10.1136/bjsports-2020-103318) We encourage readers to read the full statement for a comprehensive understanding of the science underpinning the recommendations made. In this article for the FMPA. Here we outline some of the key (but not all) practical recommendations / ‘take-home messages’ from the matchday, training day and supplementation topics: Matchday Nutrition Ultimately the key objective of football

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Matchday CHO intake is often lower than recommended, especially during recovery following evening matches, and a conscious effort should be made to increase the intake of CHOrich foods at the cost of fat intake (and possibly protein intake). It is important that practitioners work with players to educate and adapt their nutrition strategies accordingly. Finally, players should aim to start the match euhydrated by ingesting 5–7 mL/kg BM of fluid in the 2–4hours prior to kick-off. During match play Following the warm-up and during the half-time interval it is recommended that ~30-60 g CHO is consumed to maintain football-related performance. As well as starting the match hydrated, players should also drink sufficient fluids to prevent significant dehydration (>2%–3% of pre-exercise BM). It is likely that individual players

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Protein With the stresses placed on players musculoskeletal and tendinous tissues, in response to intense training, it is important to repair these proteincontaining structures to maintain and improve their integrity and function. Daily intakes up to 1.6–2.2 g/kg BM/day are recommended in professional footballers. These protein needs can easily be achieved through a normal diet and ideally spaced through three to four meals during the day. High-quality proteins that are high in leucine, with dairy and many animal-sourced proteins, best to stimulate tissue protein remodelling. Plant-based proteins can also be used, but higher protein intake is needed for the same effect on muscle protein synthesis. Fat Dietary fat is an important part of a player’s training nutrition as an energy source, a vehicle for the intake and absorption of fat-soluble vitamins (A, D, E and K) and a source of essential fatty acids. A fat intake of 20-35% of total dietary energy is suitable for elite players. Although there is a renewed interest in fat utilisation in different exercise scenarios, due to a lack of evidence, ketogenic low-CHO, high-fat (LCHF) diets are not suited to the requirements of football.

Figure 2 may be more or less sensitive to hypohydration during exercise. Recovery from match play (CHO, fluids, protein) After the match, it is recommended to start the restoration of glycogen and protein synthesis as soon as possible after a match by providing ~1 g/kg BM/h of CHO for 4 hours plus 20-25 g of high-quality protein at 3-4 h intervals. This is usually in the form of drinks and snacks in the changing rooms followed by post-match meals at the stadium, during travel and at home. It is important to note that players may not achieve these targets during evening matches, thus not optimising glycogen resynthesis. Particular focus should be placed on this during fixture congestion. Training Day Nutrition The training calendar and loading varies depending on the time of the season, match volume and individual player objectives (e.g. body fat loss or lean mass gain). Accordingly, nutrition strategies should be tailored to support training performance, recovery and adaptation to training.

Within the UEFA Expert Group Statement on Nutrition, we focus on the key components of players’ training nutrition: macronutrients (carbohydrate, protein, fat), hydration, and micronutrients (vitamin D, iron calcium). Here we summarise the key findings regarding macronutrients i.e. CHO, protein and fat. Carbohydrate requirements for training Within the UEFA Statement, we highlight how to maximise fuelling for individual players based on their specific needs. Daily CHO requirements should operate on a sliding scale of 3–8 g/ kg BM/ day depending on the training scenario, fixture schedule and individual player objectives. This will mean deliberately increasing intakes around match day and also reducing intakes on lower loading days. The available evidence indicates that players intakes operate within ~4-6 g/ kg BM/day (Anderson et al., 2017), this is therefore an important area for practitioners to work closely with players, to educate them on how they can refine their training nutrition to meet daily targets.

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Dietary Supplements As highlighted earlier in this article, our UEFA philosophy is that the football players nutrition programme should be centred around a ‘food first’ policy, with supplementation only used to meet specific health or performance objectives. Due to the risk of a positive doping violation from the use of dietary supplements, extreme caution must be taken when considering their use. Within the UEFA Statement we classify these into the categories of; micronutrients, to prevent or treat deficiency (e.g. vitamin d, iron, calcium); sports foods, supply convenient macronutrients for training/matches (e.g. carbohydrate gels, protein drinks); performance, supplements which may improve performance (e.g. caffeine, creatine). Third-party testing programmes (e.g. Kölner Liste” for Germany, “Informed Sport” for the UK) will reduce the risk of a doping violation due to contaminated supplements. This should be overseen by the team sports nutritionist and medical doctor. Future Directions This UEFA publication highlights just how important nutrition has become to support the modern player’s health and performance over a long season. It is important that clubs continue to develop nutrition services by strategically embedding them within the club and multidisciplinary team, and only utilising the services of qualified and registered practitioners. It is only then that the full impact of a nutrition service can be realised. Important future areas include research on both female and junior players, and incorporating sustainability principles into nutrition recommendations.

football medicine & performance

Figure 3

Steering committee, UEFA representatives and external experts Steering Committee - James Collins, Ronald J Maughan, Michael Gleeson, Johann C Bilsborough, Alan McCall. UEFA Representatives - Tim Meyer, Michel D’Hooghe, Charlotte Cowie, Niki Papadimitriou, Marc Vouillamoz. Experts - Asker E Jeukendrup, James P Morton, Stuart M Phillips, Lawrence E Armstrong, Louise M Burke, Graeme L Close, Rob Duffield, Enette Larson-Meyer, Julien Louis, Daniel Medina, Flavia Meyer, Ian Rollo, Jorunn Sundgot-Borgen, Benjamin T Wall, Beatriz Boullosa, Gregory Dupont, Antonia Lizarraga, Peter Res, Mario Bizzini, Carlo Castagna, Hans Geyer. To summarise the main recommendations, a series of infographics were produced by Dr Yann Le Meur (see figures 1-3)

Nutrition for football: the FIFA/F-MARC consensus conference. J Sports Sci 2006;24:663–4. Collins J, McCall A, Bilsborough J, et al.a Football nutrition: time for a new consensus? Br J Sports Med 2017;51): :1577–8. Barnes C, Archer DT, Hogg B, et al. The evolution of physical and technical performance parameters in the English premier League. Int J Sports Med 2014;35:1095–100. Bush M, Barnes C, Archer DT, et al. Evolution of match performance parameters for various playing positions in the English premier League. Hum Mov Sci 2015;39:1–11. Collins J, et al.b Br J Sports Med 2020;0:1–27. doi:10.1136/bjsports-2019-101961 Collins J, Maughan RJ, Gleeson M, et al Infographic. UEFA expert group 2020 statement on nutrition in elite football. British Journal of Sports Medicine Published

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Online First: 23 October 2020. doi: 10.1136/ bjsports-2020-103410 Wenger A. Importance of nutrition in football: the coach’s perspective British Journal of Sports Medicine Published Online First: 23 October 2020. doi: 10.1136/ bjsports-2019-101972 Meyer T. The importance of nutrition in football: perspective of a national team’s doctor. British Journal of Sports Medicine Published Online First: 23 October 2020. doi: 10.1136/bjsports-2020-103318 Anderson L, Orme P, Naughton RJ, et al. Energy intake and expenditure of professional soccer players of the English premier League: evidence of carbohydrate Periodization. Int J Sport Nutr Exerc Metab 2017;27:228–

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THE MATCH DEMANDS OF ELITE WOMEN’S FOOTBALL: IMPLICATIONS FOR FUTURE INTEGRATIVE RESEARCH FRAMEWORKS FEATURE / DR PAUL BRADLEY Introduction The popularity of women’s football has increased exponentially in recent years with both the number of registered players and spectators continuing to grow across the world (Bradley and Vescovi, 2015). For instance, approximately 13 million females are now playing organised football with around 3 million registered as players (FIFA, 2019). The FIFA Women’s World Cup is currently the largest women’s sporting spectacle on the planet with >1 billion in broadcast audiences and over a million attendees for the 2019 competition in France (Bradley and Scott, 2020). This increased popularity has resulted in a concomitant increase in the number of investigations examining the match demands of the women’s game (Andersson et al., 2010; Bradley et al., 2014b; Datson et al., 2017; Mohr et al., 2008; Park et al., 2019). Compared to men’s football, the female game is still in an embryonic stage in relation to research coverage (Kryger et al., 2021). Despite a gender disparity in football science research, there has been an increased focus on all aspects of the women’s game in

recent years or a sort of ‘awakening’. This is especially evident in the quantity and quality of papers in the match demands area of female football, hence the need for this specific piece. Thus, it is expected that impactful research will be more plentiful in future in not just match analysis research but all aspects of the female game. This information is very much needed given the increased professionalism of the women’s game. Such data would be extremely useful and valuable to the coaches and the support staff that drive the sports science and medical provision at domestic and international levels of the women’s game. Thus, this piece will present some of the existing match demands work that has been published on the female player with special reference to the game’s rapid evolution. As research and development frameworks have been key drivers in other areas of football, this piece also shines a light on an integrative research structure that aligns the match demands area with other key facets of the female game that are highly related and could aid future innovations (e.g. the menstrual cycle and injury).

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Previous Research on Women’s Match Demands Given the scarcity of information on the women’s game, an essential starting point would be to comprehensively evaluate the demands of the women’s game as most research questions will be informed by this. For instance, a granular overview of the physical demands of the elite women’s game will allow teams to create a game model that actually aligns with the activities players undertake during matches (Scott et al., 2018). Based on a literature search, it seems that Davis and Brewer (1993) provided some of the pioneering baseline work on female players’ match activities. This study found that female players covered around 8-9 km in total across the 90 min with each sprint bout covering approximately 15 m. More detailed time-motion analyses have been conducted since this early attempt and they provide more insight into the match demands of elite female players (Andersson et al., 2010; Bradley et al., 2014b; Datson et al., 2017; Mohr et al., 2008; Park et al., 2019). Total distance

football medicine & performance covered provides a very basic and indirect indicator of overall game exertion and this varies substantially across studies based on the population examined and particularly the technology used to track players (Bradley and Vescovi, 2015). This makes comparisons across studies difficult and this is further compounded by the relatively low sample sizes of the earlier studies. Research has found that elite female players cover 9.5-10.3 km a game (Bangsbo et al., 2006; Datson et al., 2017; Krustrup et al., 2005; Mohr et al., 2008). No exact measure of physical performance in elite female football exists, but the distance covered at high intensity seems to be a useful indicator given it is related to training status (Bradley et al., 2014a; Krustrup et al., 2005). This is also a distinguishing variable between competitive standards of elite female players (Andersson et al., 2008, 2010; Mohr et al., 2008). For instance, there is a definite trend between competitive level and the distance covered at high intensity. Female players at the highest competitive standard cover 1.5-1.7 km of intense running during a game and this is about 15-30% higher than the players at a lower standard (Mohr et al., 2008; Andersson et al., 2010). This elevated intense running distance is due to more frequent efforts as opposed to longer efforts. Although it specifies that high-intensity running is an important characteristic as it seems more frequent at the top end of the game, it is imperative to understand the complexity surrounding such a measure. The above studies were conducted well before the rapid evolution of the women’s game across Europe and North America. Thus, one could assume that the physical capacity of the female player had an even greater importance when this research was conducted as some players had dual time commitments (e.g. football and a fulltime occupation). This may have meant only the players with funding structures in place could fully dedicate themselves to full-time football. As professionalism has progressed, it could be that the physical capacities of players across the upper levels of the game are more consistent now. Thus, one might assume that the technical and tactical aspects are now the main differentiators between competitive standards. It is always important to mention that ‘more distance is not necessarily better’ when it comes to the match demands and that merging the physical and tactical analyses is needed to gain a global understanding of the women’s game (Bradley, 2020). In addition to competitive standards, playing position and specifically the tactical role a player undertakes has been found to be a strong modulating factor in relation to the technical and physical performances of elite male players (Bradley et al., 2009; Di Salvo et al., 2009). Although less is known regarding the positional variation

in elite women’s football, it would be safe to assume that such a relationship exists. A large number of studies have examined the demands of various positions in generic roles such as defender, midfielder and attacker as opposed to more specialised positions (Andersson et al., 2010; Krustrup et al., 2005; Mohr et al., 2008). However, some studies (Bradley et al., 2014b; Datson et al., 2017) have quantified the demands of various bespoke positions during UEFA Champions League and International matches. Datson et al. (2017) found that during International games, central and wide midfielders covered the greatest intense running distance compared to central defenders, while full-backs and forwards demonstrated comparable distances. This concurs with positional trends found in the FIFA Women’s World Cup (Figure 1). While Bradley et al. (2014b) found that during UEFA Champions League matches, central and wide midfielders in addition to forwards covered more intense running distance than central defenders. Despite these studies using semi-automated optical tracking systems to measure demands, they used slightly different systems, speed thresholds and dwell times and some of these will influence the absolute values produced (Varley et al., 2017). It is not surprising that midfield positions cover the most distance in games given that in ball possession they assist and contribute to offensive elements of play (running with the ball, support play, moving to receive/ exploit space, breaking into the box) but when there is a turnover in ball possession they are just as equally engaged in defensive play (recovery running, closing down/pressing, intercepting and covering).

Central defenders typically conduct intense efforts out of possession. However, when their team attacks, their work rate can drop off completely. Future research into women’s football needs to quantify not only the distance covered by players but the tactical purpose behind the effort (Bradley, 2020). In fact, there is limited research on the technical and tactical demands of the women’s game. Some studies are purely reductionist in nature with a limited dimensional scope and tend to study physical attributes at the expense of technical and tactical components. Given that football is a skill-based sport with a physical component in which all elements are influencing each other, it is hard to imagine how these papers can impact the game with no additional context. Gender Comparison As mentioned above, there is scant research on elite women’s football performance but even less literature detailing the gender match performance differential. Some of the earlier studies reported that intense running in elite female matches was 30% lower than their male counterparts of a similar competitive standard (Krustrup et al., 2005; Mohr et al., 2008). Some authors suggest that the demands during contemporary elite female football matches have increased (Mohr et al., 2008), but there is limited data available on female players competing at the very highest competitive standard (e.g. UEFA competitions). To accommodate for this, Bradley et al. (2014b) quantified the match performance profiles of

Figure 1 - Positional variation for high-speed running distance (19-23 km/h) for International female players. CD = central defender, FB = full back, CM= central midfielder, WM = wide midfielder, FW = forward. Manually redrawn and coloured from the original source of Bradley & Scott (2020).

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feature elite female and male players to verify possible gender differences during UEFA Champions League matches. Researchers have generally made inferences regarding gender differences from the relatively small number of studies conducted on elite female players (Bradley et al., 2014b; Krustrup et al., 2005, 2010; Mohr et al., 2008; Vescovi, 2012a). Previous studies have either used small sample sizes, lower competitive standards or could be considered outdated given the recent advances in the physical preparation of elite female players. Interestingly, Bradley et al. (2014b) found that UEFA Champions League male players only covered ~5% more total distance compared to female players, but intense running was 30% higher in male players (Figure 2). Peak Periods of Match Play The game of football could be described as a submaximal sport given the proportion of low to high-intensity activity, but this disguises the true demands of the game during intense periods. The so-called ‘worse case’ scenarios are well documented in the men’s game (Mohr et al., 2003) but limited data are available for the women’s game and

even less on the gender differences. Bradley et al. (2014b) found that the peak 5 min periods for men were higher than female players and illustrates that this trend is genderspecific (Figure 3). This information could potentially be used in a training setting to mimic intense periods of match play. Players could be overloaded even more than that found during intense match play to create a stimulus. Over time this could potentially produce an adaptation that enables players to cope with these intense periods in matches while maintaining their technical and tactical proficiency. Although this could be wishful thinking as no context is actually provided alongside these numbers and thus it is difficult to translate. Bradley et al. (2019) recently mentioned how context can be added to the numbers to create a much-needed narrative to enable the data to be used for training drill design. Establishing Female-Specific Speed Thresholds An issue that continues to create debate in this area, is the correct choice of speed thresholds that are appropriate and bespoke enough for the football population in question. Bradley et al. (2014b) reported

that there is disproportionately less high speed running and sprinting distance covered during women’s than men’s UEFA Champions League matches when using the same absolute speed thresholds (e.g. 18 to 25 km/h and >25 km/h, respectively). Match data showed that female players covered 718 m (~7% total distance) and 59 m (~1%), whereas male players covered 986 m (~9%) and 200 m (~2%) within those respective thresholds. Thus, is it a fair comparison for males and females as the same thresholds are generically used for both genders? Well to establish this, one needs to examine why there is a gender difference in performance metrics. These differences are likely to be related to a multitude of factors such as gender differences in locomotive ability and physical capacity (Bradley and Vescovi, 2015). Peak speed is ~10% lower over short distances (e.g. 10–30 m) and intermittent endurance capacity using tests like the Yo-Yo tests are 15-30% lower in female than male players (Bradley et al., 2011; 2014a; Vescovi, 2012; Ingebrigtsen et al., 2014; Haugen et al., 2012, 2013). Due to the magnitude of the gender disparity for various performance measures, it is generally accepted by the football community that gender-specific thresholds should be established (Bradley and Vescovi,

Figure 3- Peak running demands or so-called ‘worst case’ scenarios for UEFA Champions League male and female players. Manually redrawn and coloured from the original source of Bradley et al. (2014b).

Figure 2 - The total distance (upper panel) and intense running distances of UEFA Champions League male and female players (lower panel). Manually redrawn and coloured from the original source of Bradley et al. (2014b).

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football medicine & performance 2015; Park et al., 2019). Establishing generic thresholds for the women’s game poses some serious challenges. Pertinent questions include: (1) where does one start, (2) what tests/techniques do you use to create such thresholds and (3) how do you factor in gender and maturation status to provide the most appropriate threshold? Recently, Park et al. (2019) aimed to use advanced statistical techniques to objectively develop generic speed thresholds for elite female players. Longitudinal data were collected from international female players and examined using k-means, a Gaussian mixture model and a spectral clustering technique to establish various thresholds. The most appropriate upper two categories of high speed running, and sprinting were classified as >19 km/h and >23 km/h, respectively. These thresholds received an extensive critique by Vescovi (2019) as he stated that the study did not provide sufficient evidence that the new thresholds were an improvement on previous recommendations based on physiological tests (Bradley and Vescovi 2015). Another criticism is the very low distance covered sprinting using the >23 km/h threshold compared to previous research that clocked 3-4 times the values reported in the Park et al. (2019) study (Vescovi 2012a, 2016; Bradley et al. 2014b; Datson et al. 2017). Although FIFA adopted these new thresholds for the Women’s World Cup in 2019 and it must be noted that the sprinting data (~170 m) compares well with previous research. The variations in the different speed thresholds can be observed in Table 1 and the reader must be reminded that no standardised thresholds have been established and this limits our ability to compare between studies. Evolution of the Women’s Game Interest in the match performance characteristics of men’s football has grown rapidly over the last decade as it enables sports scientists to identify the current demands placed on players in competition and apply data to training and testing protocols (Ade et al., 2016; Bradley et al., 2019). Although less progress had been made in women’s football research, more has been published in the last 5 years than at any other time (Kryger et al., 2021). Although more research is still warranted regarding the match demands of female players to gain a deeper understanding of the unique characteristics inherent within this population. Some research has been published on elite female players but there is still a scarcity of information on the subject compared to the men’s game (Bradley et al., 2014; Datson et al., 2019; Kryger et al., 2021). A report on the physical demands of the Canada 2015 Women’s World Cup demonstrated that the total and highintensity match distances were very similar to that of the 2011 tournament in Germany (FIFA, 2016). This indicates that the demands have stayed relatively consistent at the

Table 1 - Breakdown of various papers on women’s football speed thresholds and the resultant distance covered in various categories. Modified from Bradley and Vescovi (2015).

Figure 4 - Match running performances of International players in the FIFA Women’s World Cups in Germany 2011 and Canada 2015 across various speed thresholds. Manually redrawn and coloured from the original source of FIFA (2016).

international level (Figure 4). However, between the Canada 2015 and the France 2019 Women’s World Cups, there was an upsurge not only in the interest and popularity of the game but also its physicality (Bradley and Scott, 2020). There was also a concomitant elevation in professionalism and the creation of major infrastructure regarding elite leagues around the world. This in turn resulted in more revenue generation and more players training and playing as full-time footballers. When FIFA published the most recent physical report (Bradley and Scott, 2020), the first surprising outcome was the sheer magnitude of the change in demands from the 2015 Women’s World Cup in Canada compared to the 2019 tournament in France. Especially given there was very little change in the demands between the 2011 and 2015 competitions. This report demonstrated that intense running (>19 km/h) had increased across various playing positions by ~20% from Canada 2015 to France 2019, and is clear confirmation of the game’s evolution. To put this into perspective, previous research on

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elite male players found a similar increase in the demands observed in the English Premier League across a 7-year period (Barnes et al., 2014). While this trend for the women’s game was over just a 4-year period and could indicate a more rapid evolution than that observed in the men’s game on a relative yearby-year basis (Figure 5). A common question posed by various stakeholders is: ‘why’ has there been such a change? A major limitation is that most match demands studies are descriptive in nature and will highlight the trends but not necessarily the mechanistic information regarding the ‘why’. However, longitudinal fitness testing data could provide some insights. For instance, Haugen et al. (2014) found that the aerobic capacity of elite female players did not change from an absolute perspective but declined slightly when expressed relative to body mass from 1989 to 2007. This latter trend was the result of a higher body mass in the 2002-2007 period compared to the 1989-1994 and 1995-2001 periods. Although body composition was not

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assessed, this ~3 kg increase may have been due to an increase in fat-free mass and thus could translate into an elevated anaerobic performance. Interestingly, Haugen et al. (2012) found that elite female players were 2% faster during a 20 m sprinting test in the 20062010 period than players from the 1995-1999 period. This trend is remarkably similar for the evolution of anaerobic match performance and physical testing indices for both elite male and female players and potentially indicates a greater anaerobic contribution to match play as a result of improved sprinting performances. Although, the reader should be aware that to truly prove this, the match performance and physical fitness indices would need to be from the same sample of players and the above trends are from different competitive standards, periods of time and countries. Integrative Framework for Future Research on the Women’s Game As these demands have increased particularly at the higher intensities, it emphasises that there should be greater importance placed on training methods to prepare players for the rigours of the modern game. This will help the coach to prepare conditioning drills to enable players to be fully prepared in relation to performance but more so in relation to mitigating the risk of injury. This latter point is particularly important given that injuries are by far the greatest problem encountered in football in terms of their impact on players. This is especially relevant for the women’s game given the potentially greater occurrence of serious long-term injuries (e.g. knee ligament injuries) compared to male players. The reader should also be aware that ‘more is not always better’ (e.g. more intense distance). However, these elevations in metrics coincide with a more entertaining and skill-based game.

Thus, these evolutions seem to be benefiting the game from a fan’s perspective, but more injuries and elevated demands could impact the physical and mental strain placed on modern players. Another important avenue for future research is a continued strive to understand the true impact of these elevated demands on players’ performance, injury risk, and general well-being. One area of well-being that is under-researched significantly in both women’s football and sport, in general, is the menstrual cycle. Two recent papers shed some light on the influence of the menstrual cycle phase on physical fitness indices and match running performances of elite female players (Julian et al., 2017, 2020) but clearly more work is needed. Additional research should be conducted on the impact of the menstrual cycle phases on not just physical performances but also technical and tactical indices to gain a more complete understanding of its influence. Moreover, subjective logs and specific interventions to manage various symptoms during seasonal phases would also provide more insights into wellness markers and practical solutions to reduce any negative impacts on performance. But a ‘bigger picture’ perspective is needed as we should ensure all of the research above is not reductionist in nature (e.g. conducted in isolation). A more joined-up approach to research is needed that links all aspects to a global research framework on football (e.g. the demands are linked to performance, injury, and wellbeing as everything is connected!). This can then feedback to stakeholders to make the relevant changes to ultimately aid coach and player development. Football Governing Bodies (e.g. FIFA and UEFA) and Football Associations and other organisations could be an important conduit for this type of research in future. Please see Figure 6 for an integrative research framework that aligns key themes to

provide a more holistic understanding of major elements of the game. Despite the growth in the quantity and quality of women’s football studies, this should not be seen as the end but only the beginning! More investment is needed to ensure the women’s game doesn’t just reach the required standard but actually sets the standard! High-quality research will be an important driver of this in the future. Conclusions Although the majority of match play is low intensity, it is the high-intensity activity that is both vital for gameplay and is the most taxing physically. The physical components of match play are evolving rapidly in the modern women’s game. As such a greater emphasis must be placed on the physical, technical and tactical preparation of elite female players. Research frameworks have been key drivers in other areas of football, and an integrative research structure that aligns the match demands area with other key facets of the female game could aid future innovations (e.g. menstrual cycle phase and injury).

Dr Paul Bradley (paulbradley94@yahoo.co.uk) Football Science Consultant and Associate Professor (Reader) at LJMU

Figure 5 - Intense running of international players in FIFA Women’s World Cup matches in Canada 2015 and France 2019 and in the men’s English Premier League from 200607 to the 2012-13 season. Manually redrawn and coloured from the original source of Barnes et al. (2014) as well as Bradley and Scott (2020). Please note: the high-intensity threshold for male players was >19.8 km/h and >19.0 for female players.

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football medicine & performance Figure 6 - An integrative R&D framework that advocates a more joined-up approach. Studies can be broken down individually but also have selected parts that overlap so interactions between studies can be examined to unveil complexities.

Ade J, Fitzpatrick J, Bradley PS. (2016). High-intensity efforts in elite soccer matches and associated movement patterns, technical skills and tactical actions. Information for position-specific training drills. J Sports Sci. 34: 2205-2214.

Bradley PS, Vescovi JD. (2015). Velocity thresholds for women’s soccer matches: sex specificity dictates high-speed running and sprinting thresholds - Female Athletes in Motion (FAiM). Int J Sports Physiol Perform. 10:112-116.

Andersson H, Ekblom B, Krustrup P. (2008). Elite football on artificial turf versus natural grass: Movement pattern, technical standard and player opinion. J Sport Sci. 26: 113–122.

Davis JA, Brewer J. (1993). Applied physiology of female soccer players. Sports Med. 16:180-189.

Andersson HÅ, Randers MB, Heiner-Møller , Krustrup P, Mohr M. (2010). Elite female soccer players perform more high-intensity running when playing in international games compared with domestic league games. J Strength Cond Res. 24:912-919. Bangsbo J, Mohr M, Krustrup P. (2006). Physical and metabolic demands of training and match-play in the elite football player. J Sports Sci. 24: 665–674. Barnes C, Archer DT, Hogg B, Bush M, Bradley PS. (2014). The Evolution of Physical and Technical Performance Parameters in the English Premier League. Int J Sports Med. 35: 1095-1100. Bradley PS. (2020). Football Decoded: Using Match Analysis and Context to Interpret the Demands. Independently Published. 1-183. Available at: https://www.amazon.co.uk/dp/B08S33ZSDH/ ref=tmm_kin_swatch_0?_encoding=UTF8&qid=&sr=

Datson N, Drust B, Weston M, Jarman IH, Lisboa PJ, Gregson W. (2017). Match Physical Performance of Elite Female Soccer Players During International Competition. J Strength Cond Res. 31: 2379-2387. Di Salvo V, Gregson W, Atkinson G, Tordoff P, Drust B. (2009). Analysis of high- intensity activity in Premier League soccer. Int J Sports Med. 30(3): 205–212. FIFA. (2016). Physical Analysis of the FIFA Women’s World Cup Canada 2015™. Zurich: FIFA 2016. Available from: http://resources. fifa.com/mm/document/tournament/competition/02/81/24/87/ physicalanalysisenweb_neutral.pdf [Accessed April 2020]. FIFA. (2019). Women’s Football: Member Associations Survey Report. Zurich: FIFA. Available from:https://resources.fifa.com/image/upload/fifawomen-s-survey-report-confederations-global-mas.pdf?cloudid=nq3enso hyxpuxovcovj0 [Accessed April 2020].

Krustrup P, Mohr M, Ellingsgaard H, Bangsbo J. (2005). Physical demands during an elite female soccer game: importance of training status. Med Sci Sports Exerc. 37:1242-1248. Krustrup P, Zebis M, Jensen JM, Mohr M. (2010). Game-induced fatigue patterns in elite female soccer. J Strength Cond Res. 24(2):437-441. Kryger KO, Wang A, Mehta R, Impellizzeri FM, Massey A, Alan McCall (2021) Research on women’s football: a scoping review, Science and Medicine in Football, DOI: 10.1080/24733938.2020.1868560 Mohr M, Krustrup P, Andersson H, Kirkendal D, Bangsbo J. (2008). Match activities of elite women soccer players at different performance levels. J Strength Cond Res. 22:341-349. Mohr M, Krustrup P, Bangsbo J. (2003). Match performance of highstandard soccer players with special reference to development of fatigue. J Sports Sci. 21(7):519–528. Park LAF, Scott D, Lovell R. (2019). Velocity zone classification in elite women’s football: where do we draw the lines? Sci Med Football. 3: 21-28. Scott D. (2018). The Rise of the Women’s Game: A Professional Perspective. Aspetar Sports Med J. 7: 39-43.

Haugen TA, Tønnessen E, Hem E, Leirstein S, Seiler S. (2014). VO2max characteristics of elite female soccer players, 1989-2007. Int J Sports Physiol Perform. 9(3):515-521.

Varley MC, Jaspers A, Helsen WF, Malone JJ. (2017). Methodological Considerations When Quantifying High-Intensity Efforts in Team Sport Using Global Positioning System Technology. Int J Sports Physiol Perform.12(8):1059-1068.

Haugen TA, Tønnessen E, Seiler S. (2013). Anaerobic performance testing of professional soccer players 1995-2010. Int J Sports Physiol Perform. 8(2):148-156.

Vescovi JD. (2012). Sprint profile of professional female soccer players during competitive matches: Female Athletes in Motion (FAiM) study. J Sports Sci. 30:1259-1265.

Haugen TA, Tønnessen E, Seiler S. (2012). Speed and countermovementjump characteristics of elite female soccer players, 1995-2010. Int J Sports Physiol Perform. 7(4):340-349.

Bradley PS, Martin-Garcia A, Ade, JD, Gomez-Diaz A. (2019). Position Specific and Positional Play Training in Elite Football: Context Matters. Football Med & Perform. 29: 31-35.

Vescovi JD. (2012a). Sprint speed characteristics of high-level American female soccer players: Female Athletes in Motion (FAiM) study. J Sci Med Sport.15:474–478.

Ingebrigtsen J, Brochmann M, Castagna C, Bradley PS, Ade J, Krustrup P, Holtermann A. (2014). Relationships between field performance tests in high-level soccer players. J Strength Cond Res. 28(4):942-949.

Bradley PS, Mohr M, Bendiksen M, Randers MB, Flindt M, Barnes C, Hood P, Gomez A, Andersen JL, Di Mascio M, Bangsbo J, Krustrup P. (2011). Sub-maximal and maximal Yo-Yo intermittent endurance test level 2: heart rate response, reproducibility and application to elite soccer. Eur J Appl Physiol.111(6):969-978.

Vescovi JD. (2012b). Sprint profile of professional female soccer players during competitive matches: female athletes in motion (FAiM) study. J Sports Sci. 30(12):1259–1265.

Ingebrigtsen J, Dillern T, Shalfawi SA. (2011). Aerobic capacities and anthropometric characteristics of elite female soccer players. J Strength Cond Res. 25:3352–3357.

Vescovi JD. (2016). Physical demands of regular season and playoff matches in professional women’s soccer: a pilot from the female athletes in motion (FAiM) study. In: Favero TG, Drust B, Dawson B, editors. International research in science and soccer II. New York: Routledge.

Bradley PS, Bendiksen M, Dellal A, Mohr M, Wilkie A, Datson N, Orntoft C, Zebis M, Gomez-Diaz A, Bangsbo J, Krustrup P. (2014a). The application of the Yo-Yo intermittent endurance level 2 test to elite female soccer populations. Scand J Med Sci Sports. 24(1):43-54. Bradley PS, Dellal A, Mohr M, Castellano J, Wilkie A. (2014b). Gender differences in match performance characteristics of soccer players competing in the UEFA Champions League. Hum Mov Sci. 33:159-171.

Bradley PS, Sheldon W, Wooster B, Olsen PD, Boanas P, Krustrup P. (2009). High-intensity running in English FA Premier League soccer matches. J Sports Sci. 27:159–168. Bradley PS, Scott D. (2020). Physical Analysis of the FIFA Women’s World Cup France 2019™. Zurich: FIFA. Available from: https://img.fifa.com/ image/upload/zijqly4oednqa5gffgaz.pdf. 1-168. [Accessed July 2020].

Julian R, Hecksteden A, Fullagar HHK, Meyer T. (2017). The effects of menstrual cycle phase on physical performance in female soccer players. PLOS ONE 12(3): e0173951. https://doi.org/10.1371/journal.pone.0173951 Julian R, Skorski S, Hecksteden A, Pfeifer C, Bradley PS, Schulze E, Meyer T. (2020). Menstrual cycle phase and elite female soccer match-play: influence on various physical performance outputs. Sci & Med Football, DOI: 10.1080/24733938.2020.1802057.

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Vescovi JD. (2019). Women’s soccer velocity thresholds: statistical techniques or physiological metrics – context is critical. Sci Med Football. 3: 81–82.

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NO TIME TO WASTE DURING THE COVID-19 PANDEMIC AND BEYOND: SCREENING FOR MENTAL HEALTH SYMPTOMS AND DISORDERS IN PROFESSIONAL FOOTBALL FEATURE / VINCENT GOUTTEBARGE Within the context of professional football, the mental health of players has been legitimately the subject of increasing scrutiny over the past years. The available body of scientific evidence suggests that the prevalence of mental health symptoms among professional footballers is substantial, or at least similar to the prevalence of the general population. Due to the ongoing COVID-19 pandemic and its related adverse consequences, professional footballers have reported recently higher rates of mental health symptoms. Regardless of how long the professional football industry will remain affected by COVID-19, there is no time to waste anymore and a systematic screening programme for mental health symptoms among players should be introduced in any professional football clubs. Definition of mental health symptoms Mental health symptoms refer to selfreported adverse or abnormal thoughts, feelings, and/or behaviours that do not meet specific diagnostic criteria and do not necessarily cause significant distress or functional impairment.1 By contrast, mental health disorders are typically defined as conditions causing clinically significant distress or functional impairment that meet certain diagnostic criteria such as in the Diagnostic and Statistical Manual of Mental Disorders 5 or the International Classification of Diseases.1 In professional football, nearly all available body of scientific evidence is directed towards mental health symptoms such as psychological distress, anxiety, depression, sleep disturbance, or alcohol misuse. Any professional footballer (as any individual) can occasionally experience sadness, anger, stress, irritability, and anxiety. However, if persistent over a long period of time and/or if impacting the player’s performance or daily life, then it may be that this player is experiencing mental health symptoms. Common experiences of mental health symptoms can include the following adverse thoughts, feelings, behaviours, and/or physical changes:2

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Thoughts: excessive self-criticism, low self-esteem, pessimism, hopelessness, problems with focus, concentration, and memory; Feelings: irritability, anger, mood swings, sadness, extreme disappointment that you just cannot shake, depression, loneliness, emptiness, lack of passion and sense of purpose, lack of motivation; Behaviours: aggression, withdrawal from others / not going outside as much, being much more quiet than usual, an unexpected drop of performance (e.g., in sport, school, work); Physical changes: low energy, poor sleep, changes in appetite, changes in weight and appearance, evidence of alcohol or other substance misuse.

Mental health symptoms in professional football during the COVID-19 pandemic Professional footballers report several mental health symptoms at rates at least similar to those of the general population. In a twelvemonth prospective cohort study conducted in 2015 among 607 male professional players, the prevalence of mental health symptoms found at baseline was 38% for anxiety/depression, 23% for sleep disturbance and 9% for adverse alcohol use.3 From March 2020, several public health measures were implemented to reduce human-to-human transmission of COVID-19, for instance, travel restrictions, mass homeconfinement directives, social distancing, and postponement or cancellation of most ongoing football competitions. Such an unprecedented COVID-19 pandemic created new strains on players, increasing potentially their vulnerability to mental health symptoms. Therefore, an observational comparative cross-sectional survey study was conducted.4 The validated Generalised Anxiety Disorder 7 (GAD-7) was used to assess anxiety symptoms and the validated Patient Health Questionnaire 9 (PHQ-9) for depressive symptoms. Data were collected from March to April 2020 in the COVID-19 study group (468 female and 1,134 male professional footballers), and from December 2019 to January 2020 in the non-COVID-19 comparison group (132 female and 175 male professional footballers). The

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prevalence rates were significantly higher during the COVID-19 pandemic than before (p<·01): • Anxiety symptoms: 18% versus 8% before in female players and 16% versus 4% in male players; • Depressive symptoms: 22% versus 11% before in female players and 13% versus 6% in male players. Similar results were found among 191 players in the top Swedish football league surveyed in May 2020.5 The extent of mental health symptoms among players, either prior or since the COVID-19 pandemic, warrants systematic screening for mental health symptoms in professional football, just as other conditions (e.g., musculoskeletal, cardiovascular) are screened. The IOC Sport Mental Health Assessment Tool 1 (SMHAT-1) In the International Olympic Committee (IOC) consensus statement on mental health in elite athletes published in 2019, one principal caveat formulated was the lack of specific tools to assess mental health symptoms and disorders in elite athletes.1 Consequently, the IOC established its Mental Health Working Group aiming in part to develop an assessment tool for the context of elite sports. Therefore, from April 2019 to March 2020, the IOC Mental Health Working Group (i) conducted narrative and systematic reviews of the scientific literature, (ii) explored through an electronic questionnaire the views of elite athletes, (iii) selected the approach and content for a provisional version of the assessment tool, (iv) evaluated and finalised the assessment tool via a modified Delphi consensus process among licensed mental health professionals, and (v) assessed the appropriateness and preliminary reliability and validity of the assessment tool.2 This exercise led to the IOC Sport Mental Health Assessment Tool 1 (SMHAT-1) published in September 2020 in the British Journal of Sports Medicine.2 The SMHAT-1 (Figure 1) is developed for sports medicine physicians and other licensed/ registered health professionals to assess elite athletes (including professional footballers) potentially at risk for or already experiencing mental health symptoms and disorders to facilitate timely management and/or referral to adequate support and/or treatment. The SMHAT-1 relies on a three-step approach: triage step (step 1) based on an existing validated

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Figure 1 - The IOC Sport Mental Health Assessment Tool 1 (SMHAT-1)

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screening instrument; screening step (step 2) based on six existing validated screening instruments related to the most prevalent mental health symptoms in elite sports; intervention and (re)assessment step (step 3) including in some cases a clinical assessment. It is important to mention that physical therapists, athletic trainers and not clinically-trained sports psychologists working with a sports medicine physician can use the SMHAT-1, but any clinical assessment, guidance or intervention should remain the responsibility of their sports medicine physician. Because the athletes themselves and all members of their entourage (e.g. friends, fellow athletes, family, coaches) are essential to support athletes’ mental health, the IOC Mental Health Working Group developed the IOC Sport Mental Health Recognition Tool 1 (SMHRT-1). The SMHRT-1 (Figure 2) aims to facilitate early detection of mental health symptoms in elite athletes (including professional footballers) to promote help-seeking for those athletes in need of assistance from a sports medicine physician or other licensed/registered health professional and to facilitate further assessment and subsequent treatment as applicable. Both the SMHAT-1 and SMHRT-1 are the first versions of the IOC tools. Analogous to sports concussion and its assessment (SCAT) and recognition (CRT) tools, the IOC Mental Health Working Group intends to revise the SMHAT-1 and SMHRT-1 in the future as needed. No time to waste within professional football The SMHAT-1 should be part of regular screening programmes within professional football: there is no justification why players would be screened systematically for musculoskeletal or cardiovascular conditions but not for mental health symptoms and disorders. Therefore, the SMHAT-1 should be used at least within the precompetition period (i.e. ideally a few weeks after the start of training), as well as when a player experiences any significant life event (e.g. major injury/illness, surgery, unexplained performance concern). In Box 1, a representative but a fictional case of a player with mental health symptoms and disorders is presented by Professor Alan Currie (Consultant Psychiatrist). The triage and screening steps of the SMHAT-1 are designed to ideally be embedded in any existing privacysecured online platforms that most professional football clubs already used. Thanks to the IOC and its SMHAT-1, there is thus no time to waste within professional football: mental health symptoms and disorders should be screened among players.

Vincent Gouttebarge Affiliations: 1. FIFPRO (Football Players Worldwide), Hoofddorp, the Netherlands 2. Amsterdam UMC, Univ of Amsterdam, Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, the Netherlands

Box 1. Case presentation by Professor Alan Currie, Consultant Psychiatrist at Regional Affective Disorders Service, Cumbria, Northumberland Tyne and Wear NHS Foundation Trust, Newcastle, United Kingdom

Screening tools for anxiety and depression were completed and compared with his scores from the pre-season SMHAT-1. His PHQ9 score had been 4 and was now 21 (severe depression). His GAD7 score had increased from 3 to 7 (mild anxiety).

Jamie is 21 and plays in central midfield in the second-tier of his country’s national league. He developed groin pain during a training session but did not disclose this. The following Saturday he played with mild pain. This became much worse during a midweek match a few days later and he had to be substituted. An acute adductor longus injury was suspected and an MRI scan was confirmatory (grade 2 tear). He was out for 3 weeks and when fit again had lost his place in the team.

He reported feeling relieved at opening up and agreed to a consultation with a sports psychiatrist when reassured that the club had worked with this psychiatrist before and that he had a good understanding of the sport. Sessions of Cognitive Behavioural Therapy (CBT) were recommended and the therapist was able to work with Jamie and the sports medicine team to incorporate elements of behavioural therapy into the injury rehabilitation program e.g. setting realistic injury recovery goals and addressing concerns about re-injury. Anti-depressant medication was also recommended. Jamie was initially reluctant but agreed after an explanation and the psychiatrist took careful account of the tolerability and side-effect profile when prescribing.

He was determined to regain his place but re-injured with a more severe tear during training. He was despondent, which made it hard to commit to rehabilitation. The physiotherapist became concerned about his mood and he opened up during a treatment session. He told of his deep unhappiness. He was lacking in motivation, energy and enthusiasm. He and the physiotherapist agreed to meet confidentially with the team doctor. During this consultation, he mentioned how bleak the future seemed and berated himself for his failure to recover. He was sleeping badly, couldn’t concentrate and had lost weight. He had no suicidal thoughts.

1. Reardon CL, Hainline B, Miller Aron C, et al. International Olympic Committee consensus statement on mental health in elite athletes. Br J Sports Med 2019;53:667-99. 2. Gouttebarge V, Bindra A, Blauwet C, et al. International Olympic Committee (IOC) Sport Mental Health Assessment Tool 1 (SMHAT-1) and Sport Mental Health Recognition Tool 1 (SMHRT-1): towards better support of athletes’ mental health. Br J Sports Med 2020 Sep 18;bjsports-2020-102411. 3. Gouttebarge V, Aoki H, Kerkhoffs G. Symptoms of Common Mental Disorders and Adverse Health Behaviours in Male Professional Soccer Players. J

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Jamie’s mood and motivation improved slowly as rehabilitation progressed. He had some matches with the reserves before returning to the first team. He completed 12 sessions of CBT followed by ‘top-up’ work with his therapist throughout the next season. He continued medication for six months before it was reduced and stopped under psychiatric medical supervision.

Hum Kinet 2015;49:277-86. 4. Gouttebarge V, Ahmad I, Mountjoy M, et al. Anxiety and Depressive Symptoms During the COVID-19 Emergency Period: A Comparative Cross-Sectional Study in Professional Football. Clin J Sport Med 2020 Sep 15. doi: 10.1097/ JSM.0000000000000886. 5. Håkansson A, Jönsson C, Kenttä G. Psychological Distress and Problem Gambling in Elite Athletes during COVID-19 Restrictions-A Web Survey in Top Leagues of Three Sports during the Pandemic. Int J Environ Res Public Health 2020;17:6693.

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Figure 2 - The Sport Mental Health Recognition Tool 1 (SMHRT-1)

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DO NIGGLES MATTER? INJURY SURVEILLANCE IS A KEY STEP IN THE PREVENTION OF INJURIES FEATURE / DR MATT WHALAN It has long been acknowledged that injury surveillance is the cornerstone for the development of effective injury prevention programs and systems (Van Mechelen et al, 1992). Without injury surveillance it is difficult to not only determine what injuries you need to target but also, surveillance ensures that your intervention is effective. Most commonly in football injury research, however, only time-loss injuries which result in a failure to fully participate in training or matches are used to determine injury incidence and severity, based on the football injury recording consensus statement (Fuller et al, 2006). As such, injuries or physical complaints that do not stop a player training or playing, non-time loss injuries or “niggles”, are not routinely reported in the literature or if they are, it is only when the injury is significant enough to impact on participation. Clarsen and Bahr (2014a) produced an excellent figure which outlines the different definitions applied to injury classification (Figure 1). As seen in this figure,

the time loss definition captures many but not all injuries that can occur to a player with the “niggle zone” previously not addressed in football injury research. The Oslo Sport Trauma Research Centre (OSTRC) Questionnaire on Health Problems for Self-Reporting Injuries. Developed in 2014 by Assoc Prof Ben Clarsen and colleagues, the OSTRC Questionnaire on Health Problems was developed to try and improve injury data collection methods across a number of sports. The survey was sent out once a week and explored the impact of any physical issue during the week on participation, performance, pain perception and training volume (Figure 2). More recently, other versions of the survey have been used to capture locationspecific (e.g. hip/groin) non-time loss injury information with much larger capture of physical issues compared with the traditional time loss method (Harøy et al 2017).

The Research Our research questions – how many niggles occur in football & can a niggle help identify a player at an increased risk of a time-loss injury? Based on the emerging research and from most practitioners’ own experience, it is likely that time loss injury rates significantly underestimate the prevalence of physical complaints in football. Furthermore, little was also known about the prevalence and impact niggles in football may have on more serious time loss injury risk. As such, we looked to capture both time loss and non-time loss (niggles) injuries over an entire season and explore the concept of injury risk. What Did We Do? Players from semi-professional football clubs in Australia agreed to participate in an injury study during the 2016 season (35 weeks). All players participated in football exposures 3-4 times per week and had any time loss (medical staff recorded via the Football Consensus injury

Figure 1 - Adapted figure from Clarsen and Bahr (2014a) highlighting different classifications of injury. The consensus for injury recording in football (Fuller et al, 2006) covers the time loss injury portion, while the OSTRC Questionnaire on Health Problems (Clarsen et al, 2014b) endeavours for a much larger injury capture. The Niggle Zone is the missing piece in football injury surveillance.

Figure 2 - The OSTRC Questionnaire on Health Problems (Clarsen et al, 2014b) explores the impact of physical complaints on 4 categories – participation, volume, performance and perception of severity.

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feature method) and non-time loss (self-reported via the OSTRC Questionnaire on Health Problems) injuries recorded. To be included for analysis, players were required to complete at least 70% of all weekly surveys. What Did We Find? Injuries and Weekly Injury Prevalence The total number of reported “physical complaints” was 2.3 times greater when selfreported (OSTRC Questionnaire) compared with a medical reported injury. However, for a number of potential reasons, time loss injury capture was much greater using the traditional injury recording methods. Each week, on average, niggles accounted for 28% of all weekly injuries with time-loss injuries accounting for 5% when recorded by the OSTRC Questionnaire (Figure 3). Interestingly, combining both methods, with niggles and time-loss injuries recorded by medical staff, a staggering 49% of players were affected by an injury each week. The Risk of a Time Loss Injury Within 7 days of Reporting a Niggle Risk of an injury for a player that reported a niggle was calculated and assessed relative to the normal risk of sustaining an injury. As can be seen in Figure 4, when a player reported a minor or moderate physical complaint but was still able to participate in football, the risk of sustaining a time-loss injury within 7 days was 3.6 to 6.9x higher when preceded by ‘minor’ and ‘moderate’ niggle, respectively. The greater the impact the niggle had on player perceived participation, severity, performance or volume, the higher the risk was determined to be. Does the location of a niggle matter? Importantly, 68% of all time-loss (TL) injuries were preceded by a niggle report, with 94% of knee and 90% of hamstring time loss injuries preceded by a niggle in the same location. The most common injury locations were the hamstring muscles and knee. The greatest risks were observed in the ankle and lower leg with variation observed across regions (Figure 5). Of note, the hip/groin and lower back were associated with the highest niggles to time loss injury ratio indicating that perhaps players are much more likely to continue to play on with these prevalent issues. So……Should We Bother Recording Niggles? Yes! For 2 very good reasons: One – in this study, over a quarter of players are affected by a non-time loss niggle each week with more than 2x the number of niggles to time-loss injuries. Players consistently reported that they perceived that these niggles impacted on their performance and should be of as much interest to performance staff as the medical staff. When designing injury prevention systems, taking into consideration the type and volume of reported niggles may be useful in directing intervention strategies.

Figure 3 - Weekly prevalence of niggles (black) and time-loss injury (orange) as recorded by the OSTRC Questionnaire on Health Problems.

Figure 4 - Associated injury risk of sustaining a time-loss injury following a niggle report for all 4 categories in the OSTRC Questionnaire on Health Problems. (adapted from an infographic by Adam Virgile; adamvirgile.com)

Figure 5 - The influence of location of a niggle report on the relative risk (RR) and prevalence of niggles compared to time loss injury (Niggle: Time Loss) for the most common injury sites in football.

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football medicine & performance Two – the presence of a niggle may help performance and medical staff to identify players at increased risk of injury. The major point that needs to be made though is that the presence of a niggle should not be used to predict if a player is going to obtain a time loss injury. The false-positive was high (low sensitivity) in this study i.e. many players that reported a niggle never had a time-loss injury in the following 7 days! As such, a niggle report can potentially be used to flag a player at risk and stimulate a conversation with the player. From this conversation or assessment, adjustments if necessary, can be performed. On the other hand, the findings potentially suggest that not all niggles are created equal. Some players may continue to play with niggling hip/groin or lower back issues however are less likely with a hamstring or lower leg complaint.

30% risk of sustaining an injury but a 70% chance that nothing happens. Additionally, when considering the high false-positive rate, it is easier to place appropriate caution to the restricting player participation. Overall, much of the implementation and adoption of reporting niggles requires excellent communication and respect from all stakeholders and planning.

Thirdly, education of all stakeholders regarding injury risk context is vital. When a coach or medical staff hears that a player is 3x more likely to get an injury due to a slight niggle, then a reaction could be to always err on the side of caution and not allow a player to participate. Of course, if a player doesn’t play or train then their risk of injury is zero, but that is unlikely to be a sustainable long-term strategy! A simple way to overcome this is to reference risk to the normal risk of sustaining an injury when nothing is wrong i.e. the normal risk in this study was 10%. Therefore, a player with a slight niggle now may have a

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Investigating the best option(s) to deal with a reported niggle is essential. For example, if a player reports hamstring tightness, and physical therapy intervention is applied, e.g. soft tissue therapy, and the niggle resolves, does the player’s risk reduce? Or perhaps modification or manipulation of training load is enough.

Key Findings • Collecting information regarding non-time loss complaints - “niggles” - provides a more in-depth picture of player health status and should be standard medical staff practice.

Translating these Findings into the Real World To record non-time loss injuries a number of things need to happen and are included in the “Niggles Checklist” (Figure 6). Firstly, the context of injury reporting matters a great deal (Bolling et al, 2018). Players need to trust the medical, performance and technical staff enough to feel comfortable to report niggles. If players think they will be “punished” or viewed as being an over-reporter then players will be less likely to volunteer this information. As such, understanding what motivates players or what they consider to be an injury is important as is educating players on the importance of reporting. Secondly, medical staff need to work hard with performance and technical staff to create a “safe” environment for players to report niggles. For example, let us take the case of a player who reports an issue with their hip/groin at pre-training monitoring but believes they can continue to participate in training. In this scenario, a strategy for the medical staff is to ensure they understand or know what the training session for the day entails. Following this, discussion with the performance and technical staff may result in a slight modification of volume for the player e.g. reduced volume of crossing in a session, however, the player can continue to participate in the session. The overall result is then that the player participates, all stakeholders are informed of the increased risk, small modifications can be easily implemented and the session integrity is maintained.

Potentially reducing the questionnaire to just one or two sections e.g. participation and performance, may reduce the time to complete it and potentially incorporating the survey into post-session reporting along with RPE may also assist with workflow.

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Over a quarter of players, on average, reported a niggle each week that did not affect their participation in training or a match, but had a self-perceived impact on their performance.

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The risk of a time loss injury is 3.6-6.9 x higher when preceded by a niggle. In fact, 68% of all time loss injuries were preceded by a niggle report, with 94% of knee and 90% of hamstring time loss injuries preceded by a niggle in the same location.

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Due to a high false positive rate, the presence of a niggle alone should not be used as a prediction tool. A niggle may be a useful secondary injury prevention strategy to flag players at increased risk of injury and open player, coach and medical staff communication.

Dr Matt Whalan Twitter: @FigtreePhysio

Figure 6 - Niggles Checklist to assist medical, performance and technical staff to translate findings into practice.

Considerations for Future Research • It’s important to note that this is the first study to investigate the impact of niggles on time loss injury risk. Further research is required to determine whether similar findings are consistent across different levels i.e. professional vs semi-professional, however, based on clinical experience it is suspected there will continue to be a benefit to encouraging the reporting and recording of niggles. •

Getting players to consistently complete the OSTRC Questionnaire was difficult over an extended period of time with only 33% consistently completing the questionnaire.

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Acknowledgements Dr John Sampson and Associate Professor Ric Lovell were integral parts of this research project. Article Reference: Whalan M, Lovell R, Sampson JA. Do Niggles Matter? – Increased injury risk following physical complaints in football (soccer). Science and Medicine in Football 2020; 4:3, 216-224, DOI: 10.1080/24733938.2019.1705996. Van Mechelen W, Hlobil H, Kemper H. Incidence, Severity, Aetiology and Prevention of Sports Injuries: A Review of Concepts. Sports Med 1992;14(2): 82-99. Fuller CW, Ekstrand J, Junge A, et al. Consensus statement on injury definitions and data collection procedures in studies of football injuries. Br J Sports Med 2006;40(3):193-201. Clarsen B, Bahr R. Matching the choice of injury/illness definition to study setting, purpose and design: one size does not fit all! Br J Sports Med 2014a;48(7):510-512. Clarsen B, Rønsen O, Myklebust G, Flørenes TW, Bahr R. The Oslo Sports Trauma Research Center questionnaire on health problems: a new approach to prospective monitoring of illness and injury in elite athletes. Br J Sports Med 2014b;48:754-760. Harøy J, Clarsen B, Thorborg K, Hölmich P, Bahr R, Andersen TE. Groin Problems in Male Soccer Players Are More Common Than Previously Reported. Am J Sports Med 2017;45(6):1304-1308. Bolling C, van Mechelen W, Pasman HR, Verhagen E. Context Matters: Revisiting the First Step of the ‘Sequence of Prevention’ of Sports Injuries. Sports Med 2018;48(10):2227-2234.

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DOES LOAD MANAGEMENT USING THE ACUTE: CHRONIC WORKLOAD RATIO PREVENT HEALTH PROBLEMS? FEATURE / TORSTEIN DALEN-LORENTSEN Background Health problems are common among elite youth footballers, who experience similar injury and illness patterns and burden as senior professional players.1-3 Previous studies in elite youth football have found that at any given time of the season, the prevalence of health problems is over 40%.3 Loss of participation due to health problems can negatively affect the players’ performance,4 their health later in their career,5 6 and ultimately, their long-term development.7 Therefore, to enhance the players’ health and to develop better football players, preventive measures are important. Recently, researchers and practitioners have increased their interest in training load as a risk factor for health problems in football,8 with numerous studies reporting an association between training load and injury.9-12 Consequently, training load monitoring and management has gained widespread popularity as a preventive measure in professional and elite youth football.8 13 There is currently no consensus

on which training load parameters should be monitored, how their cut off values should be set and how load progression should be evaluated. Moreover, load management is performed in numerous ways, is often dictated by the philosophy of the club staff or manager, and has no consensus scientifically.8 13 In 2014, Hulin et al. proposed the concept of the Acute:Chronic Workload Ratio (ACWR), whereby an athlete’s recent training load (acute workload) is divided by their training load over a longer period of time (chronic workload).14 This metric is suggested to aid practitioners in managing training load within certain ranges.15 16 The initial concept was based on avoiding sudden spikes in training load, trying to keep ACWR within an arbitrary “optimal range” of 0.8 to 1.5.15 16 Observational evidence supporting an association between ACWR and injury is inconsistent and controversial,17-20 and there are no experimental studies to determine whether using ACWR to manage training loads actually prevents injury or illness. Therefore, we aimed to assess the effectiveness of an ACWR-based

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load management intervention on health problem risk among elite youth footballers of both sexes. Study design We group randomised 34 teams from the elite U19- boys and girls divisions into either the control group or the intervention group. The intervention consisted of individualised load management of every player in the intervention group. Intervention groupcoaches planned the weekly training plan (micro-cycle) based on each player’s training load history. A commercially-available athlete monitoring system (AMS; Athlete Monitoring, Fitstats Inc., New Brunswick, Canada) assisted coaches in planning player micro-cycles, based on ACWR theory.14 ACWR was calculated as the coupled 7- to 28-day ratio using a rolling average. We instructed the intervention group-coaches on training load management theory and how to use the AMS to plan training content, duration and intensity. Each coach received a one-hour introductory session and a follow-up session two weeks later if necessary. Coaches were instructed to

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follow a periodization model based on the “optimal range” concept described by Hulin et al.,14 21 where the aim was to progress or maintain player load while ensuring they remained within the desired ACWR range of 0.8 to 1.5. All training load data (session RPE) reported by the players were instantly available on the coach dashboard in the AMS (Figure 1). The AMS combined the subsequent week’s (7-days) planned training load with the training load from the past 21-days (a rolling average of 28-days) and calculated the planned ACWR for the subsequent week. If the planned training activity in the subsequent week led to players having an ACWR below 0.8, the AMS alerted the coach with a suggestion to increase the load accordingly. Conversely, if the planned activity led to an ACWR above 1.5 for, the AMS alerted the coach (Figure 2), and suggested that they decrease the planned load. Teams in the control group trained as before. We used the OSTRC-H2 questionnaire 22 to record health data. Players responded to the questionnaire in the last week of each month and were instructed to report health problems for the previous 7-days only, giving us a weekly prevalence of 10 intervals at approximately 1-month apart.

The primary effect measure was the between-group difference in prevalence (intervention – control). The secondary effect measure was relative risk ratio (intervention/control). To evaluate the effectiveness of the intervention, we fitted generalized estimating equations (GEE) panel-data models to the two outcomes: all health problems and substantial health problems. The models were defined with a binomial family, a log-link function, and an exchangeable correlation matrix. The estimated standard errors were adjusted for clustering, and a Kauermann and Carroll biascorrected variance estimator,23 which is specifically recommended for cluster randomized trials, was used. Results We did not observe any betweengroup difference of the likelihood of health problems (Relative Risk, RR 1.01 [95% CI 0.91 to 1.12]; P=0.84) or substantial health problems ((RR 0.88 [0.72 to 1.06]; P=0.17) The study includes 2 475 health problems questionnaires. The compliance to the OSTRC-H2 questionnaire was 62% (range 10 to

100%) in the intervention group, and 76% (range 10 to 100%) in the control group, which amounts to an average of 69%. The intervention group coaches planned a total of 25 004 player sessions and received 15 253 player responses, which amounts to an overall response of 74% (range 0% to 100.0%) to the post-training questionnaire. In a post-study survey, the intervention groupcoaches replied to the following question describing their compliance with the intervention: Did you use the AMS to plan training every week throughout the season? Eight out of eleven coaches responded and five replied “yes, every week”, two replied “no, every other week” and one, “no, every month”. Discussion When planning this study, choosing the exact mode of intervention represented a major challenge. We were guided by the literature at the time, as well as the recommendations from the group that developed the ACWR approach.14 16 24 Also, we considered what was commonly used in the field, and therefore had the most practical relevance.

Figure 1 - Coaches dashboard in the AMS after next weeks training load is planned

Figure 2 - Coaches dashboard in ASM suggesting a revision of planned load

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feature Since then, there has been increased scrutiny of the ACWR concept, with several papers highlighting methodological challenges,20 25-30 and some authors questioning the validity of the entire concept.17-19 Despite many studies showing an association, no study has yet managed to predict health problems based on ACWR,10 indicating that a meaningful and pronounced relationship between ACWR and health problems is unlikely. We tested the preventive effect on health problems by using one particular approach to load management. However, there is no consensus on which load management concept should be used, or, if using ACWR, how it should be calculated.20 Our intervention was a one-size-fits-all approach, as we considered it to be the most feasible method for the coaches and because a structured individual protocol remains in a conceptual phase.31 Moreover, at the time we planned the study, the available literature recommended that a similar threshold should be used for all players.14 This one-size-fits-all approach has recently been challenged by both scientists and practitioners, as the relationship between ACWR and health problems is affected by a large number of individual moderating factors.31

scientists and practitioners, as the relationship between training load and health problems is affected by a large number of individual moderating factors. In elite football, sports medicine and performance practitioners meticulously and continuously assess each player’s training load together with numerous other factors, such as history of previous injuries, injuries, player age, wellness, non-sporting load, communication with player, screening and strength test and the importance of next match. This is done to inform subjective decisions that aim to increase performance and reduce the risk of health problems. Providing coaches with a one-size-fitsall metric does not seem to add much value to this process. We believe that, given the results of this study and the current state of knowledge in the field, load management remains just as much an art as a science. Key points: • Load management using ACWR in a one-size-fits-all approach does not appear to prevent health problems among elite youth football players of both sexes. •

The lack of a clear relationship between training load and

Methodological considerations This study involved an intervention that was arguably more technically demanding and time-consuming for coaches and players than previous prevention studies in sports.32 33 These challenges may have led to reduced adherence to the intervention by the coaches, and reduced questionnaire response rates by the players. A major limitation of the study is the method used to assess the coaches’ adherence to the intervention. Ideally, we would have logs or questionnaires describing the extent to which their training planning was influenced by the ACWR, and how often they intervened in their players’ training plan based on feedback from the AMS. However, we asked the coaches in a post-study questionnaire where they indicated that, to a large extent, the intervention had been followed. What does this mean? Although many practitioners, researchers, and players consider training load to be an important risk factor for health problems in football, supporting evidence is currently conflicting. Our intervention was a one-size-fits-all approach, which has recently been challenged by both

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health problems does not mean practitioners should abandon training load management. Its primary role has always been performance enhancement, and not health problem prediction or prevention. •

With a lack of models linking training load and health problems, practitioners should follow the general training principles such as the principle of progressive overload.

Author Bio: Torstein Dalen-Lorentsen is a sports physiologist who currently works as a PhD-Fellow at the PhD-student at the Oslo Sports Trauma Research Center. Torstein has extensive experience working with top-level athletes within different sports such as alpine skiing, handball and football. His last role in sports was with professional football club Strømsgodset, where he had the role as a high-performance manager for three seasons. Torstein’s PhD-project is titled “Can training load management reduce injury and illness risk in elite youth football?” Where the research topics have surrounded methodological issues, effectiveness and implementation of training load management. Twitter @torsteindalen

football medicine & performance

Figure 4 - Prevalence of health problems in the control group and the intervention group throughout the season.

Figure 5 - Prevalence of health problems in the control group

1. Jones S, Almousa S, Gibb A, et al. Injury Incidence, Prevalence and Severity in High-Level Male Youth Football: A Systematic Review. Sports Medicine 2019;49(12):1879-99. doi: 10.1007/ s40279-019-01169-8 2. Ekstrand J, Hagglund M, Walden M. Injury incidence and injury patterns in professional football: the UEFA injury study. Br J Sports Med 2011;45(7):553-8. doi: 10.1136/bjsm.2009.060582 [published Online First: 2009/06/26] 3. Moseid CH, Myklebust G, Fagerland MW, et al. The prevalence and severity of health problems in youth elite sports: A 6-month prospective cohort study of 320 athletes. Scandinavian Journal of Medicine & Science in Sports 2018;28(4):1412-23. doi: 10.1111/ sms.13047 4. Røksund OD, Kristoffersen M, Bogen BE, et al. Higher Drop in Speed during a Repeated Sprint Test in Soccer Players Reporting Former Hamstring Strain Injury. Frontiers in physiology 2017;8:25-25. doi: 10.3389/fphys.2017.00025 5. Maffulli N, Longo UG, Gougoulias N, et al. Long-term health outcomes of youth sports injuries. British Journal of Sports Medicine 2010;44(1):21. doi: 10.1136/bjsm.2009.069526 6. Fyfe JJ, Opar DA, Williams MD, et al. The role of neuromuscular inhibition in hamstring strain injury recurrence. J Electromyogr Kinesiol 2013;23(3):523-30. doi: 10.1016/j. jelekin.2012.12.006 [published Online First: 2013/02/09] 7. Ward P, Hodges NJ, Starkes JL, et al. The road to excellence: deliberate practice and the development of expertise. High Ability Studies 2007;18(2):119-53. doi: 10.1080/13598130701709715

J Sci Med Sport 2017;20(6):561-65. doi: 10.1016/j.jsams.2016.10.014 [published Online First: 2016/11/20] 13. Weston M. Training load monitoring in elite English soccer: a comparison of practices and perceptions between coaches and practitioners. Science and Medicine in Football 2018;2(3):216-24. doi: 10.1080/24733938.2018.1427883 14. Hulin BT, Gabbett TJ, Blanch P, et al. Spikes in acute workload are associated with increased injury risk in elite cricket fast bowlers. Br J Sports Med 2014;48(8):708-12. doi: 10.1136/bjsports-2013-092524 [published Online First: 2013/08/22] 15. Blanch P, Gabbett HT. 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. British journal of sports medicine 2016;50(8):471-75. doi: 10.1136/bjsports-2015-095445 16. Gabbett HT. The training-injury prevention paradox: should athletes be training smarter and harder? British journal of sports medicine 2016;50(5):273-80. doi: 10.1136/bjsports-2015-095788 17. Impellizzeri FM, Tenan M, Kempton T, et al. Acute:Chronic Workload Ratio: Conceptual Issues and Fundamental Pitfalls. International Journal of Sports Physiology and Performance 2020:1-7. doi: 10.1123/ ijspp.2019-0864 18. Impellizzeri FM, Woodcock S, Coutts AJ, et al. Acute to random workload ratio is ‘as’ associated with injury as acute to actual chronic workload ratio: time to dismiss ACWR and its components. SportRxiv Preprints 2020 doi: 10.31236/osf.io/e8kt4 19. Impellizzeri FM, Woodcock S, McCall A, et al. The acute-chronic workload ratio-injury figure and its ‘sweet spot’ are flawed. 2019 doi: https://doi.org/10.31236/osf.io/gs8yu

8. Akenhead R, Nassis GP. Training Load and Player Monitoring in High-Level Football: Current Practice and Perceptions. International journal of sports physiology and performance 2016;11(5):587-93. doi: 10.1123/ijspp.2015-0331

20. Dalen-Lorentsen T, Andersen TE, Bjørneboe J, et al. A cherry tree ripe for picking: The relationship between the acute:chronic workload ratio and health problems. SportRxiv Preprints 2020 doi: https://doi. org/10.31236/osf.io/nhqbx

9. Delecroix B, McCall A. Workload and non-contact injury incidence in elite football players competing in European leagues. Taylor & Francis 2019 doi: 10.1080/17461391.2018.1477994

21. Hulin BT, Gabbett HT, Lawson DW, et al. The acute:chronic workload ratio predicts injury: high chronic workload may decrease injury risk in elite rugby league players. British journal of sports medicine 2016;50(4):231-36. doi: 10.1136/bjsports-2015-094817

10. Fanchini M, Rampinini E, Riggio M, et al. Despite association, the acute:chronic work load ratio does not predict non-contact injury in elite footballers. Science and Medicine in Football 2018;2(2):108-14. doi: 10.1080/24733938.2018.1429014

22. Clarsen B, Ronsen O, Myklebust G, et al. The Oslo Sports Trauma Research Center questionnaire on health problems: a new approach to prospective monitoring of illness and injury in elite athletes. Br J Sports Med 2014;48(9):754-60. doi: 10.1136/bjsports-2012-092087 [published Online First: 2013/02/23]

11. Jaspers A, Kuyvenhoven JP, Staes F, et al. Examination of the external and internal load indicators’ association with overuse injuries in professional soccer players. Journal of Science and Medicine in Sport 2017:1-7. doi: 10.1016/j.jsams.2017.10.005 12. Malone S, Owen A, Newton M, et al. The acute:chonic workload ratio in relation to injury risk in professional soccer.

23. Kauermann G, Carroll RJ. A Note on the Efficiency of Sandwich Covariance Matrix Estimation. Journal of the American Statistical Association 2001;96(456):1387-96. doi: 10.1198/016214501753382309 24. Soligard T, Schwellnus M, Alonso JM, et al. How much is too much? (Part 1) International Olympic Committee consensus

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statement on load in sport and risk of injury. Br J Sports Med 2016;50(17):1030-41. doi: 10.1136/bjsports-2016-096581 [published Online First: 2016/08/19] 25. Lolli L, Batterham AM, Hawkins R, et al. Mathematical coupling causes spurious correlation within the conventional acute-to-chronic workload ratio calculations. British Journal of Sports Medicine 2019;53(15):921. doi: 10.1136/ bjsports-2017-098110 26. Lolli L, Batterham AM, Hawkins R, et al. The acute-to-chronic workload ratio: an inaccurate scaling index for an unnecessary normalisation process? British Journal of Sports Medicine 2018:bjsports-2017-098884. doi: 10.1136/bjsports-2017-098884 27. Sampson JA, Fullagar HH, Murray A. Evidence is needed to determine if there is a better way to determine the acute:chronic workload. Br J Sports Med 2017;51(7):621-22. doi: 10.1136/ bjsports-2016-097085 [published Online First: 2016/11/18] 28. Williams S, West S, Cross MJ, et al. Better way to determine the acute:chronic workload ratio? British journal of sports medicine 2016:bjsports-2016-096589-3. doi: 10.1136/ bjsports-2016-096589 29. Andrade R, Wik EH, Rebelo-Marques A, et al. Is the Acute: Chronic Workload Ratio (ACWR) Associated with Risk of TimeLoss Injury in Professional Team Sports? A Systematic Review of Methodology, Variables and Injury Risk in Practical Situations. Sports Medicine 2020 doi: 10.1007/s40279-020-01308-6 30. Wang C, Vargas JT, Stokes T, et al. Analyzing Activity and Injury: Lessons Learned from the Acute:Chronic Workload Ratio. Sports Med 2020;50(7):1243-54. doi: 10.1007/s40279-020-01280-1 [published Online First: 2020/03/04] 31. Bittencourt NFN, Meeuwisse WH, Mendonca LD, et al. Complex systems approach for sports injuries: moving from risk factor identification to injury pattern recognitionnarrative review and new concept. Br J Sports Med 2016;50(21):1309-14. doi: 10.1136/bjsports-2015-095850 [published Online First: 2016/07/23] 32. Harøy J, Clarsen B, Wiger EG, et al. The Adductor Strengthening Programme prevents groin problems among male football players: a cluster-randomised controlled trial. British Journal of Sports Medicine 2019;53(3):150. doi: 10.1136/bjsports-2017-098937 33. Andersson SH, Bahr R, Clarsen B, et al. Preventing overuse shoulder injuries among throwing athletes: a cluster-randomised controlled trial in 660 elite handball players. British Journal of Sports Medicine 2017;51(14):1073. doi: 10.1136/bjsports-2016-096226

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