Beruflich Dokumente
Kultur Dokumente
20 years of F-MARC
Research and Education
1994 - 2014
Editors: )HŔ´#UNŔ¨J
Astrid Junge
TABLE OF CONTENTS | FOOTBALL MEDICINE PROJECTS
Table of Contents
Preface
1 Executive Summary 2
Table of Contents
9 Bibliography 220
10 Supplements 236
10.1 Twenty years of the FIFA Medical and Research Centre (F-MARC):
From “Medicine for Football” to “Football for Health” 244
11 Acknowledgement 246
FOOTBALL MEDICINE PROJECTS | PREFACE
Preface
Since 20 years the FIFA Medical Assessment and In my capacity as chairman of the FIFA Medical Com-
Research Centre (F-MARC) has focussed on the most mittee, and together with members of our Medical
important thing in sport and indeed in society – health. Committee, I wholeheartedly congratulate to F-MARC,
Prof Jiří Dvořák (Chairman) and Prof Astrid Junge
The presented publication recognise the achievements of (Head of Research) for presenting the update of all 369
the F-MARC since its establishment in 1994. Under the scientific publications related to football. This publica-
leadership of chairman Professor Jiří Dvořák and head tion gives an unique opportunity to further develop the
of research Professor Astrid Junge, F-MARC has con- spectacular evolution in the world of our sport for the
ducted rigorous research studies that have benefited the good of more than 300 million football players.
development of our beautiful game. The results of sci-
entific studies documented in 369 original publications This evolution started with our ambition to bring medi-
by F-MARC offer many constructive answers to my cine into football, putting the various medical disciplines
original questions 20 years ago: what can medicine and at the service of the health and the physical condition
science offer to improve the game of football and how of our athletes. This led to the introduction of the Pre-
can the frequency of football-related injuries be reduced Competition Medical Assessment as well as to various
at all levels of the game? It has been proven that injuries changes and amendments to the Law of the Game and
in football can be reduced by up to 50% if the complete the regulations of our competitions. We also introduced
warm-up programme “FIFA 11+” is practised on a regu- the “FIFA 11+” warm-up programme with the success-
lar basis. Research has also shown that playing football ful intention of drastically reducing the number of non-
twice a week for 45 minutes is the best prevention tool contact injuries.
for diseases such as high blood pressure, diabetes, obesity
and others. Furthermore, we tackled the problem of sudden car-
diac arrest on the pitch, introduced new regulations for
The power and popularity of football worldwide can be cases of concussion, and proposed drinking and cool-
used to contribute to the improvement of public health, ing breaks at matches played in high temperatures. We
which has once again been well documented in stud- have already done so much, but we can still do even
ies connected to the “FIFA 11 for Health” programme, more. Indeed, we have seen that football itself can be a
which has already been implemented in 20 countries fantastic tool for improving health, and that is why, in
and becoming a global health initiative of FIFA. our mind, “medicine for football” progressively became
“Football for Health”.
Now is the time for this research to be integrated into
the daily lives of those in the football community Football, at all ages, can play a major role in the preven-
and for us to fully benefit from the achievements of tion and treatment of many illnesses, such as diabetes,
F-MARC within the 209 Member Associations of FIFA. hypertension, hypercholesterolemia, and others. With
our “FIFA 11 for Health” programme, we have even
There can be no compromise in our focus on player’s gone a step further, giving advice to millions of children
health. I have no doubt that by combining our efforts, and youngsters, in more and more countries, to prevent
we can make an important contribution towards better illnesses and improve people’s general wellbeing.
health in football and society in general.
1 Executive Summary
Football is the most popular sport worldwide with cur- been tested in prospective controlled studies on female
rently approximately 300 million players in 209 Mem- players in Norway, and on male players in California
ber Associations. The Fédération Internationale de and Nigeria. All came to the same conclusion: if the pro-
Football Association (FIFA) has, as the world football gramme is performed on a regular basis, injuries can be
governing body, the responsibility to ensure the smooth reduced by 30% while severe injuries can be reduced by
running of its various competitions, and the develop- 50%. Higher compliance with the programme results in
ment of the game for all age groups, at all levels of play, less injuries. The simple conclusion is that injury preven-
both sexes and all in the spirit of fair play. tion works but only if performed regularly.
Mindful that it also has the responsibility towards the FIFA´s Member Associations have understood the pow-
players´ health, FIFA decided to play an active role in er of the injury prevention programme, and many have
developing and supporting research on football medi- implemented the programme to all clubs within their
cine. In 1994 and upon the initiative of the current countries - to name but a few – Germany, Japan, Iran,
FIFA President, Joseph S. Blatter, the FIFA Medical Spain, Italy and others. The programme has since been
Assessment and Research Centre (F-MARC) was estab- introduced to more than 90 Member Associations, and
lished to reduce football injuries, and to promote foot- the FIFA 11+ programme become an integrated part of
ball as a health enhancing leisure activity. all FIFA development courses. The programme has been
also adapted for children and referees.
In 1994, epidemiological data related to football injury
were sparse. Thus, F-MARC established an injury sur-
veillance system at the 1998 FIFA World Cup France, 11 steps to prevent sudden cardiac death
which is now routinely implemented at all subsequent
FIFA and Confederations competitions. At the same Following the tragic death of Marc Vivien Foé dur-
time epidemiological data for recreational football play- ing the FIFA Confederations Cup 2003 France, FIFA
ers was obtained in studies performed in the Czech has been fully committed to a programme of research,
Republic and Germany. The data revealed that each education and practical implementation to prevent and
football player sustained on average 2.1 injuries per manage emergency cardiac arrest on the football field.
year, unrelated to the level of skills. Taking into account The pre-competition medical assessment has been rou-
300 million footballers worldwide, it was obvious to tinely implemented for all FIFA competitions. It has also
F-MARC that prevention is the way to go, however not been adapted for the routine examination within the
only limited to the prevention of injuries but to all nega- Member Associations in accordance with the interna-
tive aspects occurring in relation to the game of football. tional accepted guidelines and recommendations. A clear
“11” was used as synonym for prevention in football. protocol has been developed and applied for field of
play for the recognition, response, resuscitation and the
removal of the player under sudden cardiac arrest. FIFA
FIFA 11+ to prevent injuries has introduced and distributed the FIFA Medical Emer-
gency Bag, including an automated electric defibrillator,
The first injury prevention programme we developed to all 209 Member Associations. It has been reported
consisted of ten evidence based and/or best practice exer- that lives have been saved by using this equipment or as
cises enhanced by the promotion of fair play. Thus, we a result of educational courses provided by FIFA and/or
called the programme the “FIFA 11”. the Member Associations.
The programme was subsequently further developed
to be a complete warm-up programme focusing on the
prevention of injuries: “FIFA 11+”. The programme has
FOOTBALL MEDICINE PROJECTS | EXECUTIVE SUMMARY 3
11 rules to prevent doping tries taking into consideration the social economic envi-
ronment and the risk factors for diseases. It is intended
Since the last prominent doping case, involving the most that FIFA will introduce the programme to 100 Mem-
celebrated player Diego Maradona who tested positive ber Associations by 2019.
for a prohibited substance during the 1994 FIFA World
Cup, a stringent strategy has been developed and imple-
mented by FIFA to prevent doping in football. FIFA Medical Centres of Excellence
This includes in and out-of-competition doping con-
trols at the level of FIFA, Confederations and National As part of the sustainable development of football medi-
Leagues as well as educational programmes for play- cine, 42 FIFA Medical Centres of Excellence for foot-
ers, coaches, doctors and para-medical staff. FIFA sup- ball players have been accredited around the world since
ports and is compliant with the World Anti-Doping 2005. The FIFA Medical Centres of Excellence, serv-
code improving the protocol of controls by develop- ing the needs of footballers at all levels of play, offering
ing the biological profile for individual football players. independent assessments including state-of-the-art treat-
On average, approximately 30’000 doping controls are ment. Moreover, the centres have become an important
performed annually in football, revealing 0.4% positive part of the worldwide network for medical football doc-
findings (majority are so-called recreational drugs such tors, physiotherapists and paramedical staff who deal
as marijuana and cocaine) including 0.03% for perfor- with problems on a day-to-day basis with clubs and indi-
mance enhancing substances such an anabolic steroids. vidual players.
Although positive findings are rare, FIFA continues the
fight against doping in football and sports in general,
while being the first International Federation to imple- Translation of Research into Education
ment the biological profile, by collecting blood and
urine samples at the same time prior to and during the While F-MARC has so far issued 369 original scientif-
2014 FIFA World Cup Brazil. ic publications in peer-reviewed journals, an additional
future activities will be the education of medical person-
nel who cater for football players all around the world. A
FIFA 11 for Health free E-learning platform will be launched on the 1 Janu-
ary 2016 offering information on all aspects of football
Under the umbrella “Football for Health” the effects of medicine. The E-learning programme can be completed
recreational football for the prevention and the treat- by passing the examination process or assessment tool,
ment of non-communicable diseases has been extensively finally leading to a “FIFA Diploma in Football Medi-
studied involving children, mature women and ageing cine”. This way F-MARC´s concept of prevention will
men. It revealed that playing football on a regular basis be disseminated around the world and support FIFA´s
twice a week for 45 minutes has a positive impact on the mission: `Develop the game, touch the world, built a
health status, and could even be prescribed as a thera- better future.´
peutic procedure for a number of diseases such as high
blood pressure, diabetes, child obesity and others. The We sincerely thank FIFA and President J.S. Blatter for
results are based upon more than ten years of research the unconditional support of our work, and the many
work, including a collective effort of more than 150 engaged people who contributed to make F-MARC´s
researchers. projects successful.
The “FIFA 11 for Health” programme is a football- Prof Jiří Dvořák Prof Astrid Junge
based health-educational programme for school chil- FIFA Chief Medical Officer Head of Research
dren. The programme is being promoted by prominent Chairman F-MARC F-MARC
football players and has been successfully implemented
in 20 countries. The programme is continuously being
developed and is adapted towards the needs of the coun-
4 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.1.1 Football Injuries before 2000 or emergency department records) or overestimates (e.g.
a player complaint) of the actual rate of injury meaning
injury incidence statistics can be quite variable and dif-
What was known on football injuries ficult to compare between sports, between projects, even
within a particular sport as different authors use different
The ever-increasing number of active players, leading in definitions of an injury.
turn to an increasing frequency of injury with the result-
ing cost for treatment and loss of playing time, made
the need for an injury prevention programme evident. Defining an injury
The Fédération Internationale de Football Associa-
tion (FIFA), as the governing body of football, realised Most definitions of injury have three criteria in com-
this need and decided to play an active role in develop- mon: missed training sessions or matches; an anatomic
ing and supporting research on football injuries. When location of tissue damage and the need for medical treat-
F-MARC decided to approach this problem, it soon ment. Thus, a thigh contusion (location and diagnosis
became obvious that the epidemiologic information of tissue damage) that receives an ice application (treat-
regarding football injuries was inconsistent and far from ment), but does not lead to any training or match missed
complete because of the employment of heterogene- would not be classified as “an injury” because the player
ous methods, various definitions of injury, and differ- missed no time. Despite this sounding fairly objective,
ent characteristics of the teams assessed by investigators. there is much subjectivity for each of the criteria, espe-
Therefore, it was crucial for F-MARC to first establish cially time missed. Apart from different definitions, the
what exactly was known and then define our future epidemiologic information showed inconsistencies in
strategy based on that. methods, definitions, player/team characteristics and
environmental factors. To make it even more complicat-
ed, there are also many pitfalls and biases in the rational
Aims of the review estimation of the degree of severity of an injury.
UÊ>ÞÃiÊÌ
iÊÌiÀ>ÌÕÀiÊÊÌ
iÊV`iViÊvÊÕÀiÃÊ>`Ê
symptoms in football players Incidence of football injuries
UÊ`iÌvÞÊÀÃÊv>VÌÀÃÊvÀÊÕÀÞÊ>`Ê`iÃÌÀ>ÌiÊ«Ã-
sibilities for injury prevention Injury incidence is mostly defined as the number of inju-
UÊÃÃiÃÃÊÌ
iÊÜi`}iÊÊÌ
iÊÀi>ÌÃ
«ÊLiÌÜiiÊ«ÃÞ- ries occurring during a time period when there was a risk
chological factors and sports injuries of injury. Consequently, the incidence of football inju-
ries has most frequently been calculated based on hours
played during games and training. However, because of
What did the medical literature tell us about the above-mentioned problems, the injury rates reported
injuries? in the literature result in an incidence ranging from 0.5
to 45 injuries per 1,000 hours of practice and games.
The first place to search for and to better understand Furthermore, incidence also varies between match play
the nature of injury in a sport is the available medical and training, gender, age and indoor and outdoor play.
literature. The problem is that research studies differ on Obviously, the majority of injuries occur to the lower
their basic definition of injury. Defining an injury can extremities, mainly in the knees and ankles.
be quite difficult. Does it mean a player down on the
field? Any medical treatment on or off the field? Being
removed from play? For how long – minutes, hours, Psychology and football injury
days, weeks, months? Meeting an arbitrary minimum
diagnosis? Only injuries that were submitted for insur- As opposed to external influences, the primary player-
ance reimbursement? Those that required a visit to an related risk factors in risk assessment are psychologi-
emergency department? Any physical complaint by a cal components. It had been shown that they not only
player? Unfortunately, there was no universally accepted affected the overall performance of a player, but also
definition of a sports injury in the literature. As such, their injury risk. Most investigations in this regard were
reports of injury could be underestimates (e.g. insurance based on either a stress theory or a personality-profile
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 5
Country Level of play Injuries per 1000 game hours Injuries per 1000 training hours
MALES
Iceland National elite, first league 24.6 2.1
Sweden Sr. National team 30.3 6.5
Sweden National top division 25.9 5.2
US MLS professionals 35.5 2.9
UK Premier League, 1st and 2nd division 25.9 3.4
Finland Highest national league 25.9 3.4
Sweden 1st division 21.8 4.6
2nd division 18.7 5.1
3rd division 16.9 7.6
6th division 14.6 7.5
Denmark 2nd division (high) 18.5 2.3
Series (low) 11.9 5.6
FEMALES
Sweden Senior players, various skill levels 14.3 3.7
Sweden Premier, 2nd division 24 7
YOUTH (<18y)
New Zealand Schoolboy 16.2 3.7
Switzerland High level males 18.7 4.1
Low level males 21.7 8.2
Denmark Male youth 14.4 3.6
approach. Although the majority of these studies had What we learned from the reviews
employed different methods, the results were in gener-
al agreement that “life events” could influence the risk The frequency of football injuries reported in the sci-
of injury in athletes. Life events are important circum- entific literature is estimated to be approximately ten to
stances in one’s recent history such as death of a parent 35 per 1,000 playing hours (Tab. 2.1.1.1). Reviewing
or spouse, birth of a child, divorce, change in job, resi- the literature is an important first phase of any research
dential move, personal illness, and many more. In most programme. This review showed us some of the chal-
cases, some major life event preceded an injury or was lenges of research into the frequency and characteristics
related to the severity of injury. In this context, social of injury. The information regarding the sports medi-
support appeared to have a buffering effect, but the cine aspects of football injuries presented itself as incon-
influence of stress-coping strategies was somewhat ques- sistent. More research was needed to identify high-risk
tionable. groups and variables that may predict injuries within
these subgroups. A uniform definition of injury based on
sound epidemiologic and methodological principles was
Are some players just injury-prone? urgently needed.
Some coaches and players might say that a particular With regard to psychological factors, situation-related
player is “injury-prone” because of their personality. Per- emotional states and coping resources may represent
sonality traits are situation-independent and characterise important avenues for intervention. Therefore, we
a person. However, according to the scientific literature, decided to further investigate these factors be investigat-
personality traits seemed to have no influence on the risk ed with respect to injury prevention and improvements
of injury and there was no typical personality profile for in performance.
an injury-prone player. Nevertheless, several studies have
shown that a certain readiness to take risks manifested
Duration: 1996 - 1998
by personality traits such as lack of caution, tough-mind-
Countries: International
edness or an enterprising or adventurous spirit might be
References:
a factor related to injury. We might think that anxiety
Dvořák J, Junge A (2000). Football injuries and physical symp-
might be a factor in injury. In this regard it is important
toms – review of the literature. American Journal of Sports
to distinguish between general anxiety as a personality
Medicine 28 (5 Suppl): S 3-S9
trait and situational anxiety in relation to competition.
Junge A (2000). The influence of psychological factors on
There was no data showing that general anxiety had any
sports injury – a review of the literature. Am J Sports Med 28 (5
role in injury. However, competitive anxiety has been
Suppl): S 10-S15
shown to be of utmost importance in injury occurrence.
6 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.1.2 Football Injuries in Children and broader perspective on the injury problem in children
Adolescent Players and youth football.
What was already known about football injuries What did the literature tell us about injuries
among children and adolescent players? among children and adolescent players?
Football is the world’s most popular sport with both UÊIncidence of injury
active players and spectators, and people all over the The overall injury incidence varied mostly between
world are enthralled by the power of the beautiful game. two and seven injuries per 1,000 hours of football
However, it is still the smallest fraction of the playing for players aged 13-19. The review showed that the
population, made up of adult male professionals, which incidence of injury in children’s and youth football
attracts most of our attention while by far the highest increases with age. Thus, incidence values observed
proportion of participants (22 million of the 38 million in players of both sexes aged 17-19 approached the
officially registered players) are actually under the age of values observed in adult players. It was furthermore
18 years. Previous research has shown that football may revealed that growth-related conditions may have
have beneficial health effects on players of all ages but an impact on the vulnerability of adolescent players,
that there is also a high risk of injury. Epidemiological and that the potentially fluctuating maturation status
data were collected on the incidence and characteristics among peers should be considered when comparing
of football injuries, and a consensus regarding the meth- players of the same age group. Match injury was found
odological standards for epidemiological studies was to increase with age, whereas training injury remained
published. With regard to children and young players, rather stable. No relevant difference in injury inci-
however, comprehensive and comparable data on the dence of boys and girls was apparent, and a compari-
frequency and characteristics of football injuries have son between the injury incidence in elite youth players
largely been missing. and sub-elite players suggested that the two groups
have a similar injury risk.
2.2.1 Influence of Definition and Data all injuries are easily seen on videotape. For example, it
Collection on Injury Incidence is very difficult to tell exactly when a player suffered a
groin strain. Finally, self-administered surveys vs. one-
to-one personal, telephone or mail interviews do not give
Why we conducted this study the same results. Further questions were: Should a single
team or a single league be studied for one season or more
In our review of the medical literature, we found a con- than one season? Can we compare men with women, or
siderable variation in the incidence of football injuries youth with adult players?
that were reported by different investigators. We realised
that these differences may be caused, in part, by method- Research design: In many injury studies, players were
ological differences such as, for example, different injury asked to remember injuries in their past. This method
definitions. In the same way, methods of data collection, is called retrospective and leads to the problem of bias
observation periods, study designs, and sample char- recall: the longer the recall period, the more details are
acteristics play a role. Whilst it was clear that the lack forgotten. This means that only the most severe injuries
of standardisation disallowed the comparison of injury and the injuries with the most medical intervention are
studies in football, it was however difficult for us to esti- remembered. Therefore, prospective studies became the
mate the magnitude of the influence of these different norm where only newly occurring injuries are recorded.
methodologies on the reported incidences of football
injuries. Therefore, we began to think about developing Observation period: The observation period that is
a system to allow multiple sports to be compared with studied is another crucial point. There are published
each other. studies on periods of all lengths, from one competition
to half a season, from a full season to a full calendar year
and even more than one year. Further decisions to be
Aims of the study taken are: Do we include the pre-season training? Do we
assess only games or games and training?
UÊ,iÛiÜÊÌ
iÊ`vviÀiÌÊiÌ
`}iÃÊ>««i`ÊÊÌ
iÊ
evaluation of football injuries
UÊ>ÞÃiÊÌ
iÊyÕiViÊvÊ`vviÀiÌÊ`iwÌÃÊ>`Ê`>Ì>Ê How we collected the data
collection methods on the incidence of football inju-
ries F-MARC decided to record injuries on a weekly basis for
at least one year. For one year, all teams included in this
prospective study were visited weekly by a physician who
Factors influencing the results of injury study examined each player. This lead to 264 football players
from the Czech Republic being systematically followed.
How to define an injury: When investigating the inci- In addition, the players were asked to complete a ques-
dence of injuries, one must first define “injury” “Foot- tionnaire at the end of the year. Their answers were then
ball injury” is a general term; but there was no consen- compared with the weekly injury reports of the physi-
sus among sports physicians about its exact definition, cians.
except that the injury was a result of participation in
football. The many questions arising in this regard have The F-MARC definition of a football injury is “any
been elaborated in the previous chapter. physical complaint caused by football” F-MARC
recommends the additional documentation of the con-
Method of data collection: There were also many ques- sequences of the injury with respect to the duration of
tions with regard to the best way to collect data. Firstly, restrictions in the participation in, or the absence from
who reports an injury? Athletes may under-report inju- (time loss) regular training sessions and/or matches.
ries and their severity. Why would they do this? Simply
because they want to play! The trainer or physiotherapist
may or may not report the injury to the doctor because Results
many minor injuries do not need a physician’s supervi-
sion and the doctor’s position may be influenced by con- In the retrospective questionnaire of the players, their
fidentiality issues. Video analysis is an option, but not personal incidence of injuries as well as their history of
football-related complaints was significantly lower than
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 9
2.2.2 Consensus on the Injury Definition and full participation is referred to as an ‘‘early recurrence’’,
Data Collection Procedures one occurring two to 12 months after a player’s return
to full participation as a ‘‘late recurrence’’ and one occur-
ring more than 12 months after a player’s return to full
The need for a common approach to football participation as a ‘‘delayed recurrence’’.
injury research
Simply sustaining an injury is only one part of the prob-
As outlined in the previous chapters, it had become lem. The group also had to define the severity of injury:
very clear to F-MARC that variations in definitions and
methods in sports injury research led to problems in What is a severe injury?
interpreting research study results. Despite repeated calls The number of days that have elapsed from the date of
for common strategies to be adopted, basic differences injury to the date of the player’s return to full participa-
in definitions and implementation were continued to be tion in team training and availability for match selection
found in studies of sports and football injuries. There- determines the injury severity.
fore, FIFA and F-MARC decided to host an Injury Con- UÊÃ}
ÌÊäÊ`>ÞÃÊÃÌ
sensus Group. Using what is called a “nominal group UÊ>Ê£ÎÊ`>ÞÃÊÃÌ
consensus model”, the invited experts with a long history UÊ`Ê{ÇÊ`>ÞÃÊÃÌ
in the study of football injuries were asked to develop a UÊ`iÀ>ÌiÊnÓnÊ`>ÞÃÊÃÌ
consensus statement on definitions and methodological UÊÃiÛiÀiÊÓnÊ`>ÞÃÊÃÌ
issues when investigating football injuries. They had to
address and define key issues for data collection as well Finally, the group had to define exposure according to
as guidelines for reporting surveillance, risk factor and match and training. Exposure is the denominator in
intervention studies. reporting injury rates. Rates of occurrence are generally
reported as injuries per 1,000 player hours. In football,
rates are reported per 1,000 match or training hours.
Defining an injury
What is match exposure?
The starting point for the consensus group was what we Play between teams from different clubs.
might think would be a simple definition:
What is training exposure?
What is a football injury? Team-based and individual physical activities under the
Any physical complaint sustained by a player that results control or guidance of the team’s coaching or fitness
from a football match or football training, irrespective of staff that are aimed at maintaining or improving players’
the need for medical attention or time loss from foot- football skills or physical condition.
ball activities. An injury that results in a player receiving
medical attention is referred to as a ‘‘medical attention’’
injury and an injury that results in a player being unable Reporting an injury
to take a full part in future football training or match
play as a ‘‘time loss’’ injury. Finally, the group suggested the following methodologi-
cal concepts to improve reporting, interpreting and com-
The next task was to define a “recurrent injury” because paring football research studies:
players get hurt multiple times and it is important to UÊ-ÌÕ`iÃÊÃ
Õ`ÊLiÊvÊ>Ê«ÀëiVÌÛi]ÊV
ÀÌÊ`iÃ}ÊÌÊ
define what is a new injury and what is a re-injury for minimise the occurrence of errors associated with
the most accurate reporting of various aspects of injury recall, which is a problem with retrospective study
incidence. designs.
UÊ-ÌÕ`iÃÊÃ
Õ`ÊÀiVÀ`Êi`V>Ê>ÌÌiÌÊ>`ÉÀÊÌiÊ
What is a recurrent injury? loss injuries.
An injury of the same type and at the same site as an UÊÕÀiÃÊÃ
Õ`ÊLiÊV>ÃÃwi`ÊLÞÊV>Ì]ÊÌÞ«i]ÊL`ÞÊ
index injury and which occurs after a player’s return to site and mechanism of injury (traumatic or overuse)
full participation from the index injury. A recurrent inju- and whether the injury was a recurrence. A traumatic
ry occurring within two months of a player’s return to injury refers to an injury resulting from a specific,
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 11
2.2.3 Injury Surveillance in Multi-Sport the different needs. However, the most important prin-
Events ciples and advantages of the system were preserved, such
as the definition of injury, injury report by the doctor
responsible for the athlete, daily reports independent
Why we conducted this study of whether or not an injury occurred, and one report
form per team and not per injury or athlete. Based on
The protection of athletes’ health by preventing inju- this procedure, a simple and concise injury report form
ries is an important task for international sports federa- including the most important variables was developed
tions. Systematic injury surveillance is able to provide and tested during the 2007 World Championships of
directions for injury prevention in different sports. But the International Association of Athletics Federations
comparison of injury incidence between sports is diffi- (IAAF) in Osaka.
cult indeed, not only due to lack of standardisation of
methods, but also due to the different nature of sports.
On the one hand, conducting a comparative study dur- Results
ing a major tournament, such as FIFA World Cups™
or the Olympic Games, offers the great advantage that The following key points of the system were identified:
multiple sports with athletes of a comparable skill level
participate and that the observation period is defined by Definition of injury:
the event. Furthermore, a high standard of environmen- UʺÞÊÕÃVÕÃiiÌ>ÊV«>ÌÊiÜÞÊVÕÀÀi`Ê`ÕiÊÌÊ
tal factors, such as the quality of the playing fields and competition and/or training during the tournament
equipment, is guaranteed. On the other hand, the large that received medical attention regardless of the conse-
number of teams from different backgrounds and with quences with respect to absence from competition or
diverse medical support makes it more difficult to obtain training.’’
reliable information about the incidence, occurrence and UÊÕÀiÃÊÃ
Õ`ÊLiÊ`>}Ãi`Ê>`ÊÀi«ÀÌi`ÊLÞʵÕ>-
characteristics of injury. Therefore, a standardised and fied medical personnel (team doctor, physiotherapist)
feasible injury-reporting system for multi-sport events to ensure valid information on the characteristics of
would immensely assist in optimising the protection of the injury and a comparable standard of data. In gen-
the health of athletes. eral, the chief doctor of the national team should be
responsible for reporting the injuries of their athletes.
The team doctors should report all newly incurred
Aims of the study injuries (or the non-occurrence of injuries) daily on
the provided injury report form and should return it
UÊÊiÛi«Ê>ÊÕÀÞÊÃÕÀÛi>ViÊÃÞÃÌiÊvÀÊÕÌëÀÌÃÊ daily.
tournaments involving team and individual sports, UÊ/
iÊÃ}iÊ«>}iÊvÀÊvÀÊ>ÊëÀÌÃÊÕÀiÃÊÌ
>ÌÊÀiViÛiÊ
using the 2008 Olympic Games in Beijing as an exam- medical attention from the team doctor during the
ple day or, if no athlete is injured, the non-occurrence of
UÊ
Ài>ÌiÊ>Êëi]ÊyiÝLi]Ê>VVi«Ì>Li]ÊÃiÃÌÛi]ÊÀi«Ài- injury, require documentation of: accreditation num-
sentative and immediate/timely system as a role model ber of the athlete, sport and event, round/heat/train-
for future studies ing, date and time of injury, injured body part, type of
injury, cause of injury and an estimate of the expected
duration of subsequent absence from competition
How we collected the data and/or training.
Absence in days:
UÊ/
iÊÌi>Ê`VÌÀÊÃÊ>Ãi`ÊÌÊ«ÀÛ`iÊ>ÊiÃÌ>ÌiÊvÊÌ
iÊ
number of days that the athlete will not be able to
undertake their normal training programme or will
not be able to compete. Duration of absence from
sport is regarded as an indicator of injury severity.
UÊ>ÞÃÃÊvÊ`>Ì>ÊÃ
Õ`ÊVÕ`iÊÀiëÃiÊÀ>Ìi]ÊvÀi-
quency and characteristics of injury, athletes included,
exposure and injury incidence for competition and
training separately.
2.3.1 Injuries of Male Players of Different strains the most common diagnoses. The average number
Age and Skill Level of injuries per player per year was 2.1, ranging from 1.8 to
3.8 (Tab. 2.3.1.1). Injuries were classified as mild (52%),
moderate (33%), or severe (15%). Almost half of all inju-
Why we conducted these studies ries were contact injuries and half of all the contact inju-
ries were associated with foul play. Nine out of ten play-
Most coaches and parents who watch numerous games had ers had some football-related complaint. Only 23 players
developed some observation regarding injuries in older vs. reported no injuries and no complaints related to football.
younger age groups, or between high vs. low level play-
ers. Some believed that older players suffer more injuries The younger players (14-16 years old) had slightly fewer
than younger players, others that highly skilled players injuries per player and a lower injury rate than the 16-18
are injured more and again others that highly skilled play- years old players yet the data for the 16-18 years old was
ers had fewer injuries than players of poorer skill. Another nearly comparable with the adults. The injury rate during
question was whether there were regional differences. We training for the low level players was more than twice as
therefore decided to look further into the injury incidence high as that of similar aged players of high level. Game
question by collecting information on injuries in different injury rates for the low level players were almost twice as
age groups, skill levels and regions. high as those of the high level players. For the adult play-
ers, if one assumes that local teams are of lower skill than
competitive amateur teams and both are of lower abil-
Aims of the studies ity than the third league and top level players, a similar
pattern of injury rate is seen with the lower level adults
UÊÛiÃÌ}>ÌiÊÊ>Ê«ÀëiVÌÛiÊ>iÀÊÌ
iÊV`iViÊvÊvÌ- having a much higher rate of injury than the more skilled
ball-related injuries and complaints among football play- adults.
ers of different ages and skill levels
UÊ
«>ÀiÊÌ
iÊV`iViÊ>`ÊVÀVÕÃÌ>ViÃÊvÊvÌL>Ê
injuries in youth players of two European regions Football-related complaints
Top 3rd league Amateur Local High level Low level High level Low level
Training hours 307.4 337.1 184.3 133.8 267.7 148.5 249.9 135.6
Game hours 51.3 60.2 46.3 54.7 55.4 40.6 51.4 32.2
Training /game ratio 6.0 5.6 4.0 2.4 4.8 3.7 4.9 4.2
Tab. 2.3.1.1 Exposure time and average number of injuries per player in different age and skill-level groups
What we learned from the studies Set up for the epidemiological study in Prague
2.3.2 Severe Injuries of Male Players of 18.5%. With regard to diagnoses joint sprains clearly
dominated (30%), followed by fractures (16%), muscle
strains (15%), ligament ruptures (12%), meniscal tears
Why we conducted this study and contusions (8%), and other injuries. The most fre-
quent location for severe injuries was the knee (29%),
The injury literature categorises severity of injury accord- before ankle (19%) and spine (9%).
ing to time lost from work. A person with a mild inju-
ry would miss less than one week of work, a moderate Of the knee injuries, just under one quarter were inju-
injury keeps a person out of work for one to four weeks ries to the anterior cruciate ligament and another quar-
and a severe injury would keep a person out of work for ter were meniscal injuries. About two thirds of the knee
four weeks or more. According to our own results, about injuries did not involve contact with another player.
80-90% of football injuries from the hip and below are Five knee injuries happened during match play and four
mild or moderate. When considering the potential pop- of these players had a history of prior knee injury, one
ulation of football players, however, the public health during the same game. The two oldest players who sus-
impact of the 10-20% of injuries that are severe would tained a serious knee injury consequently retired from
be substantial. As a next step in our research programme, play.
we therefore wanted to analyse factors related to severe
football injuries in players by age (14 to 42 years) and Nearly 60% of severe injuries occurred during games.
skill level (local teams to first league teams). Two thirds of all severe injuries happened at away
matches. There was no real pattern to the location on
the field where the injury occurred. Injuries were evenly
Aims of the study distributed across playing positions.
How we collected the data All but one of the groin injuries were non-contact and
half were felt to be from overuse. The average age of
We followed up on 398 players for one year in the Czech these players was 19 years. Twenty-four percent of the
Republic. After a baseline examination, all teams were injured players had suffered an injury to the same, previ-
visited weekly by a physician, who documented all inju- ously injured, body part.
ries and complaints. All players who sustained a severe
injury were asked to see the orthopaedic surgeon, who The average time lost due to injury was 9.2 weeks.
then conducted a standard clinical examination and Three-quarters of the injured players fully returned to
an analysis of the medical history. All players answered play in less than eight weeks, but about 10% were out
a questionnaire concerning the circumstances of their of football for more than six months. The incidence of
injury (for example, training, game, contact) and their severe injuries per 1,000 hours in the low level players
judgment of the situation (for example, foul play). was twice that of the high level players.
Age groups
14-16 16-18 18-25 25-41
35
30
25
% injuries
20
15
10
0
in
re
in
ion
ine
pt nt
ca oint
a
ra
ra
ctu
Te
Ru me
e
n
Sp
us
ur
Sp
St
tio
J
us
Fra
nt
a
cle
Lig
int
isc
Co
slo
us
en
Jo
Di
M
2.3.3 Injuries of Female Players of the from nine teams (aged 22.4 ± 5.0 years) for one com-
German National League plete outdoor season. Injury epidemiology data is usu-
ally reported as the rate of injury per 1,000 hours, so
each team trainer documented exposure to football for
Why we conducted this study each player on a weekly basis. Each team physiotherapist
reported all injuries with regard to their location, type
FIFA President Joseph S. Blatter once said “We have and circumstances of occurrence. An injury was defined
seen the future of football and that future is feminine.” as any physical complaint associated with football that
In 2004, it was estimated that there were over 20 mil- limited sports participation for at least one day.
lion female players in over 100 nations with over six mil-
lion female players in the US alone. The FIFA Women’s
World Cup 1999 final in the US drew over 90,000 spec-
tators – history’s largest audience for a women’s event.
But despite the growth in participation in women’s foot-
ball, the study of women’s football had lagged behind.
Research on other sports had shown that it is a mistake
to train women using the same guidelines as normally
used for men. When this happened, the rate of injury to
women rose dramatically over that of men. The unique
physiology of women and the differences in capacity
versus men required that women in sports train differ-
ently than men. While there had been some work pub-
lished on training women, especially in track-and-field
and swimming, there was little reported on women in
football. There were only a few studies on any aspect
of women’s football, be it fitness, technique or tactics.
Numerous injury epidemiology studies investigated
on men’s football, but the data on female football was Results
scarce. It has been known for some time that there is a
clear difference between men and women in the rate of Of the 165 players followed, 115 players (correspond-
injuries to the anterior cruciate ligament (ACL) of the ing to 70%) reported 241 injuries, meaning that each
knee. Female football players sustain three to six times injured player sustained about two injuries. In this
more knee ligament injuries than men. As the F-MARC study, 16% of injuries were due to overuse and 84%
mission was to explore the nature of football injuries, it were traumatic. Forty-two percent of the traumatic
seemed appropriate to focus our attention on women injuries happened during training (2.8 per 1,000 hours
football players. Thus, we undertook a large scale pro- training), and 58% during match play (23.3 per 1,000
ject on injuries to females playing in the German profes- match hours). The ratio of training to match hours as a
sional league. factor in injuries and performance in this study was 5.9,
meaning that each female player trained about six hours
for each match hour. Considering this ratio, the match
Aim of the study injury rate was over eight times greater than the train-
ing rate. Just over half of the traumatic injuries were due
UÊ>ÞÃiÊÌ
iÊV`iViÊ>`ÊÀÃÊv>VÌÀÃÊvÊvÌL>ÊÕ- to contact and the remaining traumatic injuries occurred
ries in elite female football players without any contact (Fig. 2.3.3.1). The most frequent
site of injury was to the thigh, knee and ankle, as all sus-
tained about the same number of injuries (Fig. 2.3.3.2).
How we collected the data Regarding the type of injury, the most frequent diagno-
sis was an ankle sprain. Injury severity was determined
In an attempt to determine injury incidence in high according to time lost from play. According to this,
level women’s football, we studied the German national 51% of injuries were classified as minor, 36% as mod-
league. Data was obtained on 165 female football players erate, and 13% as severe. Half the severe injuries were
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 19
ion
Ch ing
all
rs
pla
tin
pin
he
n
yb
dir ge
c
llis
nn
tio
Ta
oo
Ot
m
ul
an
tb
Co
Ru
Ju
Sh
Fo
Hi
20 18 19 18
15
11
%
10 8
7
6
5
5 Germany wins the FIFA Women‘s World Cup China 2007™
0
ad
ity
nk
igh
ee
kle
eg
ot
Fo
Kn
em
He
Tru
rl
An
Th
we
xtr
Lo
re
pe
Up
s RUPTURES OF KNEE LIGAMENTS INCL ELEVEN !#, RUPTURES
s 3IX LIGAMENT RUPTURES OF ANKLE
s 4WO FRACTURES LOWER LEG FOOT
s 4WO STRAINS OF THIGH
s /NE KNEE SPRAIN
s 3IX OTHERS
This study was conducted over an entire professional In approximately one third of injuries, a strain of the
league season. All teams in the first and second Tunisian thigh muscle was diagnosed. Additionally, ten muscle
professional football leagues were asked to participate. ruptures of the thigh were reported whereas two muscle
During the spring season of 2002, any football inju- ruptures occurred in the lower leg. Forty-one injuries
ries that resulted in absence from at least one scheduled (23%) were sprains of the ankle (n=35) or knee (n=5).
training session or match were reported by the team doc- Injuries that constituted severe tissue damage included
tors on a weekly basis. Incidence and rate of injury were three fractures (nose, rib, metatarsal), two dislocations
described according to their diagnosis and circumstances (foot, elbow), three ruptures of the knee ligaments and
of occurrence. For each player, the coaches recorded the one meniscus lesion.
amount of time in training and matches, as well as the
reason for any absences. Sixty-one percent of the injuries resulted in absence from
training or matches for up to one week, one third of the
injuries resulted in absence for eight to 28 days, and 11
injuries in absence for more than 28 days. The over-
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 21
all incidence of injuries resulting in absence for at least What we learned from the study
one month was 0.3 per 1,000 hours exposure, although
four of the 11 severe injuries occurred in one team. The So, could we say that “football is football” when it comes
majority of these injuries (73%) were sustained during to injuries? The overall incidence of injury in the first
matches, but only two of them were the result of con- Tunisian professional league was similar to that reported
tact with another player. Injuries resulting in a subse- for high-level European teams, but was lower than what
quent absence of more than one month affected mainly had been reported for major international tournaments.
the knee (two ligament ruptures, two sprains) and the The major difference, however, was in the fraction of
thigh (three muscle ruptures, one contusion with hae- total injuries that were non-contact in nature and this
matoma); the other three severe injuries included a frac- percentage was substantially higher in these Arabic play-
ture of the metatarsal bone, inflammation of the Achilles ers. Some consider that non-contact injuries are among
tendon and pubalgia. Of the four long lasting knee inju- the most preventable of injuries, so it seemed advisable
ries, three occurred in the same team, which was also the that these teams improved their efforts in the prevention
team with the highest overall incidence of injury. of injuries. Preventive interventions aiming at improve-
ment in the quality of training and adequate rehabilita-
tion after injury were recommended to reduce the rate
6 of injury.
Injuries
4
3.3 3.2
Injuries with absence of more than 28 days
2
First league Second league
s 4WO LIGAMENT RUPTURES IN THE KNEE
0 s 4WO SPRAINS OF THE KNEE
Fig. 2.3.4.1 Incidence of overuse injuries and injuries during training s 4HREE MUSCLE FIBRE RUPTURES IN THE THIGH
s /NE CONTUSION WITH HAEMATOMA IN THE THIGH
s /NE TENDONITIS OF THE !CHILLES TENDON
s /NE FRACTURE OF THE METATARSAL BONE
s /NE PUBALGIA
30
22.5
Injuries
20
10 First league
7.2
Second league
0
match injuries per 1000 match hours
Fig. 2.3.4.2 Incidence of match injuries
UÊiÌiÀiÊÌ
iÊV`iViÊ>`ÊV
>À>VÌiÀÃÌVÃÊvÊvÌL>Ê
injuries among African league-level players
2.4.1 Injuries during FIFA Competitions each match. The response rate was 84% on average, but
1998 - 2001 as teams and physicians became more familiar with the
forms and responsibilities, the response rate in the most
recent competitions was 100%.
Why we conducted this study
female, futsal and outdoor, Olympic Games, and FIFA Fig. 2.4.1.1 Injuries per match in male and female players
Tab. 2.4.1.1 Incidence of injury in FIFA competitions and the Olympic Games
Concussion 4 1 0 2 2
UÊ>ÞÃiÊÌ
iÊV`iVi]ÊVÀVÕÃÌ>ViÃÊ>`ÊV
>À>VÌiÀÃ-
tics of injury during the 2002 FIFA World Cup™ Upper 8 3 0 5 2
extremity
UÊ
«>ÀiÊÌ
iÊw`}ÃÊÜÌ
Ê`>Ì>ÊÀi«ÀÌi`ÊvÀÊ«ÀiÛÕÃÊ
Trunk 2 2 1 1 0
international men’s football tournaments
Hip 6 6 3 2 1
Groin 9 8 8 1 0
How we collected the data Thigh 30 26 17 4 8
Knee 22 15 4 11 6
The physicians of 32 participating teams (Fig 2.4.2.1) Lower leg 29 15 5 6 16
were required to report on all injuries after each match
Ankle 25 19 3 8 12
on the standardised F-MARC injury report form.
Foot 14 8 4 3 5
Because F-MARC had been doing this for all FIFA com-
petitions since 1998, the team doctors were well aware Tab. 2.4.2.1 Number and circumstances of injury
of their role in this data collection process. All team
doctors attended a pre-tournament meeting to confirm
the procedures and their responsibilities. As such, our
response rate was 100% for FIFA World Cup™ inju-
ries.
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 27
Fig. 2.4.2.1 Participants of the FIFA team physician workshop during the 2002 FIFA World Cup Korea/Japan™
foul noncontact
Noncontact Contact
injuries (n=45)* injuries (n=122)* contact, mechanism
no foul not reported
Estimate of n (%) n (%) 40
absence
35
No absence 5 (11.9) 47 (40.5)
30
Number of injuries
0
-3
-4
-6
-7
-9
>9
0-
16
31
46
61
76
2.4.3 Injuries during the 2006 FIFA World Cup In addition to this injury assessment by the team doc-
Germany™ tors, all on-pitch treatments during matches were cat-
egorised and digitally recorded. These on-pitch treat-
ments during play were compared against the written
Why we conducted this study injury reports from the team doctors.
Competition 2002 FIFA World Cup 2006 FIFA World Cup Location and All With All With
Japan/Korea™* Germany™ Diagnosis absence absence
No of matches 64 64 Head 25 5* 13 4
Response rate, 100 (128) 100 (128)
% (n) Upper 8 3* 12 5*
extremity
Match hours docu- 2112 2112
mented Trunk 6 6 15 11*
Second half 46 (72+3) 50 (64 +2) Tab. 2.4.3.2 Location of injuries during the 2002 FIFA World Cup™
and 2006 FIFA World Cup™
Estimated severity of injury, % (n)
Duration: 2006
Countries: International
Cooperation: All team physicians of the 2006 FIFA World
Cup™
Reference:
Dvořák J, Junge A, Grimm K, Kirkendall D (2007). Medical
report from the 2006 FIFA World Cup Germany™. Br J Sports
Med 41: 578-581
30 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.4.4 Injuries of Female Players in Top-Level Women’s World Cups 2002 and 2004, the FIFA U-20
International Competitions Women’s World Cup 2006 and Women’s Olympic
Football Tournaments in the 2000 and 2004 Olympic
Games. As usual, the physicians of all attending teams
Why we conducted this study were instructed in the use of the single-page form, on
which all injuries during a given match or, when appli-
From the very beginning, F-MARC has realised the dis- cable, the non-occurrence of injury were recorded, at a
crepancy between the ever growing popularity of wom- pre-competition instructional meeting. For each match,
en’s football and the limited research directed to the both team doctors were asked to return the completed
female player. Accordingly, we had undertaken a study form for their team to the FIFA Medical Officer. Confi-
on 165 female football players from nine teams in the dentiality of all information was ensured. An injury was
German national league for one complete outdoor sea- defined as any physical complaint during a match which
son in 2003/2004 as described in a previous chapter. received medical attention from the team doctor, regard-
The team physiotherapists had reported all physical less of the consequences with respect to absence from the
complaints associated with football that limited sports rest of the match or training. In the first competition
participation for at least one day as well as their location, (FIFA Women’s World Cup 1999), an earlier version of
type and circumstances of occurrence. The injury rates the form was used, which did not include the physician’s
reported in that study were similar to those reported for judgment about foul play and the consequences of the
male players. There had been a high match injury rate injury.
and a comparably low training injury rate while ACL
ruptures occurred rather frequently.
Results
In general, the published work on injuries in women’s
football focused mostly on injuries to elite players dur- A total of 387 injuries were reported in the seven competi-
ing their competitive season, yet injuries during major tions. This is equivalent to 2.2 injuries per match or 67.4
international competitions assuming a high public pro- injuries per 1,000 player hours. The injury rates ranged
file and placing considerable pressure on players, were from 1.3 injuries per match in the FIFA Women’s World
investigated infrequently. In the previously described Cup 1999 to 2.9 injuries per match in the FIFA U-20
study on twelve major international football competi- Women’s World Cup 2006 (Tab. 2.4.4.1).
tions, F-MARC had reported that the incidences of inju-
ry in female players in the 1999 FIFA Women’s World The overall injury rate was similar for each half, but the
Cup and the football competition of the 2000 Olympic lowest rate occurred during the first 15 minutes of each
Games were considerably lower than the rates in the cor- half. Most injuries occurred during player-to-player con-
responding competitions for male players. Therefore, tact.
F-MARC decided to give these competitions particular
attention. The lower extremity was most commonly affected, fol-
lowed by the head and neck, trunk and upper extremity
(Tab. 2.4.4.2). The exact body parts injured most often
Aim of the study were the ankle (24%) and head, followed by thigh, knee
and lower leg. Most injuries were diagnosed as contusions
UÊ>ÞÃiÊÌ
iÊV`iVi]ÊV
>À>VÌiÀÃÌVÃÊ>`ÊVÀVÕ- (45%), sprains or ligament ruptures (26%) and less often
stances of injuries occurring in top-level international strains or muscle fibre ruptures. Twelve injuries were diag-
women’s football competitions nosed as a concussion, 13 ligament ruptures, nine frac-
tures, eight dislocations and two lesions of the meniscus.
The most common diagnosis was an ankle sprain (16%),
How we collected the data followed by contusions of the head, thigh and lower leg
and injuries to the knee ligaments. There were seven liga-
Data collection was undertaken following the established ment ruptures and 15 sprains of the knee.
F-MARC method immediately post match at seven
international women’s football competitions: the FIFA Only 16% of all injuries were non-contact. In the opinion
Women’s World Cups 1999 and 2003, the FIFA U-19 of the team doctor, 35% of all contact injuries were due
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 31
to foul play. However, the referee sanctioned only half of bers reported in men’s competitions. Possible explana-
those injuries. tions for more concussions being diagnosed in females
might be because there is more caution evident in the
Tournament Injuries per Injuries Time loss Time loss
match per 1000 injuries per injuries women’s game or that some concussions in the men’s
match hrs match per 1000 matches were missed or some concussions were recorded
match hrs as contusions.
FIFA Women’s 1.3 39
World Cup A primary distinction with the circumstances of injuries
1999
in males was that about half of all injuries in men are
Women’s 2.1 65 0.8 24
due to foul play while in women, only about one third
Olympic
Football of injuries were a result of foul play.
Tournament
2000
Location Total Without With time
FIFA U-19 2.8 85 1.6 49 time loss loss
Women’s
World Cup Head/neck 67 32 17
2002
FIFA Women’s 1.7 52 0.9 27 Trunk 33 12 14
World Cup
2003 Upper Extremity 32 15 13
Women’s 2.3 70 1.0 30
Olympic Hip/groin 12 8 4
Football
Tournament
2004 Thigh 47 19 21
2.4.5 Injuries during the FIFA Futsal World on the standardised form after each match. Due to the
Cups 2004 and 2008 different duration of futsal matches and a smaller num-
ber of players, number of injuries per match would not
allow for comparison with football, so we also calculat-
Why we conducted this study ed injuries per 1,000 player hours and per 1,000 player
matches as had been recommended for team sports.
Futsal is a variant of association football played on a
smaller pitch with a smaller ball, both indoors and out-
doors. It is the official FIFA-recognised version of five- Results
a-side football and as such has similarly strictly defined
Laws of the Game. It is played on a hard surface without The average response rate throughout all three events was
using boards or walls, allowing it to be staged on hand- 93%. In total, 253 match reports were analysed, corre-
ball or basketball courts. Having its roots in some Euro- sponding to 843 player hours. This resulted in 165 inju-
pean countries and South America, futsal is continuously ries overall which translated into 1.3 injuries per match,
gaining more and more supporters worldwide. The first 195.6 injuries per 1,000 player hours and 130.4 injuries
FIFA Futsal World Cup was played in 1989. per 1,000 player matches.
The game is considered a “school of football” with high With regard to circumstances, more injuries (64%)
demands on technique and skills, speed and agility. It occurred during contact with another player and less than
is therefore used for youth development in many coun- half of these injuries were due to foul play. Overall, one
tries. Considering this broad use in youth players, it is quarter of all injuries was due to foul play. Based on the
a concern that it is far less extensively studied from a judgement of the team doctors, two thirds of these foul
sports medical and scientific perspective than football. plays were consequently sanctioned by the referees. There
A few studies on its physical demands showed that fut- was no difference in injury occurrence between the first
sal includes more high intensity activities than football. and second half of matches.
With regard to injuries, some studies on indoor football
had shown inconsistent results when compared with 11- About 70% of all injuries concerned the lower extremity,
a-side outdoor football, and nothing was known on fut- with the second most frequent location being the head
sal injuries. We therefore decided to gain a better under- and neck with 13%. The knee was the most often affected
standing of injuries in futsal in order to be able to design body part prior to the thigh and ankle. Most injuries were
targeted prevention measures. classified as contusions, followed by joint sprains and liga-
ment ruptures. Information on the expected loss of play-
ing time due to the injury was available in 84% of all inju-
Aim of the study ries, and showed that almost half of the injuries resulted
in some absence from play, most of them of a duration of
UÊ>ÞÃiÊÌ
iÊV`iViÊ>`ÊV
>À>VÌiÀÃÌVÃÊvÊÕÀÞÊ`ÕÀ- one to three days.
ing FIFA Futsal World Cups and compare the results
with FIFA World CupsTM
What we learned from the study
How we collected the data This study was the first to provide a more detailed pic-
ture of the frequency and characteristics of injuries in
We investigated three Futsal World Cups in 2000, futsal based on a scientifically validated recording meth-
2004 and 2008. As our objective was to compare the od. In absence of comparable data from futsal, the most
frequency and characteristics of injuries in futsal with important and relevant comparison to make was the one
injuries in football, we applied exactly the same injury with football. Importantly, this would need to consider
recording definitions and system as had been used at all the different duration of matches, rules and player num-
other FIFA World Cups™. An injury was defined as bers. Therefore, injury frequency had to be based on the
any physical complaint resulting from match play and time effectively played and not on match incidence.
attended to by the team doctor. The team doctor would
record the details of injuries that occurred in their team
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 33
2.4.6 Injuries and Illnesses at the 2010 FIFA “incidence”, illnesses were defined as any physical com-
World Cup South AfricaTM plaint (unrelated to injury) newly incurred during the
event. Pre-existing chronic disease was not to be report-
ed unless an exacerbation necessitated medical attention
Why we conducted this study by the team doctor. Both training injuries and illnesses
had to be reported daily.
During three consecutive FIFA World Cups™, and
multiple youth and women’s events, F-MARC had
recorded all injuries occurring during matches, resulting Results
in a comprehensive database allowing for comparison
between different player groups and observing trends Overall, the 2010 FIFA World Cup™ comprised 64
over time. However, much less was known about inju- matches and 736 players. As half of the teams were
ries occurring during training and illnesses of players expelled after the group matches and the remaining teams
during these events. The European Football Confed- stayed for a variable further period of time, all calculations
eration UEFA had documented training injuries dur- for illnesses and training injuries were made based on
ing its championships in 2004 and 2008 showing that player days which amounted to a total of 13,179. Overall
they resulted in absence from play during elite events in response rate by team doctors was 97.4% with four match
football. F-MARC had considerably contributed to the reports missing, and in about 13% of the daily non-match
expansion of the injury recording system to include ill- day reports the training times were either missing or illeg-
nesses at the 2008 Olympic Games. In a pilot study dur- ible.
ing the FIFA Confederations Cup 2009, F-MARC had
found an incidence of illnesses of 16.5 per 1,000 play- A total of 125 injuries were reported, resulting in an inci-
er days with the majority being respiratory tract infec- dence of two injuries per match. Almost two thirds of
tions. It was therefore decided to extend the established the injuries resulted from contact with another player,
surveillance of injuries during matches to training inju- less than a quarter of these due to foul play. Injury fre-
ries and illnesses occurring at any time during the 2010 quency showed a continuous increase with the duration
FIFA World Cup™ in order to give more meaning to of play and was highest during the last 15 minutes of
the Confederations Cup data by comparison. matches. As previously seen, almost three quarters of the
injuries were to the lower extremities, with contusion of
the thigh and lower leg as well as a thigh strain being the
Aims of the study most frequent diagnoses. About a third of the injuries did
not prevent the player from continuing to play, and half
UÊ>ÞÃiÊÌ
iÊV`iViÊ>`ÊV
>À>VÌiÀÃÌVÃÊvÊÕÀiÃÊÊ of them resulted in an absence from play of one to three
both match play and training during the 2010 FIFA days. Only two injuries resulted in absences of more than
World CupTM a month. The overall incidence of time-loss injuries was
UÊ>ÞÃiÊÌ
iÊV`iViÊ>`ÊV
>À>VÌiÀÃÌVÃÊvÊiÃÃiÃÊÊ 1.3 per match.
players during the 2010 FIFA World CupTM
During training sessions, 104 injuries occurred, corre-
sponding to 7.9 injuries per 1,000 training hours. About
How we collected the data 40% of injuries occurred in contact with another player, a
quarter was classified as overuse injuries and about 13% as
All team doctors were informed in detail of the planned a recurrence of a previous injury. The most frequent diag-
extended investigations at the team workshop four noses where ankle sprains and thigh strains. About 57%
months prior to the event. The existing and well-estab- of training injuries resulted in an absence from play, in
lished injury recording system during matches at FIFA half of them this absence was estimated to be one to seven
competitions was amended to include training injuries days.
and illnesses. The definitions of injury and recording
parameters remained the same, but in addition team During the event, 99 illnesses occurred in 89 players
doctors were asked to provide the duration of training (12.1% of all players), corresponding to 7.7 per 1,000
sessions and document injuries occurring during the player days. Most illnesses concerned either the respiratory
same. In compliance with the definition of the term or the digestive system, with the most frequent diagnosis
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 35
being an upper respiratory tract infection (almost a third illnesses complied with what would be usually expected
of cases) followed by gastroenteritis (21%) and sleep dis- in a travelling party.
orders (10%). The most frequent symptoms were pain,
fever, diarrhoea/vomiting and dyspnoea/cough. Causes
identified were in the vast majority infections and less
often environmental. Medication was the most often used
therapy, with antibiotics and oral analgesics, either alone
or in combination, being the most frequently used type
of medication. Most of the illnesses did not cause any
absence from play (59%) or only a short absence of one to
three days with an average time loss per illness of 1.8 days.
2.4.7 Injury Surveillance in World Football ation because of the different setting and rules of these
Tournaments 1998-2012 games.
Protecting the health of their athletes should be a key From 1998-2012, 1,681 matches were played in the 53
concern for all international sports bodies, and injury top-level tournaments, and the team doctors returned
surveillance is an important prerequisite for injury pre- 3,091 completed injury report forms to the FIFA Medical
vention. FIFA started to systematically document all Officers. This corresponds to an average response rate of
injuries incurred by players during its tournaments as 92%.
early as 1998. Until the end of 2012, football injuries
have been surveyed in all 51 FIFA tournaments as well A total of 3,944 injuries were reported from 1,546 match-
as in the four Olympic Games (2000-2012), and valu- es, which is equivalent to 2.6 injuries per match. The
able insights on the incidence and characteristics of foot- incidence of injury varied between 1.9 (FIFA Women’s
ball injuries could be gained. This study is unique in World Cups) and three (FIFA U-20 World Cups) inju-
that no other report on such comprehensive number of ries per match in the different types of tournaments. In
tournaments or over a period of 14 years has yet been general, the injury incidence was lower in tournaments
published. for female players compared with the respective tourna-
ments for male players (except for the Olympic Games).
The incidence of injuries in male players decreased in the
Aims of the study FIFA World Cups™ and in the football tournaments of
the Olympic Games from 1998 to 2012. The opposite
UÊ/Ê>>ÞÃiÊÌ
iÊV`iVi]ÊV
>À>VÌiÀÃÌVÃÊ>`ÊVÀVÕ- trend was observed for female players in the FIFA Wom-
stances of football injury during FIFA tournaments en’s World Cups 1999 to 2007, the football tournaments
and the Olympic Games from 1998 to 2012, and to of the Olympic Games from 2000 to 2008, and the FIFA
discuss trends in injury incidence in different types of U-17 Women’s World Cups 2008 to 2012 (see Figures
tournaments during this period 1 and 2). For the World Cups, it could be shown that
the contrary trends for men and women were due to the
changes in the number of contact injuries.
Method
Most injuries affected the lower extremity (70%), fol-
During a pre-tournament meeting the team doctors of lowed by injuries to the head and neck (15%), trunk (8%)
all participating teams were instructed on how to fill in and upper extremities (7%). The majority of injuries were
the standardised injury report form. The injury report sustained during contact with another player while 20%
form consisted of one single page on which all injuries of all injuries were due to non-contact activities. Based on
occurring during a given match, or when applicable the judgment of the team doctors, almost half (47%) of
the non-occurrence of injury, should be described by the contact injuries were caused by foul play. In tourna-
the team doctors in tabular form after each match. An ments of female players, significantly fewer contact inju-
injury was defined as any physical complaint (including ries were caused by foul play than in the respective tour-
concussion) that occurred during a match and received naments of male players (except for the FIFA U-19/U-20
medical attention from a team doctor, regardless of its World Cups). Since only half of the injuries incurred
consequences with respect to absence from the match during matches (47%) actually prevented players from
or training. For all injuries, information had to be participating in a match or training, the overall incidence
documented on: time of injury (minute in the match), of time-loss injuries was 1.1 per match. The incidence
injured body part and type of injury, circumstances of time-loss injuries was similar in male and female play-
(non-contact, contact, foul play) and consequences of ers when the same types of tournaments were compared,
injury (referee’s sanction, treatment, time loss in training except for the FIFA World Cup™ where the injury rate
or match). The FIFA Futsal World Cups and the Beach was significantly lower in female players.
Soccer World Cups were not included in the data evalu-
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 37
2.5.1 Risk Factors of Injuries in Different Ages 19 years of age. A majority of the players (82%) were
and Skill Level injured during the observation period.
during that season. If we used two risk factors as the cut- work load in a session and throughout the season, a rea-
off score, more than 80% of the players were correctly sonable training/match relationship and more. Medical
classified as to whether they went on to incur an injury professionals need to ensure adequate rehabilitation and
(Tab. 2.5.1.1). Another important finding was that the recovery, pay attention to player’s complaints and suggest
more baseline risk factors, the more severe the injury preventive measures. Finally, officials and administrators
(Fig. 2.5.1.2). The multidimensional sum of risk factors need to continually look at the rules with an eye towards
was a reasonable way to identify who might be injured, safety.
but failed to correctly identify the nature of injury, e.g.
contact vs. non-contact.
Uninjured Injured
uninjured
injured Number of previous injuries
17.0 36.2
(more than 6)
100
Pain in the joints
4.3 15.9
80 (more than ‘a little’)
60 Muscular warm-up
6.5 19.4
%
3
2.21
2
0
y
ild
re
ur
at
ve
m
inj
er
se
od
no
The research group during the risk factor study in Prague 1996
What we learned from the study
2.5.2 Risk Factors for Injuries in Elite Female The physiotherapist also recorded injuries and rea-
Football Players sons why a player was unable to participate. An injury
was defined as “any physical complaint associated with
football (received during training or match play), which
Why we conducted this study limits athletic participation for at least the day after the
day of onset”. A player was injured until she was able to
Epidemiological data on injuries in elite female foot- participate fully in games and/or training. An overuse
ball players had been rare for a long time. Consequent- injury was the consequence of repetitive micro-trauma.
ly, F-MARC had aimed to contribute to the body of An injury was traumatic if it was caused by a single trau-
knowledge and conducted prospective epidemiological matic incident. Traumatic injuries were classified further
studies in professionals and world championship events, as contact or non-contact.
which found that in high level female football, injury
incidence is as high as in professional male football.
Results
Risk factors in elite football had also been only incom-
pletely evaluated. In Iceland, increasing age and previous In these elite female football players, we found the fol-
injury were the main risk factors for injury. In contrast, lowing (see also Tab. 2.5.2.1):
age was not a factor in lower division Swedish female
players. Although many possible variables had been UÊ/
iÊÌ>iÃÌÊ«>ÞiÀÃÊ£ÇxV®Ê
>`ÊÌ
iÊ
}
iÃÌÊÀ>ÌiÃÊvÊ
evaluated in studies on risk factors, only a few consistent injury.
results had been reported. This could have partly been
due to differences in, for instance, the gender or skill UÊ/
iÊ
i>ÛiÃÌÊ«>ÞiÀÃÊ>ÃÊÜiÊ>ÃÊÌ
iÊ«>ÞiÀÃÊÜ
Ê
>`Ê
level of the populations investigated. However, no study played the most matches in the previous season
had so far analysed risk factors for injuries in elite female showed the highest non-contact injury rate.
football players, and we therefore decided to finally
address this issue. UÊÕÀi`Ê«>ÞiÀÃ]ÊiëiV>ÞÊÌ
ÃiÊÜÌ
ÊVÌ>VÌÊÕ-
ries, were found to have the least training and total
exposure time.
Aims of the study
UÊ/
iÊ«>ÞiÀÃÊÜÌ
ÊÌ
iÊ
}
iÃÌÊ>ÌV
ÊiÝ«ÃÕÀiÊ{xÊ
UÊ`iÌvÞÊÀÃÊv>VÌÀÃÊvÀÊÕÀiÃÊÊvi>iÊvÌL>Ê hours per season) had the lowest injury rate.
players in the German national league on the basis of
player characteristics UÊ*>ÞiÀÃÊÜÌ
Ê>Ê«ÀiÛÕÃÊ
ÊÀÕ«ÌÕÀiÊ
>`Ê>Ê
}
ÊÀÃÊ
UÊÊ>Ê«ÀëiVÌÛiÊ>iÀ]Ê`VÕiÌÊÌ
iÊÕÀÞÊV- of another rupture. However, a history of an ankle or
dence over an entire outdoor season knee sprain was not predictive of another sprain.
UÊ/
iÊÕÀÞÊÀ>ÌiÊvÀÊ`ivi`iÀÃÊ>`ÊÃÌÀiÀÃÊÜ>ÃÊ}Ài>ÌiÀÊ
How we collected the data than for midfielders or goalkeepers. Injuries to field
players were mostly contact injuries while injuries for
All twelve teams of the German women’s professional the goalkeeper were mostly non-contact.
league were invited and eight teams submitted complete
data. Each team was contacted weekly to ensure compli- UÊÊÌÌ>ÊvÊÈÓ¯ÊvÊ«>ÞiÀÃÊÜiÀiÊiÌ
iÀÊÕÕÀi`ÊÀÊ
ance and update data records. A total of 143 players were sustained only one injury during the season; 15%
followed over an entire season. had two injuries, 13% had three injuries and 10%
had four or more injuries. Thus, the players who sus-
The coach reported exposure and the physiotherapist for tained four or more injuries accounted for 30% of all
each team recorded baseline information. This included reported injuries.
anthropometric data, position, preferred leg, prior season
matches and a detailed medical history with emphasis on UÊÀiÊÕÀiÃÊVVÕÀÀi`ÊÌÊÌ
iÊ`>ÌÊLÊiëiV>ÞÊ
past ligament injuries. more ankle injuries, ligament ruptures and contusions.
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 41
Tab. 2.5.2.1 Mechanism, affected body part as well as diagnosis of injuries as related to the injured leg
We felt that with some understanding of tackle param- On-pitch medical attention
eters it could be possible to identify changes to the laws Tackle
of football relating to tackling to reduce the level of inju-
No medical attention
ry in football. To improve safety of players during these
risky situations, we needed to detail just what actions Foul
went into a tackle and the outcome of that tackle.
On-pitch medical attention
UÊi>ÀÊ
ÜÊÌ>V}Êi>`ÃÊÌÊvÌL>ÊÕÀiÃ
UÊiÛi«Ê>ÊV>ÃÃwV>ÌÊÃÞÃÌiÊvÊÌ>ViÃ
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 43
The critical findings about tackling What we learned from the studies
Of special interest in this project were the tackling These are probably the only investigations into tack-
action, mode and direction that led to injury. Con- ling in such detail with comparison in relation to player
versely to what was believed prior to the study, tackles error. Our analysis suggested that player error during
from the side were twice as likely to require post-match tackling, inadequacies in the laws and/or their applica-
medical attention as tackles from behind. Injuries to the tion by referees were equally responsible for the high lev-
head or neck (for both players) and the torso (for tack- els of injury observed.
ling players) were most likely to receive on-pitch medical
attention while injuries to the foot (for both players) and Although referees play a major role in managing on-
the lower leg and thigh (for tackling players) were less pitch incidents, the greater responsibility for injuries
likely to receive on-pitch medical attention. Tackles with rests with the football’s ruling bodies to ensure the Laws
the greatest tendency for injury involved clash of heads of the Game are adequate, implemented efficiently,
and two-footed tackles (for tackled players) and clash of and that players are held accountable for serious inju-
heads, two-footed tackles, jumping vertically and tackles ries resulting from their errors whether by poor tackling
from the side (for tackling players). From information technique, lack of experience, or deliberate violation of
like this, a framework of injury mechanisms and risk of the laws of football. This study showed that, different to
injury was developed (Tab. 2.5.3.1). previous belief, tackling from the side is far more dan-
gerous than tackling from behind. The laws of football
Tackle category/injured player’s status relating to tackling need to be continuously reviewed to
Framework sector Tackled Tackling
ensure greater protection from injury by reducing the
overall level of risk and by protecting players from tack-
Very high Clash of heads Clash of heads les with the highest propensity for injury.
High Two footed - Side
- Jumping vertically
- Two footed
Very low
UÊ/>V}Ê>VÌÊ>`«Ìi`ÊLÞÊÌ
iÊÌ>V}Ê«>ÞiÀÊi
Why we conducted this study footed, two-footed, use of arms, use of upper-body,
use of head)
It had been reported that ‘‘the women’s game is rapidly
changing not only in playing dynamics but also the dis- UÊ>ÌV
ÊÀiviÀii½ÃÊ`iVÃÊvÕ]ÊvÕ]ÊÞiÜÊV>À`]Ê
tinct athletics of the players’’. Accordingly, public inter- red card)
est in women’s football is constantly on the rise. This
reflected a positive trend in the international standing of UÊ"«ÌV
ÊÌÀi>ÌiÌÊ`iwi`Ê>ÃÊ>ÞÊi`V>Ê>ÌÌi`>ViÊ
female football players and of the sport in general, and seen on video
more and more international competitions have been
integrated within the official calendar of FIFA. UÊ/iÊÊÌ
iÊ>ÌV
Most tackles that led to injury in females were from the side
How we collected the data (52%), front (38%), and behind (11%). One-footed tack-
les or tackles with an upper body action accounted for 86%
We studied six FIFA women’s competitions from 1999 of all injuries. Injuries from a two-footed tackle were all to
to 2004. Injuries were recorded using the established F- the tackled player (Tab. 2.5.5.1).
MARC injury reporting procedures. Videotapes of each
match were provided by FIFA Information Systems and There was no difference in injuries according to playing
used to identify relevant parameters of injury. For each position, time in match, type or stage of competition. Goal-
contact injury recorded on videotape, the following fac- keepers were injured from tackles from the front while for-
tors were determined: wards and defenders were hurt from tackles from the side.
Defenders sustained more injuries as the tackling player
UÊ/>V}Ê`ÀiVÌÊvÊÌ
iÊÌ>V}Ê«>ÞiÀÊÜÌ
ÊÀiëiVÌÊÌÊ than any other position. Non-contact injuries were most
the tackled player (behind, side, front) common in forwards and least in midfielders. This type of
injury increased by 30% in the second half of play.
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 47
Injuries Injuries
laws of the game. Differently from men’s football, the use
per 1000 per 1000
# 1-footed of elbow in aerial challenges was rarely seen as a cause of
tackles - tackles -
women men injury in women’s football.
From
behind
Findings like these once more cautioned F-MARC against
Standing 10 9 3.4 12.7
applying what we know about men’s football to the wom-
Side 5 5 10.3 14.8 en’s game. These gender differences in tackle properties
jumping 6 0 2.6 15.9 need to be taken into account by the match referees to
From the ensure the safety of the players.
side
Standing 54 36 5.9 31.6
Half of all injuries led to some time loss. This was a con-
stant across all variables of injury (location, playing posi- Distribution of injuries in female football players
tion, time of injury, various tackle parameters). Fourteen
time-loss injuries leading to seven or more days away from
play were identified on the videotapes. Four of the 14 were
non-contact injuries and all required the players to be sub-
stituted. The ten contact injuries were equally split between
tackles from the front or side. The referee sanctioned the
offending player in three instances (one yellow card) and all
but one was substituted within ten minutes of the tackle.
This study identified several differences in the causation of Duration: 1999 - 2006
Countries: International
injuries between women’s and men’s football. Tackles from
Cooperation: University of Zurich, Switzerland; University of
behind were rarely seen in injury situations in female play-
Nottingham, UK
ers, whereas sliding-in tackles were shown to have a much Reference:
higher risk than in men’s football. Several investigations Tscholl P, O’Riordan D, Fuller CW, Dvořák J, Gutzwiller F,
had identified elbowing as frequent high-risk tackling- Junge A (2007). Causation of injuries in female football players
mechanisms and these have led to suggested changes in the in top-level tournaments. Br J Sports Med 41(1 Suppl): i8-i14
48 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.5.6 Tackling Situations of Female Players in tact between at least two players occurred. At least one of
Top-Level Competitions the players had to be challenging for the ball. The tack-
led player was defined as the player being either in pos-
session of the ball or the player from the team in control
Why we conducted this study of the ball immediately prior to contact.
With the aim of prevention, it is not only important to Every tackle had the following factors recorded
know the number of injuries sustained in football train-
ing and matches, but also to understand the circum- UÊ/>ViÊ`ÀiVÌÊqÊvÀÊLi
`]ÊÃ`iÊÀÊvÀÌ
stances in which they occur. Tackling is the most dan- UÊ/>ViÊ`iÊqÊÃÌ>Þ}viiÌ]ÊÃ`}ÊÀÊÕ«}Ê
gerous aspect of football play, so a full understanding vertically
of tackling should help with developing suggestions for UÊ/>ViÊ>VÌÊqÊivÌi`]ÊÌÜvÌi`]ÊÕÃiÊvÊ>ÀÉ
injury prevention. hand, upper body or head challenge
UÊ,iviÀiiÊ`iVÃÊqÊvÕ]ÊvÕ]ÊÞiÜÊV>À`]ÊÀi`ÊV>À`
Contact injuries during tackling and collisions had been UÊ"«ÌV
ÊÌÀi>ÌiÌÊqÊ>ÞÊi`V>Ê>ÌÌi`>ViÊÃiiÊÊ
reported to be responsible for between 44% and 87% of video
all traumatic injuries in men’s, women’s and adolescents’ UÊ/iÊÊÌ
iÊ>ÌV
football. In 1995, the English FA reported that 37% of UÊÞÊÌ>ViÊÜ
iÀiÊÌ
iÊ>ÌV
ÊÜ>ÃÊÌiÀÀÕ«Ìi`ÊLÞÊÌ
iÊ
all injuries or more than 90% of all contact injuries were referee, a player was on the ground for more than 15
due to tackling actions. In earlier reports, “tackle action” seconds, a player appeared to be in pain or a player
did not include unintentional collisions, use of elbows received medical treatment during the match
and heading, whereas in later publications, all mecha-
nisms that lead to contact between two or more players Corresponding to injuries reported as the number per
were considered as a tackle. 1,000 player hours, we expressed the tackles per 1,000
player hours and number of injuries per 1,000 tackles.
However, the available, if limited, data on tackling and
injury in football was focused exclusively on men’s foot-
ball. While at first glance the games appear to be simi- Tackle analysis
lar, F-MARC had already found subtle as well as obvious
differences between the men’s and women’s game from A total of 3,531 tackles were analysed. This worked out
tactics to skills to injuries. Consequently, it was only to 147 tackles per match (or 1.6 tackles per minute).
logical for us to specifically analyse tackle mechanisms in Over 60% of the tackles were from the side and in
female players, too. 65% of all tackles, the tackling player stayed on her
feet. Combining these two factors showed that 44%
of all tackles were by a player on her feet tackling from
Aims of the study the side. Sliding tackles accounted for only 12% of all
tackles, but nearly two thirds of all sliding tackles came
UÊ>ÞÃiÊÌ>Vi>VÌÃÊÊÜi½ÃÊvÌL>Ê`ÕÀ}Ê from the side. While tackles from the side while standing
match situations was the most common tackle for both women and men,
UÊÃÃiÃÃÊÌ
iÀÊÀëÌiÌ>Ê>ÃÊvÕVÌÃÊvÊ«>ÞiÀýÊ>}i]Ê the rate of this tackle was far greater for women than for
playing position and stage in a competition men (Tab. 2.5.6.1).
UÊ
«>ÀiÊÌ
iÊÀiÃÕÌÃÊ>LÕÌÊÌ>ViÊ«>À>iÌiÀÃÊLÃiÀÛi`Ê
in women’s football with the results reported previ- A standing tackle from the side had the lowest injury
ously for men’s football rate (16 per 1,000 tackles). Sliding tackles from the
front had the highest injury rate (126 per 1,000 tackles).
However, the referees sanctioned tackles from behind
How we collected the data and sliding tackles the most.
A total of 24 matches from four FIFA competitions and The different tackle codes were similar across time of the
two Olympic Games were studied. A tackle referred to match, but 46.1% of all yellow cards were given in the
any incident during normal play where an obvious con- last 15 minutes of each half with no differences between
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 49
the first and second half. The incidence of injurious situ- except for sliding-in tackles. While sliding-in tackles had
ations per tackle and on-pitch treatments for the last 15 previously been shown to have the highest propensity for
minutes of each half was more than that observed in the injury, they were not specially regarded by the referees
first 30 minutes of each half. in injury situations. Therefore, it was concluded that the
context of sliding-in tackles and referees’ decision had to
Over half of the tackles were to midfielders, yet when be elaborated further to ensure players’ health.
controlling for the number of players playing each posi-
tion, forwards were the most tackled players at an aver-
age of 13 challenges per match. There were few dif-
ferences in tackle parameters according to the type of
competition or the stage (group vs. knock-out) of the
competition.
2.5.7 Refereeing in Injury Situations that resulted in injuries. The results of the video analysis,
referee’s decision, and panel conclusion were compared.
Why we conducted this study The incidents leading to 148 contact injuries were iden-
tified on videotape of which the referees reached a con-
Because of their unique role, the referee can be consid- sensus decision on the foul/non-foul status of 139 inci-
ered an extrinsic factor in injuries. In their previous stud- dents. Further, a total of 128 head/neck injuries was
ies, F-MARC had shown that contact is a factor in half reported by the team doctors, of which the incidents
to three-quarters of all acute football injuries and that leading to 84 injuries were identified on videotape. For
foul play is an important risk factor for injury. But not the general injuries, the match referees identified 47%
all contact leads to injury and not all injuries from con- and the panel identified 69% to have resulted from foul
tact are called a foul. Referees must decide quickly, in a play. The match referees and panel agreed on 70% of
very public setting, whether the contact was or was not the decisions. The referee panel was in good agreement
within the laws of the game. In fact, our research had (91%) with the match official on the decision where a
revealed that football players appear to suffer from high foul occurred, but agreed with the match official only
levels of injury from tackles that match referees deem to 49% of the time when no foul was called. Most of the
be fair. general injuries occurred in the attacking goal area and
involved a vertical jump or aerial contact.
As a next step in our approach to prevention of inju-
ries in football, we therefore decided to investigate and For head/neck injuries, the match referees identified
identify whether these injuries occur because the current 40% and the panel identified 49% as foul play. The
rules are inadequate to protect the players from injury match referees and the referees’ panel agreed on 85% of
or because referees cannot implement the existing rules the decisions. There was no typical situation involving
effectively during competition. head/neck injuries meaning the referee did not have any
specific cues prior to an injury. This resulted in further
disagreement by the referee panel on the presence of a
Aims of the study foul (94% agreement) or no foul (only 20% agreement)
at the time of a head/neck injury (Tab. 2.5.7.1). The sit-
UÊiÌiÀiÊÜ
iÌ
iÀÊÀiviÀiiÃÊVÕ`ÊÀi>LÞÊ`iÌvÞÊÌ
iÊ uation where the referee panel identified a foul that the
legality of incidents leading to injury match referee had not identified involved actions with
UÊiÌiÀiÊÜ
iÌ
iÀÊÌ
iÊÀÕiÃÊvÊvÌL>Ê>`iµÕ>ÌiÞÊ a vertical jump. Notice that whereas for general injuries
protect players from injury there was better agreement on head/neck injury fouls in
UÊiÌiÀiÊÜ
iÌ
iÀÊÕÀiÃÊVVÕÀÊ>ÃÊ>ÊÀiÃÕÌÊvÊ«>ÞiÀÃ½Ê the attacking goal area, in head/neck injuries the pro-
non-compliance with the rules with special focus on portion of injuries that were awarded a foul decreased
head/neck injuries by both the referee and the panel as the attack moved
toward goal (Tab. 2.5.7.2).
doctors on the details of match injuries from twelve Tab. 2.5.7.1 A comparison of decisions by the match referee and the
FIFA competitions (398 matches). In addition, we col- panel on head/neck injury incidents
lected video recordings of tackles to identify the factors
of the foul and injury. A tackle referred to any event
that occurred during the normal course of a match and What we learned from the study
involved physical contact between two or more players
while one or more of the players challenged for posses- The referees taking part in the FIFA competitions were
sion of the ball. Then, a panel of FIFA international ref- among the best referees from around the world; how-
erees with an average number of 8.8 years’ experience as ever, the match referees were required to make decisions
an international referee assessed the legality of incidents in difficult circumstances and within very short time
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 51
Ratio of fouls awarded to number of injuries It was, therefore, the effectiveness with which referees
(number of incidents)
could identify foul situations during match and the will-
General injuries Head/neck injuries
ingness of players to comply with the rules of football
Area of Match Panel A Match Panel B
pitch referees referees referees referees
that were the main issues to be addressed by FIFA as
Defensive football’s governing body.
* * * *
goal area
Defensive
0.70 0.85 * *
midfield
Attacking
0.49 0.77 0.50 0.72
midfield
Attacking
0.21 0.36 0.28 0.31
goal area
Referee taking a decision during a match at the 2006 FIFA World Cup Referee cautioning a player with the yellow card during a match at the
Germany™ 2006 FIFA World Cup Germany™
2.5.8 Risk of Injury on Artificial Turf The third study was performed on twenty European elite
level teams (15 male, 5 female) playing home matches
on artificial turf prospectively; their injury risk when
Why we conducted these studies playing on artificial turf was compared with the risk on
grass. Individual exposure, injuries (time loss) and injury
Football has traditionally been played on natural grass. severity were recorded by the team medical staff.
However, artificial turf has become more popular with
an increasing number of pitches being built in countries
where the climatic conditions are unsuitable for grass Results
pitches. In 2006, FIFA approved the use of artificial
turf for all matches. In addition to match play issues, The main findings of the two studies of the US college
artificial turf provides a year-round, all-weather training and university players showed no major differences in
surface. Still, acceptance of artificial turf by players has either the risk or the cause of training or match inju-
remained limited because of a continuing perception of ries on artificial turf and grass in both male and female
a different pattern of injury and an increased injury risk. football players. Neither did the severity nor the causes
Before FIFA could widely promote artificial surface, the of injury differ significantly between the two surfaces in
football community needed proof that these new prod- both genders. In both match and training the most com-
ucts are no different from grass in terms of injury risk. mon injury location on both surfaces was the lower limb
Preliminary data from the FIFA U-17 World Cups in in both genders. Three to four times more matches and
2003 and 2005 had suggested no significant difference training hours were analysed for grass than for artificial
in the incidence, nature, cause and severity of injuries turf, which accounts for the difference in injury numbers
sustained on both surfaces, but the study had been too recorded.
small for definite conclusions.
During matches, a total of 848 injuries for men (artifi-
cial turf: 183, grass: 665) and 946 for women (artificial
Aims of the studies turf: 134, grass: 812) were recorded. The injury rate
on grass for male (23.92) and female (21.79) players
UÊ
«>ÀiÊÌ
iÊV`iVi]Ê>ÌÕÀi]ÊÃiÛiÀÌÞÊ>`ÊV>ÕÃiÊvÊ per 1,000 match injuries was similar to previous find-
match and training injuries sustained on grass and ings and there were no differences in match injuries as
artificial turf by American collegiate male and female compared to artificial turf for men (25.43 injuries/1,000
football players match hours) or for females (19.15 injuries per 1,000
UÊ
«>ÀiÊÌ
iÊV`iViÃÊ>`ÊÕÀÞÊ«>ÌÌiÀÃÊvÊvi>iÊ match hours, Tab. 2.5.8.1). There were also no surface-
and male elite teams when training and playing related differences for non-season-ending time-loss inju-
matches on artificial turf and natural grass ries. The most common injuries during matches were for
men a lateral ankle sprain, hamstring strain and concus-
sion; for women a lateral ankle sprain, concussion, and
How we collected the data ACL tear.
The two studies in the US on match and training inju- During training, three to four times more teams were
ries were conducted on American college and university analysed on grass. A total of 818 injuries to men (arti-
football teams over two seasons – for 52 men’s and 64 ficial turf: 189 grass: 629) and 774 to women (artificial
women’s teams (in 2005) and 54 men’s and 72 wom- turf: 122, grass: 652) were recorded. Similarly to the
en’s teams (in 2006). The studies included all organised matches, no differences in training injuries for males on
matches from their pre-season, in-season and post-sea- artificial turf vs. grass (3.34 vs. 3.01 injuries/1000 train-
son football competitions. Detailed injury reports were ing hours respectively) or for females (2.60 vs. 2.79 inju-
recorded on the playing surface, location, diagnosis, ries per 1,000 training hours respectively) were found.
severity and cause of all match injuries. The number The most common training injuries were in men lateral
of days lost from training and match play was used to ankle sprain, groin strain and quadriceps or hamstring
define the severity of an injury. The incidence of inju- strain; in women lateral ankle sprain, quadriceps or
ry was documented per 1,000 player match or training hamstring strain and concussion.
hours.
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 53
Match Training
Tab. 2.5.8 .1 Overall injury rates (per 1000 player hours) by gender, play
setting
2.5.9 Influence of Match Events on Injury website. A yellow/red card, injury and goal were defined
Incidence during FIFA World Cups™ as potentially game-disrupting incidents (PGDI).
Football is a sport of a highly competitive nature, espe- From the three FIFA World Cups™, 441 injuries were
cially at the top level. Changes in the score, foul play, reported, giving an overall injury incidence of 67.8 per
injuries or yellow/red cards may have a profound impact 1,000 match hours. There were statistically significant
on the course of a match. They may influence players’ differences in the injury incidence related to the changes
attitudes, emotion, concentration, behaviour and team in the score and to the teams’ drawing/losing/winning
strategies, and thereby affecting the risk of injury. status. The injury incidence was lowest during the initial
0-0 score and highest when the score was even but goals
In FIFA World Cups™ (and other international tourna- had been scored. Teams currently winning had a higher
ments), the importance of the result of a single match is injury incidence than drawing or losing teams. There
crucial, which might emphasise the specific roles of the were also statistically significant differences in the injury
different playing positions (i.e. forwards having to score incidence between the playing positions, with forwards
goals), and consequently affect their risks for suffering an having the highest injury incidence, followed by defend-
injury. Furthermore, FIFA World Cups™ are tourna- ers, midfielders and goalkeepers.
ments with intense match schedules, which could hypo-
thetically lead to incomplete recovery between matches, The injury incidence was significantly higher during
and therefore increase the risk of injuries. Few studies on match periods within the minute of or during a five-
the relationship between recovery time and injury inci- minute period following a PGDI than in other periods
dence in top-level football have been published. of the match. The frequency of PGDIs had a tendency
to increase towards the end of each half (Fig. 2.5.9.1),
and a yellow card was the most frequent PGDI.
Aims of the studies
The incidence of non-foul injuries was significantly
UÊÛiÃÌ}>ÌiÊÌ
iÊÀi>ÌÃ
«ÊLiÌÜiiÊÕÀÞÊV`iViÊ higher than of foul play injuries. Lower leg and ankle
and changes in the score of the match, teams’ current injuries were significantly more often caused by foul
drawing/losing/winning status, red / yellow cards, than non-foul play, whereas the opposite was observed
injuries and foul play, as well as differences in the for thigh injuries. Contusions were a significantly more
injury incidence between the playing positions often caused by foul than non-foul play, while the oppo-
UÊÛiÃÌ}>ÌiÊÌ
iÊÀi>ÌÃ
«ÊLiÌÜiiÊÕÀÞÊV`iViÊ site was found for muscle strains/ruptures/tears. Foul
and recovery time between matches play injuries were significantly less severe (defined by
UÊ>ÞÃiÊ`vviÀiViÃÊLiÌÜiiÊvÕÊ«>ÞÊÕÀiÃÊ>`Ê resulting days of absence from playing/training football)
foul injuries with regard to injury types and locations, than non-foul play injuries. No significant differences
as well as match circumstances in which they occur between the incidence of foul play and non-foul injury
regarding match period, teams’ current drawing/losing/
winning status or playing position were observed. We
How we collected the data also found a linear relationship between number of fouls
and of injuries in a match (Fig. 2.5.9.2).
The studies were based on team doctors’ post-match
injury reports from the FIFA World Cups™ in 2002,
2006 and 2010. The injury data were obtained through What we learned from these studies
the injury surveillance system developed by F-MARC,
and methods applied are in accordance with the consen- The high injury incidence following PGDIs could be a
sus statement on injury definition and data collection potential target for intervention. Opportunities for sanc-
procedures. Other match information were retrieved tions, including temporary expulsion from a match for
from FIFA’s official match statistics for all 192 match- players committing violent fouls, could be considered. A
es of the same tournaments, accessed on FIFA’s official few minutes’ absence for the player violating the rules could
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 55
Fig. 2.5.9.2: Average number of fouls per matches in matches with diffe-
rent number of injuries
2.6.1 Head and Neck Injuries during FIFA How we collected the data
Competitions
We analysed incidents resulting in head/neck injuries
in 20 FIFA competitions (men and women) from 1998
Why we conducted this study to 2004. Again, team doctors provided medical reports
using the same methodology as the other F-MARC
As in other contact sports such as basketball, ice hockey injury studies on frequency, characteristics, risk factors
and rugby the risk of concussion in football players had and causes. We defined injuries by the need for players
always been a major concern and the risks associated to receive post-match medical attention from their team
with head injuries had been recognised by FIFA for a doctors. To assess the incidents leading to injury, we
long time. There was also a concern that repeated head obtained video recordings of heading incidents and stud-
injuries may lead to long-term brain damage. Despite ied these videos to identify a range of parameters associ-
these concerns and the potential of long-term disability, ated with the incidents.
recognition of head injuries had not received the atten-
tion that other injuries had. The English Football Asso-
ciation stressed that “a head injury is a potentially seri- Identifying head injuries
ous injury which can lead, in a small number of cases,
to significant complications. No head injury is trivial.” From the physician reports, we identified a total of 248
But while the football medicine community had gained head/neck injuries of which 163 were identified and
a good understanding of ankle, knee, muscle and other analysed on video sequences (Tab. 2.6.1.1). The most
injuries, head injuries had not been studied to the same common injuries were contusions (53%), lacerations
degree as other injuries. Therefore, F-MARC decided to (20%) and concussions (11%). The incidence of all
further investigate into the matter. A major first step in head/neck injuries was 12.5/1,000 player hours (men:
the prevention of any injury is recognising the factors 12.8; women: 11.5) and 3.7 for time-loss injuries (men:
that lead to injury. 3.5; women: 4.1).
Injury most likely to cause injury involved the use of the upper
diagnosis
extremity or the head, but in the majority of cases the ref-
As identified by team As identified by videotape eree deemed the challenges to be fair and within the current
physicians laws of the game.
Men Women All Men Women All Group most Location of incident on pitch possession status
common cause prior to challenge direction of challenge mode
Concussion 8 22 11 9 26 12 of injury risk of challenge action during challenge intent
factor
Fracture/ 2 6 3 2 6 3
dislocation Gender Men: Defensive outfield free ball from the side
jumping use of upper extremity fair challenge
Contusion 57 41 53 59 34 54
Women: Defensive outfield free ball from the
Laceration/ 21 15 20 24 17 23 front jumping use of head fair challenge
abrasion
Tournaments < 20 years: Attacking outfield free ball from
Others 12 17 13 5 17 8 for players the side jumping use of upper extremity fair
aged challenge
Tab. 2.6.1.1 Percentage of injury type in male and female players
> 20 years: Defensive outfield free ball from the
side jumping use of head fair challenge
Tournament Incidence of injuries Injury Concussion: Attacking outfield free ball from
per 1,000 player hours diagnosis the front jumping use of head fair challenge
All injuries Lost time injuries Contusion: Attacking outfield free ball from
the side jumping use of upper extremity fair
Men Women Men Women challenge
FIFA U-17 World Cup 11.1 – 4.1 – Laceration/abrasion: Defensive outfield free ball
from the side jumping use of head or upper
FIFA U-19 World Cup – 11.1 – 4.7 extremity fair challenge
Tab. 2.6.1.2 Incidence of head and neck injuries per 1000 player
hours in male and female players
2.6.2 Biomechanical Aspects of Head Injuries and motion analysis software which allowed the devel-
opment of a mathematical model of heading and ball
impact that was tested on one player and permitted
Why we conducted these studies investigation of heading technique later in the other
players.
Heading as the intentional use of the unprotected head
to control and advance the ball is a most unique aspect Through the use of a computer, we made modifications
of football. Media reports and earlier scientific infor- to how the athlete performed the skill and the outcome
mation on perception deficits in a fraction of football- on impact, head and ball trajectories, as well as accelera-
ers had fed the growing controversy regarding potential tion and loads on the head. We could also make changes
long-term consequences of repeated low-severity head to the structural properties of the ball and the closing
impacts of heading. While there was substantial emotion velocity, the motion of the torso, activation of muscle as
about this sensitive topic, there had been little scientific modifiers of heading skill.
data available on skill and forces that occur when head-
ing a football.
UÊiÛi«ÊÌ
iÊ>LÀ>ÌÀÞÊÌÃÊii`i`ÊÌÊÃÌÕ`ÞÊÌ
iÊL-
mechanics of heading
UÊ`iÌvÞÊ
i>`}ÊÃÌÀ>Ìi}iÃÊÌ
>ÌÊ}
ÌÊÀi`ÕViÊÌ
iÊ
potential for injury
UÊ««ÞÊÌ
iÊÌÃÊ>`ÊÌiV
µÕiÃÊÌÊÌ
iÊÃÌÕ`ÞÊvÊ
i>`}Ê
using human subjects Fig. 2.6.2.1 Bite plate mounted with an accelerometer
UÊÌÌi«ÌÊÌÊ`iÌvÞÊÃÌÀ>Ìi}iÃÊÌÊ«ÀÛiÊ
i>`}ÊÌiV
-
nique Applying the model
The responses of the head were tested against current What we learned from the studies
injury assessment functions of mild traumatic brain
injury which come from a number of sources that have Using biomechanic modelling methods as F-MARC had
studied settings like motor vehicle accidents, bicycle applied them in this study demonstrated that the accel-
accidents, falls and others. Finally, we developed a Head erations heading causes to the head of a player are below
Impact Power Index that we hoped would have a better the levels associated with brain injury.
predictor picture of mild brain injury.
Fig. 2.6.2.2 Positive sign conventions of the numerical model for the
head, neck, and torso
In fact, heading led to accelerations that are well within
accepted tolerance limits of head injury in trauma sci-
ence.
current serious neck injury. This revealed only a low the impacts may exceed the parameters used in the labo-
neck injury risk (<5%). ratory.
2.6.4 Biomechanical Analysis of Ball using our model, we were able to look at the differences
Properties in ball construction under wet/dry conditions to deter-
mine dynamic ball characteristics experimentally. Lin-
ear and angular accelerations of the head were measured
Why we conducted this study and compared to injury assessment functions and Head
Impact Power. We also used the numerical model to
Footballs have evolved over the years from an inflat- assess neck responses.
ed pig’s bladder to a leather encased bladder. The first
guidelines were set in 1872 with regard to the ball. The It was interesting to see that three of the five balls used
current laws of the game set standards for the ball: cir- in this project gained water weight that exceeded the
cumference of 680-720mm, mass of 410-450 grams and +
Ê}Õ`iiÃÊVÀi>ÃiÃÊvʳÓÓ¯ÊÌʳ{ǯ®Ê/>L°Ê
inflation pressures of 600-1100g/cm2 (0.6-1.1 bar). The 2.6.4.1).
VÕÀÀiÌÊÊ+Õ>ÌÞÊ
Vi«ÌÊ+
®ÊÃiÌÃÊ>ÀÀÜiÀÊ
standards on circumference and mass plus restrictions on The effect of water had variable effects of ball response
shape, size, water absorption, pressure loss, rebound and properties: some balls with the lowest responses when
balance. FIFA-sanctioned matches must use balls that dry had the highest results when wet. If ball mass is
V«ÞÊÜÌ
ÊÌ
iÊ+
ÊÀiµÕÀiiÌð reduced by up to 35%, the responses on the head are
also decreased by up to 23%-35% in both the numerical
Heading is a specific and essential part of the game and and subject trials.
yet the impacts of heading have been implicated in mild
and acute neuropsychological impairment. Some pub- Similar decreases in neck axial (forces that try to either
lished studies had suggested that ball characteristics press or separate the head from the trunk) and shear
affect the impact response of the head; however, the (forces that push the head front, back, right or left)
biomechanics of the interaction of the ball on the head responses were observed. If the inflation pressure was
were not well understood. Consequently, the next step reduced by 50%, head and neck responses were reduced
of F-MARC in their approach to head injuries was that by up to 10%-30% for the subject trials and numerical
we wanted to study whether ball mass, pressure and con- model.
struction characteristics can help reduce head and neck
impact response. Ball Type Condition Pressure Mass (kg) Water
(bar) Uptake
neck responses of up to 20%. See table 2.6.4.2 for a results from modified heading techniques will make any
summary of responses from changing ball characteristics. skill recommendations difficult to implement.
It was concluded that to reduce ball mass and inflation
pressure would lead to improvements in both the peak Another option would be to reduce ball mass and infla-
linear acceleration and power index. Other ball charac- tion pressure. Our study showed that improving the
teristics such as stiffness and construction must be con- classical ball characteristics of mass and pressure might
sidered in conjunction with traditional ball characteris- have immediate effect on heading scenarios regardless
tics. of the player’s skills. Though research on a wider range
of ages, skill, sex, heading scenarios, etc. will aid in the
Ball Type Linear Angular Power further understanding and improvement of heading bio-
Acceleration Acceleration Index
mechanics, changes to the ball characteristics have been
Baseline mass, = = = shown to provide on overall benefit and can be effec-
pressure
tively implemented. The possible fall-off in playabil-
Lowest mass ++ ++ +++
ity and handling characteristics using balls with reduced
Low mass ++ - +++
mass and/or pressures would need to be balanced against
the possible safety benefits. The constraints provided by
Low pressure ++ -- ++ Ì
iÊ>ÜÃÊvÊÌ
iÊ>iÊ>`ÊÌ
iÊ+
ÊÜÕ`Ê
>ÛiÊÌÊLiÊ
reviewed.
High pressure -- -- +*
UÊ
Û>Õ>ÌiÊÌ
iÊivviVÌÛiiÃÃÊvÊÌ
ÀiiÊÌÞ«iÃÊvÊvÌL>Ê
Why we conducted this study headgear
Results
Fig. 2.6.5.2 Volunteer prepared for heading (bare head configuration
shown)
The data showed that at low and high speed ball impacts,
whether using the human or the dummy head form,
headgear failed to appreciably alter the impact response
on the head during heading. The acceleration of the
head, when wearing any head protection, was within
the variability seen for the unprotected condition. The
surface that underwent the greatest deformation was the
surface that is absorbing the impact and high speed video
showed that the ball, being the softer surface, appeared
to absorb most of the impact of heading. The responses
observed in all ball-to-head tests indicated a low risk of
mild traumatic brain injury.
Product Linear Angular Linear Angular of the colliding heads means that a compliant headgear
A -22.1 -25.7 -24.5 -31.9 helps reduce the impact by dissipating energy.
B -19.0 -14.1 -17.9 -16.6
C -55.6 -55.9 -57.7 -45.7
2.6.6 S-100 Beta Serum Levels after normal exercise as well as in other patients who had sus-
Controlled Heading tained a minor traumatic brain injury.
brain injury, the neuroprotein S-100 Beta is released into Normal exercise group .10 .11 .09
the circulation and is considered to be a reliable marker Patients with a .62 .32
of brain damage. Brain cells are held together by a com- + CAT scan
plex scaffolding of supporting cells. When the brain is Patients with a .10 .08
– CAT scan
injured, some of these supporting cells also become dam-
aged and release specific compounds into the blood. In
+ CAT = patients with a CAT scan positive for head injury
the absence of brain injury, the levels of one of these – CAT = patients with a CAT scan negative for head injury
proteins in the blood, S-100 Beta, are negligible, but
become measurable in the blood following brain injury. Tab. 2.6.6.1 Average S-100 Beta (ng/ml) results by time and group
2.6.7 Serum Levels of S-100 Beta after Minor ing session without heading and after a low-intensity
Head Trauma training session with heading exercises only
Football is one of the few sports to use an unprotected All players in the elite Norwegian league, the Tippeli-
head to control and advance the ball. There had been an gaen, were invited to participate prior to the 2004 and
increasing concern that heading could lead to chronic 2005 seasons. The total number of players followed over
brain injury like that seen in boxing. This was first pos- these two seasons were 289 (2004) and 332 (2005),
tulated in 1992 based on a series of cross-sectional stud- meaning that the study covered 621 player seasons.
ies using neurological exams, neuropsychological tests, Baseline morning blood sampling prior to both seasons
computer tomography scans and electroencephalography was performed for all teams during their pre-season
exams on active and older retired Norwegian football training camp. Post-match or training samples were
players. Since then, the neurological deficits found in a obtained immediately after play or training as well as the
small fraction of football players were a matter of debate next morning (twelve hours post-match).
as studies had shown different results. In our own stud-
ies, F-MARC had found that heading duels leading to The two match groups were differentiated according to
head-head or head-elbow impact expose players to an whether there was no recorded head trauma or wheth-
increased risk of head trauma and had been hypothesised er there was head trauma recorded during play. A head
as the mechanism for the reported cognitive deficits trauma was defined as follows: a player appeared to
rather than heading itself. receive an impact to the head (including the face and
the neck), the match was interrupted by the referee, and,
As mentioned, an important issue had always been to the player laid down on the pitch for more than 15s. A
actually recognise that a concussion has occurred. There total of 228 head impacts that met these inclusion crite-
is no conclusive, objective test or image that verifies the ria were identified on video from 352 matches and 69 of
presence of a concussive injury. Several different mark- these head traumas were followed up by blood sampling.
ers for brain injury had been investigated and the S-
100B protein seemed to be the most promising marker Training sessions were either of high intensity with no
for evaluation of traumatic brain injury in patients with heading or low intensity including heading. The high
minor head injury. Elevation of S-100B indicates some intensity sessions were aimed at mimicking match play
level of structural damage to the brain. but heading was disallowed. Players were questioned
after both sessions assessing their level of fatigue and
Studies in small groups of players suggested that S-100B how often they headed the ball during the current day’s
is increased after playing a football match and appears to training compared to a regular match (much less, less, a
be related to the number of headers. The F-MARC study little less, the same, a little more, more or much more).
described in the previous chapter had shown a transient This score was then divided into the two groups of “less”
increase in S-100B levels after controlled heading. How- and “the same or more” for analysis.
ever, no large-scale prospective study had assessed S-
100B levels after minor head impacts in football and we
decided to address this problem. Results
Table 2.6.7.1 Average S-100B values* (ng/ml) by training emphasis, player perceptions and time
2.6.8 The Value of Neuropsychological the National Football League, National Hockey League
Testing after Head Injuries and many university athletic programmes began clinical
concussion management programmes that featured neu-
ropsychological testing as a critical tool.
Why we conducted these studies
The use of these brief test batteries serve mostly as a
It had been stated that only one out of five concussions screening approach to cognitive assessment. Brief test
are recognised by the players after a head impact in a batteries allow baseline assessment of many athletes in
match, indicating that many players continue to play the pre-season, but do not allow for comprehensive eval-
with undiagnosed concussions. Thus, an important issue uation of cognitive processes. So there are limitations to
for the sports physician when assessing and managing Ì
iÀÊÕÃiÊ>`ʵÕiÃÌÃÊÌÊLiÊ>ÃÜiÀi`°Ê+ÕiÃÌÃÊiÊ
concussions had always been the reliance on the subjec- the most appropriate battery of tests, interpretation of
tive reporting of symptoms by athletes. Cognitive func- the tests and the control of factors that can affect test
tion testing had been used for the study of brain func- performance.
tion for a very long time, but the last two decades had
seen a wide expansion in the use of neuropsychological Which ground are we at?
testing in the evaluation of concussion injury. The idea Which team are we playing today?
that neuropsychological tests could be used to provide an
Who is your opponent at present?
objective measure of cognitive recovery in the concussed
Which half is it?
athlete initially arose from work in severe traumatic brain
injury. Later, computerised testing programmes that can How far into the half is it?
be administered to multiple people using portal comput- Which side scored the last goal?
ers had been introduced. These programmes were new Which team did we play last week?
and still needed to be validated against the long accepted Did we win last week?
and traditional paper and pencil tests. It seemed there-
fore critical to F-MARC to provide football physicians Tab. 2.6.8.1 The Maddocks questions for use after a head injury
with guidance on the best test to use.
At the sideline
Aims of the studies
The sideline clinician needs a simple and valid tool to
UÊ-Õ>ÀÃiÊÌ
iÊ`vwVÕÌiÃÊÊ`>}Ã}Ê>ÊVVÕÃÃ determine whether an athlete is concussed to aid in
UÊiÃVÀLiÊÌ
iÊV
>i}iÃÊÊ`iÛi«}ÊÀiÌÕÀÊÌÊ«>ÞÊ decisions such as removal from play for detailed assess-
guidelines ment. In the early 1990s, the so-called “Maddock’s ques-
UÊ-
ÜÊÌ
iÊÌiÀ>VÌÊvÊÃÃÕiÃÊÊÌiÀ«ÀiÌ}ÊiÕ- tions” were validated using Australian Rules football and
ropsychological data showed that a simple sideline test of recent and remote
UÊ-Õ>ÀÃiÊÌ
iÊÃÃÕiÊvÊVVÕÃÃÊÊvÌL> memory could be sensitive at separating concussed from
non-concussed athletes (Tab. 2.6.8.1). Another option
is the “Standardised Assessment of Concussion (SAC)”
Which test is best? that can also be given on the sideline, but is more com-
plex and takes longer than the Maddock’s questions.
Traditional approaches to cognitive assessment involv- The most recent sideline assessment tool, the “Sport
ing extensive testing by trained neurophysiologists, was Concussion Assessment Tool (SCAT)” combining all
impractical for the evaluation of large groups of athletes. the previous tests, was developed at the 2nd International
At about the same time in the US and Australia, two Symposium on Concussion in Sport in Prague in 2004.
research groups began to study the use of abbreviated A detailed summary of that conference is contained
neuropsychological assessment in sports concussion. The within the chapter on improving standards of care.
establishment of the “45’ test” battery developed for the
American football team Pittsburgh Steelers proved that a
brief battery of tests were a reliable and valid adjunct in
the clinical management of sports concussion. From this,
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 71
2.6.9 Effects of Heading Exposure and heading actions per match), player career, etc. The Cog-
Previous Concussions Sport™ tests for seven different subtasks: Simple Reac-
tion Time (SRT), Choice Reaction Time (ChRT), Con-
gruent Reaction Time (CgRT), Monitoring (MON),
Why we conducted this study One-Back (OBK), Matching (Match) and Learning
(Learn). The stimulus for all tasks consists of play-
The football community had become aware that a frac- ing cards with responses given using the keyboard. The
tion of football players displayed some cognitive dys- heading actions of 18 players observed in four matches
function in factors like short-term memory, information were counted and correlated with their self-reported val-
processing, concentration and more from earlier studies. ues.
As laid out in the previous chapters, these studies had
since come under question because researchers raised
methodological issues pertaining to alternative hypoth- Results
eses other than routing heading as the reason for the
noted dysfunction. Those earlier studies, while drawing A total of 137 players, that means just about more than
attention to the issue, implicated heading the ball as the half of players, reported having had one or more concus-
cause while ignoring alternative hypotheses. Later reports sions and 112 players reported a football-related concus-
stated that the reported deficits are more likely to be the sion. Defensive players reported to head the ball most
result not from routine heading, but from head injuries, frequently, followed by attackers. The manual count in
specifically concussions – the most common of serious 18 players showed an average of 8.5 headings per player
head injuries. per match.
After having addressed the value of neuropsychological The first thing of interest then was if there was a positive
testing after head impacts more generally, F-MARC con- association between the numbers of previous concus-
sidered it necessary to further investigate the association sions and match heading exposure. It should be expected
between previous concussions and heading exposure with that the players who head the ball the most should be
neuropsychological test performance. We also felt that, at the greatest risk of head injury (Fig. 2.6.9.1). This
as all previous studies had looked at a limited number of assumption, based on the figure, appeared to be true
players for a shorter period of time, it was necessary to – those who head the ball the most are the ones most
follow a larger number of players for an entire league sea- likely to have had a concussion. The estimated lifetime
son in order to get a more reliable picture of the effects of heading exposure as well as the self-reported number of
heading and concussion in football. Further, we intended headings were correlated with the number of previous
not to use a paper and pencil, but a computer based test. concussions.
(N mes
(N es
(N es
(N er
9)
5)
1)
)
=3
v
tim
tim
=6
=1
=6
=9
Ne
ti
ti
10
20
1–
-2
6-
>
11
completed a questionnaire assessing previous concus- Fig. 2.6.9.1 Relationship between estimated heading per match and
sions, match heading exposure (self-reported number of concussion history
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 73
Neither match nor lifetime heading exposure showed 19 players scored below the 95% confidence interval for
any association with the neuropsychological test perfor- one or more of the tasks. The 95% confidence interval
mance of these players. represents the scores encompassing 95% of people who
have taken the test. These 19 players with the lowest
When the CogSport™ data is plotted against concus- scores were no different from the rest of the players in
sion number, we see a horizontal line (Fig. 2.6.9.2), terms of the number of previous concussions or life-
which means no relationship between test results and time or match heading exposure adding more evidence
concussion number. If, however, cognitive performance against heading as a factor in low neuropsychological
was related to concussion injury, then test performance performance.
should become poorer in players with more concussions.
Obviously, not everyone scores the same on these tests What we learned from the study
and there will be players who perform poorly on the
assessments. What about these players who had the This study is, by far, the largest study to date on neu-
poorest performance on these tests? Of the 271 players, ropsychological test performance in football players.
Similar to other studies, we found an association between
2000
1500 heading frequency and concussion. Contrary to previous
1000 findings among footballers, we found no impairments in
this group of professional footballer players if compared
500
400 to the normal range defined by the test manufacturers.
300
200
We also failed to find a relationship between previous
concussions, heading exposure and test performance.
100 Simple reaction time
Our findings did not confirm that either concussive or
2000
the repetitive sub-concussive traumas from heading have
Cogsport mean reaction time (log 10 scale, ms)
1500
1000 a cumulative effect causing brain function impairments
among football players.
500
400
300
200
However, as stated in the summary on injuries in FIFA
competitions, studying one team or league or tourna-
100 Choice reaction time The back task ment must be expanded to give the most stable conclu-
2000
1500
sions on this most important topic.
1000
500
400
300
200
500
400
300
200
5)
3)
6)
2)
5)
3)
6)
2)
33
33
=5
=4
=1
=2
=5
=4
=1
=2
=1
=1
(N
(N
(N
(N
(N
(N
(N
(N
(N
es
es
es
es
es
es
es
es
Reference:
0
0
tim
tim
tim
tim
tim
tim
tim
tim
>4
>4
largest deficits when tested, but deficits were also dem- What we learned from the study
onstrated among asymptomatic players.
A reduced test performance was found after minor head
Players who experienced one or more head impacts dur- impacts in football as compared to results prior to the
ing the 2004 season also showed a reduction in neu- impacts. The largest reductions were found for the play-
ropsychological performance when tested prior to the ers who showed symptoms at the time of testing. The
2005 season (Fig. 2.6.10.2). However, none of these study is also the first to demonstrate neuropsychological
footballer players were impaired when compared to deficits after minor head impacts where the player did
results to be expected in an average population. not report any acute concussive symptoms. Our findings
emphasise the need for increased awareness of concussion
signs and symptoms, not only among the team’s medical
personnel, but also among the players themselves. Con-
cussive symptoms are often not recognised by the players
and, if recognised, symptoms are often not reported.
2.7.1 Injuries in FIFA Competitions loskeletal complaints. The referees were also asked to
report on their refereeing qualifications and experience,
other medical problems and time spent in training and
Why we conducted these studies in matches retrospectively.
According to FIFA’s “big count”, there were more than During the competitions, the characteristics and conse-
840,000 registered referees and assistant referees in 2006 quences of all injuries and complaints incurred by the
worldwide. In the last ten years, several studies had 63 male and 36 female officiating referees were pro-
examined various aspects of performance and training of spectively documented. During the two FIFA World
football refereeing. During a competitive match, a refer- Cups™, the referees and assistants travelled by air from
ee may cover a distance of between nine and 13 km, part the headquarters to their appointed matches at the ven-
of these with high intensity such as sprinting. Backwards ues. For each match, a physiotherapist documented the
and sideways running are typical movements of the ref- injuries and complaints. Confirmation of the diagnosis
eree during the course of a match. In fact, the elite level was made by a physician at the referees’ headquarters.
referee is generally exposed to similar physical demands Every acute injury incurred during match or training
as those placed on a midfielder. But, in comparison to was recorded according to the consensus statement on
the players they need to control, they are not only up to injury definition described in chapter two, and also used
15 to 20 years older and rarely full time professionals, by F-MARC in our studies on football players. All mus-
but also cannot be substituted during a match. A referee culoskeletal complaints that received medical attention
must therefore be prepared to perform at high intensity were also recorded.
throughout the match and clearly is exposed to a certain
risk of injury.
Results
While some studies had addressed the physical demands
of refereeing, very little was known on injuries and mus- Compared to their female counterparts, the male refer-
culoskeletal complaints in referees. In a study on elite ees were older (41 vs. 35 years) and had a longer career,
Swiss referees, F-MARC had found that almost 90% of holding their official license for on average 19 vs. 12
these had had some sort of complaint and almost a third years, and their FIFA license for an average of eight vs.
suffered an acute injury in the twelve months under six years, during which time they had also been officiat-
investigation. We therefore decided to further investigate ing international matches. Almost 85% of the male ref-
these health issues in the international elite referees at erees, but less than two thirds of female referees received
FIFA’s flagship events. training advice from expert staff.
How we collected the data During the FIFA Women’s World Cup 2007, the frac-
tion of female referees with an acute injury was almost
During the preparation camps for the 2006 FIFA World twice as high as the fraction of their male counterparts at
Cup™ in Germany and the FIFA Women’s World Cup the 2006 FIFA World Cup™. However, the incidence
2007™ in China, all 123 male and 81 female referees of injuries of 20.8 for male and 34.7 for female refer-
pre-selected for the competitions completed a specially ees per 1,000 match hours was considerably lower than
developed questionnaire on their injuries and muscu- compared to male and female players with injury rates
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 77
of 68.7 resp. 81 per 1,000 match hours at the respective skeletal complaint during their career. However, due to
competitions. The most common acute injuries in both the known problems with limited recall, these reports of
genders were hamstring strains, calf strains, and ankle complaints during a career of several years might repre-
sprains. Musculoskeletal complaints were reported to sent rather an under-reporting than the true incidence.
the same degree for male and female referees. There were
slight differences with regard to the most frequent loca- Considering the high prevalence of musculoskeletal
tions of complaints between the two genders, but both complaints, the injury profile, and the high physiological
men and women often reported low back pain. demands of refereeing, F-MARC strongly recommend-
ed the development of specific injury prevention pro-
Male referees Female referees grammes and their integration into the fitness training
routine of the male and female referee.
Complaints during career (%) 62.8 76
14 14
Injuries during WC (n)
(total 63) (total 36)
2.7.2 Injuries of Referees at All Levels of Play cal complaints caused by either refereeing a match or by
in Switzerland the training for officiating. The referees were also asked
to report on their refereeing qualifications and experi-
ence, other medical problems and time spent in training
Why we conducted this study and in matches retrospectively.
The study of the 204 male and female referees selected At amateur level, 489 active referees representing a rep-
for the recent FIFA World Cups™ (see previous chap- resentative sample of all Swiss referees officiating at the
ter) alerted F-MARC to the high frequency of injuries different levels of play including youth were interviewed
and musculoskeletal complaints among referees and by telephone using essentially the same questionnaire
confirmed our view that this group requires the same as above, but adapted for the specific conditions of a
preventive efforts as players. However, the FIFA World telephone interview.
Cup™ group represented mainly professionals and in
fact corresponds to only 0.02% of all registered referees
in the 208 member associations of FIFA worldwide. In Results
players, injury incidence varies with the level of play,
therefore F-MARC also wanted to look at the next lower The male elite referees were on average 36 years old and
level of referees and decided to examine injury incidence held their official license for about 16 years. They had
and complaints in the elite referees of the top leagues in been officiating in the top leagues for about 7.5 years.
Switzerland. The amateur referees were of similar average age (36.6
years) and had a shorter career, holding their official
However, the number of elite referees on national level is license for on average of twelve years. Elite match referees
again small compared to the number of referees involved trained for about 6.4 hours a week, whereas the assistant
in amateur football. In Switzerland, the 71 referees offici- referees trained less than their superiors (4.7 hours) but
ating in the two top divisions represent only 1.6% of the about the same time as reported by the amateur referees
4452 registered referees (season 2005/06). As in players, (4.8 hours).
this large number of amateur football referees contrasts
with the fact that there is hardly any research done on With regard to injury and physical complaints, some
the injuries and complaints of these referees caused by important differences were observed between the two
their activities in football. Therefore, F-MARC decided groups: In the elite referees, 44% had suffered from
to additionally examine the amateur referees in Switzer- at least one injury during their career whereas about
land, using a similar assessment as for the elite referees. only one quarter of the amateur referees had (s. Table
2.7.2.1). Elite referees suffered 62% of their injuries
during training and 39% in matches as compared to far
Aims of the study fewer training injuries (21%) than match injuries (79%)
in referees on lower levels. In both groups, thigh muscle
UÊÛiÃÌ}>ÌiÊÌ
iÊÕÀiÃÊ>`ÊÕÃVÕÃiiÌ>ÊV«>ÌÃÊ (hamstring) strain and ankle sprain where the most com-
of all Swiss Top Division referees and assistant referees mon diagnoses.
UÊÛiÃÌ}>ÌiÊÌ
iÊÕÀiÃÊ>`ÊÕÃVÕÃiiÌ>ÊV«>ÌÃÊ
of a representative group of Swiss referees and assistant Another important difference between the two groups
referees at all levels of play was the frequency of musculoskeletal complaints.
Eighty-six percent of the elite referees reported com-
plaints caused by their refereeing but only about one
How we collected the data quarter of the referees at lower levels of play suffered
from complaints.
During a training camp organised by the Swiss Refer-
ees Association, all 71 referees and assistant referees of
the two top divisions were asked to complete a specially
developed questionnaire and were subsequently inter-
viewed to gain more information about the reported
injuries. The questionnaire asked for injuries and physi-
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 79
Incidence of match injuries last year per 1000 match hours 6.8 2.1
concussion injury rate was nearly five times greater in Football Rugby
rugby than in football (0.32 vs. 1.45 concussions per
Injury
1,000 hrs) and fracture/dislocation injury rates were Rate/1000
% % per/1000
hrs
five to seven times higher in rugby players. Rugby play- hrs
ers suffered 1.5 times more overuse and training injuries
Circumstance
in relation to exposure time and 2.7 times more match
injuries than football players. Whereas age had no effect Overuse/training 34 15.4 34 22.4
in rugby players between 16 and 17 year olds (50.1 vs.
50.6), the incidence of injury increased by nearly 50% Match 66 47.5 66 129.8
in football players of similar age (23.5 vs. 35.1). Three
rugby players, but no football players, had to cease from
further participation in sport because of severe injury. Contact
No 52 14.4 33 16.4
Location
2.8.2 Injuries during the Olympic Games in capturing injury information that had been productive in
Athens 2004 previous work: Before the competition started, all medi-
cal staff met to agree on the procedure and definitions
for the different aspects of injury. After each competitive
Why we conducted this study match, a standardised one-page injury report form was
filled in by the physician of the participating teams or by
It had always been the aim of F-MARC to establish and the official medical representative of the sport.
apply standard definitions and data collection proce-
dures for the investigation of injury rates, so that these The average number of injuries per match ignores the
rates could be compared across different ages, levels of number of players in a match and the duration of a
competition, genders, and competitions. As mentioned, match. An exposure-time related incidence of injuries
numerous studies had analysed injury incidence in a per 1,000 player hours is widely used, but the playing
variety of sports, but the results of these studies could time is hard to determine in some team sports due to a
not be compared, because of the different injury defini- continuous clock (e.g. football), a non-continuous clock
tions, methods of data collection, observation periods, (e.g. basketball) or no clock at all (e.g. baseball, softball,
study designs and sample characteristics. Only a few volleyball). Therefore, we decided to express a player’s
studies compared exposure-related injury incidences in individual risk of injury for the different sports as in
different sports using the same methodology, but many “injuries per player matches”.
of these investigations were restricted to schoolchildren,
nationwide sport leagues or showed other limitations.
Only one project at the Australian University Games, a Results
multi-sport event featuring 5106 participants compet-
ing in 19 sports, looked across sports at a high level of We obtained data on 456 out of 488 team sport matches
competition in 1994. It was concluded then that ice corresponding to a response rate of 93%, meaning we
hockey, handball, basketball, football, rugby and field obtained records on 93% of all matches; an excellent
hockey shared a relatively high risk of injury. The great participation for the first attempt at a multi-sport event.
advantages of conducting a comparative study during a We could analyse 911 forms covering 6,953 player-
major international tournament are that multiple sports matches. A total of 377 injuries were reported which is
with players of a comparable skill level can be included equivalent to an incidence of 0.8 injuries per match or
and that the observation period is defined by the event. 54 injuries per 1,000 player matches.
Furthermore, a high standard of environmental factors,
such as the quality of the playing fields and equipment, The incidence, diagnosis and cause of injuries differed
is guaranteed. substantially between the team sports leading to specific
profiles of injury in each sport (Fig. 2.8.2.1 and Tab.
2.8.2.1). Handball, football, and basketball all had rates
Aim of the study per 1,000 player hours exceeding 70 while the rates for
the remaining sports were substantially lower. More than
UÊÊ>ÞÃiÊ>`ÊV«>ÀiÊÌ
iÊV`iVi]ÊV
>À>VÌiÀÃÌVÃÊ that, football and handball had nearly twice the injury
and causes of injuries in all team sport tournaments rate than the next highest sport, basketball.
(football, handball, basketball, field hockey, baseball,
softball, water polo, volleyball and beach volleyball) Half of all injuries affected the lower extremity and 24%
during the 2004 Olympic Games of the injuries involved the head or neck. The two most
prevalent diagnoses were contusion of the head and
ankle sprain. The majority of injuries (78%) were caused
How we collected the data by contact with another player and half of these injuries
were, in the opinion of the recording physician, a result
During the 2004 Olympic Games, 14 team sport tourna- of foul play. However, a significantly higher percent-
ments were contested: football, handball, basketball, field age of non-contact than of contact injuries resulted in
hockey, water polo, volleyball (both men’s and women’s absence from match or training.
competitions) baseball (men only), and softball (women
only). We used the standardised F-MARC procedure for
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 83
On average, 42% of the injuries were expected to pre- Sport Number of Number Injuries Injuries
matches of injuries per match per 1000
vent the player from participating in sport for some hrs
time. The incidence of time-loss injuries per 1,000 play-
Football – 32 77 2.4 73
er matches was substantially higher in males (24.7) than
men
in females (15.9). Time-loss injuries most frequently
Football – 20 45 2.3 70
affected the ankle (20%), knee (13%), thigh (12%) and women
head (10%). There were 15 injuries that were of suf-
Handball – 44 49 1.2 89
ficient severity to keep a player out of competition for men
four or more weeks: eight fractures, one shoulder dislo- Handball – 33 65 2.0 145
cation, four knee ligament ruptures, one meniscal injury women
and one ankle ligament rupture. Basketball – 42 27 0.6 96
men
Incidence of injuries per 1000 player matches
ll
ll
ey
ll
all
lo
ll
ba
ba
ba
ba
ba
po
ck
ftb
Volleyball – 38 2 0.05
ot
nd
et
se
ey
ho
er
So
sk
Fo
Ba
ll
Ha
women
Vo
at
Ba
ld
W
Fie
Baseball 32 16 0.5
Fig. 2.8.2.1 Number of injuries per 1000 player matches
Softball 32 1 0.03
2.8.3 Handball Injuries during Major medical attention from the team doctor regardless of the
International Competitions consequences with respect to absence from the match
or training. For each match, both team doctors were
supposed to return the completed single page form for
Why we conducted this study all injuries or, where applicable, the non-occurrence of
injury for their team to a medical representative of the
Together with football, volleyball and basketball, hand- IHF. The incidence of injury was expressed as the num-
ball is one of the most popular sports in Europe. Team ber of injuries per match and additionally as the number
handball is a high-intensity sport with frequent physical of injuries per 1,000 player hours.
contact between the players. As per 2004, the Interna-
tional Handball Federation (IHF) officially numbered
150 member federations representing approximately Results
800,000 teams and more than 19 million sportsmen and
women. As in football, several authors had analysed the A total of 478 injuries were reported from the six tourna-
incidence of handball injuries, but the results were dif- ments, which corresponded to an incidence of 108 inju-
ficult to compare because of differences in study design, ries per 1,000 player hours or 1.5 injuries per match. The
injury definition, observation periods and level of play. incidence of injury varied between the different types of
Most studies were on adolescent players, only two stud- tournaments; it was the lowest in the 2002 Women’s
ies each looked on adult amateur players and major European Cup and the highest in the women’s tourna-
international tournaments. The information on handball ment of the 2004 Olympic Games. In general, the inci-
injury in top-level players however was very limited. The dence of injuries increased towards the middle of each
comparative F-MARC study on injuries in eight team half and decreased towards their ends. Half of the con-
sports during the Olympic Games 2004 as described in tact injuries, or 45% of all injuries, were caused by foul
the previous chapter had shown that the incidence of play as judged by the team doctor and the injured player.
injuries per 1,000 playing hours was highest in hand- However, only 60% of these injuries were sanctioned by
ball. As knowledge of the incidence, circumstances and the referee. The most frequent diagnosis was a contusion.
characteristics of handball injuries would considerably
aid in developing preventive programmes, a standard- The injuries affected most frequently the lower extrem-
ised approach as developed by F-MARC in football for ity (42%), followed by injuries of the head (23%),
recording the data was required. upper extremity (18%) and trunk (14%). The most fre-
quent diagnosis was contusion of head (14%) followed
by an ankle sprain (8%). The majority of injuries were
Aim of the study caused by contact with another player. Time loss injuries
occurred on average 27 times per 1,000 player hours, and
UÊ>ÞÃiÊÌ
iÊV`iVi]ÊVÀVÕÃÌ>ViÃÊ>`ÊV
>À>VÌiÀÃ- were significantly more frequent in men than in women.
tics of team handball injuries in women and men dur- Less than a quarter of the injuries prevented the player
ing the major international tournaments from participating in a match or training for up to one
week, 5% of the injuries led to a longer absence. Regard-
ing time loss injuries only, the incidence was the highest
How we collected the data in the Olympic Games in men and women, and the low-
est in the Europe Cup and the Women’s World Cup.
Injury incidence was recorded at six major handball
competitions. The injury-reporting system applied fol- Overall, the incidence of injury was similar for men and
lowed the established F-MARC scheme, except for the women. Furthermore, the location and type of injuries
exchange of the word ‘‘football’’ to ‘‘handball’’ in the did not vary significantly between men and women.
injury report form. During a pre-competition instruc- Women incurred significantly more non-contact injuries
tional meeting, the physicians of all teams participat- than men (20% vs 12%), but significantly less injuries of
ing were asked to report all injuries incurred during the women than of men were expected to result in absence
competition and were instructed about how to fill in the from play.
injury report forms. An injury was defined as any physi-
cal complaint incurred during the match that received
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 85
How we collected the data Even though based on the established F-MARC proce-
dure for team sports tournaments, the injury report sys-
The established injury-reporting system originally devel- tem proved feasible and practicable for individual sports
oped by F-MARC for team sports competitions was during the IAAF’s World Championships 2007 and
modified to be applicable for both individual and team achieved good acceptance by the national team doctors.
sports. The most important principles of the system are The data suggested that the injury surveillance system
comprehensive definition of injury, injury report by the covered almost all athletes for the first six days of the
doctor responsible for the athlete, a single-page report of championship. However, the response rate of team doc-
all injuries, and daily report irrespective of whether or tors decreased during the last three days of the champi-
not an injury occurred. All national team doctors were onship, and thus, it is estimated that the true injury inci-
asked to report all newly incurred injuries or the non- dence of the championship was higher than reported.
occurrence thereof on the standardised one page injury
report form. In addition, the medical centre in the sta- It was concluded that, following further adaptations to
dium reported daily on the injured athletes treated there. the organisational and logistical specificities of the event,
the system was suitable for implementation during the
2008 Olympic Games in Beijing.
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 87
The Congress of IAAF which approved the injury study at the 11th
IAAF World Championship
Duration: 2007
Countries: International
Cooperation: IAAF, IOC, all physicians of the 11th IAAF World
Championship
Reference:
Alonso JM, Junge A, Renström P, Engebretsen L, Mountjoy
M, Dvořák J (2009). Sports injury surveillance during the 2007
IAAF World Athletics Championships. Clin J Sport Med 19(1):
26-32
88 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
2.8.5 Injuries during the 2008 Olympic Games guished from missing data; the response check is easier;
in Beijing and injury documentation is promoted as a matter of
routine. In addition, the medical centres at the different
Olympic venues and the polyclinic in the Olympic Vil-
Why we conducted this study lage reported daily on the injured athletes treated there.
Only injuries incurred during the period of the Games
Comparison of injury incidence between sports is dif- were included in the analysis.
ficult, not only due to lack of standardisation of meth-
ods, but also due to the different nature of sports. Major
events such as the Olympic Games offer several advan- Results
tages in this regard. The observation period is clearly
defined, athletes of a comparable skill level compete in The physicians of 92 national teams took part in the
multiple sports and a high standard of environmental study and returned a total of 1,314 injury reports on
factors, such as the quality of the competition grounds 9,672 athletes (88% of all athletes). Though some partic-
and equipment, is guaranteed. At the same time, the ipating NOCs did not return forms on all days (response
large number of individuals and teams from different rate 80%), the injury surveillance system is likely to have
backgrounds and with varying medical support make it covered almost all athletes. A total of 1055 injuries were
more difficult to obtain reliable information about the reported, with no significant difference between men and
incidence, occurrence and characteristics of injury. Based women regarding the location, type and severity of inju-
on the injury reports routinely used in football, a group ry. On average, almost every tenth athlete was injured
of experts from different international sports federations, during the Games; approximately one out of twenty ath-
under the leadership of F-MARC and the IOC, had letes incurred a time-loss injury.
developed a concise injury surveillance system for multi-
sports events for both team and individual sports, that More than half (55%) of the injuries affected the lower
had been tested during the 2007 World Championships extremity, 20% the upper extremity, 15% the trunk and
of the International Association of Athletics Federations 10% the head. The most common diagnoses were thigh
(IAAF) in Osaka. The system had been accepted by strains and ankle sprains. About a quarter of injuries were
experienced team doctors and shown to be feasible for incurred during training, three quarters in competition.
single-sport and multi-sport events. One third of the injuries were caused by contact with
another athlete, followed by overuse (22%) and non-con-
tact injuries (20%). In relation to the number of regis-
Aims of the study tered athletes, the risk of incurring an injury was highest
in taekwondo, football, hockey, handball, weightlifting
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iÊÕÀÞÊÃÕÀÛi>ViÊÃÞÃÌiÊÊ>Ê"Þ- and boxing where more than 15% of the athletes got
pic sports injured.
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petitions and/or training during the Olympic Games
2008 in Beijing What we learned from the study
Match opening ceremony at the women‘s tournament in Beijing Maradona and Ronaldinho in Beijing
Opening Ceremony of the Olympic Games in Beijing 2008 Argentina and Nigeria, finalists at the Olympic Games in Beijing
2.8.6 Sports Injuries and Illnesses during the in their absence, a team physiotherapist were asked to
2009 FINA World Championships report daily on all newly incurred injuries and illnesses,
or the non-occurrence thereof. Reporting forms could
be submitted at confidential mailboxes adjacent to
Why we conducted this study swimming pools, by fax and by electronic submission.
In addition, the LOC medical teams at the medical sta-
F-MARC had for some years assisted other sporting tions at the venues submitted daily reports, too. Injury
codes to establish their own injury surveillance systems and illness definitions followed those recently used at the
based on the experiences made in football. Aquatic 2008 Olympic Games and only included newly incurred
sports have followers all over the world and are enjoyed events requiring medical attention during training and
by many people on a recreational basis, while at the same competition. Chronic conditions were not recorded
time being among the most popular Olympic sports. unless an acute exacerbation required medical attention.
Injury incidence and characteristics were first looked at
as a part of investigations at multisport events such as
the Olympic Games, but no studies had been under- Results
taken during exclusively aquatic events. Also, nothing
was known about illnesses in aquatic athletes apart from Overall response rate by the medical staff from partici-
indications from anti-doping activities that a comparably pating countries was 42% with variation among the dif-
large proportion of aquatic athletes use asthma medica- ferent disciplines and countries. This related to 67% of
tions. It was therefore decided to take the occasion of the all athletes being included in the study (n=1745). The
so far largest aquatic sports event, the 13th FINA World majority of injuries (83%) and illnesses (73%) were
Championships with almost 2,600 athletes, to investi- reported by team doctors, the remainder by the LOC
gate both injuries and illnesses among the participating medical teams.
athletes. Importantly, the event included five disciplines
(swimming, water polo, diving, synchronised swimming In total, 171 newly incurred acute injuries were report-
and open water swimming) requiring an approach suit- ed during the Championships, equivalent to an injury
able for both individual and team sports. rate of 65.6/1000 athletes. Female athletes had a higher
risk of injury (68.4 per 1,000 athletes) than male ath-
letes (52.1 per 1,000 athletes). Most injuries affected the
Aim of the study upper extremity (36.8%), followed by the lower extrem-
ity (27.5%), head/neck (19.3%) and trunk (16.4%). The
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iÊvÀiµÕiVÞÊ>`ÊV
>À>VÌiÀÃÌVÃÊvÊÕÀiÃÊ most frequently injured body parts were the shoulder
and illnesses during the 13th Fédération Internationale (14.6%) and head (12.3%). The most common types of
de Natation (FINA) World Championships 2009 injury were sprains and skin lesions.
2.8.7 Sports Injuries and Illnesses during the centres at the Vancouver and Whistler Olympic clinics
2010 Winter Olympic Games reported daily on all athletes treated for injuries and ill-
nesses. F-MARC once more assisted in the collection,
assertion of completion and analysis of data. Injury
Why we conducted this study definition included any newly incurred musculoskeletal
complaint, whether in training or competition, requir-
Protection of the athletes’ health is a clearly articulated ing medical attention and regardless of an absence from
objective of the International Olympic Committee. In training or competition caused. Illness definition was
2008, F-MARC had assisted the International Olympic one of any newly occurring physical complaint unrelated
Committee in implementing a comprehensive injury to injury.
and illness surveillance system at the XXIX Summer
Olympic Games. The comprehensive injury recording
through the medical staff of the participating National Results
Olympic Committees and the sports medicine clinics
revealed that almost 10% of all athletes incurred an inju- All 33 NOCs with more than ten registered athletes
ry during the Beijing Games. The incidence of injuries were included in the analysis of the response rate. These
and illnesses varied substantially between sports. Based countries represented 2,417 of the total of 2,567 athletes
on the findings on illness occurrence at the Champion- (1,045 females, 1,522 males) from 82 NOCs participat-
ships of International Federations, it was considered ing at the games. The reported 287 injuries and 185 ill-
important to include illnesses occurring Olympic Games nesses resulted in an incidence of 111.8 injuries and 72.1
at future events. Longitudinal surveillance of injuries and illnesses per 1,000 registered athletes.
illnesses was hoped to provide valuable data to identify
high-risk sports and disciplines where not yet done by On average, 11% of athletes suffered an injury during
the individual sporting codes. This would then form the the event. Female athletes were more often injured than
foundation for introducing tailored preventive measures male athletes. In relation to the number of registered
both in the individual sport and at multisport events in athletes, the risk of sustaining an injury was highest for
future. bobsleigh, ice hockey, short track, alpine freestyle and
snowboard cross. In these sports, 15-35% of all registered
athletes were affected.
Aim of the study
Conversely, the injury risk was lowest for the Nordic
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iÊvÀiµÕiVÞÊ>`ÊV
>À>VÌiÀÃÌVÃÊvÊÕÀiÃÊ skiing events (biathlon, cross country skiing, ski jump-
and illnesses during the XXI Winter Olympic Games ing, Nordic combined), luge, curling, speed skating and
in Vancouver in 2010 freestyle modules with less than 5% of registered athletes
affected by injuries.
How we collected the data The most frequent injury cause was non-contact, fol-
lowed by contact with a stationary object followed by
The data collection method followed the procedure at contact with another athlete. Injury location and type
the 2008 Summer Olympic Games taking into account differed with the sport. The head, cervical spine and knee
the lessons learnt then as documented in the IOC Inju- were the most common injury locations. Injuries were
ry Surveillance system. In addition to injuries incurred evenly distributed between training (54%) and compe-
during training and competitions, acute illness occur- tition (46%). Less than a quarter (23%) of the injuries
ring at any time during the event and requiring medi- resulted in an absence from training or competition.
cal attention was to be reported. Based on written infor-
mation provided in due advance, and oral information In skeleton, figure and speed skating, curling, snowboard
given during a session prior to the event at the venue, cross and biathlon, every tenth athlete suffered from at
all National Olympic Committees’ (NOC) head physi- least one illness. More female than male athletes suffered
cians were asked to report daily the occurrence (or non- from an illness. In 113 illnesses (62.8%), the respiratory
occurrence) of newly sustained injuries and illnesses on system was affected. The most frequent symptoms were
a standardised reporting form. In addition, the medical pain and dyspnea/cough. About a third of illnesses were
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 93
2.8.8 Sports Injuries and Illnesses during data collection the response rate of all NOCs with more
the 2012 Summer Olympic Games in than 30 participating athletes was recorded, and they
London were frequently visited in order to encourage continuous
medical reporting throughout the Games.
Seventy-four of the 204 NOCs had more than 30 par-
Why this study was conducted ticipating athletes; these comprised 89% of all athletes.
Throughout the 17 days of the London Games, the 74
There is a risk of injury in any sport, and irrespective NOCs submitted a total of 1204 of a maximum of 1258
of whether incurred during training or in competi- forms (96%).
tions; injuries may seriously harm an athlete’s health and
development. According to the Olympic Charter, one of
the main roles of the International Olympic Committee Results
(IOC) is thus to encourage and support measures pro-
tecting the health of athletes, and as previous research A total of 10,568 athletes (44% women, 56% men) par-
has shown, systematic injury surveillance is the foun- ticipated in the London Olympic Games. The NOCs
dation for developing effective preventive measures in and LOCOG medical staff reported 1,361 injuries
sports. and 758 illnesses. At least 11% of the athletes incurred
an injury during the Games while 7% of the athletes
Following up the injury surveillance system developed incurred an illness.
by F-MARC and routinely applied in all international The number of injuries during competition and train-
football tournaments since 1998, the IOC entrusted ing was similar with 55% occurring in competition and
a group of experts with the development of an injury 45% during training. The four most commonly reported
surveillance system for multi-sports events. This injury injury mechanisms were overuse (n=346, 25%), non-
surveillance system was successfully implemented in contact trauma (n=275, 20%), contact with another ath-
the2008 Beijing and in the 2010 Vancouver Olym- lete (n=197, 14%) and contact with a stationary object
pics, and it was further developed for the 2012 Summer (n=164, 12%). The injury rates in women and men were
Olympic Games in London as described in this study. similar. The risk of an athlete being injured was the high-
est in taekwondo, football, BMX, handball, mountain
bike, athletics, weightlifting, hockey and badminton,
Aims of the study and the lowest in archery, canoe slalom and sprint, track
cycling, rowing, shooting and equestrian. More than a
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iÊÓä£ÓÊ third (35%) of the injuries were expected to prevent the
Summer Olympic Games in London athlete from participating in competition or training.
UÊ/ÊV«>ÀiÊ`vviÀiÌÊ}i`iÀÃÊ>`ÊëÀÌà About 41% of the illnesses affected the respiratory sys-
tem, and the most common cause of illness was infec-
tion (46%). Women significantly suffered more illnesses
How we collected the data than men (86.0 vs. 53.3 illnesses per 1,000 athletes). The
rate of illness was highest in athletics, beach volleyball,
All National Olympic Committees (NOCs) were football, sailing, synchronised swimming and taekwon-
informed about the study four months in advance of the do. About one fifth of the illnesses incurred during the
Olympic Games, and one day before the opening of the Games were expected to result in absence from training
Games, the medical staff of the NOCs was invited for or competition.
a meeting covering the details of the study. During that
meeting, the daily injury and illness report forms as well
as an instructional booklet detailing the study protocol What we learned from the study
were distributed. Employing the IOC injury and illness
report forms for multi-sports events, the daily occur- The incidence and characteristics of injuries and illness-
rence (or non-occurrence) of injuries and illnesses was es during training and competition varied substantially
reported by the medical staff of all National Olympic between sports and gender. The continuous surveillance
Committees (NOC) and by the medical staff operating of injury and illness is a fundamental prerequisite for
in the polyclinic and medical venues. Throughout the athlete health protection, and international sports bod-
FOOTBALL MEDICINE PROJECTS | EPIDEMIOLOGY OF FOOTBALL INJURY 95
Duration: 2012
Countries: International
Cooperation: IOC and medical staff of participating countries
Reference:
Engebretsen L, Soligard T, Steffen K, Alonso JM, Aubry M,
Budgett R, Dvořák J, Jegathesan M, Meeuwisse WH, Mountjoy
M, Palmer-Green D, Vanhegan I, Renström PA (2013) Sports
injuries and illnesses during the London Summer Olympic
Games 2012. Br J Sports Med 47:407-414
96 EPIDEMIOLOGY OF FOOTBALL INJURY | FOOTBALL MEDICINE PROJECTS
Fig 2.8.9.1 Number of all and time-loss injuries during training and competition in different discipline categories (*For some injuries information on
discipline (competition or training) or time loss is missing or injury occurred apart from discipline)
3.1 Review of Literature 1. Establish the extent of the football injury problem
2. Establish the aetiology and mechanism of football
injury
What was known on prevention of injuries 3. Introduce preventive measures
4. Test the effectiveness of the preventive measures by
There are hundreds of research articles on injuries and repeating the first step
their prevention in sports. The challenge for any particu-
lar research group or physician is finding, reading, inter-
preting and finally evaluating all these papers. A review Incidence and characteristics
article summarises the numerous papers on football inju-
ries in a single paper and also provides an evidence-based Several investigators had studied the incidence, causes
evaluation of their content. This way, football medicine and risk factors of football injuries in male professional
physicians could read a single paper and get informa- players; however, epidemiological data on injuries in
tion from a large number of previously published papers female football players was still limited. From the data
without having to search, find and finally assess each reviewed, it could be estimated that, on average, every
paper with regard to its scientific value. elite male football player incurs approximately one per-
formance-limiting injury each year. The overwhelming
In our first review on the incidence of football injuries in majority of injuries were due to trauma, mostly dur-
2000, F-MARC had concluded on the inconsistency of ing matches with between one quarter and one half of
the data reported. We had also identified the problems all traumatic injuries being non-contact in nature and
where more research was urgently needed. In the follow- about one quarter of all injuries being re-injuries. Inju-
ing years, F-MARC conducted own studies in order to ries were a little more frequent in the second half as play-
close these gaps and establish further details on football ers become fatigued.
injuries, always in view of our aim to eventually devel-
op evidence-based prevention strategies. As a next step, Football injuries predominately affected the ankle, the
it was therefore required to once more assess the in the knee and the muscles of the thigh and calf. The most
meantime considerably grown body of knowledge on common injuries were sprains, strains and contusions.
injury incidence, aetiology and mechanisms, but in addi- Other important factors were contact with another play-
tion also the evidence on the possibilities and results of er and here particularly foul play.
prevention in order to move forward in the direction of
developing a F-MARC prevention programme.
Ways of preventing football injuries
Aims of the review Most prevention programmes include the following gen-
eral activities:
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iÊÌiÀ>ÌÕÀiÊÊÌ
iÊV`iViÊvÊÕÀiÃÊÊ UÊ7>ÀÊÕ«Ê>`ÊVÊ`ÜÊÜÌ
ÊëiV>Êi«
>ÃÃÊÊ
football stretching
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iÊÌiÀ>ÌÕÀiÊÊÌ
iÊV
>À>VÌiÀÃÌVÃÊ>`ÊV>ÕÃiÃÊ UÊ`iµÕ>ÌiÊÀi
>LÌ>ÌÊ>`ÊÌiÊvÀÊÀiVÛiÀÞÊvÀÊ>Ê
of injuries in football injury
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iÊVÕÀÀiÌÊÜi`}iÊÊÌ
iÊ«ÃÃLÌiÃÊvÀÊ UÊ«ÀÛiiÌÊÊwÌiÃÃÊÜÌ
ÊëiV>Êi«
>ÃÃÊÊ«À«-
preventing injuries and the effectiveness of prevention rioceptive training
programmes UÊ*ÀÌiVÌÛiÊiµÕ«iÌ
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UÊ>ÀÊ«>Þ
What did the medical literature tell us about
injuries in 2004? Other programmes add further items to this general list
such as pre-competition screening, nutrition and hydra-
F-MARC reviewed and reported on 62 papers that dis- tion, improved technique and better injury recording.
cussed injury incidence and injury prevention. Our liter-
ature review was structured in accordance with the typi-
cal methods used to prevent injuries:
F-MARC PROJECTS | PREVENTION OF FOOTBALL INJURY 99
Ekstrand 6 teams 6 teams male 17-37 yrs multi-modal intervention program Fewer injuries in the intervention than in the
et al. 1983 control group
Heidt et al.2000 42 players 258 players female 14-18 yrs Frappier Acceleration Training Program Significantly lower incidence of injury in the
trained than in the untrained group
Junge et al.2002 101 players 93 players male 14-19 yrs multi-modal intervention program Fewer injuries in the intervention than in the
control group
Tropp 60 players, 65 players 171 players male senior Use of orthosis or Ankle disk training Both techniques reduce the frequency of
et al. 1984 with previous ankle ankle sprains in players with previous ankle
problems problems
Surve 117 players 260 players male senior Instruction to wear a semi-rigid A semi-rigid orthosis significantly reduced the
et al. 1996 without and orthosis on the previously sprained ankle incidence of recurrent ankle sprains in players
127 players with or on the dominant ankle with previous history of ankle sprains
previous ankle sprains
Söderman 62 78 players female mean Balance board No preventive effect on severe knee injuries
et al. 2000 players 21 yrs training or ankle sprains
Hewett 97 players 193 players female high Preseason neuro-muscular training A trend towards a higher incidence in the
et al. 1999 school program untrained than in trained group
Askling 15 players 15 players male mean 25 Training with eccentric overload Fewer injuries in the training than in the
et al. 2003 control group
Mandelbaum et 1885 players 3818 teams female PEP programme Significant reduction of ACL injuries
al. 2005 14-18
3.2.1 “The 11” – A Prevention Programme for ing movements to toughen tissues and train nerve cells
Amateur Players to stimulate a specific pattern of muscle contraction so
the muscle generates as strong a contraction as possible
in the shortest amount of time. Sport-specific plyomet-
The need for prevention rics, agility and speed are the key for responding to the
football demands on the field.
According to our review of the literature, several preven-
tive programmes had been developed and proven effec- Three exercises aim at core stabilisation: “the bench”,
tive in reducing the incidence of football injuries. How- “sideways bench” and “cross-country skiing”. The so-
ever, none of these programmes had been implemented called “Russian” or “Nordic” hamstrings were included
in the everyday training routine of football life. To effec- to increase eccentric hamstring strength. Three exercises
tively reduce injuries on a large scale, any prevention in an “active” single leg stance with weight on the fore-
programme clearly had to address the amateur player. foot were chosen to train proprioception and balance.
Under the leadership of F-MARC, a group of interna- The centre of attention is the bent knee, bent hip and
tional experts set out to filter the essence of injury pre- straight leg alignment (“knees over toes”). Dynamic
vention out of the large body of knowledge. Our chal- stabilisation and jump technique are trained with three
lenge was to create a simple, catchy and time-efficient exercises: “jumps over a line” (forward-backward, side-
preventive programme. ways), “zigzag shuffle” and “bounding”. These exercises
include plyometric training of the leg muscles, straight
leg alignment (no “kissing knees”) and landing on the
The essentials of “The 11” forefoot with bent knees and hips.
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exercises being enhanced by education and promotion ... plus fair play
of Fair Play.
UÊ/
iÊ«À}À>iÊÃÊ`iÃ}i`ÊÌÊÀi`ÕViÊÌ
iÊÃÌÊV- However, football injury can only partly be prevented by
mon football injuries identified by F-MARC, such as improved physical condition. Knowing that a substantial
ankle sprains, hamstring and groin strains and liga- amount of injuries are caused by foul play, the regard for
ment injuries in the knee. fair play is an essential aspect in the prevention of injury.
Uʺ/
iÊ££»ÊÀiµÕÀiÃÊÊiµÕ«iÌÊÌ
iÀÊÌ
>Ê>ÊL>]ÊV>Ê
be completed in ten to 15 minutes and should be per-
formed as a matter of routine. Distribution and implementation of “The 11”
UÊ/
iÊ«À}À>iÊV>ÊLiÊ«iÀvÀi`ÊÊÌ
iÊwi`ÊÜÌ
Ê
the players wearing their usual equipment and football The F-MARC experts offered FIFA the best available
boots. knowledge and state of the art of medical science trans-
UÊ/
iÊiÝiÀVÃiÃÊV>ÊLiÊV>ÀÀi`ÊÕÌÊ>ÞÜ
iÀiÊ>ÌÊ>ÞÊÌi]Ê lated into a simple programme. It was now up to FIFA,
ideally daily and not only during training sessions or the confederations and the member associations to dis-
matchdays. seminate the messages to their players and implement
the preventive programme on a broad scale.
The ten exercises... “The 11” comes as a DVD with instructions included
as a booklet to reinforce learning. “The 11” is available
The exercises focus on core stabilisation, eccentric train- in five languages (English, French, German, Italian and
ing of hamstrings, proprioceptive training and dynamic Spanish). A poster of “The 11” and a list of frequently
stabilisation with plyometrics and straight leg align- asked questions are also available to support the DVD
ment. Core stability and strength is essential to control (Fig. 3.2.1.1).
trunk, pelvis and the lower extremity, while an optimal
neuromuscular control of the lower extremities is crucial
for joint stability. Plyometric training involves practic-
F-MARC PROJECTS | PREVENTION OF FOOTBALL INJURY 101
Essentials of the “FIFA 11+” F-MARC experts used their latest experience and best
knowledge to further improve the F-MARC prevention
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iÊ«À}À>iÊ}°ÊΰӰӰ£®ÊÃÌ>ÀÌÃÊÜÌ
Ê>Êi}
Ì programme “The 11” into a complete warm-up pro-
minute running session, with forward, backward gramme. Again, it is now up to FIFA, the confederations
and sideways jogging. The intensity of the running and the FIFA member associations to disseminate the
programme gradually increases, and can be very high. messages to their players and implement the preventive
This part of the programme will be performed in all programme on a broad scale.
training sessions and matches.
UÊ/
iÊÃiV`Ê«>ÀÌÊvÊÌ
iÊ«À}À>iÊV«ÀÃiÃÊvÊViÀ- “FIFA 11+” comes as a poster and a DVD with instruc-
tain exercises as described below. tions, included as a booklet to reinforce learning. “FIFA
UÊ/
iÊÌ
À`Ê>`Ê>ÃÌÊ«>ÀÌÊvÊÌ
iÊ«À}À>iÊVÃÃÌÃÊvÊ 11+” is available in four languages (English, French,
a two-minute intensive running session with more German and Spanish).
running, sprinting and cutting, to provide the players
with a final warm-up and preparation for the training
session. The second and third parts of the programme
are only to be performed prior to the training sessions,
not matches.
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iÊvVÕÃÊÃÊÊiiÊVÌÀÊ>`Ê
awareness, landing techniques and cutting and plant-
ing, all factors known to be important in preventing Duration: 2006 - 2008
ankle and knee injuries. Countries: Norway, USA
UÊvÌiÀÊ>ÊÃ
ÀÌÊ«iÀ`ÊvÊv>>ÀÃ>ÌÊÌ
iʺʣ£³»Ê Cooperation: Oslo Sports Trauma Research Center, Norway;
can be completed in 20 minutes, and will replace the Santa Monica Orthopaedic and Sports Medicine Group,
ordinary warm-up programmes teams typically use. Research and Education Foundation, California, USA
Reference:
Bizzini M, Junge A, Dvořák J (2011). FIFA 11+. A complete
warm-up programme to prevent injuries. Manual and DVD.
Official publication of the Fédération Internationale de Football
Association (FIFA), Zurich, Switzerland
F-MARC PROJECTS | PREVENTION OF FOOTBALL INJURY 103
FIFA 11+
PART 1 RUNNING EXERCISES · 8 MINUTES
1 STRAIGHT AHEAD
Why we conducted this study 2 CIRCLING PARTNER
3 ZIGZAG SHUFFLING
The physiological match demands of refereeing have 4 FORWARDS & BACKWARDS SPRINTS
increased over the years due to the development of mod- 5 for MA: SLALOM FORWARDS & BACKWARDS
ern football. During a high level match, a referee may for AR: ALTERNATE SHUFFLING
cover a mean distance of 11.5km (a mix of walking, run- 6 for MA: FORWARDS & BACKWARDS WITH ROTATIONS
ning, sprinting), which is comparable to the distance for AR: CARIOCAS
covered by a midfielder. Elite referees may perform up
PART 2: STRENGTH, PLYOMETRICS AND BALANCE
to 1,270 activity changes (direction changes, as an exam-
EXERCISES
ple), and take more than 130 decisions during a match.
Considering the high demands put on the cardiovascular LEVEL 1
and musculoskeletal system, officiating entails a certain 1 BENCH – ALTERNATE LEGS
risk of acute and overuse injuries. 2 SIDEWAYS BENCH – RAISE AND LOWER HIP
3 BRIDGE – ALTERNATE
F-MARC studies (See chapter 2.7) showed that the risk 4 HAMSTRINGS – BASIC
of non-contact injuries for elite male and female refer- 5 CALF – BASIC
ees is similar or lower than that of a football player. The 6 SQUAT JUMPS
career prevalence of musculoskeletal complaints (“over- 7 for MA: SINGLE-LEG STANCE - MOVE THE OTHER LEG
use”) can be estimated to be at least 90%. The most for MA: FRONT LUNGE
common injuries were hamstring strains, calf strains and 8 for AR: LATERAL LUNGE 45°
ankle sprains. Musculoskeletal complaints in the low for AR: LATERAL JUMP
back, hamstring, knee, calf and Achilles tendon were fre-
quent. The injury type and location of musculoskeletal
LEVEL 2
complaints were similar among referees at all levels of
1 BENCH – ONE LEG LIFT AND HOLD
performance and between genders.
2 SIDEWAYS BENCH – WITH LEG LIFT
3 BRIDGE – ON ONE LEG
4 HAMSTRINGS – ADVANCED
Aims of the project
5 CALF – ADVANCED
UÊ/
iÊL>ÃVÊ«ÀiÛiÌÊ«À}À>iÊvÀÊ>iÊ>`Êvi>iÊ 6 BOUNDING
referees and assistant referees aims to reduce acute 7 for MA: SINGLE-LEG HOPS
non-contact injuries and minimise musculoskeletal for AR: LATERAL LUNGE 90°
complaints throughout referees’ careers 8 for MA: SCISSORS JUMPS
for AR: DOUBLE LATERAL JUMP
World cup referees performing “FIFA 11+ for referees” running drills before the technical training session.
The “FIFA 11+ for referees” programme is available as Fig. 3.2.3.1 Two examples of exercises of the “FIFA 11+ for referees”
manual and DVD in four languages, and will be dissem- injury prevention programme.
From left to right (above): sideways bench with leg lift, the bench –
inated worldwide within the courses of the FIFA Refer- alternate legs
eeing Department (Fig. 3.2.3.2). From left to right (below): eccentric hamstring (partner exercise), and
the bridge-alternate legs
3.2.4 “FIFA 11+ Kids” orientation, anticipation, and attention particularly while
dual-tasking as it is a common challenge in football, (2)
whole body and unilateral leg stability as well as move-
Why we are conducting this study? ment coordination and (3) appropriate fall techniques.
Similar to the “FIFA 11+”, a modular approach is used
Football is the world’s most popular sport and 58% of with exercises from the three main categories and five
officially registered players are younger than 18 years. difficulty levels to be composed for a single training ses-
Playing football can induce considerable beneficial sion (warm-up). The development of the programme is
health effects, and thus has a great potential to support a a close cooperation between different international insti-
healthy lifestyle. However, football also bears the risk of tutions and experts (Dr O. Faude, R. Rößler, University
injury. It is therefore necessary to implement preventive of Basel, Switzerland; Dr M. Bizzini, F-MARC, Zurich,
measures that reduce the risk of injury and consequently Switzerland; Prof. E. Verhagen, Amsterdam, Nether-
support the health benefits associated with playing foot- lands; Prof. T. Hewett, Cincinnati, U.S.A.; Prof. J. Cho-
ball. Comprehensive epidemiological data on football miak, Prag, Czech Republic; N. Mathieu, Sion, Switzer-
injuries are currently obtained in order to develop prom- land).
ising prevention programmes.
In a second step, the developed programme will be
Several studies evaluated injury prevention programmes evaluated with regard to (a) the feasibility and accept-
Ê>`iÃViÌÊ>`Ê>`ÕÌÊ«>ÞiÀÃÊÊ£ÎÊÞi>ÀÃÊ`®°ÊÊÃÌÊ ance among young children and coaches as well as (b) to
studies, there was good evidence that injury prevention possible beneficial adaptations in movement skills and
programmes were effective. When an injury prevention physical fitness. For this purpose a two-armed cluster-
programme failed to show beneficial effects, poor com- randomised controlled trial will be conducted.
pliance was considered to be the main reason. Younger This pilot study will include 120 children between seven
players seem to have partly different injury characteris- and 12 years who play organised football in Switzerland.
tics and, thus, adapted needs in injury prevention. To Twelve teams consisting of approximately ten children
date, no study has investigated the prevention of football each will be randomly assigned to either the interven-
injuries in children under the age of 13 years. The pre- tion or the control group, respectively. Regular training
vention programme “FIFA 11+” was designed for play- should take place at least twice per week. Training and
iÀÃÊÊ£ÎÊÞi>ÀÃÊ`®Ê>`Ê
>ÃÊÃ
ÜÊÃÕLÃÌ>Ì>Ê«ÃÌÛiÊ match exposure and training contents will be recorded by
effects in reducing football injuries. The development of the coaches.
an equivalent programme for players younger than 13
years seems necessary. The intervention period will last 12 weeks (24 training
session). The injury prevention programme is included at
the beginning of the usual football training by replacing
Aims of the study the traditional warm-up. The control group will receive
the instruction to regularly perform a common warm-up
UÊ/Ê`iÛi«Ê>Ê>`>«Ìi`ÊÕÀÞÊ«ÀiÛiÌÊ«À}À>iÊ programme consisting of running and ball-based exercis-
for football players under the age of 13 es (sham treatment).
UÊ/Ê>>ÞÃiÊ>`>«Ì>ÌÃÊÊÛiiÌÊÃÃÊ>`Ê«
ÞÃ-
cal fitness as a consequence of the programme Before and after the training period various tests will be
UÊ/ÊV`ÕVÌÊ>ÊÕÌViÌÀiÊÌiÀÛiÌÊÃÌÕ`ÞÊÊÌ
iÊ conducted. Tests will be performed to assess locomotor
“FIFA11+ Kids” programme skills (e.g. balancing, running, jumping) and object con-
trol skills (e.g. controlling the ball, dribbling, passing).
How we conduct the survey In the third step, after developing the “FIFA 11+ Kids”
programme, F-MARC is currently conducting a large
In a first step, there is the need to adapt the existing pro- multi-centre intervention study in four European coun-
gramme (“FIFA 11+”) with regard to the particular char- tries: Switzerland, Germany, Czech Republic, and the
acteristics of football injuries in younger children (< 13 Netherlands.
years). The available programme was complemented with
three main categories of exercises focusing on (1) spatial
F-MARC PROJECTS | PREVENTION OF FOOTBALL INJURY 107
3.2.5 Enforcement of the Laws of the Game medical treatment. Each incident was classified accord-
ing to the cause (opponent-player contact, teammate-
player contact, ball-player contact or non-contact) and
Why we conducted this study body location involved. We also categorised the referee’s
decision (no foul, foul for, foul against) and the referee’s
The risk of injury during football matches is 1,000 times sanction (no sanction, yellow card or red card).
higher than high-risk industrial occupations. A recent The methodology of the UEFA injury system has been
study from Oslo Sports Trauma Research Center docu- implemented in Norwegian professional football, using
mented an increased incidence of acute match injuries in the time-loss definition of injury.
Norwegian professional football from 2002 to 2007. To evaluate the effect of stricter rule enforcement, a
Previous studies have found that between 44% and pre-/post-intervention design was employed. Prior to
59% of all acute match injuries at club level are caused the 2011 season video recordings of incidents and inju-
by player-to-player contact. Video analyses from FIFA ries from the 2010 season were analysed and refereeing
tournaments showed that the match referee identified guidelines were agreed upon according to FIFA regula-
47% of all injuries, and 40% of head injuries as foul tions. This involved sanctioning of two-foot tackles as
play. A study in Norwegian professional football con- well as tackles with excessive force and intentional high
cluded that most referee decisions were correct accord- elbow with an automatic red card. The plans for stricter
ing to the Laws of the Game, but that there might be rule enforcement were introduced to each team in meet-
a need for more strict interpretation of the Laws of the ings with referees appointed for the 2011 season. In addi-
Game in order to protect players from dangerous play. tion, the study group and the Head of Refereeing in the
As a consequence, The International Football Associa- Football Association of Norway held a similar meeting
tion Board gave referees the authority to severely sanc- for the media, thereafter, a press conference with a high-
tion fouls that were recognised to be injurious, such as profile player, a manager and FIFA representative were
intentional elbows to the head and brutal tackles. After organised.
this, the incidence of match injuries was significantly
lower in the 2010 FIFA World Cup™ for men com-
pared to the mean incidence found in the three previous Results
World Cups. However, the effect of rule changes and
their interpretation have neither been evaluated through A total of 2,140 incidents were identified during the
prospective injury surveillance systems nor through vid- three seasons, 419 in 2000, 868 in 2010 and 853 in
eo analysis, a key element missing in the current sport 2011. The corresponding overall rate of incidents was
injury prevention research portfolio. 74.4 per 1,000 player-match hours of exposure (95%
CI: 67.3 to 81.5) in the 2000 season and 109.6 (95%
CI: 102.3 to 116.9) in the 2010 season, an increase from
Aims of the study 2000 to 2010 (rate ratio: 1.47, 95% CI: 1.31 to 1.66).
We observed a higher rate of opponent-to-player contact
UÊ
«>ÀiÊÌ
iÊÀ>ÌiÊvÊV`iÌÃÊÜÌ
Ê>Ê«À«iÃÌÞÊvÀÊ and non-contact incidents in the 2010 season. We found
injuries between the seasons 2000 and 2010 no change in the awarding of yellow or red cards between
UÊ/Ê>ÃÃiÃÃÊÜ
iÌ
iÀÊ>ÊÃÌÀVÌiÀÊÌiÀ«ÀiÌ>ÌÊvÊÌ
iÊ>ÜÃÊ the two seasons.
of the Game could reduce the potential for injuries in
Norwegian male professional football The rate of contact incidents was 92.7 (95% CI: 86.0 to
99.4) in the 2010 season. After the introduction of strict-
er rule enforcement, the incident rate was 86.6 (95% CI:
How we collected data 80.3 to 99.4) in the 2011 season, showing no difference
between the 2010 and 2011 seasons. We found, howev-
We collected videotapes of league matches and injury er, a reduction in the incidence of head incidents (rate
information prospectively during the 2000, 2010 and ratio (RR): 0.81, 95% CI: 0.67 to 0.99), and head inci-
2011 season. dents caused by arm-to-head contact (RR: 0.72, 95% CI:
An incident was said to occur if the match was inter- 0.54 to 0.97). We found no difference in tackling charac-
rupted by the referee, the player stayed down for more teristics or injury rate caused by player-to-player contact.
than 15 seconds, and appeared to be in pain or received
F-MARC PROJECTS | PREVENTION OF FOOTBALL INJURY 109
UÊ
Û>Õ>ÌiÊÌ
iÊivviVÌÊvÊÌ
iÊ«À}À>iÊÊ>Ê«ÀëiVÌÛiÊ 8
6.78 6.95
study 6.35
6
4
How we collected the data
2
20 18.7
physician or physiotherapist taking care of the players. 17.7
Seven teams took part in an intervention programme 15
13.1
that stressed education and supervision of coaches and
10
players (intervention group), while seven control teams
were instructed to train and play football as usual (con- 5
trol group). Complete weekly follow-ups were available
in 101 players of the intervention group and 93 players 0
Dieter Rösch with some members of the prevention group Dieter Rösch with a youth football player
The rates of overuse injuries and training injuries were and training injuries, while unaffected in the high-level
unchanged in the high-level teams, however, the inci- teams, were reduced by over 50% in the low-level teams.
dence of similar injuries in low-level was 54% lower For the development and implementation of prevention
than in the control teams (Tab. 3.3.1.1). programmes, the initial situation of the players and their
environmental risks should be considered, such as qual-
There were 44% fewer injuries and 21% fewer play- ity of pitches and equipment. Furthermore, an impor-
ers suffering an injury for an overall 21% lower injury tant aspect in the prevention of football injury concerns
rate in the intervention group. Non-contact injuries are the observance of the Laws of the Game and especially
of particular interest as many feel these are the injuries the spirit of Fair Play. A broader view and the inclusion
most likely to be reduced by a prevention programme. of other target groups (such as referees, parents, official
In this project, the rate of non-contact injuries was representatives and others) will lead us all to a healthier,
reduced by nearly 20% in the high level teams and safer game.
almost 40% in the lower level teams. Of particular inter-
est was the substantial reduction in mild injuries in both
groups. The most frequent football injuries are minor, so
reducing the mildest of injuries will also have a consider-
able impact on the average injury severity.
Prevent injury and enhance performance program PEP Trained Control % difference*
3. Strengthening
- Walking lunges 20 yd 2 passes
What we learned from the study
- Russian hamstring NA 30 s
- Single-toe raises NA 30, bilaterally It is well known that young females are at risk for non-
4. Plyometrics contact ACL injuries and any prevention programme
- Lateral hops 2- to 6-in cone 30 s must be directed at young girls, but should also be used
- Forward hops 2- to 6-in cone 30 s for males to reduce the overall rate of ACL injuries.
- Single-legged hops 2- to 6-in cone 30 s
- Vertical jumps NA 30 s
- Scissors jumps NA 30 s The 80% reduction in ACL injuries as a result of the
PEP programme clearly showed that a preventive training
5. Agilities
- Shuttle run 40 yd 1 programme may well decrease the number and incidence
- Diagonal run 40 yd 1 of ACL injuries in female athletes. This work, along with
- Bounding run 45-50 yd 1 a number of other prevention studies, suggested that this
Tab. 3.3.2.1 The training programme serious injury in females can be dramatically reduced
with a specific prevention programme that stresses neu-
romuscular control of the lower extremity through the
Results use of strengthening exercises, plyometrics, and sports-
specific agilities. The proprioceptive and biomechanical
Over the full two year period there were a total of six deficits that programmes like this are designed to correct
ACL injuries in the PEP trained group and a total of 67 further demonstrate the high-risk present in the female
ACL injuries in the control group. During the 2000 sea- player population. This project was encouraging and
son, there was an 88% decrease in anterior cruciate liga- supported the further study of prevention programmes
ment injury and in 2001, there was a 74% reduction in to decrease ACL injuries in this high-risk population.
anterior cruciate ligament tears in the intervention group
Duration: 2003 - 2005
compared to the age- and skill-matched controls. The
Country: USA
data were analysed according to athlete exposures, by
Cooperation: Santa Monica Orthopedic and Sports Medicine
team and by player.
Group Research and Education Foundation, California, USA
References:
No matter how the data was analysed, the reduction
Mandelbaum BR, Silvers HJ, Watanabe DS, Knarr JF,
in ACL injuries as demonstrated was always significant
Thomas SD, Griffin LY, Kirkendall DT, Garrett W Jr (2005).
(Tab. 3.3.2.2). Overall, there was an 80% reduction in
Effectiveness of a neuromuscular and proprioceptive training
ACL injuries as a result of the PEP training programme.
programme in preventing anterior cruciate ligament injuries in
Simply stated, the programme was successful in reducing
female athletes: two-year follow-up. Am J Sports Med 33: 1003-
ACL injuries.
1010
Gilchrist J, Mandelbaum BR, Melancon H, Ryan GW, Silvers
HJ, Griffin LY, Watanabe DS, Dick RW, Dvořák J (2008).
A randomized controlled trial to prevent non-contact anterior
cruciate ligament injury in female collegiate soccer players. Am J
Sports Med 36(8): 1476-1483
114 PREVENTION OF FOOTBALL INJURY | F-MARC PROJECTS
3.3.3 Prevention of Injuries in Female of the “FIFA 11+” programme. The “FIFA 11+” includ-
Adolescent Amateur Players ed key exercises from “The 11”, but was expanded with
additional exercises to provide variation and progression.
It also included a new set of structured running exercises
Why we conducted this study that made it better suited as a complete warm-up pro-
gramme (see box). We asked them to replace their usual
F-MARC studies as well as the literature had repeatedly warm-up with the complete exercise programme for
reported injury rates in female football players similar every training session throughout the season, and to use
to that of their male counterparts. In spite of the urgent the running exercises of the programme as part of their
need for preventive programmes, there existed only a warm-up prior to every match. We asked the coaches of
few scientifically valid studies on injury prevention in the clubs in the control group to warm up as usual.
female football players. In the study described on the
“FIFA 11+” - a complete warm-up programme
previous pages, we had examined the effect of the struc-
tured prevention programme “The 11” over one season The programme consists of three parts:
The first part is running exercises at slow speed combined with active
among 2,000 female players aged 13 to 17 years. We
stretching and controlled partner contacts.
had observed no difference in the injury risk between the
intervention group and control group. However, these The second part consists of six different sets of exercises, these included
strength, balance and jumping exercises, each with three levels of dif-
results were hard to assess due to the low compliance of
ficulty,
the teams. Low compliance is considered an important
limitation of injury prevention programmes. The third part is speed running combined with planting and cutting move-
ments.
This prompted F-MARC to convene an expert group All parts of the “FIFA 11+” constitute a complete warm-up programme
to further develop the exercise programme in order to and are to be performed prior to every training session. The running
exercises of the programme are to be performed as part of the warm-up
improve both the preventive effect of the programme
prior to matches. Once players are familiar with the programme, it takes
and the compliance of coaches and players. We decided about 20 minutes to complete.
to not only offer variation and progression for the origi-
nal “The 11” exercises, but also to include components An injury was defined as any injury during training or
of the PEP programme which had proven successful in match causing the player to be unable to fully take part
preventing injuries to the anterior cruciate ligament of in the next training or match. In both groups, the coach-
the knee in female players. Further, running exercises es reported injuries and participation of individual play-
were to be incorporated, too. The aim was to design the ers for each training session and match on weekly regis-
new programme “FIFA 11+” as a complete warm-up tration forms. “FIFA 11+” coaches also recorded to what
programme prior to training, thereby facilitating the reg- extent the warm-up programme was carried out at each
ular performance within existing training schemes. session throughout the study period. Further, specifically
trained injury recorders called every injured player to
. assess aspects of her injury based on a standardised injury
Aim of the study questionnaire. Injury type, location and severity were
recorded.
UÊ
Ý>iÊÌ
iÊivviVÌÊvʺʣ£³»]Ê>ÊV«iÌiÊÜ>À
up programme designed to reduce the risk of injuries
in female youth football Results
of match injuries, training injuries, lower extremities ing, cutting, jumping and landing is meant to develop
injuries, knee injuries and acute injuries was reduced by less vulnerable movement patterns (Fig. 3.3.3.1) and
26 to 38%. players should be encouraged to land with increased hip
and knee flexion, and to land on two legs rather than
The “FIFA 11+” teams used the prevention programme one.
in 77% of all their sessions. The more a team used the
programme in their training sessions, the more the risk
of injury was reduced.
Training injuries 50 63
Acute injuries 112 130 Exercise: single-leg balance, throwing ball with partner
Severe injuries 45 72
3.3.4 Importance of Compliance with knee alignment, as well as in landing from jumps. The
Preventive Programmes coaches were asked to use the programme at every train-
ing session for 15 consecutive sessions and thereafter
once a week during the rest of the season. They were
Why we conducted these studies contacted by telephone and/or e-mail at least once a
month to record all training and match activities and
Female players have injury rates similar to male play- new injuries for their team. Injured players were inter-
ers and most often suffer injuries to the knee, ankle and viewed by specially trained injury recorders to assess
thigh, too. As described in our previous study, female aspects of their injury based on a standardised injury
players may even be at greater risk of serious injury than questionnaire.
males as the rate of anterior cruciate ligament injuries
is considerably higher. However, only a few studies on To assess the importance of compliance with the injury
injury prevention in female football players had investi- prevention programme further, we also investigated the
gated the effect of structured prevention programmes in teams and coaches of the intervention group participat-
a prospective way. ing in the study on “FIFA 11+” described in the follow-
ing chapter. Attitudes and beliefs of 65 coaches towards
F-MARC’s “The 11” and later “FIFA 11+” had been exercise-based prevention were assessed as well as the
developed as football-specific prevention programmes individual participation of players in training and match
mainly aimed at common injuries of the lower extremi- play (meaning exposure to the game of football, in min-
ties on the basis of previous F-MARC research. We utes) and the exact performance of the warm-up at every
intended to test the actual effect of these programmes session, again including individual player participation.
in female football players following them during one
football season. The results of this first study on “The
11” made it clear that we needed to have a closer look at Results
compliance with the advanced “FIFA 11+” programme
and the influence thereof on injury frequency, too. In “The 11” study, 58 teams (1,073 players) in the inter-
vention group and 54 teams (947 players) in the con-
trol group were followed during the season lasting eight
Aims of the studies months. Every fifth player of the total of 2,020 players
sustained at least one injury. No difference was observed
UÊÛiÃÌ}>ÌiÊÌ
iÊivviVÌÊvʼ¼Ì
iÊ££½½ÊÊÕÀÞÊÀÃÊÊ in the proportion of injured players between the inter-
female youth football players vention group with 19.0% and the control group with
UÊiÌiÀiÊÌ
iÊ«>VÌÊvÊÌ
iÊ`i}ÀiiÊvÊV«>ViÊ 20.3%. By far the most injuries were acute (87%) and
with “The 11” and “FIFA 11+” on the injury prevent- to the lower extremities (86%). An ankle sprain was
ing effect of the programmes the most common type of injury. In 42%, the injury
occurred in a non-contact playing situation, while 58%
of all acute injuries resulted from player-to-player con-
How we collected the data tact (Table 3.3.4.1).
All teams in south-east Norway registered in the Compliance with the programme was defined as at least
under-17 league system during the 2005 season were 20 prevention training sessions during the season. Dur-
invited to take part in the first study on “The 11”. Of ing the whole observation period, “The 11” teams used
157 teams, 113 teams with a total of 2,100 players the prevention programme at 52% of their training ses-
agreed to participate. The prevention programme was sions. During the first half of the season from March
introduced to the teams in the intervention group at the through June, the programme was used in 14 (60%) of
beginning of the pre-season, with guidance and surveil- all training sessions, and after the summer break in 9
lance by instructors who were each responsible for two (44%).
to three teams. The main focus was on performing the
exercises properly. The players were encouraged to con- Fifty-two of the initial 65 teams and 56 coaches com-
centrate on the quality of their movements, and empha- pleted the “FIFA 11+” compliance study. Teams per-
sis was placed on core stability, hip control and proper formed the “FIFA 11+” in 77% of their football sessions
F-MARC PROJECTS | PREVENTION OF FOOTBALL INJURY 117
during the season and 60% of these did so twice or even tion of players and coaches to perform the programme
more often. Compliance was higher during the first part and put these findings into practice when developing the
of the season. Based on this team compliance, individ- “FIFA 11+”.
ual player compliance was calculated to be 47% of the
maximum programme sessions of teams. No influence of Our second study confirms the correctness of this inter-
team compliance on injury risk was found, but players in pretation since compliance with “FIFA 11+” was mark-
the highest compliance tertile showed a 35% lower risk edly higher. This study also confirmed the lower injury
of injury in general (39% for acute injuries) than those risk for players with high compliance, but it was shown
in the intermediate tertile. All coaches believed that that individual instead of team compliance has to be
injury prevention is important and 88% perceived their assessed. Further important findings were the influence
players to be at either high or moderate risk for injury. of coaches’ attitudes on player compliance and of coa-
Low compliance by teams was associated with coaches’ ches’ experience with preventive approaches on the suc-
belief that the programme was too time consuming or cess of an injury prevention programme.
did not include enough football-specific activities.
Training injuries 42 59
Tab. 3.3.4.1 Injury incidence in “The 11” intervention group and the
control group
FIFA 11+ coaching courses in USA (Abb 1 and 2: Phoenix, Arizona) and Japan (Abb 3-5 Nagoya)
1 2
3 4
Duration: 2011
5 Country: Canada
Cooperation: Sport Injury Prevention Research Centre,
University of Calgary, Canada; Department of Sports Medicine,
Oslo Sports Trauma Research Center, Norwegian School of
Sport Sciences, Oslo, Norway; Centre for Healthy and Safe
Sport & the Australian Centre for Research into Sports Injury
and its Prevention, University of Ballarat, Victoria, Australia
Reference:
Steffen K, Meeuwisse WH, Romiti M, Kang J, McKay C,
Bizzini M, Dvořák J, Finch CF, Myklebust G, Emery CA
A group of Canadian football coaches participating at the first FIFA (2013). Evaluation of how different implementation strategies
11+ instructor course in Calgary, with the study coordinators of an injury prevention program FIFA 11+ impact team adher-
Maria Romiti and Kathrin Steffen, University of Calgary (standing,
respectively 1st and 3rd from right) and Dr. Mario Bizzini, F-MARC ence and injury risk in Canadian female youth football players.
(first row, 2nd from left) Br J Sports Med 47(8):480-487
120 PREVENTION OF FOOTBALL INJURY | F-MARC PROJECTS
3.3.6 Benefits of High Adherence with regard players regardless of how the “FIFA 11+” programme
to Performance and Injury Risk was delivered to the team. However, better functional
balance and 72% reduced injury risk was found for play-
ers who highly adhered to the prescribed exercises during
Why we conducted this study the season compared to those with less adherence.
The German National Team, winner of the 2014 FIFA World Cup, and official FIFA 11+ representatives
The Japan National team, winner of the 2011 Women’s World Cup, and official FIFA 11+ representatives
The Spain National Team, winner of the 2010 FIFA World Cup, and official FIFA 11+ representatives
122 PREVENTION OF FOOTBALL INJURY | F-MARC PROJECTS
3.3.7 Physiological and Performance Effects vertical jump height, stiffness, isometric maximal volun-
of “FIFA 11+” tary contraction, rate of force development, star excur-
sion balance test, oxygen uptake, lactate and core tem-
perature.
Why we conducted these studies
Eighty-one (n=81) players were randomly assigned to
The “FIFA 11+” is a complete warm-up package, which the intervention (n=42; age 23.7±3.7 years) or the con-
combines cardiovascular activation and preventive neu- trol group (n=39; age 23.2±3.8 years). The interven-
romuscular exercises. It has been developed to be admin- tion group performed the “FIFA 11+” programme three
istered as a warm-up routine. A good warm-up should times a week for nine weeks; the control group complet-
improve the subsequent performance but should also ed the usual warm-up. The outcome variables measured
not be so demanding as to cause detrimental effects before and after the training period were: time-to-stabi-
due to fatigue-related factors. However, no studies have lisation and eccentric/concentric flexors strength, eccen-
examined the immediate effects of the “FIFA 11+” on tric/concentric extensors strength, balance test, core-sta-
performance and warm-up criteria. The key element of bility, vertical jump height, sprint speed, and agility.
the programme is the promotion of proper neuromus-
cular control during all exercises ensuring correct pos-
ture and body control. Although the main purpose of Results
the “FIFA 11+” is injury prevention, the knowledge of
training effects elicited by this programme can help in Immediately after performing the “FIFA 11+”, the play-
identifying the potential mechanisms behind the report- ers increased their ability to sprint, jump, change direc-
ed reduction in injury incidence as well. Furthermore, it tions, and balance. This was probably related to physi-
might increase the consequent implementation of and ological mechanisms such as increase in baseline oxygen
compliance with the programme, if it has additional uptake (+14%) and core temperature (+1%).
performance benefits other than injury prevention. The
few previous studies, which examined the effects of the Players performing the “FIFA 11+” for nine weeks sig-
“FIFA 11+” on performance and neuromuscular control, nificantly improved in their ability to stabilise the body
had small sample size and/or were not very well con- after landing on one leg from a jump, core stability, and
trolled. leg strength (Fig. 3.3.7.1; Fig. 3.3.7.2).
Fig. 3.3.7.1. Difference after training between the players completing Fig. 3.3.7.2 Difference after training between the players completing
the “FIFA 11+” and the control group (abbreviations: ECC PF, eccen- the “FIFA 11+” and the control group.
tric strength peak force; CONC PF, concentric strength peak force).
Duration: 2012
Country: USA
Tab. 3.3.8.1 Control versus intervention: injury rates and days lost to Cooperation: Santa Monica Sports Medicine Foundation,
injury Santa Monica, CA, USA, University of Delaware, Dept. of
Biomechanical and Movement Sciences and Biostatistics Core
Facility, College of Health Sciences, Newark, DE, USA
Reference:
Silvers H, Mandelbaum B, Adenij O, Insler S, Bizzini M, Pohlig
R, Junge A, Dvořák J. The efficacy of the FIFA 11+ injury pre-
vention program in the collegiate male soccer player (submitted)
126 PREVENTION OF FOOTBALL INJURY | F-MARC PROJECTS
3.4.2 Country-wide Campaign to Prevent Oceania Player of the Century) to further ensure media
Football Injuries in New Zealand coverage.
UÊ/ ÀÕ} Ê>ÊvÀiiÊ« iÊÕLiÀÊ«>`ÊvÀÊLÞÊ
®Ê
The launch of “The 11“ for the public to call to obtain a copy of “The 11”
resources
To generate interest and inform the football commu- UÊ/
ÀÕ}
Ê iÜÊ<i>>`ÊÌL>]ÊÌ
iÊÃiÛiÊi`iÀ>ÌÃÊ
nity on “The 11”, an official launch of “The 11” was of Football in New Zealand and NZS affiliated foot-
scheduled for 1 March 2005 at North Harbour Stadium, ball clubs nationwide
Auckland, with Professor Jiří Dvořák, FIFA Chief Medi- UÊ/
ÀÕ}
ÊÌ
iÊ iÜÊ<i>>`Ê-iV`>ÀÞÊ-V
Ê-«ÀÌÃÊ
cal Officer and chairman of F-MARC, present. Having Council (NZSSSC). Every school in New Zealand
FIFA representation present in New Zealand to launch has a sports coordinator and NZSSSC had agreed to
“The 11” was intended to create positive media interest distribute “The 11” via the sports coordinators to all
and to encourage more people to use “The 11”. It was schools where football is played.
proposed that the Minister for Sport, the Honourable
Trevor Mallard, be invited to attend the launch as well This distribution system was meant to ensure optimal
as some football personalities (e.g. Wynton Rufer, FIFA coverage of “The 11” in New Zealand.
F-MARC PROJECTS | PREVENTION OF FOOTBALL INJURY 129
Also identified were target coaches as well as players. The evaluation of success
Coaches have a significant influence on the training and
playing technique of players and their involvement is an Evaluation occurred in three ways:
indispensable part of the implementation of any preven- UÊÊV«>ÀÃÊvÊ
ÊiÜÊvÌL>ÊiÌÌiiÌÊV>ÃÊ
tion programme. A goal was to train as many registered data. In 2003, there were over 1,200 moderate to seri-
coaches as possible in the delivery of “The 11”, but at ous claims and 13,000 minor claims. Claims relating
the same time it was recognised that “The 11” can be specifically to knee and ankle soft tissue injuries were
used without formal training and that printed and video monitored.
resources had been developed with simplicity in mind. UÊÊÌL>Ê-ÕÀÛi>ViÊ-ÌÕ`ÞÊÛÛi`ÊÌii«
iÊÌiÀ-
This option for independent self-education was particu- views with each of over 500 players on a weekly basis
larly important as reportedly only 26% of New Zealand throughout the 2005 football season.
adult football players are coached. Training in “The 11” UÊÊÀi}Õ>ÀÊÃÕÀÛiÞÊÌ
>ÌÊi>ÃÕÀi`ÊvÌL>Ê«>ÞiÀýÊÜ-
was performed by the NZS Senior Physiotherapist and edge, attitude and behaviour towards injury.
directed at NZS Technical Department personnel and
the National Development Officers who are responsible
for “up-skilling” coaches at all levels of the game. Refer-
ence to and/or training in “The 11” became part of eve-
ry NZS Coaching and Education Scheme course.
FIFA started the dissemination of “FIFA 11+” in its In the next years FIFA and F-MARC will continue the
209 member associations (MAs) in 2009. Related mate- worldwide implementation of the “FIFA 11+”, with par-
rial includes a detailed manual, an instructional DVD, a ticular attention on seeking the best possible cooperation
poster, a website and a promotional booklet with DVD. with the member associations adopting the “FIFA 11+”
All material is available in several languages on www.F- injury prevention programme.
MARC.com/11plus. Based on the experience with the
countrywide implementation in Switzerland and New
Zealand, a guideline on how to implement the “FIFA
11+” injury prevention programme on a larger scale in
amateur football was developed. The implementation is
conducted either in close cooperation with MAs or via
FIFA Coaching Instructor courses.
4.1.1 PCMA at the 2006 FIFA World Cup™ prior the event, the requirements for the performance of
the assessment were explained to all team doctors. Pri-
or to assessment of the data, all player and team details
Why we conducted this study were anonymised by allocating fictional team and player
names. In order to retrospectively analyse the paper-
Pre-competition medical assessments (PCMA) in sports based data and explore possibilities to improve the ques-
at different levels are generally advocated by health pro- tionnaire by using an electronic format, F-MARC asked
fessionals and sports organisations alike. Still, to date, the Cerner Corporation, USA, to convert the paper form
there is not one specific approach to the PCMA or to into an electronic one and establish an electronic data-
establish best practices for risk factor determination base suitable for statistical analysis. Apart from refusal or
prior to participation in sports. In general, a standard- non-submission of consent by the player, no exclusion
ised, validated PCMA that meets medical standards for criteria were defined for the analysis of data. The criteria
quality and provides sensitive screening is highly desir- of analysis were as follows: Completeness of question-
able. It seems, however, that the pre-competition medi- naire, quality of information, positive findings on the
cal assessment of athletes should be tailored to the type pre-competition medical assessment form. The cardiac
and scope of activity in the respective sport, gender, age assessment results were reviewed by two independent
and the level of performance. A particular concern is the sports cardiologists.
prevention of Sudden Cardiac Death, a tragic event that
might be triggered by exercise in case of an underlying
heart disease in a player (See chapter 4.2). F-MARC Results
decided to develop a standardised PCMA specifically for
the world’s elite football players prior to the 2006 FIFA Of all 32 teams participating in the 2006 FIFA World
World Cup Germany™ as a pilot project. Cup™, the completed questionnaires of 26 teams cor-
responding to a response rate of 81% were returned by
their team doctors and entered into the database. In
Aims of the study total, the assessments of 582 players could be analysed as
the forms of 16 players of four teams were no submitted.
UÊ
Ài>ÌiÊ>ÊÀiÊ`iÊvÀÊÌ
iÊ«ÀiV«iÌÌÊi`V>Ê The average age of the players that took part in the 2006
assessment of international elite football players aimed FIFA World Cup™ was 26.8 years. The average degree
at maximum certainty to identify cardiac risk factors of completeness of the whole PCMA among the differ-
UÊÃÃiÃÃÊÌ
iÊvi>ÃLÌÞÊvÊÃÌ>`>À`Ãi`ÊÀiµÕÀiiÌÃÊvÀÊ ent teams ranged from 78% to 94%. Average complete-
international teams from countries with variable medi- ness of the different sections of the PCMA was by far the
cal backgrounds highest for the medical history and the general examina-
UÊ
iVÌÊ`>Ì>ÊÊÀÃÊv>VÌÀÃÊvÀÊÀiÌÀëiVÌÛiÊ>>ÞÃÃÊÊ tion, indicating that the team doctor were well aware of
this target group the vital importance of these parts of the PCMA (Tab.
4.1.1.1)
How we collected the data Some deficits regarding the quality of the completion of
the form were identified indicating the need for more
The design and development of the PCMA form was detailed instruction and further improvement of the
focused on the cardiovascular and the musculoskel- design of the form and for the provision of norm values.
etal system. It included a 12-lead resting electrocardio- Free text entries were whenever possible to be avoided.
gramme (ECG), a maximal exercise test and an echocar- In the summarising assessment of the PCMA, all play-
diography. The assessment of the musculoskeletal system ers were considered eligible for competitive football. The
was based on the F-MARC Football Medicine Manual. team doctors reported suspected heart disease in three
Finally, the examining physician had to conclude on the players, one of them a player with known hypertrophic
eligibility of the player for competitive football. cardiomyopathy. Six of the 582 players participating in
the 2006 FIFA World Cup™ retrospectively had find-
The performance of the FIFA PCMA was requested for ings on echocardiography suspicious of serious cardio-
all players participating in the 2006 FIFA World Cup vascular disease demanding further investigation.
Germany™. At the FIFA team workshop three months
F-MARC PROJECTS | PREVENTION OF SUDDEN CARDIAC DEATH 133
Duration: 2009
Countries: International
Cooperation: All team physicians of the 8th CAF U-17
Championship; Pieter D’Hooghe, MD, Belgium; Winne
Meeuwisse, MD, Canada
Reference:
Schmied C, Zerguini Y, Junge A, Tscholl P, Pellicia A, Mayosi
B, Dvořák J (2009). Cardiac findings in the precompetition
medical assessment of football players participating in the 2009
African Under-17 Championships in Algeria. Br J Sports Med
43(9): 716-721
136 PREVENTION OF SUDDEN CARDIAC DEATH | F-MARC PROJECTS
All participating teams of the 2010 FIFA U-17 and All players were declared eligible to play.
U-20 Women’s World Cups received a circular highly
recommending the performance of the F-MARC stand-
ardised PCMA in all their players prior to the competi- What we learnt from the studies
tion. At that time, there was not regulatory base to make
the PCMA a requirement for participation, therefore the The acceptance of performing the PCMA in female
performance remained voluntary. FIFA did not provide youth players among FIFA member associations was
funding for the examinations but at the U-20 World remarkably high, and the quality of data submitted par-
Cup offered to perform the echocardiography at the ticularly from African, Asian, Central and South Ameri-
competition venues at no cost for the teams. Submission can teams exceptionally good. We observed that the
of the forms to F-MARC was also voluntary and not quality increased when the team doctor was in control
specifically requested. Teams were only asked to confirm of and coordinated all examinations, and completed the
if they had performed a PCMA in their players. forms.
The F-MARC PCMA form was slightly amended with An important lesson learnt was the refusal of the major-
questions on the menstrual cycle and measurements of ity of teams to perform examinations at the venues
calcium and ferritin to assess specific female aspects. prior to the competition since they considered this to
F-MARC PROJECTS | PREVENTION OF SUDDEN CARDIAC DEATH 137
4.1.4 PCMA of Referees and Assistant The 51 referees and assistant referees selected for the
Referees FIFA Women’s World Cup 2011™ were examined just
prior to the event at the location by a team of F-MARC
experts including a female cardiologist. The screening
Why we conducted these studies was performed in collaboration with local clinics. The
female referees did not undergo exercise testing as they
FIFA and F-MARC had been pioneers in performing tended to be younger than their male counterparts and
pre-competition medical assessment (PCMA) of players did not exhibit cardiac risk factors.
and developed a standardised PCMA which they tested
at different levels as described in the previous chapters.
There was a considerable body of knowledge in the lit- Results
erature on the different approaches to PCMA in young
athletes and players. In football, the referee at a match The male referees had an average age of 39 years, the
covers distances of comparable length and speed as the female referees of 33 years.
player he or she supervises. Different from the players,
however, referees are usually considerably older. With One male referee had diabetes and one referee had
increasing age, risk factors and causes of sudden cardiac hypertension, both well controlled under treatment.
(SCD) tend to change. Above 35 years of age, coronary Approximately 40% of the referees reported a history of
heart disease becomes the most frequent cause of SCD cardiovascular disease. About one third of the male ref-
in athletes. In view of their age-related risk and the phys- erees showed an abnormal finding on cardiac examina-
ical load on referees during matches and training, it did tion such as murmurs on auscultation, suspicious ECG
seem highly indicated to screen the world’s best referees changes or mild valve disturbances, however none of
in a similar way to players prior to the two highest level these was shown to be of clinical relevance in the follow-
international football events for men and women. up investigations. All referees demonstrated excellent
physical fitness. Almost all referees showed some patho-
logical finding in the orthopaedic examination, mainly a
Aims of the studies laxity of the ankle or knee joints, but there was also lim-
ited range of motion of the hip or local tenderness over
UÊ-VÀiiÊ>ÊÀiviÀiiÃÊÃiiVÌi`ÊvÀÊÌ
iÊÓä£äÊÊ7À`Ê the Achilles tendon and groin.
Cup™ using the F-MARC standardised PCMA
UÊ-VÀiiÊ>ÊÀiviÀiiÃÊÃiiVÌi`ÊvÀÊÌ
iÊÊ7i½ÃÊ Among the female referees, four reported a family his-
World Cup 2011™ using the F-MARC standardised tory of SCD. However, none of these referees had any
PCMA pathological findings on examinations. In the personal
medical history, the most commonly reported finding
was an allergy. None of the referees had any symptoms
How we collected the data at rest or when exercising. There were no pathological
findings with regard to blood pressure measurements
All 90 referees and assistant referees selected for the 2010 and only mild functional heart murmurs on ausculta-
FIFA World Cup™ underwent the standard PCMA tion. All referees were completely asymptomatic and
examination including medical history, physical exami- showed no abnormal findings in the resting ECG or
nation, blood parameters, resting ECG and echocardiog- echocardiography with the exception of one referee with
raphy by a team of F-MARC experts three months prior a change in one aspect of her ECG curve, which was rec-
to the competition. All examinations were performed at ommended for regular follow-up.
the FIFA Medical Centre of Excellence in Zurich on the
occasion of a workshop for the referees at the Home of
FIFA. Considering the higher age of the referees as com- What we learnt from the studies
pared to players, and the consequently higher probabil-
ity of asymptomatic coronary artery disease, all referees None of the female and male referees screened prior to
underwent a self-limited exercise ECG in addition to the the FIFA World CupsTM showed any relevant pathologi-
standard examinations of the FIFA PCMA. cal findings upon screening with the F-MARC standard-
ised PCMA. Both approaches to the performance of the
F-MARC PROJECTS | PREVENTION OF SUDDEN CARDIAC DEATH 139
Dr. D.Keller performing an echocardiography examination on a World Cup referee. (additionally, from left to right: Dr. C. Schmied, Dr. M.Bizzini
and Prof. J. #UNŪ¨J)
4.2.1 Statement on Sudden Cardiac Death mary cause is hypertrophic cardiomyopathy (HCM), an
inherent disease of the heart muscle. Above the age of 35
years, the primary cause is coronary artery disease.
Why we held the meeting HCM as the most common cause of SCD in young ath-
letes is characterised by hypertrophy of, essentially, the
On the one hand, regular physical exercise helps to pre- left ventricle of the heart. One to two percent of those
vent and treat cardiovascular disease, but on the other suffering from HCM die per year, mostly due to ven-
hand sports can serve as a trigger for Sudden Cardiac tricular rhythm disturbances. If there are any symptoms,
Death (SCD). Participation in competitive sports in they are predominantly chest pain, dyspnea, rhythm dis-
particular increases the likelihood of SCD. The vast turbances and fatigue. A resting electrocardiogramme
majority of non-traumatic deaths in sports is caused by (ECG) is important as a screening method because the
SCD that occurs up to 90% under the eyes of the public overwhelming number of patients with HCM will show
during training or competition. The international foot- an abnormality. However, definite diagnosis of HCM is
ball community had to witness such tragedy when Marc made with echocardiography.
Vivien-Foé died on the pitch during the FIFA Confed-
erations Cup 2003.
Screening programmes
Any such event, particularly in a young athlete, is not
only a tragic event considerably affecting their personal In American athletes, the primary cause of death was
entourage, but also the public in general as well as the found to be HCM in 36% of the athletes. The usual
sporting world and sports medical community. There- pre-participation examination in the US includes history
fore, screening of athletes to identify risk factors for taking and physical examination. This assessment had
SCD is a concern for all sports organisations. In Decem- identified only three percent of athletes with suspected
ber 2005, the International Olympic Committee (IOC) abnormalities, indicating that history taking and physi-
convened an international meeting to in detail address cal examination was ineffective in identifying athletes
the problem of SCD in young athletes. with underlying cardiovascular disease.
Have you ever had chest tightness, cough, or wheezing which made
it difficult for you to perform in sports?
Do you have or have you ever had racing of your heart or skipped
heartbeats?
Do you get tired more quickly than your friends do during exercise?
Have you ever been told you have a heart murmur, a heart arrhyth-
mia, rheumatic fever?
Has anyone in your family under the age of 50 years old died sud-
denly and unexpectedly?
Has anyone in your family been treated for recurrent fainting?
The son of Marc Vivien Foé (who died on the pitch in 2003) speaks at
Has anyone in your family suffered unexplained drowning while the FIFA Confederations Cup 2009
swimming?
Has anyone in your family had an unexplained car accident?
4.2.2 Practical Management of Sudden portable, automatic external defibrillator (AED) within
Cardiac Arrest on the Field of Play 1-2 minutes has a success rate of 90% for resuscitation
by converting the heart rhythm back to normal. The
probability of success for any attempt to defibrillate the
Why we conducted these reviews player thereafter steeply declines with the time elapsed
(about 10% per minute), and, at the same time, the
Time and again, the football family is deeply stirred by probability of permanent brain damage increases. Man-
reports of apparently healthy players dying on the pitch, ual chest compressions may help to maintain minimal
or even the live broadcasting of such tragic events. Due blood flow to the brain, but do not suffice to keep the
to the popularity of the game and its broad media cov- victim alive.
erage, a series of cases involving popular players has
achieved sad publicity over recent years, creating a per- In football, there are several reasons leading to a delay of
ception in the media and the public that these events treatment in incidents of SCA. The Laws of the Game
occur particularly often in football. Sudden Cardiac are such that medical staff is only allowed to run onto
Arrest (SCA) is the unexpected, sudden stop of heart the pitch and provide care to an injured player when
action which will inevitably lead to Sudden Cardiac being specifically called to do so by the referee. If a
Death (SCD) as described in the previous chapter unless player goes down in the course of action in a match, e.g.
immediately treated by an electrical shock. The possible through contact with another player, the referee is usu-
causes and underlying disease have also been elaborated ally nearby and may assess the player immediately. If a
on in the previous chapter. It does appear from more player collapses due to SCA, this does not necessarily
recent studies, that the incidence of SCD might in fact happen during a fight for the ball but might in fact do so
be far higher than what had been estimated in 2005. far away of the current match action. Therefore, the ref-
The time available to save a player’s life basically is a few eree needs to first become aware of an event which is not
minutes in SCA, and there are multiple examples of inci- in the centre of their attention, then recognise the sever-
dents at football matches where these minutes elapsed ity, then approach the player and assess them before he
without appropriate action. We therefore conducted a may finally call the medical team on the pitch. Given the
review of the literature and the current practice in the 1-2 minute time limit mentioned above, all these actions
management of SCA in football to identify the reasons might already take up a large part of the time available to
for this failure and give recommendations to improve successfully resuscitate the player.
the situation.
Further, players with SCA often show seizure-like move-
ments in the first moments, most likely due to a lack
Aim of the reviews of oxygen in the brain, which might be mistaken for a
seizure or even normal movement. Players may also
UÊ-Õ>ÀÃiÊÌ
iÊVÕÀÀiÌÊÜi`}iÊ>`Ê«À>VÌV>Ê>- exhibit what is called agonal breathing which is different
agement of SCA in football and conclude on recom- from normal breathing but again might be mistaken for
mendations for best practice breathing still taking place. These signs and symptoms,
albeit typical, might not be recognised by the insuffi-
ciently trained responder, resulting in further delay of
How we collected the data diagnosis and treatment of SCA. Until an AED is avail-
able for defibrillation, the only indicated action in SCA
A review of the current literature, the current regulations is immediate chest compression to maintain some blood
and rules applying to medical treatment on the pitch flow to the brain. There are also several examples where
and recent examples of SCD and its management in the physician called on the pitch did not take the appro-
football was performed. priate action, most likely due to a lack of training in the
specific treatment of SCA. Usual sports medicine train-
ing rarely includes the acute management of SCA, and
Results even less so regular practice of the same under life condi-
tions which is essential to exert the required routine pre-
In a player collapsing on the pitch because of SCA, an cisely.
electrical shock (called defibrillation) performed with a
F-MARC PROJECTS | PREVENTION OF SUDDEN CARDIAC DEATH 143
Finally, the availability of an AED within close proxim- kit to each of their member associations and practical
ity of the pitch is not yet standard at football matches training at courses to the national football physicians.
all over the world. If action is to be taken within 1-2 The recommended change in the provisions of medical
minutes, the AED indispensably has to be at hand at the treatment on the pitch necessitates discussions on execu-
sideline to allow for immediate emergency response by tive level that have to be informed by medical advice.
either the stretcher team or the team doctor. A reasonable rule-of-thumb in the meantime for refer-
ees and side-line staff might be to consider every player
who collapses without contact with another player or a
What we learned from the reviews steady object, and who is unresponsive, to be suffering
from SCA. Importantly, movement or breathing does
These reviews were inspired by the practical experience not exclude SCA.
of the FIFA Medical Committee and F-MARC and
several tragic examples of SCD in football. The require-
ment of an AED being available at the side-line was
standard at FIFA competitions for several years, but it
became clear that this availability needed to be extended
to lower levels of play and be amended with hands-on
training of team doctors and side-line stretcher teams in
the diagnosis and treatment of SCA. Training of other
individuals present at the pitch such as referees, coaches
and other staff in at least chest compression is highly
recommended. Further, the action to be taken in case
of SCA on the pitch needs to be planned ahead and the
plan of action has to be laid down in writing and duly
communicated to all medical staff involved in order to
clearly identify tasks and responsibilities.
s %VERY TEAM AND VENUE HOSTING FOOTBALL TRAINING OR A
competition should have a written emergency response
plan for SCA.
s 0OTENTIAL RESPONDERS TO 3#! ON THE FIELD IE COACHES
referees, physiotherapists, athletic trainers, and other
medical staff) should be regularly trained in cardiopulmo-
nary resuscitation and AED use, and demonstrate skills
proficiency in this regard.
Duration: 2009 - 2014
s !N !%$ SHOULD BE IMMEDIATELY AVAILABLE ON THE PITCH Countries: International
during competitions.
Cooperation: University of the Witwatersrand, Johannesburg,
South Africa
s "OTH TEAMS SHOULD REVIEW PRIOR TO THE MATCH THE LOCA-
tion of the AED and details of the emergency response References:
plan. Kramer E, Dvořák J, Kloeck W (2010). Review of the manage-
ment of sudden cardiac arrest on the football field. Br J Sports
Med 44(8): 540-545
A course programme was consequently launched based
Kramer E, Botha M, Drezner J, Abdelrahman Y, Dvořák J
on the deficits identified in the practical management
(2012). Practical management of sudden cardiac arrest on the
of SCA. Emergency courses were held at both FIFA
football field. Br J Sports Med 46(16):1094-1096
Medical Conferences 2009 and 2012, at AFC and CAF
Schmied C, Drezner J, Kramer E, Dvořák J (2013). Cardiac
Medical Conferences and in Brazil in preparation of the
events in football and strategies for first responder treatment on
medical staff prior to the 2014 FIFA World Cup Bra-
the field. Br J Sports Med 47:1175-1178
zil TM. CAF in 2012 provided an emergency medical
144 PREVENTION OF SUDDEN CARDIAC DEATH | F-MARC PROJECTS
4.2.3 FIFA 11 Steps to Prevent Sudden FIFA Medical Emergency Bag (FMEB)
Cardiac Death and the FIFA Medical
Emergency Bag As the consensus meeting revealed, about 13 emergen-
cy medical conditions can be defined that are likely to
occur on the football field (Box 4.2.3.1). Taking these
Why we initiated this project conditions into account, it was agreed by the experts that
the contents of the FMEB should primarily be designed
Life-threatening medical emergencies are a rare but pos- to medically manage a player for approx. 60 minutes,
sible event in football, and sudden cardiac arrest (SCA) and that it should be aimed at players older than 14
remains the leading cause of death during football. Prop- years of age and with a weight of 50 kg or more. The
er prevention strategies, emergency medical planning inclusion of a rigid durable immobilisation-carrying
and timely access to emergency equipment are required device was considered mandatory, and the specialists
to prevent fatal outcomes. FIFA and F-MARC are com- recommended that a pressurised metered inhaler and
mitted to protecting the health of players worldwide. volumetric spacer should be used for acute asthma rath-
By formulating the FIFA 11 steps to prevent sudden er than a nebuliser system as this might be difficult to
cardiac death in football and providing the FIFA Medi- apply in some stadiums due to logistical difficulties of
cal Emergency Bag (FMEB), FIFA and F-MARC pro- having stored oxygen routinely available on scene dur-
pose a standard for emergency preparedness and medical ing training or competitions. The contents of the FMEB
response to serious or fatal on-field injuries in football. have been selected mainly in a generic format such that
all of the items can be replaced if used in an emergency
or expired using the equivalent locally available stocked
Aims of the project items. A key feature of the FMEB is that the automated
external defibrillator (AED) is stored in the FMEB in
UÊ/ÊÃÕ««ÀÌÊ>`Ê«ÀÌiÊ>ÊÃÌ>`>À`Ãi`Ê>`ÊVÃÃÌiÌÊ such a way that it is immediately visible and ready to be
level of advanced life support and emergency medical applied in an emergency.
care on the football field
UÊ/Ê«ÀiÛiÌÊ>`Ê>>}iÊÃÕ``iÊV>À`>VÊ>ÀÀiÃÌÊÊÌ
iÊ
football field FIFA 11 steps to prevent sudden cardiac death
(SCD)
How we developed the programme The FIFA 11 steps to prevent SCD in football reflect
the insight that a consistent approach to prevention,
The FMEB was developed in a process of expert consul- planning and protocol are of utmost importance when
tation and consensus encompassing a group of football- it comes to managing life-threatening medical emergen-
experienced and actively involved medical specialists cies on the field. The specialists agreed that a pre-par-
from the fields of neurology, cardiology, orthopaedic ticipation screening, which identifies athletes with pre-
surgery, sports and emergency medicine from countries existing conditions placing them at risk of SCD should
including Switzerland, England, the USA, Brazil and be universally supported, and that a Pre-Competition
South Africa. Drawing from their extensive experience Medical Assessment (See chapter 4.1) should be routine-
with the medical management of international football ly undertaken. They also suggested that an exercise test
events, the experts brought together their knowledge should be considered in athletes older than 35 years of
to allocate the appropriate contents of a football medi- age and when otherwise indicated. Moreover, the experts
cal emergency bag that would be universally applica- pointed out the crucial importance of regular and appro-
ble and suitable in a multitude of locations worldwide. priate training measures to ensure that the on-duty
They moreover established the FIFA 11 steps to prevent medical personnel is familiar with the emergency medi-
sudden cardiac death (SCD), which is a comprehen- cal protocol (EMP) and can function efficiently in life-
sive action plan for the management of life-threatening threatening emergencies on the field. It was agreed that
emergencies on the field of play. a FMEB with AED must be in position at the field-side
before the commencement of all training sessions and
all games, and that an adequately staffed and equipped
ambulance must be positioned at the field-side before
F-MARC PROJECTS | PREVENTION OF SUDDEN CARDIAC DEATH 145
Box 4.2.3.1
Box 4.2.3.2
4.2.4 Cardiac Findings and the Athlete’s In addition, we identified 62 Caucasian Italian players in
Heart in African Adolescent Players order to compare the ECG and echocardiography find-
ings between the two groups of black African and Cau-
casian players. The Italian players were matched to the
Why we conducted these studies championship players with regard to their age, training
intensity, level of play and the time of examination.
The analysis of the forms of the P-Competition Medical
Assessment (PCMA) performed prior to the 2006 FIFA
World CupTM had revealed a high percentage of ECG Results
findings in black players that as per the standard crite-
ria used for ECG interpretation at the time would have There were numerous different African ethnic groups
been termed abnormal. It was known that black athletes represented among the eight teams. One third of the
had a higher risk of Sudden Cardiac Death (SCD) than players had never been examined by a physician before.
Caucasian athletes. Therefore, identifying black players Only 9 of the players reported heart symptoms, and two
at high risk of SCD appeared particularly important, yet had elevated blood pressure in the clinical examination.
there were no criteria how to achieve this as the defined Slightly more than a quarter of the U-17 players showed
standard criteria produced a lot of “false positive” results abnormal ECG findings, but none of them had any
in black athletes, meaning the ECG would be rated signs of abnormality on echocardiography. There were
abnormal, but further investigations did not show any certain changes that were found particularly often. Black
abnormality. This implied that there was probably a African players particularly often showed ECG signs of
need to develop specific interpretation criteria for the left ventricle hypertrophy. The most frequent finding in
ECG of black players and athletes to be able to distin- about half of the black African players concerned what is
guish normal from abnormal findings. We therefore called an R wave, and one fifth had a particular change
decided to examine the young black African players at in what is called the T wave. It was not possible to assign
the CAF U-17 Championship in detail and with a par- structural abnormalities to these changes, meaning that
ticular focus on the heart investigations to gain more these players need further follow-up.
insight into this matter.
Thirteen players had an abnormal echocardiography,
two of them showing signs compatible with beginning
Aims of the studies cardiomyopathy. Athletes typically show left ventricle
hypertrophy. In our study population, Caucasian and
UÊ-VÀiiÊ>Ê«>ÞiÀÃÊ>ÌÊÌ
iÊnth CAF U-17 Champion- African players had comparable left ventricle dimen-
ship 2009 in Algeria for cardiac risk factors using the sions, but African players showed markedly thicker walls
standardised F-MARC PCMA of the ventricle, which were more often above the upper
UÊiwiÊÌ
iÊ
Ê>`ÊiV
V>À`}À>«
VÊV
>À>VÌiÀÃÌVÃÊ normal limit than in Caucasian players. In the same way,
found in African adolescent athletes the mass of the left ventricle was larger and more often
UÊ
iVÌÊ`>Ì>ÊÊV>À`>VÊÀÃv>VÌÀÃÊÊÌ
ÃÊÌ>À}iÌÊ}ÀÕ« above the upper normal limit (Fig. 4.2.4.1)
All eight qualified teams for the 8th CAF U-17 Cham- Among African players, abnormal ECG changes were
pionship 2009 respectively their 155 players were exam- more frequent in black African than in non-black Afri-
ined by a team of F-MARC physicians prior to the com- can players. These ECG changes could however not be
petition. All examinations were performed according to related to distinguishable structural changes or diseases
the revised F-MARC PCMA form and included medi- of the heart. To establish ECG interpretation criteria for
cal history, family history, physical examination, 12-lead black players, it is important to know the interpretation
resting ECG and echocardiography. All heart examina- criteria in black non-athletes which so far have not been
tion findings were assessed by three cardiologists to min- identified. Therefore, there is a need to establish popu-
imise individual error. lation–based data of normal ECGs in adolescent black
Africans and correlate it to echocardiographic findings.
F-MARC PROJECTS | PREVENTION OF SUDDEN CARDIAC DEATH 147
Neck pain 30 10 28 21 12 16 20 11
Muscle/tendon 38 39 16 42 30 35 31 38
Joint pain 33 46 40 39 37 41 40 44
any complaint 78 76 76 74 73 73 81 84
Tab. 5.1.1.1 Prevalence (percent of players) of complaints in football players of different age and skill levels
Any sign of ACL injury 12.5 7.3 16.0 15.6 2.4 23.1 4.2 5.5
Tab. 5.1.1.2 Percent of players with pathologic signs of knee or ankle ligament injury
reporting no past or current complaint. The most fre- prior injuries and most of the injuries were to the non-
quent symptoms were pain in the lower back, the joints, dominant leg. It is obviously not advisable to play with
and the muscles or tendons followed by headaches and an incompletely healed injury under the false sense of
neck pain. Players reported an average of 6.6 previous security that tape and bandages will have a preventive
injuries and 15% had prior surgery for a football-relat- effect. F-MARC concluded that in our future research
ed injury. At the time of the examination, 24% of the to ensure and maintain the health of football players, we
players said they still felt the effects of a previous injury would need to pay more attention to the current patho-
which obviously suggested that these player complaints logic findings and complaints as well as the secondary
should affect current, and even future, play. Almost one- structural changes that may occur as a result of playing
quarter of the players had a pathologic finding in either football.
the right or left knee (Tab. 5.1.1.2). Even more play-
ers (28%) had instability (anterior drawer) of either the
right or left ankle. When evidence of any ankle instabil-
ity was separated out by age and ability, our youngest
players in the lowest level of play had a higher fraction
of instability (36%) than the professionals (20%). While
not a statistically proven relationship, evidence of ankle
instability symptoms decreased with increasing age and
ability level. Pathologic findings of the knee and ankle
were associated with previous bony, ligament, soft tissue
injuries, or surgery. Fig. 5.1.1.1 Medical examination of the knee
5.1.2 Psychological Characteristics Inventory, the State Competitive Anxiety Test, and the
State-Trait-Anger-Expression-Inventory. Test results were
compared with historical results in the scientific literature.
Why we conducted this study We also asked for a series of football-specific characteris-
tics that included playing experience, positions played,
Playing football demands not only good physical perfor- style of play, number of training hours and games, as well
mance, but also mental preparation and most probably as aspects of fair play. We also tested the reaction time of
specific psychological qualities. The nature of the game players. Simple reaction time to an optical stimulus was
requires particular gifts and features that draw people tested twice: once without the influence of physical exer-
with specific personality traits to participate. Within the cise and once with the effect of exercise by testing reaction
game, only certain players advance up the ladder of the time after completion of a 12-minute run.
sport. It might be that players at different levels of play
might vary not only in their football skills and their way
of playing, but also in psychological factors like concen-
tration, reaction time, or competitive anxiety.
UÊ
Ý>iÊ«ÃÞV
}V>Ê>`ÊvÌL>ëiVwVÊV
>À>VÌiÀ-
istics at different levels of play Fig. 5.1.2.1 Players filling in the questionnaires
UÊ>ÞÃiÊÌ
iÊÀi>ÌÃ
«ÊLiÌÜiiÊ«ÃÞV
}V>ÊV
>À>V-
teristics and attitudes toward fair play
Results
How we collected the data At rest, reaction time was slower for the lower level play-
ers, most pronounced in youth players. After exercise,
A group consisting of 588 football players from Czech reaction time was significantly shorter in high-level than
Republic, Germany and France filled out questionnaires in low-level players of all three age groups. When com-
(Fig. 5.1.2.1). As in our previous study, adult players were paring groups, the top level adults and the top level
categorised into four skill level groups: top-level (first and 16-18-year-old youth players had the shortest reaction
second league), third league, amateur teams (division), times of all (Tab. 5.1.2.1)
and local teams. Youth players were divided into two age
groups (14- to 16-year-old players and 16- to 18-year- Essentially, the psychological traits were the same across
old players) and two skill-level groups (high and low). A the age groups in this study. Coping skills (such as cop-
total of 13% of the players were professionals. We assessed ing with adversity, amenability to being coached, confi-
psychological characteristics using three established self- dence, mental preparation) were similar regardless of age
evaluation questionnaires: the Athletic Coping Skills and level of play. Yet, there were a few differences within
F-MARC PROJECTS | OTHER RECOGNISED MATTERS 151
Age started playing (y) 6.6 6.4 6.3 6.7 5.9 6.8 5.8 6.7
Preferred foot
Right (%) 38 48 54 47 50 60 46 67
Left (%) 8 8 17 5 10 12 10 15
Both (%) 54 45 29 47 40 27 45 17
Field leader?
31 26 27 18 35 21 33 17
(% yes)
Physical player?
44 58 38 52 46 62 50 58
(% yes)
Tab. 5.1.2.1 Reaction Time of Football Players of Different Age and Skill Levels
the age groups. High level youth had fewer worries about What we learned from the study
their performance and high level 14-16-year-old youth
had more mental strength under pressure and better con- The reaction time seemed in general to be longer in low-
centration than lower level players of the same age. Nei- level players than in high-level players. The replies from
ther the Sport Competitive Anxiety Inventory (SCAT) the questionnaire regarding fair play clearly indicated that
nor State-Trait-Anger-Expression-Inventory was different the rules of the game, its regulations and the spirit of fair
across the other football groups. play is not paid sufficient respect by football players.
When comparing the football players against other groups The willingness to commit a “professional foul” was alarm-
reported in the literature, the football players had higher ingly high and not associated with any specific personality
levels of anger, outward expressions of anger, and com- trait. The players felt that depending on score and match
petitive anxiety, but lower levels of anger control. The importance, a “professional foul” might just be needed
football players scored lower on all aspects of coping and they would be willing to commit such a foul. To the
skills with the exception of “freedom from anxiety”. We psychologist, this means that the “professional foul” is not
also looked at the interaction of personality traits and fair a spontaneous act. On the other hand, retaliation would
play statements. For example, players who refrained from be committed by those with high levels of anger and poor
verbal interaction with the opponents were usually better control over anger expression.
prepared, had more focused concentration, were easier to
coach, and coped better with adversity and anger. Those
who would react to a hidden foul had higher levels of
anger and less control of it. In addition, those players had Duration: 1996 - 1998
lower levels of concentration, poor coping abilities, and Countries: Czech Republic, Germany, France
were difficult to coach. Ninety-two percent of the play- Cooperation: Czech Football Association
ers said they would commit a so-called “professional foul” Reference:
if necessary. Half of the players had responded physically Junge A, Dvořák J, Rösch D, Graf-Baumann T Chomiak J
when provoked by an opponent, and nearly 60% would (2000). Psychological and sport-specific characteristics of foot-
pay back a hidden (unpenalised) foul. ball players. Am J Sports Med 28 (5 Suppl): S22-28
152 OTHER RECOGNISED MATTERS | F-MARC PROJECTS
5.1.3 Assessment of Performance Lengthwise leg splits: The player stands on the board
and uses the chair for support. He kneels on the board
and extends the other leg straight in front. The distance
Why we conducted this study from the groin to the ground is measured.
All sports are a combination of technique, tactics, physi- Single leg knee bend: The player stands on the board and
cal fitness and psychological fitness. The complexity of uses the chair for support. They kneel on the board and
football is such that the relative importance of each of extend the other leg as far as possible behind them. The
these variables can change from match to match. Prob- distance from the groin to the ground is measured.
ably one of the reasons that football is played by so many
is that the game requires no specific gifts in order to be Forward trunk bending: The player stands on a bench.
successful. Some games have traits that are unique to With straight legs, the player bends as far forward as pos-
their sports, such as strength and power for American sible. The distance from the fingertip to the ground is
football, height for basketball, speed for sprinting or measured.
endurance for distance running. In contrast, football,
while not requiring any specific trait for success, does
require some ability in all aspects of physical fitness. The Football skills
most important variables for measuring performance in
team sports in general are physical condition and techni- Examples are:
cal and tactical performance. However, in football, it was Speed dribbling: The player dribbles the ball around
difficult to ascertain the relative importance of each of a specific course for time. The course is laid out over a
these variables. 50m linear distance, but the multiple changes of direction
increase the overall running distance (Fig. 5.1.3.1).
Aim of the study Long passing: The player gets five attempts to see how
many times he can kick a stationary ball into a 2m radius
UÊiÛi«Ê>ÊÃÌ>`>À`Ãi`ÊÌiÃÌÊL>ÌÌiÀÞÊÌÊiÛ>Õ>ÌiÊ«
ÞÃV>Ê circle which centre is 36m away.
performance characteristics in football players
Short passing: The player gets five attempts to see how
many times he can pass a dribbled ball into a hockey goal
How we collected the data that is eleven metres away.
Again, the 588 football players from Czech Republic, Ger- Shooting: Using a stationary ball 16m from a goal, the
many and France of multiple ages and playing levels were player gets three attempts to shoot into each upper cor-
examined. The three hour session to assess performance ner. All scoring tests have a progressive scoring system for
included a warm-up procedure, tests of flexibility, football accuracy.
skills, power, speed and endurance and ended with a cool-
down. Some additional stretching was done prior to the
flexibility tests.
Flexibility
Examples are:
Supine straight leg raise: The player lies on their back,
then raises one leg up as far as possible. A partner then Fig. 5.1.3.1 Dribbling at speed test
helps raising the leg even further. The angle of the leg to
the ground is measured.
F-MARC PROJECTS | OTHER RECOGNISED MATTERS 153
25
24.2
22.9
Dribble in seconds
22.3
21.4 21.5 21.3
20.2 20.7
20
er
el
el
el
el
eu
gu
To
lev
lev
lev
lev
lay
at
lP
low
low
Am
hig
hig
ca
d
3r
Reference:
Lo
8y
6y
8y
6y
-1
-1
-1
-1
14
16
14
5.2.1 Influence of Ramadan on Performance ity, power, speed and a dribbling task. The timing of
tests corresponded to their usual match time in the early
afternoon. Each player was interviewed regularly during
Why we conducted this study the study for their subjective opinions on sleep quality,
eating, symptoms and their perception of their training
Islam is a major religion with over one billion people liv- and match performance.
ing under Islamic laws. One of the most important peri-
ods for Muslims is Ramadan when healthy adult Muslims
fast from sunrise to sunset for the four-week period. The Results
original objectives of this fasting period are physical and
mental regeneration combined with intensified praying. In the fourth week of Ramadan, performance was reduced
Muslims are invited to abstain from all types of liquid or on a wide range of tests (20m speed, speed dribbling, agil-
solid nutrient intake as well as undesirable behaviour dur- ity, endurance and recovery) and was below the initial
ing this period of purification with the exact timing of values when tested two weeks after the end of the fasting
food and liquid intake depending on the times of sunrise period (Fig. 5.2.1.1). Nearly a quarter of all players felt
and sunset. So Ramadan is a phase shift of food intake they ate more during Ramadan while half felt they ate
and sleep and less a traditional fast where food is generally less. Weight did not significantly change. Food volume
avoided. returned to normal after Ramadan. About 70% of players
reported that the quality of their training was poorer dur-
Football is the largest spectator sport and as a means of ing the fast, and just over 75% of the players thought that
physical exercise the most popular leisure activity in many their match performance was reduced during the fast.
Muslim countries. While there had been a number of
studies on the physical and clinical effects of Ramadan Sleep volume was reduced by just over 30 minutes during
with regard to metabolism, hormones and behaviour, little Ramadan, but nearly three quarters of the players said that
was known on the influence Ramadan has on athletic per- the quality of their sleep was poorer than before Ramadan
formance. There were also reports on the effects of food because the sleep cycle was disrupted to accommodate
restriction and sleep deprivation on performance in the food intake.
laboratory. With Muslim footballers playing worldwide
and the increasing chance of international matches involv- Finally, a series of symptoms changed during the fast,
ing Muslim and non-Muslim teams being contested dur- especially an increase in headache and vertigo (Fig.
ing Ramadan, it seemed appropriate to F-MARC to assess 5.2.1.2). In most cases, after the fast, subjective ratings by
how the Islamic competitive player is affected by this reli- the players had either returned to pre-Ramadan values or
gious period. rebounded above pre-fasting levels. Importantly, nearly all
the players believed that their training and match perfor-
mance had improved to close to pre-Ramadan levels once
Aims of the study the fast had been concluded (Fig. 5.2.1.3).
UÊiÌiÀiÊÌ
iÊivviVÌÃÊvÊ,>>`>ÊÊ«
ÞÃV>Ê«iÀ-
formance and football performance
UÊÃÃiÃÃÊÌ
iÊÃÕLiVÌÛiÊ«ÃÊvÊÌ
iÊ«>ÞiÀÃÊÊÃÞ«-
toms, behaviour and performance
Fig. 5.2.1.3 The player’s opinion of their training and match perfor-
mance declined through Ramadan, but returned to acceptable levels
after Ramadan has concluded
In the youth football players observing Ramadan dur- We recommended that players should ensure adequate
ing the Tunisian residential training camp, none of the sleep and good nutrition during Ramadan to preserve
performance variables was negatively affected by fasting football performance and general health. The effect of
while nearly all variables showed significant improve- changed sleeping and eating patterns will depend on the
ment at the third test session. Changes in performance length of the daylight period, weather conditions and
were most likely due to the effects of training and famili- other environmental and cultural factors.
arity with the tests. The results of blood tests showed
that the changes in eating time and frequency during
Ramadan fasting, along with the continuation of normal
training load, had no important effect on metabolism.
Previous studies by others and our own study in 2004 Duration: 2006 - 2007
had shown decrements in performance and subjec- Countries: Tunisia, Oman
tive variables during Ramadan. In this F-MARC study Cooperation: School of Sport and Exercise Sciences,
however, biochemical, nutritional, subjective well-being Loughborough University, Loughborough, United Kingdom;
and performance variables were not adversely affected in National Center for Medicine and Scientific Research in Sport,
young male football players who followed Ramadan fast- Tunis, Tunisia; Orthopaedic Sports Medicine Unit, Khoula
ing in a controlled training camp environment. Based on Hospital, Muscat, Oman
our data, the changes in the timing of food intake and Reference:
sleep patterns during Ramadan had little effect on objec- Zerguini Y, Dvořák J, Maughan RJ, Leiper JB, Bartagi Z,
tive tests of physical performance. In fact, physical per- Kirkendall DT, Al Riyami M, Junge A. (2008). Influence of
formance generally rather improved, but match perform- Ramadan fasting on physiological and performance variables in
ance was not measured. football players: summary of the F-MARC 2006 Ramadan fast-
ing study. J Sports Sci 26(3 Suppl):S3-6
158 OTHER RECOGNISED MATTERS | F-MARC PROJECTS
5.2.3 Ramadan and Sports Performance What we learned from this consensus meeting
Summary
Duration: 2011
Countries: International
References:
Ramadan and Football (2012). Supplement of the J Sport Sci
30(S1) (for details see Bibliography)
160 OTHER RECOGNISED MATTERS | F-MARC PROJECTS
5.3 Use of Medication and Nutritional by the players or administered to them in the 72 hours
Supplements in FIFA Competitions preceding the match. The team doctors also had to note
down any non-prescription medicines or food supple-
ments taken by the 23 players of their team.
Why we conducted these studies
Substance intake was calculated as follows:
Public interest in the intake of medication by sportsmen UÊÊ ÃÕLÃÌ>ViÊÉÊ«>ÞiÀÊÉÊ>ÌV
Êi>ÊÌ>iÊ«iÀÊ«>ÞiÀ®
focuses on doping, meaning the abuse of illegal substanc- UÊÊ ÕLiÀÊvÊ`Û`Õ>Ê«>ÞiÀÃÊÀi«ÀÌi`ÊÌÊLiÊÕÃ}Ê>ÊÊ
es such as anabolic steroids with the aim of performance substance
enhancement. FIFA was one of the first international fed- UÊÊ ÃÕLÃÌ>ViÊÉÊ«>ÞiÀÊÉÊV«iÌÌÊ
erations to adopt stringent anti-doping measures in 1970,
and since then has meticulously recorded illegal abuse.
The extremely low incidence of positive doping tests in Results
professional football is testament to the success in pro-
tecting players from this health risk. However, legal sub- At the two FIFA World Cups™ (2002, 2006), a total
stances prescribed for treatment may also endanger play- intake of 10,384 substances was documented, of which
ers’ health due to adverse effects, accentuated by excessive more than half were classified as nutritional supple-
use over an extended time period. Eighty percent of the ments. The average consumption in 2002 and 2006 per
athletes participating in the Olympic Games 2000 were player was 1.8 substances or 0.8 medications prior to
found to use some sort of medication. Studies in profes- each match; the same was reported in 2010 (Tab. 5.3.1).
sional footballers had indicated a rather high intake of Some players took as many as seven different substances.
both supplements and of non-steroidal anti-inflammato- Only one out of five players did not take any medica-
ry drugs (NSAIDs). The FIFA Medical Committee had tion. NSAIDs were the most frequently prescribed sub-
since long been concerned about the extensive use of pre- stances, accounting for almost half of all medications
scribed drugs in elite football. Therefore, just before the used. More than half of the players took NSAIDs at
1998 FIFA World Cup™ in France a new initiative was least once during the competition and almost one third
launched to record the use of medication and nutritional prior to a match. By 2010 the number of players tak-
supplements in each player prior to each match on the ing NSAIDs per match increased significantly (p<0.01).
doping control form. F-MARC then decided to analyse The range of medication reported was from 0.22 to 3.13
these data not only for FIFA’s flagship event, but also for per player per game; NSAID prescription ranged nearly
the youth and women’s competitions to get a clearer pic- 20-fold – from 0.06 to 1.17 NSAIDs per player and per
ture of the magnitude of the use of medication and the match. Differences in prescription practice varied enor-
health risks associated with this practice in elite football. mously among countries.
I. Completely unfused
II. Early fusion: minimal hyperintensity within physis
III. Trabecular fusion of less than 50% of radial
cross-sectional area
IV. Trabecular fusion of more than 50% of radial
Fig. 5.4.1.1 Example of a MRI of the wrist cross-sectional area
F-MARC PROJECTS | OTHER RECOGNISED MATTERS 163
V. Residual physis, less than 5mm on any one section degree of fusion, and at the same time there were signifi-
VI. Completely fused cant differences between age groups. But for football players
from four international U-17 competitions, there was no
In a second step, MRIs were done at four international correlation between age and grade of fusion. U-17 football
youth competitions to compare the results. In total, 189 players seemed in general to be more mature than a norma-
players were examined during the four U-17 competitions; tive population of football players of the same age category.
48 players from each of the FIFA U-17 World Cup Fin- If U-17 players were categorised in age-groups according
land 2003, the AFC U-17 championship Japan 2004, and to their official documents, a higher degree of fusion was
AFC U-17 championship Singapore 2006, and 45 players observed in all groups. Based on the MRI results of the
from the FIFA U-17 World Cup Peru 2005. In the last of wrist, the age stated in the official documents of the U-17
these, three players from one team could not be examined players examined might not be correct in all cases.
for logistic and technical reasons. Age 14-15y 15-16y 16-17y 17-18y 18-19y 19-20y
Fusion
I 11 40 16 5
Results
II 10 62 65 37 4
III 11 16 10 8
In the general player population, the average age as docu-
mented increased significantly with a higher category of IV 8 15 21 12
3
Due to the different definitions for U-17 competitions, all
players in the AFC competitions were under 17 years of age 2
6y
7y
8y
17
17
9y
0y
-1
-1
-1
-1
-1
-2
U-
U-
15
16
17
18
19
(15%) in the AFC and 25 players (27%) in the FIFA com- | Finnland |
Japan
petitions had complete fusion of the distal radius (grade VI; Fig. 5.4.1.3 Percentage of subjects by age and fusion level
Tab. 5.4.1.3). The respective values of the normative popu-
lation were less than 1% of under-17-year-old players and
10% of 17-year-old players. In all four U-17 competitions, Duration: 2003 - 2006
more players had the two highest degrees of fusion (grade V Countries: Switzerland, Malaysia, Algeria, Argentina
and VI) than in the age-related general population (AFC, Cooperation: Prof. Juerg Hodler, Balgrist Clinic, University
48% vs. 14%; FIFA, 61% vs. 37%). of Zurich, Switzerland; Dr John George, University of Kuala
Lumpur, Malaysia; Dr G Singh, Asian Football Confederation;
Dr R Madero and Dr P Ortega, Buenos Aires, Argentina; Dr AY
What we learned from the studies Zerguini and Dr N Abed, Algier, Algeria
References:
In consideration of the biological variability, an estima- Dvořák J, George J, Junge A, Hodler J (2007). Age
tion of “true” age of an individual can only be made with Determination by MRI of Wrist in Adolescent Male Football
a certain probability. However, in the general player popu- Players. Br J Sports Med 41(1): 45-52
lation, the grades of fusion of the wrist as determined by Dvořák J, Georges J, Junge A, Hodler J (2007). Application of
MRI proved to be a reliable method for age determination. MRI of the wrist for age determination in international U-17
Age indicated by the birth certificate highly correlated with soccer competitions. Br J Sports Med 41 (8): 497-500
164 OTHER RECOGNISED MATTERS | F-MARC PROJECTS
UÊÛiÃÌ}>ÌiÊÌ
iÊ«ÃÃLÌiÃÊvÊ,ÊvÊÌ
iÊ>VÊVÀiÃÌÊ>«-
Why we conducted these studies physis for the purpose of evaluating skeletal maturation
in under-20 (U-20) football players
In soccer, age-related tournaments play an important role
in guaranteeing equal chances to the competitors for dif-
ferent age groups. Giving an incorrect age to compete in How we collected the data
a lower age class allows a player to benefit from physical
advantages that older players often have over their peers. Magnetic resonance (MR) scans of the iliac crest apophysis
An older player with advanced maturity may also increase were prospectively evaluated in 152 German male tourna-
the risk of injuries to their opponents, especially in con- ment soccer players aged between 18 and 22 years. The
tact sports such as soccer. study was approved by the local ethics committee and is
in compliance with German ethical standards. Written
However, over-age participants are not always intention- informed consent was obtained from all participants.
ally cheating when they play in an inappropriate team. In A four-stage classification system was applied for the assess-
particular, players from developing countries in Africa, ment of the apophyseal ossification.
Asia, or South America often cannot guarantee the accura-
cy of their birth certificates, or their countries do not even UÊ -Ì>}iÊ£Ê"ÃÃvV>ÌÊViÌiÀÊ
>ÃÊÌÊÞiÌÊÃÃvi`°
issue such certificates. Therefore, the problems of interna- UÊ -Ì>}iÊÓÊ"ÃÃvV>ÌÊViÌiÀÊ
>ÃÊÃÃvi`]Ê«
ÞÃi>ÊV>ÀÌ>}iÊÊ
tional sporting federations are similar to those of judges in has not ossified.
criminal proceedings when the adolescents accused have UÊ -Ì>}iÊÎÊ*
ÞÃi>ÊV>ÀÌ>}iÊ
>ÃÊ«>ÀÌ>ÞÊÃÃvi`°
neither a valid identification document, nor a reliable UÊ -Ì>}iÊ{Ê*
ÞÃi>ÊV>ÀÌ>}iÊ
>ÃÊV«iÌiÞÊÃÃvi`°
birth certificate, or they simply do not want to give their
correct age. If possible, further sub-classification of stages 2 and 3 into a,
b, and c modified according to Kellinghaus et al were per-
Today, age diagnostics of living individuals is well estab- formed.
lished in forensic sciences as well as in competitive sports,
to ensure that athletes are competing fairly and with suf- Between February and June 2011, T1 gradient echo 3D
ficient health protection. However, age estimations in this FFE sequences of the whole pelvis were performed with
field should not rely on imaging methods that include a 3.0 T MR system (Achieva, Philips) and an 8 elements
exposure to radiation. Thus, determination of skeletal age SENSE cardiac coil. Multi-planar reconstructions allowed a
is significantly complicated. Moreover, especially for U-20 simultaneous view of multiple dimensions.
competitions, novel morphological criteria are sought, as Ossification stages were determined for both the right and
the skeletal maturation of hand and wrist bones is com- the left pelvic side. MR assessments were done by one
plete well before the age of 20 years. examiner, who was unaware of the age of the individuals
before and during the examinations. Results are expressed
The iliac crest apophysis has recently been shown to be of as minimum, maximum, mean ± standard deviation, and
value in forensic age estimation settings using convention- median with lower and upper quartiles. Comparison of left
al projection radiography as well as sonography [20, 21]. versus right side was done by means of Wilcoxon test. Sig-
In an anthropological approach, Coqueugniot and Weav- nificance was assumed at p \ 0.05 (exact, two-sided).
er demonstrated that complete fusion between the apoph-
ysis and iliac bone occurs at the age of 22 years in women
and 20 years in men. Therefore, the present pilot study Results
addresses the question of whether the investigation of this
skeletal region by means of a modern cross-sectional tech- In all subjects examined (n = 152), a reliable MR assess-
nique, such as the magnetic resonance imaging (MRI), ment of the apophyseal iliac crest ossification was possible
might serve as an additional criterion for age diagnostics on both pelvic sides. The ossification stages 1 to 4 were
in U-20 soccer competitions. demonstrated in (Fig. 5.4.2.1 a–c). A determination of
sub-stages according to Kellinghaus et al did not appear
feasible because of movement artefacts, the relatively large
F-MARC PROJECTS | OTHER RECOGNISED MATTERS 165
Fig. 5.4.2.1 Ossification stages of the iliac crest apophysis visualized by means of magnetic resonance imaging. Each panel shows a right pelvic side
in a coronal view. a Stage 2: The ossification center of the apophysis has ossified. There are no osseous connections between ossification center
and iliac wing. b Stage 3: The ossification center has partially fused with the iliac wing. The inner part of the former physeal cartilage has ossified.
The arrow demonstrates a thin osseous bridge in the outer part between ossification center and Os ilium. c Stage 4: The physeal cartilage has
completely ossified
UÊ*ÀÛ`iÊ>ÊV«Ài
iÃÛiÊÛiÀÛiÜÊvÊÌ
iÊVÕÀÀiÌÊ
knowledge of cartilage injury pathophysiology, epide- Results
miology, and etiology
UÊi«Ê>`Û>ViÊÌ
iÊÃViViÊ>`ÊÕ`iÀÃÌ>`}ÊvÊ>ÀÌVÕ- Steinwachs, Engebretsen, and Brophy established the
lar cartilage injury and degeneration in the football scientific evidence base for cartilage injury and repair in
player and to investigate options for future treatment the athlete. These injuries and the inherent risk of the
and prevention methods of articular cartilage in foot- game create an overall prevalence of knee articular carti-
ball lage lesions of 36% and up to 72%. The football player
UÊ/ÊÀi`ÕViÊÌ
iÊV`iViÊvÊV>ÀÌ>}iÊÕÀÞÊ>`ÊÀÃÊvÊ with articular cartilage injury is often faced with a signif-
osteoarthritis in football players of all ages and skill icant challenge because of the high demands placed on
levels the normal, repaired, and regenerated tissue by the game
over time. The doctors showed that cartilage defects in
athletes could be treated with microfracture, osteochon-
How we collected the data dral autogenic or allogenic tissues but that the ultimate
challenge is the quality of the repair tissue, as this must
A number of studies were conducted by researchers closely resemble and function like normal hyaline carti-
worldwide to investigate the issue of articular cartilage lage.
injury in football players. Research findings were pre-
sented in 12 scientific papers and jointly published as Mithoefer and Steadman investigated a case series
supplement in the journal Cartilage in 2012. While all of professional, injured football athletes, concluding
studies made individual contributions to the illumina- that the microfracture technique followed by appropri-
tion of the subject, they may be subsumed under the ate rehabilitation provides restoration of the knee joint
“spectrum of care” paradigm. This paradigm has been function and may thus allow for a high rate of return to
formulated for the management of articular cartilage play. However, the doctors also pointed to the issue of
injury and degeneration in football players with the aim deterioration of clinical results in some cases after two
of facilitating and accelerating an injured athlete’s return years.
to play. The paradigm rests on four cornerstones: (1)
F-MARC PROJECTS | OTHER RECOGNISED MATTERS 167
Panics, Hangody, Baló, Vásárhelyi, and Gál estab- about a third of professional players and diagnosed four
lished that autologous osteochondral mosaicplasty in to five years earlier.
competitive elite and recreational football players is a
good alternative procedure to repair cartilage damage
with best results in younger athletes with smaller lesions. What we learned from the studies
Mithoefer, Peterson, Saris and Mandelbaum dem- The probability of developing osteoarthritis in football
onstrated that articular cartilage repair with autologous players is five to 12 times more frequent than in the gen-
chondrocyte implantation especially in elite football eral population. Factors determining a successful return
players often allows for successful return to play with to football after articular cartilage repair of the knee
excellent durability at 5 years and beyond. However, the include player age, time between injury symptoms and
doctors also pointed out that the disadvantage of this treatment, competitive level of participation, defect size,
technique lies in the long time for tissue maturation and and repair tissue morphology. Sports and exercise par-
consequent return to play. ticipation after cartilage repair may facilitate joint resto-
ration, functional recovery, and fitness levels. Promoting
Görtz, Williams, Gersoff, and Bugbee described oste- the “spectrum of care” paradigm for the management
ochondral allograft reconstruction as an increasingly of articular cartilage injury in football players as well as
popular treatment option for osteoarticular lesions in encouraging players and coaches to actively incorporate
athletes. These allografts provide mature and immune- the “FIFA 11+” programme into their training prac-
privileged hyaline cartilage on an osseous scaffold that tice are therefore promising moves towards a reduction
serves as an attachment vehicle. This is rapidly replaced of articular cartilage injuries and their consequences in
via creeping substitution, leading to reliable graft inte- football. It must be noted, however, that not all players
gration that allows for simplified rehabilitation and will return to football after articular cartilage repair.
accelerated return to sport. The next step in the FIFA/ICRS initiative will be to
investigate how this progression of osteoarthritis can be
Bekkers, de Windt, Brittberg, and Saris provided a delayed, with research s. a. presented by Zaslav et al in
critical review of the “state of cartilage repair” in foot- their evaluation of new frontiers for cartilage repair and
ball athletes as well as a critical review of the best avail- protection leading the way.
able evidence for cartilage surgery and treatment selec-
tion. They furthermore evaluated specific patient profiles
for professional and recreational athletes and proposed a
treatment algorithm for the treatment of focal cartilage
lesions in football players.
6.1.1 Football Medicine Manual In spring of 2003, the preparations for the F-MARC
Football Medicine Manual started. Our objective was to
create a single and practically orientated resource for the
Background medical care of the football player. In order to improve
the standards of care for the millions of players world-
In our continuous effort to protect the health of play- wide that have no access to the sophisticated medical
ers worldwide, F-MARC had realised that FIFA mem- services available to elite players, the Football Medicine
ber associations were in need of a comprehensive educa- Manual had to primarily address those who take care of
tional tool that dealt with all medical aspects of football. the players at grassroots level (Fig. 6.1.1.1).
While the information was mostly published, anyone
interested had to go to multiple sources in sports medi- As a first step, the main focus and individual topics of
the publication needed to be identified. Following
F-MARC’s research strategy, prevention was clearly
one of the most fundamental concerns. Therefore, after
addressing the epidemiology of injuries and risk man-
agement in football, one chapter was dedicated to injury
prevention, but also to nutrition and doping control
in order to demonstrate the comprehensive F-MARC
definition of prevention. According to our findings on
the frequency and characteristics of injury in football,
the treatment and rehabilitation as well as return-to-
play considerations of the most relevant injuries were
described in individual chapters. Finally, the diagnosis,
treatment and return-to-play issues of diseases being
important in football were explained.
The next step was to identify the respective experts for
the different topics. A list of individuals was developed
not only to encompass the breadth of football medicine,
but also to ensure comprehensible and practically orien-
tated reporting on research findings to those members
of the medical profession less exposed to scientific lit-
erature (Fig 6.1.1.2). In an intense workshop, the iden-
tified experts created drafts of their respective chapters,
and then presented the drafts to their peers to react, to
criticise and to complement on. One year later, a smaller
group of the original authors gathered to edit the manu-
script and finalised the English version. Football medi-
cine colleagues from around the world were then asked
to translate the Football Medicine Manual into the other
three FIFA languages of French, German, and Span-
ish. Since then, the manual has also been translated into
Arabic, Czech, Japanese, Mandarin, Polish, and Russian
with more language versions being prepared.
6.1.3 First Aid Manual Players should always be approached and managed by
the “ABCDE (Airways-Breathing-Circulation-Disabil-
ity-Expose/Examine)” approach.
Why we conducted this project This approach is applicable for assessing all injuries
you encounter on entering the football or training
This booklet is designed for use by coaches and non- field of play for player injuries and is not just applica-
medically qualified First Aiders working within foot- ble to Basic Life Support (BLS).
ball around the world and specifically in the developing The aim of the First Aider is to ensure what is known
countries. It is a short and practical guide to dealing with as the 3Ps:
injuries and illnesses, mainly on the field of play, both Preserve Life - Prevent deterioration of the player’s
in training and in matches (Fig. 6.1.3.1). It provides a health situation - Promote Recovery
comprehensive guide to immediate first aid management
of player injuries and illnesses from critical to minor. UÊ Wounds and bleeding
The intentions have been to provide a “holistic” view This chapter focuses on the ability to recognise that
of first aid because of the limited medical resources that bleeding (external/ internal) is taking place and on
may exist. It also advises on appropriate return to play how to stop it. It is one of the most important aspects
guidelines for a wide range of conditions and advises of first-aid casualty survival.
on equipment the First Aider should carry to all events The assessment of the severity of the bleeding and the
when dealing with players (Fig. 6.1.3.2). management of a wound centres on:
This manual may be of use to those therapists and doc- - Control of bleeding
tors just starting out in their football medical careers. - Prevention of infection
- Prevention of further complications
Availability and distribution Fig. 6.1.3.2 A basic first aid kit for a first Aider to cover a football
match
Duration: 2011 - 2014
In order to disseminate the knowledge compiled in the
Countries: UK, South Africa
Football First Aid Manual, print copies are made avail-
Cooperation: Exercise Medicine Centre for Sports Medicine,
able in English to any sports physician and member
University of Nottingham, UK; Department of Emergency
association on request. Furthermore, the manual is dis-
Medicine of the University of Witwatersrand, Johannesburg,
tributed at F-MARC conferences and courses.
South Africa
Reference: Hodgson L, Kramer E (2015). First Aid Manual
and Related Healthcare Issues for Football - with special regard
to first aiders and coaches. Official publication of the Fédération
Internationale de Football Association (FIFA), Zurich,
Switzerland
174 IMPROVING STANDARDS OF CARE | F-MARC PROJECTS
The new 2012 Zurich Consensus Statement is designed One of the critical issues in “Concussion Management”
to build on the principles outlined in the previous docu- are the “Return to Play (RTP)” guidelines, which were
ments and to develop further conceptual understand- already a focal point at the Prague Conference. The cor-
ing of this problem using a formal consensus-based nerstone of the most updated concussion management
approach. is physical and cognitive rest until the acute symptoms
resolve, and then a graded programme of exertion prior
This consensus paper is broken into a number of sec- to medical clearance and RTP follows (Tab. 6.2.1.1):
tions In the case of complex concussion, rehabilitation will
1. A summary of concussion and its management, with be more prolonged and return to play decisions will be
updates from the previous meetings; more cautious. Such complex cases should be managed
2. Background information about the consensus by physicians with a specific expertise in the manage-
meeting process; ment of concussion injury.
3. A summary of the specific consensus questions The Sport Concussion Assessment Tool (SCAT) was
discussed at this meeting; developed as part of the conclusions of the second con-
4. The consensus paper should be read in conjunction sensus conference. This tool represents a standardised
with the SCAT3 assessment tool, the Child SCAT3 method of evaluating players after a suspected concus-
and the CRT (designed for lay use). sion in football. SCAT2 was created following the third
consensus meeting and has two forms – a sideline assess-
ment form for team doctors and coaches and a more
What we learned from the meetings detailed medical evaluation form (Fig. 6.2.1.1).
A future SCAT test battery (ie. SCAT3) should include
At the fourth conference in Zurich 2012, a panel discus- an initial assessment of injury severity using the Glasgow
sion was held regarding the review of the definition of Coma Scale (GCS), immediately followed by observing
concussion and its separation from mild traumatic brain and documenting concussion signs. Once this is com-
injury (mTBI). Minor revisions were made to the “Defi- plete, symptom endorsement and symptom severity, as
nition of Concussion”, which is defined as follows: well as neurocognitive and balance functions, should be
F-MARC PROJECTS | IMPROVING STANDARDS OF CARE 175
Fig. 6.2.3.2 “Health and Fitness for the Female Football player”
In 2008, the FIFA Medical Committee and F-MARC There are large inter-individual differences in heat toler-
were mandated by the FIFA Executive Committee to ance among players, meaning that one player may suffer
study the different environmental conditions football heat exhaustion before another does have any symptoms.
players may be exposed to while training or playing foot- Further, a number of substances may reduce a player’s
ball. This was meant to include a review of the literature, ability to cope with heat stresses, as they are used in
carrying out new research where necessary, and devel- medications for allergies, colds, sleep or hyperactive dis-
oping recommendations for organisers of competitions orders. As continuous body temperature measurements
and match officials who have to deal with matches being are not feasible, the best approach to individual risk
played in extreme conditions. Heat is one of three envi- assessment is a pre-participation examination.
ronmental conditions raising most concerns in relation Environmental factors influencing the ability to cope
to performance issues and the health of players, together with high temperatures are most importantly high
with high altitude and cold. humidity, which impairs sweating, but also wind speed
and direct sun radiation. Therefore, environmental risk
cannot be properly assessed by dry air temperature meas-
Aims of the study urements alone. The currently best method to assess heat
illness risk is to measure the Wet Bulb Globe Tempera-
UÊÛiÃÌ}>ÌiÊÌ
iÊivviVÌÃÊvÊ`ÀÞÊÛiÀÃÕÃÊ
Õ`Ê
i>ÌÊV`- ture (WBGT), a composite of air temperature, humid-
tions ity, wind speed and sun radiation. Special devices are
UÊÃÃiÃÃÊLiÃÌÊ«À>VÌViÊvÀÊ>VV>ÌÃ>ÌÊÌÊ
ÌÊiÛÀ- available for measuring the WBGT at the spot. Where
ments and develop evidence-based recommendations these are not readily available, WBGT may be calculated
based on a formula derived from shaded dry bulb tem-
perature and humidity.
How we collected the data
A natural protection mechanism against heat illness is
The proceedings of a conference on sporting activi- to reduce exercise intensity. In football, this is reflected
ties in extreme heat conditions organised and hosted in less sprinting, less high-intensity running and small-
LÞÊ-*
/,ÊqÊ+>Ì>ÀÊ"ÀÌ
«>i`VÊ>`Ê-«ÀÌÃÊi`- er distances covered during the second half of matches.
cine Hospital, a FIFA Medical Centre of Excellence in Preventive measures further include adequate hydration
Doha, together with a number of studies investigating to avoid fluid losses of more than 2% of body weight,
the impact of hot environments when playing football which needs to be practised by each individual player.
supported by F-MARC formed the base for a position Further strategies are half-time cooling measures, or the
statement by international experts on playing football in introduction of additional fluid breaks.
hot environments.
F-MARC PROJECTS | IMPROVING STANDARDS OF CARE 183
What we learnt from the studies or to the match. This was first practiced at the final of
the Men’s Olympic tournament in Beijing, and thereaf-
The capacity to exercise is markedly reduced in hot envi- ter introduced by the FIFA administration as an impor-
ronments, with high humidity posing further physiologi- tant measure to protect players’ health at all FIFA com-
cal strain on the body. The combination of exercise and petitions.
hot environments increases the risk of heat illness and heat
stroke.
Observe signs and symptoms Fig. 6.2.5.1: Supplement “Exercise in Hot Environments: From Basic
High risk 28-30 Concepts to Field Applications”
Watch at-risk individuals
6.3.1 Gender Verification Regulations large it may be. In this regard, it has to be further noted
that among healthy men, the actual levels of circulating
testosterone and also their determination of muscle mass
Background and strength vary considerably.
The division of athletes into male and female catego- Finally, as all these individuals have grown up with a cer-
ries is widely accepted practice throughout sports. The tain gender identity, suddenly challenging this identity
rationale behind this separation is that there are sex dif- may potentially disrupt their concept of life. Doing so
ferences resulting from differences in testosterone and through publicly exposing them without respecting their
oestrogen levels. Testosterone, the major male sex hor- gender identity means a humiliation and trauma that
mone (androgen), increases muscle mass and strength, should be prevented at any cost.
bone size, mineral and haemoglobin content. Based
on numerous studies demonstrating the performance The FIFA Medical Committee and F-MARC therefore
enhancing capacity of testosterone, the use of artifi- decided to develop a proposal on gender verification
cially produced androgens (and of drugs which raise the regulations in football based on current standards of best
body’s natural androgen levels) in sports is prohibited. practice in medicine and science.
The previous use or current exposure to androgens is
considered as criteria for unfair competition in general.
Objectives
While this argumentation might appear straightforward
and the differences between men and women obvious, UÊ
ÃÕÀiÊ>ÊiÛiÊ«>Þ}Êwi`
there are a number of important considerations if we UÊ*ÀÌiVÌÊÌ
iÊ«ÀÛ>VÞÊ>`Ê`}ÌÞÊvÊ«>ÞiÀÃ
are to ensure a level playing field for all players, but also,
and at least as importantly, protection of the dignity and
privacy of the individual. Major stipulations
Deliberate cheating by men masquerading as women to The FIFA Gender Verification Regulations apply for all
gain an advantage in football is nowadays highly unlikely FIFA competitions and consequently have been adopted
and, moreover, would be easily revealed. A by far larger by the FIFA confederations. They major responsibility
and much more complicated problem is constituted by on the FIFA member associations to prevent exposure of
individuals having what is, albeit controversially, called players at an international level.
“disorders of sexual development”. This term includes
a broad variety of conditions where the sex of a person For FIFA men’s competitions, only men are allowed to
cannot easily be defined due to either a discrepancy play. For FIFA women’s competitions, only women are
between the sex as defined by their chromosomes as allowed to play. Each FIFA member association shall
opposed to their bodily characteristics, an ambiguity of ensure the correct gender of all their players by actively
their chromosomal sex itself, an underdevelopment of investigating any perceived deviation in secondary sex
their adrenal glands leading to hormone disturbances, characteristics and by keeping complete documenta-
and several other conditions. In all these conditions, the tion of the findings. A gender verification procedure
concerned individual is, rightly or wrongly, or out of may only be requested by either the player concerned, a
ignorance, assigned a sex at birth defining the person´s FIFA member association, the appointed FIFA Medical
gender identity. To complicate matters further, all these Officer or the FIFA Chief Medical Officer. The formal
conditions occur to a different degree, rendering correct requirements for requesting a gender verification proce-
sex assignment even more difficult. dure are strictly regulated, but one of the most impor-
tant points is that in case of an unfounded or irrespon-
While all these conditions represent constellations differ- sible request, the FIFA Disciplinary Committee may
ent from what is normally found in women and men, impose sanctions on the requesting body/person.
there is no scientific evidence as to whether a perfor-
mance advantage actually exists, respectively results, if If a request for initiating a gender verification procedure
the concerned person participates in sports. There is also is accepted by FIFA, the respective team doctor and
no evidence to define, if such advantage existed, how player have to provide the medical documentation estab-
F-MARC PROJECTS | IMPROVING STANDARDS OF CARE 185
Conclusions
References:
The FIFA Gender Verification Regulations entered into force
on 1 June 2011, prior to the FIFA Women´s World CupTM
(available from:
http://www.fifa.com/mm/document/footballdevelopment/medi-
cal/01/45/42/02/genderverification_efsd.pdf
186 IMPROVING STANDARDS OF CARE | F-MARC PROJECTS
Zurich ’05 Cape Town ’08 Sao Paulo ’09 Brugge ’10 Melbourne ’12 Pachuca ’12 Tokyo ’13
Auckland ’07 Doha ’08 Algiers ’10 Budapest ’10 Lyon ’12 Porto ’12 Kobe ’14
Johannesburg ’07 Oslo ’08 Durham ’10 Rome ’10 Barcelona ’12 Innsbruck ’13 Madrid ’14
Kawasaki ’07 Regensburg ’08 Guadalajara ’10 Stockholm ’10 Brasilia ’12 St. Georges Park ’13 London ’14
Munich ’07 Bologna ’09 Prague ’10 Cardiff ’12 Clairefontaine ’12 Murcia ’13 Poznan ’14
Santa Monica ’07 Saarbrücken ’09 Zeist ’10 Bangkok ’12 Istanbul ’12 New York ’13 Warsaw ’14
1. Schulthess Clinic Zurich, CH 29. ‘Centre Technique National de Football’ Medical Centre, Clairefontaine, FRA
2. UniSports Sports Medicine, Auckland, NZ 30. Acibadem Fulya Orthopedics and Sports Medicine Clinic, Istanbul, TUR
3. Centre for Exercise Science and Sports Medicine, Johannesburg, RSA 31. Intermédica, Medical SA Ideas de CV, Pachuca, MEX
4. St Marianna University School of Medicine, Kawasaki, JPN 32. Clínica Espregueira-Mendes (Clínica EM), Porto, POR
5. Orthopädische Klinik, Munich, GER 33. OSM Research Foundation, Innsbruck, AUT
6. Santa Monica Orthopaedic and Sports Medicine, Santa Monica, USA 34. The Football Association Sports Medicine & Sports Science Department, St.
7. UCT/MRC Research Unit for Exercises Science and Sports Medicine Cape George’s Park, UK
Town, Cape Town, RSA 35. Ripoll y de Prado Sport Clinic, Murcia, ESP
8. ASPETAR – Qatar Orthopaedic and Sports Medicine Hospital, Doha, QTR 36. Hospital for Special Surgery, New York, USA
9. Oslo Sports Trauma Research Center, Oslo, NOR 37. Juntendo University Hospital, Tokyo, JPN
10. University Medical Centre, Regensburg, GER 38. Kobe University Graduate School of Medicine, Hyogo Prefectural
11. Isokinetic Medical Group, Bologna, ITA Rehabilitation Centre, Center Hospital, Kobe, JPN
12. Institut für Sport- und Präventivmedizin, Universität des Saarlandes, 39. Clinica CEMTRO, UCAM-Universidad Catolica San Antonio, Clínica
Saarbrücken, GER Traumatológica, Madrid, ESP
13. Instituto de Ortopedia e Traumatologia da FMUSP, Sao Paulo, BRA 40. Fortius Clinic, London, UK
14. Clinique Chahrazed – Département Médecine et Traumatologie du Sport, 41. Rehasport Clinic sp. z.o.o., Poznan, POL
Algiers, ALG 42. Carolina Medical Center, Warsaw, POL (FIFA Medical Clinic of Excellence)
15. Duke University Medical Center, Durham, USA
16. Sport Med ‘Clinica de Medicina del Deporte’, Guadalajara, MEX (FIFA
Medical Clinic of Excellence),
17. Department of Orthopaedics of the 1st Faculty of Medicine of Charles
University and Teaching Hospital na Bulovce, Prague, CZ
18. Royal Netherlands Football Association Sports Medical Centre, Zeist, NED
19. Bruges – Roeselare AZ St-Jan av, Department Sports Medicine, Brugge, BEL
20. Uzsoki Hospital, Budapest, HUN
21. Villa Stuart Sport Clinic, Institute of Sport Medicine – CONI – FMSI, Rome,
ITA
22. Capio Artro Clinic, Stockholm, SWE
23. Cardiff Sport and Exercise Medicine Centre, Cardiff School of Sport, Cardiff
Metropolitan University, Cardiff, UK
24. Bangkok Hospital Medical Center (BMC), Bangkok, THA
25. Olympic Park Sports Medicine Centre Pty Ltd, Melbourne, AUS
26. Albert Trillat Centre, Croix-Rousse Hospital, Centre Orthopédique Santy,
Lyon, FRA Duration: 2005 - ongoing
27. FC Barcelona, Medical Services, Barcelona, ESP
28. HOME – Hospital Ortopédico e Medicina, Especializada, Brasilia, BRA
Countries: International
Cooperation: International
188 THE FIGHT AGAINST DOPING IN FOOTBALL | F-MARC PROJECTS
7.1. FIFA’s Approach to the Fight against following their Hippocratic Oath as well as their profes-
Doping in Football sional and ethical values.
UÊ1«
`Ê>`Ê«ÀiÃiÀÛiÊÌ
iÊiÌ
VÃÊvÊëÀÌ
UÊ->vi}Õ>À`ÊÌ
iʫ
ÞÃV>Ê
i>Ì
Ê>`ÊiÌ>ÊÌi}ÀÌÞÊvÊ Statistics
the player
UÊ
ÃÕÀiÊÌ
>ÌÊ>ÊV«iÌÌÀÃÊ
>ÛiÊ>ÊiµÕ>ÊV
>Vi The confederations and/or member associations that
come under FIFA’s umbrella carry out their own doping
FIFA introduced doping controls in 1970 to ensure that controls at the competitions they stage. Also National
the results of matches played as part of its national and Anti-Doping Organisations (NADOs) are allowed to
international competitions were a fair reflection of the conduct testing of national players (in- and out-of-com-
ability of those taking part. The FIFA Medical Commit- petition), as well as of players from other countries com-
tee has the overall responsibility for not only implement- peting within that nation’s borders. Urine and/or blood
ing doping controls at all FIFA competitions but also samples collected must, however, be analysed at WADA-
for the harmonisation with confederations and member accredited laboratories. These laboratories send reports
associations. It is supported by the FIFA Doping Con- on any “chemically positive” A samples – so called
trol Sub-Committee, and since 2007, by the TUE advi- Adverse Analytical Findings (AAFs) or Atypical Findings
sory group. The administrative management of the dop- - to the member associations, FIFA Anti-Doping Unit
ing controls is overlooked by the FIFA medical office, for management and to WADA for information.
and since May 2009, by the FIFA Anti-Doping Unit. Once the FIFA Anti-Doping Unit receives a positive A
sample result, follow-up information is required by the
Over the years, F-MARC has developed a worldwide member association and/or confederation in question to
network of specialists, who are involved in the educa- be informed on the results of the B sample and particu-
tional process within the confederations and member larly the respective disciplinary committee decision. If
associations as well as in the practical approach for the the information is not provided, the FIFA Disciplinary
domestic, international and FIFA competitions. The Committee takes appropriate action.
physicians play the key role in FIFA’s long-term strategy Between 1994 and 2013, 11,086 doping tests were per-
of prevention and education in the fight against doping, formed at FIFA competitions (Tab. 7.1.1). Of these, 13
samples tested positive: five samples of anabolics, two of
F-MARC PROJECTS | THE FIGHT AGAINST DOPING IN FOOTBALL 189
ÊiViLiÀÊÓääÎÊÊ
>É+>Ì>ÀÊÌÊiÝÌi`ÊÃ>VÌÃÊ of specially trained physicians who act as FIFA Doping
by the FIFA Disciplinary Committee of member associa- Control Officers (DCO). With regard to medical con-
tions (being expelled) for all international matches fol- fidentiality and the necessity for specific knowledge in
lowing the same method of individual case management. the field, FIFA exclusively appoints physicians (MDs) to
In 2009 it was further decided to establish a new admin- perform this task.
istrative body, the FIFA Anti-Doping Unit to coordi- The FIFA doping control procedure is straightforward
nate the activities of the different departments involved and transparent leaving no place for cheating or wrong-
and ensure and survey implementation of the WADA doing when all steps are performed in the presence of
Code in 2009 at all levels of the organisation. With the representatives from both teams.
implementation of the new World Anti-Doping Code in FIFA DCOs have all attended instructional seminars
2015 and the FIFA Anti-Doping Regulations 2015, fur- conducted by F-MARC and the FIFA Anti-Doping
ther measures and procedures were institutionalised to Unit in order to secure “unity of doctrine”. The DCOs,
ensure that all FIFA member associations comply with as members of the FIFA network, are located around the
the WADA Code. world. A new education and training scheme was devel-
oped and presented to the FIFA Medical Committee at
the beginning of 2009 and has been implemented since
Prohibited substances prescribed for medical that time.
reasons – Therapeutic Use Exemption (TUE)
7.2 Comprehensive Information for longer at the top of the list of prohibited compounds
Laymen detected at WADA-accredited laboratories. Canna-
bis might be considered as having an indirect impact
on performance by reducing anxiety before a match or
“Make the game doping free” is the aim of the anti- increasing relaxation after a match. However, regular
doping strategy of FIFA. Not only is the integrity of the use can alter behaviour, concentration and motivation.
game at stake, but so too is the need to protect the play- Cocaine is the most powerful naturally occurring stim-
ers’ health and keep them from the harm that can result ulant of the nervous system and is highly addictive. It
from doping. Football players who compete in FIFA has no performance enhancing effect on running times
World Cups™ are ambitious professionals and FIFA or endurance. The addictive nature of the drug can lead
wants to ensure their support in the fight against doping a player to redirect their energies away from sport and
whilst demonstrating respect for the privacy and dignity towards how to obtain their next dose. Both drugs are
of each player. easily detected in urine.
Beta-2 agonists
Duration: 2006
Glucocorticoids Countries: International
Cooperation: Martial Saugy, Laboratoire suisse d‘Analyse
This class of compounds has unchallenged therapeutic du Dopage, University of Lausanne, Switzerland; Michel
potential for treating numerous inflammatory and other D‘Hooghe, Bruges, Belgium; FIFA Medical Office, Zurich,
diseases and is a first line therapy for the treatment of Switzerland
asthma. Sports medicine physicians have used gluco- Reference:
corticoids for numerous situations such as muscle inju- Dvořák J, Grimm K (eds) (2006). The Fight against Doping in
ries, tendon injuries, musculoskeletal inflammation and Football. A comprehensive introduction and overview. FIFA’s
more. The World Anti-Doping Agency bans all oral, strategy, the relevant substances, their effects and detection.
intravenous or intramuscular routes of administration Official publication of the Fédération Internationale de Football
and requires a formal use exemption for athletes treated Association, Zürich, Switzerland
194 THE FIGHT AGAINST DOPING IN FOOTBALL | F-MARC PROJECTS
4.0 4.0
NE/NA ratio A
NE/NA ratio B
3.0 3.0
2.0 2.0
1.0 1.0
0.0 0.0
0 24 48 0 24 48
Time (h) Time (h)
350 350
NE NA
300 300
250 250
Abundance (x 1000)
Abundance (x 1000)
200 IS 200
150 NA 150 IS
NE
100 100
50 50
0 0
14.00 15.00 16.00 17.00 18.00 19.00 20.00 14.00 15.00 16.00 17.00 18.00 19.00 20.00
Time (min) Time (min)
Fig. 7.3.1.1 NE:NA ratios (top) for two volunteers after the oral administration of two doses of nandrolone and corresponding chromatograms (bot-
tom) obtained by GC-MS from spot urines collected at 50.5 h (A) and 54 h (B) after the first nandrolone dose (t0).
7.3.2 Testosterone Variability – the Influence for the study. More specifically, samples from 57 Afri-
of Ethnicity on Steroid Profiles of can players (Uganda, South Africa), 32 Hispanic players
Football Players (Argentina), 32 Asian players (Japan) and 50 Caucasian
players (Switzerland, Italy) were taken. All samples were
analysed to determine the T/E ratio and analyse the ster-
Why we conducted this study oid profile and isotopic ratio of testosterone metabolites.
A new method for detection and quantification of ster-
When looking at the statistics of adverse analytic fin- oid conjugates in urine samples was used in addition to
dings (AAFs) reported by the WADA-accredited labora- already established methods.
tories during the last years, it becomes obvious that tes-
tosterone accounts for a high proportion of these cases.
This does not reflect the actual use of endogenous ste- Results
roids in sport, in particular not in football, but rather
indicates that currently used parameters for the detection No sample showed an absolute steroid concentration
of steroids are leading to false positive results. This rep- higher than the respective threshold defined by WADA.
resents one of the most important problems internation- /
ÀiiÊÃ>«iÃÊ£°Ç¯®ÊÃ
Üi`Ê>Ê/É
À>ÌÊ{]ÊLÕÌÊÌ
iÊ
al sport federations face nowadays. Previous studies with above-mentioned IRMS did not reveal evidence for
volunteers receiving testosterone had shown considerable exogenous steroid use. Significant differences of the T/E-
variability between individuals regarding the diagnostic ratio were observed between all ethnic groups. Based
results of testosterone abuse. on the results, ethnic-specific T/E-ratio thresholds were
developed (Africans 5.6; Asian 3.8; Caucasian 5.7; His-
Recently, the World Anti-doping Agency Code 2009 panic 5.8).
was adopted establishing the need of submitting a sam-
ple to isotopic ratio mass spectrometry (IRMS), if the Defining a unique and non-specific threshold to indicate
urinary T/E ratio value is equal to or greater than four anabolic steroid abuse is not fit for purpose in doping
(previously at six). If such IRMS does not readily indi- control. Individual steroid profiling in players would
cate exogenous steroid intake, the result is reported as allow individual reference values (endocrinological pass-
inconclusive and further longitudinal studies can be per- port) to be identified. It was also shown that the thresh-
formed. While longitudinal studies to investigate elevat- old value of four lies considerably below the ethnic-spe-
ed T/E ratios are very costly, there is no strong scientific cific threshold values in all but the Asian players.
evidence supporting the following decisions of discipli-
nary committees. F-MARC therefore sees a clear need
to conduct further investigations in individuals showing
different metabolism speed in order to identify more val-
id biomarkers of steroid abuse.
UÊÛ`Êv>ÃiÊ«ÃÌÛiÊÀiÃÕÌÃÊÜ
iÊVÕÀÀiÌÞÊÕÃi`Ê«>À>
meters are measured including consequences with
regard to costs, time etc.
UÊ*ÀÛ`iÊëÀÌÊ>ÕÌ
ÀÌiÃÊÜÌ
ÊivwViÌÊÌÃÊÌÊÌ>iÊ
their decisions based on scientific data in case of an
altered steroid profile
7.3.4 Profiling of Steroid Metabolites after 12 targeted steroid metabolites quantified in this study
Transdermal and Oral Administration of in more than 500 urine samples was evaluated with
Testosterone respect to both route of T administration based on indi-
vidual threshold levels.
Fig. 7.3.4.1 Principal component analysis (PCA) biplot combining samples distribution (scores) and analytes’ contributions (loadings) for the 12 tar-
geted steroids. (A) Transdermal T patch administration and (B) oral TU pills intake. Empty ◊,i and Δ correspond to the control samples from the del/
del, ins/del and ins/ins UGT2B17 genotype, respectively. Full t, l and p are related to samples exposed to transdermal or oral T for the del/del, ins/
del and ins/ins UGT2B17 genotype, respectively. X represents the contributions of the targeted steroids. The variables were represented by PC1 and
PC2 on the biplot.
on Monday and Wednesday. The patch system (P) was As samples collected at different time points constituted
stuck on the shoulder and removed after 48 h. During homogeneous clusters, no chronological trend could be
that time urine and blood were taken at times P-t00 = highlighted on the PCA biplot for control and transder-
0 h, P-t01 = 2 h, P-t02 = 4 h, P-t03 = 8 h, P-t04 = 12 mal data. Therefore, T patch administration could not
h, P-t05 = 24 h and P-t06 = 48 h. Time points P-t07 reveal a detectable influence on the steroid profile sug-
= 60 h, P-t08 = 72 h and P-t09 = 96 h were collected gesting that the induction of the phenomenon was
after the application of the second patch. Apart from too small. The effect of the treatment was confounded
the mentioned collection times, all the urines produced with the biological variability and could certainly be
were gathered during 48 hours after the application of attributed to the low dose and bioavailability as well
the first patch. During the two following weeks, the as the slow kinetic release of topical system. Neverthe-
first morning urine as well as a blood sample was col- less, three clusters could be clearly distinguished, corre-
lected on Mondays. Following a wash-out period of sponding to the three UGT2B17 genotypes and indicat-
two weeks, two TU tablets of 40mg were taken orally }Ê>Ê}À>`>ÌÊvÊÃÌiÀ`ÊiÛiÃÊ`iÉ`iÊÊÃÉ`iÊÊÃÉ
by the volunteers on Monday and Wednesday. During ins). This observation suggests that the basal level of the
the fifth week, urine and blood specimens were collected steroid profile is closely related to the UGT2B17 geno-
after oral pill ingestion (O) at the same time points to type and correlates with the TG/EG level in urine. The
those of T patch administration (O-t01-09). Blood tests PCA biplot of samples from volunteers exposed to oral
included one EDTA tube of 7mL and two serum tubes TU and controls revealed a different picture. While no
of 4.5mL. In this study, blood samples were only used effect of this high dose could be highlighted for the del/
for genotyping but frozen at -20 °C for future studies. del UGT2B17 genotype, a clear trajectory was revealed
UGT2B17 and UGT2B15 genotyping was conducted for the inserted heterozygotous and homozygotous indi-
and genotypes were well balanced with 5 del/del, 7 ins/ viduals by linking the time points. Del/del individuals
del and 7 ins/ins genotypes for UGT2B17 and 5 YY, 4 remained apparently unaffected by the treatment, as the
DD and 10 YD for the rs1902023SNP of UGT2B15. samples were clustered with controls, but time points 2,
Urine samples were then analysed with the UHPLC– 4, 8 and 12 h post-dose of ins/del and ins/ins genotypes
+/"-ÊiÌ
`° were clearly separated from the control samples follow-
ing a chronological trajectory. By these means, an acute
excretion state, starting from 2 h to 12 h after TU pill
Results intake could be distinguished from a basal level, and the
analysis of the variables’ contributions indicated TG/
Two principal component analysis (PCA) models were EG, TG, DHTG and 5αββ-AdiolG as compounds driv-
calculated to assess the trends related to both T admin- ing the trend highlighted after TU pill administration.
istration routes compared to control urines (Fig 7.3.4.1).
202 THE FIGHT AGAINST DOPING IN FOOTBALL | F-MARC PROJECTS
Fig. 7.3.4.2 TG/EG, DHTG and EtioS excretion profiles. Subjects 01, 13 and 15 are depicted with the individual threshold (bold line) after transder-
mal T and TU oral administration.
ROC curve analysis was performed to evaluate the over- individual thresholds were set up, to avoid the influence
all accuracy of the measured parameters for the discrimi- of ethnicity and genotyping on the reference limit, as
nation between control and T administered subjects. proposed for the forthcoming ASP approach.
For that purpose, true positive rate (sensitivity) and The usefulness of each marker after transdermal and oral
false positive rate (1-specificity) were assessed at differ- administration of T was evaluated by setting subject-
ent thresholds. Transdermal testosterone administration based thresholds. Detection time was defined as the time
ROC curves were built for each targeted steroid from after T administration when the measured concentration
the control and the patch group. The most relevant was higher than the individual threshold, assuming that
markers of the steroid profile were TG and the TG/EG the administration of T will increase the levels of the
ratio. Regarding topical T application, TG and TG/ metabolites (Fig. 7.3.4.2).
EG were poorly predictive. ROC curves of all the oth-
er compounds had very low discrimination power. The Only a few markers revealed detection ability based
poor sensitivity could be attributed to the low dose and on individual threshold after transdermal testos-
bioavailability of the topical route, as well as the geno- terone administration. While the concentration of
typicUGT2B17 diversity included in the study. Oral EG, DHEAG and ES never rose beyond the indi-
testosterone administration ROC curves of 5 biomarkers vidual threshold, the best markers were TG, the TG/
from the steroid profile, including the TG/EG, present- EG ratio and the AG/EG ratio. Individual thresholds
ed good accuracy indices after TU administration. As were reached for 13 volunteers out of the 19, and the
expected, TG and TG/EG provided the best discrimina- effect was less pronounced for the del/del genotype, as
tion power but parameters such as AG as well as DHTG expected. The elevation of those markers after T patch
showed also satisfactory performance indices. From the administration followed the slow-kinetic release of the
sulfo-conjugated steroids, EtioS revealed also appropri- topical route with detection time mostly between eight
ate accuracy. To assess the pertinence of each biomarker, hours and 24 hours after T patch administration. The
F-MARC PROJECTS | THE FIGHT AGAINST DOPING IN FOOTBALL 203
other targeted steroids quantified in the urinary samples erences, as found in the ASP, implemented with novel
were not notably modified after T patch administra- biomarkers (hydroxy-, sulfo-conjugated) would thus be
tion. While the classic biomarkers used to screen for T the most adequate tool to screen for T misuse. Eventu-
misuse were not able to detect low T transdermal dose ally, the blood matrix collected during this clinical trial
administration, the longitudinal follow-up of these will constitute invaluable complementary information to
markers based on subject-based thresholds presented reveal T doping as a future perspective. In addition, as
higher detection ability predominantly at time 24 hours an untargeted acquisition over the entire selected mass
after patch application. However, most of the parame- À>}iÊÜ>ÃÊ«ÃÃLiÊÜÌ
ÊÌ
iÊ+/"Ê>ÃÃÊëiVÌÀiÌiÀ]Ê
ters remain below the individual threshold for the indi- unknown markers could be extracted. In the future, the
viduals bearing the del/del genotype. Regarding subject- predictive ability of these markers will be investigated
based detectability after TU pill administration, the with respect to T transdermal and oral administration,
most relevant biomarkers were glucuro-conjugated ana- without necessity to re-analyse the samples. The selec-
lytes including TG, AG, EtioG, 5αββ-AdiolG, DHTG, tion of untargeted metabolites is promising for a broader
as well as the ratios TG/EG and AG/EG. However, TG, steroid profiling on fresh and well-structured clinical
5αββ-AdiolG, DHTG, TG/EG and AG/EtioG ratios study samples.
could not detect exogenous intake of TU by individu-
als bearing the del/del genotype. For all of the elevated
markers and in accordance with several studies, the
detection window ranged from two hours to 12 hours,
with an excretion peak between four hours and 12 hours
and returned to the baseline level 24 hours after pill
intake. Based on individual threshold strategy, the inte-
gration of multiple parameters in a longitudinal follow-
up could enhance the detection ability and discrimina-
tion power between confounding factors, individual
biological variability and oral TU intake doping.
7.3.5 Influence of Multiple Injections of ed at a concentration above this value, considering that
Human Chorionic Gonadotropin (hCG) over production of hCG could become from tumor cells.
on Urine and Serum Endogenous It is therefore complex to put forth doping with hCG in
Steroids Concentrations male athletes using only the urinary matrix.
Serum T, LH and hCG as well as urine LH and hCG the successive injections while the rest of the individu-
were measured by immunoassays with an IMMULITE als presented stabilisation. It is known that when hCG is
2000 machine, using T, LH and hCG kits. The sample intra-muscularly administered, the maximum plasmatic
analyses were conducted in duplicate and the mean value level is reached between two and six hours. Further-
was considered for result evaluations. more, hCG is eliminated in two phases with a first of
During the clinical study part conducted in 2010 in 8–12 hours and a second of 23–37 hours, principally in
Switzerland after approval by the Human Research the kidney. As a consequence, the inter-individual vari-
Ethics Committee Vaud, the method was applied to ability observed in the excretion through urine is more
healthy male volunteers (n = 10). Three HCG injec- important than in serum. The concentrations observed
tions (2000 I.U. Choriomon®) were performed at days in the spot urines were comparable to serum levels for
0, 2 and 4 between the hours of 7.00 and 8.00 just after eight individuals, but two other subjects presented very
urine and serum collection. Other urine and serum col- low levels of urinary hCG.
lections were scheduled as described in Tab. 7.3.5.1.
Basal levels of the molecules of interest were determined The mean level in all subjects of serum T increased 12
on four samples (B1–B4 and U1–U4). After the third hours after the first injection and increased some more
hCG injection, every spot urine were collected for 48 after 24 hours. Likewise, the mean value increased 24
hours (8–25 samples depending on the subject). Serums hours after the second injection. Twelve hours after the
were aliquoted and kept frozen at −20 °C until analy- last injection, the mean serum concentration was slight-
sis. Serum LH, hCG and T were measured 4 months ly decreased. Interestingly, the mean testosterone level
after collection. Urine samples were divided in several in serum was significantly decreased twelve days after
vials and frozen at −20 °C prior to analysis within two the last injection dose compared to the basal level. It is
months. This protocol was approved by the Ethical important to note that at the basal level, the circadian
Commission for the Clinical Research of the Faculty of influence on T production was significant with a high-
Biology and Medicine (University of Lausanne, Laus- er value on morning blood samples than evening. The
anne, Switzerland). same difference was observed on the two last samples
collected in the morning and the evening 12 days after
the last injection.
Results
The serum LH level decreased along the study due to
All subjects responded to the hCG injections by an the negative feedback on the hypothalamopituitary axis
increase of hCG levels in serum and urine. Twelve (HPA) performed by T up regulation. The average LH
hours after the first injection, nine subjects presented the basal level remained stable 12 hours after the first injec-
maximal serum concentration of hCG. One individu- tion and decreased after 24 hours and further on after
al still presented an increase between 12 and 24 hours 48 hours. The average LH concentration remained low
whereas the others presented a decrease in hCG level. 24 hours after the second injection and 12 hours after
In four individuals, an accumulation was observed after the last injection. Twelve days after the last injection, the
206 THE FIGHT AGAINST DOPING IN FOOTBALL | F-MARC PROJECTS
Fig. 7.3.5.1 T/LH ratio follow-up along the study in serum (a) and in urine (b) (mean ± standard error of the mean (SEM))
LH level among volunteers was not significantly differ- samples collected on mornings and evenings. In order to
ent from the basal concentrations measured before the compare A/Etio levels along the study, morning values
first treatment. were compared to morning basal values and evening val-
ues to evening basal values. This ratio was significantly
As a consequence, the T/LH ratio in serum was sub- increased from 12 to 24 hours after the first injection,
jected to a major increase due to hCG administration at 12 hours and 24 hours after the second injection and
(Fig. 7.3.5.1). The average basal ratio value was 4.6 and 12 hours after the last injection with a maximal value
increased to 6.3 after 12 hours and 13.3 after 24 hours. observed 12 hours after the last injection. If the elimi-
At the second injection time, the T/LH ratio was of 24.9 nation kinetic is similar to T for the other steroids, the
and increased to 44.3 after 24 hours. A large inter-indi- recovery of basal values 12 days after the study was dif-
vidual variation was observed on the T/LH ratio mainly ferent regarding the steroid. While E followed the same
due to the T response to hCG injections. Three individ- significant tendency as T, i.e. to be below the basal level,
uals presented a decrease of the T/LH ratio between the A, Etio, DHT, 5α-diol, 5β-diol and DHEA were not
second injection and 24 hours later essentially due to a significantly different from basal values 12 days after the
rapid tendency to recover basal LH levels. Twelve hours last hCG injection.
after the last injection, the influence on the T/LH ratio
was still important. And as a consequence of the low Regarding urinary LH, the profiles were not significantly
T level 12 days after the last hCG injection, the T/LH influenced by the hCG treatment during the whole pro-
ratio was significantly below the basal value. tocol, however unpredictable fluctuations were observed.
Nevertheless, the T/LH ratio in urine was studied as an
Urinary T excreted under its glucuro-conjugated form alternative to the T/E ratio to deter hCG administra-
adjusted to specific gravity presented essentially similar tion, particularly in UGT2B17 deleted individuals. The
pattern to serum except that the inter-individual vari- hCG injections affected the T/LH ratio by an increase
ability was much higher. Two subjects presented a ster- of up to 110 times when the maximum T/E increase in
oid profile typical of individuals devoid in UGT2B17 UGT2B17 del/del subjects is of 1.9 times.
with an average basal T glucuronide level in urine sig-
nificantly inferior. Only for individuals with inserted Relative serum T/LH (absolute values corrected by the
UGT2B17, the T increase in urine was significantly individual basal values) as biomarker of hCG adminis-
delayed compared to serum 24 hours after the first injec- tration presented the highest discriminating power, fol-
tion, at the second injection time and 24 hours after the lowed by T in serum and T in urine. Due to the difficul-
second injection. The excretion patterns of the steroid ty to measure low concentration of LH in urine, the T/
profile were similar to T with differences in the accu- LH ratio in urine was prone to outliers’ events in some
mulation after the successive injections of hCG. This cases. In order to satisfy anti-doping requirements, the
explains for instance the non-significant variation for the cut-offs were defined for a maximal specificity.
T/E. It is important to note that a significant difference
in basal values of the A/Etio ratio was observed between
F-MARC PROJECTS | THE FIGHT AGAINST DOPING IN FOOTBALL 207
8.1.1 Prevention of Risk Factors for Non- training on performance, muscle adaptations and health
Communicable Diseases profile follow.
Football’s worldwide governing body (FIFA) attaches Football practice organised as small-sided games for two
particular importance to health. In 1994, an independ- to 14 players provides a marked physiological response
ent research unit was established, the FIFA Medical even for youngsters, elderly and untrained individuals.
Assessment and Research Centre (F-MARC), with the
objective of developing the scientific basis to protect the
health of all players and promote football as a health- Effect of regular participation in small-sided
enhancing leisure activity. The focus of ‘‘Football for games on performance and muscle adaptations
Health’’ is not only on players’ health, but also on the
health of society as a whole. Football’s popularity gives Football training for 12–16 weeks carried out as small-
it the potential to play a unique role in awareness and sided games two to three times (one hour) a week of
prevention of diseases – and at very low costs. FIFA/F- untrained middle-aged male and female players without
MARC has clear goals: to protect the health of the 265 prior experience with football, led to e.g.:
million active participants worldwide and to promote UÊ
>Vi`Êi>ÊL`ÞÊ>ÃÃÊ>`Êi}ÊÕÃViÊ>ÃÃ
football as a safe and healthy leisure activity contributing UÊ
>Vi`Ê>Ý>Ê`Þ>VÊ
>ÃÌÀ}ÊÕÃViÊ
to an improvement in health of the general population. strength
UÊ «ÀÛi`Ê«ÃÌÕÀ>ÊL>>Vi
Thus, 12–16 weeks of football training is sufficient
Aims of the studies to induce a variety of performance enhancements and
muscular adaptation, which can be maintained, and
UÊÛiÃÌ}>ÌiÊ
i>Ì
Ê>`ÊwÌiÃÃÊLiiwÌÃÊvÊÀi}Õ>ÀÊ«>À- some further elevated if training is continued even at a
ticipation in small-sided football games of various age reduced frequency.
groups over a period of up to 16 months
UÊ>ÞÃiÊÌ
iÊivviVÌÃÊvÊvÌL>ÊÌÀ>}ÊvÀÊ>Ê«
ÞÃ-
ological, medical, social and psychological perspective Health benefits of regular participation in
football practice
Results
Social and psychological effects
A summary and interpretations of the main findings
divided into an analysis of the physical demands during The psychological effects of football training organised
training of various groups and the effect of a period of in small groups of 10–20 participants, most of whom
F-MARC PROJECTS | FOOTBALL FOR HEALTH 209
were untrained and had no particular prior experiences ferent ages with proper control groups are warranted to
or skills, were as follows e.g.: obtain evidence-based recommendations for using foot-
UÊ ÊÀiÜ>À`}Ê«ÃÞV
}V>ÊÃÌ>Ìi]Ê`ÕÀ}ÊvÌL>ÊÌÀ>- ball in the early treatment of obesity and related co-mor-
ing bidities in childhood.
UÊ `iÀ>ÌiÊÀ>Ì}ÃÊvÊ«iÀViÛi`ÊiÝiÀÌÊ>`ÊÜÊÃVÀiÃÊ
for worry
UÊ ÌL>ÊÌÀ>}ÊÃÊvÕÊ>`Ê>ÊÀiÜ>À`}Ê>VÌÛÌÞÊÜÌ
Ê What we learned from the study
the social capital and health promotion
The studies demonstrated that carrying out regular foot-
ball training organised as small-sided games two to three
Comparison of football training and endurance times a week, causes significant cardiovascular and mus-
running cular adaptations, including muscle growth and elevated
muscular strength independent on the level of training,
Regular recreational football training was compared with lack of experience with football, gender and age. The
endurance running in a number of studies using physi- effects can be maintained for a long period even with
ological, psychological and sociological methods. Most a reduced frequency of training to one to two times
of the results and adaptations were the same for football for one hour a week. Recreational football, therefore,
and running, but in a number of areas football training appears to be an effective type of training leading to per-
exceeded that of endurance running, e.g. formance improvements and significant beneficial effects
UÊ Ài>ÌiÀÊÛ>À>ÌÊÊ
i>ÀÌÊÀ>ÌiÊ>`Ê>>iÀLVÊiiÀ}ÞÊ to health, including a reduction in the risk of cardiovas-
turnover cular diseases, falls and fractures. In a number of aspects,
UÊ VÀi>ÃiÊÊÕÃViÊ>ÃÃÊ>`ÊiiÛ>ÌÊÊ6"2max football training appears to be superior to running train-
UÊ ÌÛ>Ìi`ÊLÞÊÌ
iÊ>VÌÛÌÞÊ>`ÊvÕÊ>`ÊLi}ÊÌ}iÌ
iÀÊ ing. Football training can also be used to treat hyperten-
in the group sion and it was clearly superior to a standard treatment
strategy of physician-guided traditional recommenda-
tions.
Effects of lifelong participation in football The supplement papers reveal that football is a motivat-
practice for the elderly ing activity that promotes social interactions and has the
potential to facilitate adherence to an active life style.
Elderly men (63-78 years) exposed to lifelong football The supplement offers scientific evidence that football
had superior muscle force characteristics and better pos- can be promoted as a health-enhancing leisure activity.
tural stability compared with untrained age-matched
individuals, and the same levels as untrained young
men. A higher rate of force development in the football-
trained elderly could be attributed to qualitative neuro-
muscular and tendinous factors, such as motor unit fir-
ing rate and tendon stiffness, rather than quantitative
factors such as muscle size.
8.2.1 Development and Evaluation in area; (2) the availability of local organisations with suffi-
Different Settings cient experience to help deliver the football-based health
education programme on site; (3) access to a suitable
group of men/women who could be trained as instruc-
Why we conducted these studies tors and coaches and who were fluent in the local lan-
guage and familiar with local culture. To strengthen the
The World Health Organization (WHO) has identified appeal of the programme, each health message received
the major worldwide mortality risk factors, and has esti- the support of an international elite football player as
mated that, by 2020, preventable non-communicable a role model to encourage children to follow the pro-
diseases will be responsible for ~70% of deaths. Only gramme.
20% of chronic disease deaths occur in high-income
countries, 80% occur in low and middle-income coun- The intervention consisted of 11 90-minute sessions,
tries. divided into two 45-minute halves of Play Football
(football skills) and Play Fair (health issues). Each ses-
In 2006, FIFA recognised the unique role of football in sion focused on one specific health issue or health risk
the promotion of exercise and health behaviour. Given factor. Main outcome measures for the implementa-
the strong evidence that exercise is suitable as a thera- tion were: (1) health knowledge using a 20-item (South
py for a wide range of diseases, and football being the Africa), and 30-item questionnaire (Mauritius; Zim-
most popular sport worldwide, FIFA decided to help to babwe), implemented pre- and post-intervention; (2)
reduce the burden from communicable and non-com- coaches’ attitudes towards their training using a ten-item
municable diseases to its best endeavours. This led to the questionnaire (South Africa); and (3) children’s attitude
development of a football-based health education pro- towards the health education programme using a six-
gramme, which was named “Football for Health”, and item questionnaire designed with the Likert scale.
was first implemented in South Africa in 2009. In 2010,
the programme was then implemented in Mauritius and Based on the results from a pilot study, it was suggest-
Zimbabwe, and received its current name “FIFA 11 for ed that a sample size of ~110 children would be needed
Health”. to identify with 95% confidence and 90% power an
increase in the proportion of correct responses to 80%
after the intervention. It was assumed that an overall loss
Aim of the studies of ~25% would occur in the follow-up so that the mini-
mum initial sample size required in each group should
UÊiÛi«]Ê«iiÌÊ>`Ê>ÃÃiÃÃÊ>ÊÌiÀ>VÌÛi]ÊvÌL> be ~150 children.
based health education programme for children in
South Africa, Mauritius and Zimbabwe The implementation took place in 2009 in South Africa
in two schools, and in 2010 as in-school intervention
at 11 secondary schools on Mauritius and as an out-of-
Method school intervention using local coaches in Zimbabwe.
Overall, three groups of 370-395 school children aged
In the initial stage, two focus groups comprising doc- 12-15 participated in the implementation.
tors, researchers and representatives of government
and non-government organisations from Africa met in
2007 to discuss the build-up of the programme. It was Results
decided that the implementation and evaluation of the
programme should follow the ten-stage process already South Africa: Average attendance levels were 89.5% for
proposed by the WHO for AIDS health promotion pro- the intervention group, grade 7; 93.9% for the control
grammes. Two additional health messages were added to group, grade 7; 93.4% for the intervention, grade 6.
the programme: “use of bed nets” to prevent the spread There were no significant differences between the num-
of malaria and dengue fever, and “respect for girls and ber of boys and girls included in each group, and no
women” to reduce the spread of sexually transmitted dis- statistically significant differences in the demographic
eases. It was based on three factors: (1) the prevalence data for the children. Responses to the health-related
of communicable and non-communicable diseases in the statements were measured at an overall accuracy of 99.7.
F-MARC PROJECTS | FOOTBALL FOR HEALTH 213
Planning
Why we conducted this study Moving from a regional pilot study completed success-
fully in South Africa, Mauritius and Zimbabwe to a
The social and economic burden associated with com- nationwide project in Mauritius meant that additional
municable diseases, such as HIV/AIDS, malaria and concepts, such as the individual, organisational and
gastrointestinal diseases, is a major concern in the devel- social dimensions of the health promotion, as well as
oping countries of Africa. According to WHO reports additional implementation issues had to be considered.
however, non-communicable diseases, such as coronary Furthermore, given the large scale of the project, it was
heart disease, hypertension, and diabetes will become an necessary to distribute lead responsibilities for various
even greater problem by 2030, if no appropriate preven- aspects of the project.
tive actions are taken.
Since 1994, FIFA/F-MARC has been committed to Implementation
research aimed at improving the health prospects of a) Pilot study
football players of all levels of skill in different environ- An implementation protocol for the delivery of the
ments around the world. In 2006, the centre moved its “FIFA 11 for Health” programme was developed by
research focus from “Medicine for Football” to “Football F-MARC which included: (1) preparation of a manu-
for Health”: the main objectives being to use the popu- al; (2) arrangements for teachers’ training courses and
larity of football to encourage greater physical activity (3) a time schedule for delivering the teachers’ train-
among all age groups and to deliver health education to ing courses, the interventions and the pre- and post-
children in developing countries. course programme evaluation questionnaires. Schools
“FIFA 11 for Health” is a football-based health educa- were recruited with the help of the local coordinator
tion programme for children, developed by F-MARC, and upon assessment visits by F-MARC. Teachers from
and consisting of 11 simple messages designed to address the participating schools together with football coaches
the most common risk factors for communicable and from the Mauritian Football Association (MFA) were
non-communicable diseases. taken through a five-day interactive training course by
F-MARC.
Materials used to support the pilot and nationwide The study drew attention to issues involved in transfer-
project ring the ownership of the “FIAF 11 for Health” pro-
The successful implementation of a football-based edu- gramme to national bodies and showed that adapting
cation programme requires the input of informative or changing individual health messages from the pro-
literature and other resources. F-MARC developed a gramme may be necessary or even crucial as differing
manual for the training course and provided teachers health issues may predominate in the various countries.
with a summary of (1) the skills required to deliver the
programme, (2) the content of each of the 11 sessions, The positive results of the measured post-intervention
(3) the timings for each aspect of each session, and (4) health knowledge among children and the overall posi-
health information sheets that contained additional tive response from teachers and coaches, governmental
information to support the teachers when answering and non-governmental bodies shows that a football-
children’s questions during session discussion periods. based health education programme such as the “FIFA
Activity cards were used to highlight issues related to 11 for Health” programme is capable of attracting the
the session’s health topic, and the equipment needed support and commitment of local and national stake-
for implementing the interactive games in each session holders. It presents a promising tool in the fight against
was distributed. Health knowledge questionnaires and communicable and non-communicable diseases as
attendance records were applied to evaluate the project. defined by the WHO.
Results
Fig. 8.2.3.1: Change in health topic knowledge (%, absolute change from baseline value)
What we learned from the study are most likely linked to the very high satisfaction rating
given to the programme by the children involved, which
The “FIFA 11 for Health” programme produced sig- was reflected in the high attendance levels achieved dur-
nificant increases in children’s health knowledge and ing each session. The results obtained also demonstrate
their awareness of disease prevention using an in-school, the contribution that international sports governing
football-based health education programme. This suc- bodies can make in health education and helping to
cess was most likely linked to the very high satisfaction reduce the prevalence of communicable and non-com-
rating given to the programme by the children involved. municable diseases in sub-Saharan Africa.
The success of the interventions also demonstrated the
benefit of collaborating with the Ministries of Education
in each country.
Duration: 2010 - 2014
This study demonstrated that the “FIFA 11 for Health” Countries: Nambia, Tanzania, Malawi, Zambia, Ghana
programme offers an effective way of engaging with chil- Cooperation: Namibia Football Association, Tanzania
dren in order to increase levels of physical activity and Football Federation, Football Association of Malawi, Football
to enhance health knowledge, improve understanding of Association of Zambia, Ghana Football Association
health risk factors and provide guidance on prevention Reference:
strategies for the major diseases in sub-Saharan Africa. Fuller CW, Junge A, Amaning J, Kaijage R, Kaputa J,
When delivered through national education systems, the Magwende G, Pambo P, Dvořák J (2014). ‘FIFA 11 for Health’:
programme has the potential to reach a very high pro- implementation in five countries in sub-Saharan Africa. Health
portion of the target population. The results obtained Education Journal 74(1):103-119
218 FOOTBALL FOR HEALTH | F-MARC PROJECTS
8.2.4 FIFA in the Fight against Ebola simple preventative measures to help combat the spread
of Ebola. “11 against Ebola” is a campaign encompass-
ing 11 simple messages and featuring Ronaldo, Neymar,
Why we conducted this campaign Drogba, Lahm, Xavi, Piqué, Obi Mikel, Boateng, Bale,
Varane and Guardiola.
Just over a year has passed since the Ebola epidemic
broke out in West Africa. The Ebola disease, which is Using the umbrella slogans “Together, we can beat Ebo-
transmitted through direct contact with bodily fluids, la” and #wecanbeatebola, the world stars convey the 11
was first detected in Sudan and the Democratic Repub- messages in a multi-media campaign incorporating ani-
lic of Congo in 1976. The current epidemic is the most mated films, commentaries, banners, posters and images.
widespread outbreak of the disease ever recorded. In
total, 21,689 cases have been detected, 8,626 of which
have resulted in death (WHO, 18.01.2015). There is What we learned from the campaign
currently no cure – only the symptoms themselves can
be treated. Due to the highly contagious nature of the In the event of an emergency, we can count on the pow-
Ebola virus, taking hygienic precautions is of utmost er of football in helping to lessen people’s misfortune.
importance. Ebola will only be conquered if people learn What we have also learnt is that we have to act faster,
how to protect themselves from infection. be prepared and click into gear should a similar situation
occur.
The virus has even had an impact on football in West
Africa. National championships had to be brought to a Moreover, the Ebola situation underlines the funda-
halt, qualification for the 2015 Africa Cup of Nations mental philosophy of the FIFA Medical Assessment and
was an organisational nightmare and the tournament Research Centre – prevention.
itself was in considerable doubt until Equatorial Guinea
stepped into replace Morocco as hosts. The football platform proved to be successful in dissemi-
nating simple educational messages about health among
children through the voice of football stars.
Aims of the campaign
UÊ,>ÃiÊ}L>Ê>Ü>ÀiiÃÃÊÌ
ÀÕ}
ÊÌL>ÊÊÌ
iÊw}
ÌÊ
against Ebola
UÊ
`ÕV>ÌiÊ«i«iÊ>LÕÌÊÌ
iÊ`Ãi>ÃiÊ>`Ê
ÜÊÌÊ«ÀiÛiÌÊÌÊ
from spreading
TOGETHER,
WE CAN BEAT
EBOLA.
11 PLAYERS, 11 MESSAGES, REPORT UNUSUAL KNOW THE SYMPTOMS
ONE GOAL ILLNESSES
Didier Drogba Neymar Jr.
The “11 against Ebola” campaign brings together Chelsea FC FC Barcelona
Please seek urgent medical help if you Avoid direct, skin and body contact Wash your hands regularly and disinfect anything
have a fever with additional symptoms. with anyone suffering from Ebola. RMSAFCB@WQSQNCARCBMPAMLjPKCB#@MJ?QSDDCPCPQ
Wild animals and bats can carry Avoid direct contact with dead Ebola victims Please seek help from local authorities to bury
the Ebola virus. Avoid them. or anyone who has died from a strange disease. any victims of Ebola or strange diseases.
11 AGAINST EBOLA
220 BIBLIOGRAPHY | F-MARC PROJECTS
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temperature response of football players. Scand J Sci Sports 2010;20(3
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Temperature and neuromuscular function. Scand J Med Sci Sports
2010;20(3 Suppl):1-18
Bandelow S, Maughan R, Shirreffs S, Ozgünen K, Kurdak S, Ersöz
G, Binnet M, #UNŔ¨J J.
Meeusen R, Roelands B.
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Johnson JM.
Grantham, Cheung SS, Connes P, Febbraio MA, Gaoua N,
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González-Alonso J, Hue O, Johnson JM, Maughan RJ, Meeusen R,
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Position Statement. Current knowledge on playing football in hot envi-
Maughan RJ, Shirreffs SM.
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Dehydration and rehydration in competitive sport. Scand J Med Sci
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10 Supplements
2000 2005
2004 2005
F-MARC PROJECTS | SUPPLEMENTS 237
2006 2006
2006 2006
238 SUPPLEMENTS | F-MARC PROJECTS
2007 2008
2007 2008
F-MARC PROJECTS | SUPPLEMENTS 239
2009 2010
2009 2010
240 SUPPLEMENTS | F-MARC PROJECTS
2010 2011
2011 2011
F-MARC PROJECTS | SUPPLEMENTS 241
2011 2012
2011 2012
242 SUPPLEMENTS | F-MARC PROJECTS
2013 2013
2013 2013
F-MARC PROJECTS | SUPPLEMENTS 243
2013 2014
2014 2015
244 SUPPLEMENTS | F-MARC PROJECTS
10.1 Twenty years of the FIFA Medical and Research Centre (F-MARC):
From “Medicine for Football” to “Football for Health”
Medicine for Football FIFA World Cup Brazil™ (Baume et al, 2015). All
players were tested unannounced prior to the competi-
In 1994, epidemiological data on the incidence of inju- tion, and results from the individual players were then
ries during major football competitions were scarce. compared with the samples provided after each match
Thus, F-MARC established an injury surveillance sys- during the 2014 FIFA World Cup Brazil™ (two play-
tem at the 1998 FIFA World Cup France™, and has ers randomly selected from each team). The steroid pro-
routinely implemented it in all subsequent FIFA com- files of the urine of the players were stable and consist-
petitions. This database now enables comparison of the ent with previously published publications. The blood
incidence and characteristics of injury between competi- parameters showed no significant differences in haemo-
tions for different age, gender and skill-levels, and over globin value between pre-competition and post-match
time. From the 2002 to the 2014 FIFA World Cup™, samples. The experience from Brazil documented that
the incidence of injuries decreased by 37% (Junge & the implementation of biological monitoring during
Dvořák 2015). Reasons for the decrease might be the the time of a footballers career is feasible, offering more
better preparation of the players for the competition, information on the potential manipulation of the body
the strict application of the Laws of the Game by the by prohibited substances.
referees, and also the improved approach of the players
towards of fair play. The use of medication has been analysed since the 2002
FIFA World Cup™. More than two thirds of adult
Since the large majority of the football players around male players used medication(s) during the tournament,
the world are recreational players, F-MARC developed and more than half were using non-steroidal anti-inflam-
an injury prevention programme for these players based matory drugs (NSAIDs). Up to one third of the play-
on scientific evidence and best practice. Bizzini and ers were using NSAIDs prior to every match. Despite of
Dvořák (2015) summarised the scientific evidence of the potential side effects especially of NSAIDs, No decrease
effectiveness of “FIFA 11+” in reducing injuries by up to in the use of medication was observed during 2014 FIFA
50% if performed regularly. Since 2009, FIFA has been World Cup Brazil™ (Tscholl et al, 2015).
disseminating “FIFA 11+” through the network of its
209 member associations (MAs) and implementing the Following the tragic death of Marc-Vivien Foé during
programme on a large scale. the FIFA Confederations Cup 2003, FIFA has been fully
committed to a programme of standard research educa-
Prevention is possible on the level of recreational football tion and practical implementation to prevent and man-
players by implementing the “FIFA 11+” programme. age emergency cardiac arrest on the football field (Kram-
However, the survey on the perception and practice of er et al, 2015). In the meantime, this strategy has been
the injury prevention strategies of physicians from the routinely implemented with the aim of detecting foot-
32 participating national teams at the 2014 FIFA World ball players with a medical risk during mandatory pre-
Cup Brazil™ documents the need for improvement competition medical assessment and by implementing
in developing preventive strategies at top level football the international accepted guidelines for the interpreta-
(McCall et al, 2015). tion of an athlete’s ECG based upon the Seattle criteria.
A clear protocol has been developed and applied for on
The 2014 FIFA World Cup Brazil™ was played in five the field of play for the recognition response, resuscita-
different regions from temperate to tropical environ- tion and the removal of a player under sudden cardiac
mental conditions. The web bulb globe temperature arrest. FIFA have introduced and distributed to all MAs
(WBGT) was obtained prior to, during and after the the FIFA Medical Emergency Bag including an Auto-
match while various physical and technical performance mated External Defibrillator (AED). The FIFA Sudden
parameters were recorded during each match for both Death Registry has been established at the FIFA Medical
teams. Nassis at al (2015) reported that top-level play- Centre of Excellence of the Saarland University to doc-
ers seemed to modulate their activity patterns during ument and examine fatal events in football worldwide
matches in hot and humid environments to preserve the (Scharhag et al, 2015).
global match characteristics.
Football for Health five regions of Brazil, and the results were equivalent to
those previously obtained in sub-Saharan Africa.
The effects of recreational football for prevention and
treatment of non-communicable diseases from children
to mature women and ageing men were summarised by
Bangsbo et al, 2015. Regular football training in small-
sided games for 45-60 minutes up to three times a week
reduces blood pressure, lowers resting heart rate, makes
favourable adaptations in cardiac structure and function,
improves lipid profile, elevates muscle mass, re-uses fat
mass and ultimately improves functional capacity.
11 Acknowledgement
The F-MARC-studies could and can only be conducted Football Association, Grenada Football Association,
with the substantial support of a broad number of per- Fédération Guinéenne de Football Federazione Italiana
sons and institutions. F-MARC would like to thank all Giuoco Calcio, Jamaica Football Federation Limited,
collaborating experts, team physicians, coaches, research Japan Football Association, Liberia Football Association,
assistants and people “behind the scene” who substan- Fédération Malagasy De Football, Football Association
tially contributed to the success of the studies and, espe- of Malawi, Football Association of Martinique, Mauri-
cially, the players for their participation in the various tius Football Association, Federación Mexicana De Fút-
projects. In particular, we are extremely grateful for the bol Asociación, A.C., Myanmar Football Federation,
untiring support of the following people and organisa- Namibia Football Association, New Zealand Football
tions: Inc., Norges Fotballforbund, Oman Football Associa-
tion, Federación Puertorriqueña De Fútbol, Schweiz-
erischer Fussballverband, Sierra Leone Football Asso-
FIFA ciation, Solomon Islands Football Federation, Football
Federation of Sri Lanka, St. Lucia Football Association
President: JS Blatter; Honorary President: J Havelange; Tanzania Football Federation, Tonga Football Associa-
Chairman FIFA Medical Committee: M D’Hooghe; tion, Fédération Tunisienne de Football, Türkiye Futbol
Secretaries General: U Linsi and J Valcke; Deputy Federasyonu, U.S. Soccer Federation, Football Associa-
Chairmen FIFA Medical Committee: A Diakite, W tion of Zambia.
Makudi and D Chung; Former and present members
FIFA Medical Committee: L Peterson, N O’Hata, R
Gittens, Y Zerguini, R Madero, T Graf-Baumann, L Players, Coaches, Referees and Clubs
Toledo, YS Yoon, S Kannangara, HA Ahmed, T Bab-
wah, G Singh, T Edwards, M Al-Riyami, H Aoki, S Alonso X, Alves D, Bale G, Boateng J, Buffon G, Capel-
Fusimalohi, B Mandelbaum, C Palavicini, J V Ramath- lo F, Charisteas A, Puyol C, del Bosque V, Demel G,
esele, J Chomiak, E Hermann, M Dohi, J Segajugo; Drogba D, Essien M, Eto’o S, Falcao R, Forlan D,
Directors of Member Associations and Development: M Gekas T, Guardiola P, Henry T, Hernandez (Chich-
Harvey, T Regenass; FIFA Refereeing Department: G arito) J, Hodgson R, Irmatov R, Klinsmann J, Lahm P,
Cumming; JM Garcia-Aranda Encinar, S Denoncourt, Luis D, Luxemburgo V, Magnin L, Marta, Mascherano
C Pilot, E Strelsov, M Busacca, F Tresaco-Gracia, C J, McCarthy B, Messi L, Mikel J, Miyama A, Modise P,
Pilot, M Navarro, J Otero; FIFA Women´s Department: Muamba F, Nedved P, Neves T, Neymar, Pagliuca G,
T Haenni, R Smith; FIFA Legal Affairs: H Tännler, M Parreira C, Piqué G, Prinz B, Rizzoli N, Ronaldo Ch,
Villiger; FIFA Development Officers: H McIntosh, A Ronaldo (Fenomeno), Rosetti R, Santa Cruz R, Sawa H,
Mamelodi, G Turner; FIFA Medical Office: H Boban, Scolari F, Signori G, Steinhaus B, Touré K, Valdez N,
K Grimm, R Charles, S Schlumpf, A König, M Keller, P Varane R, Webb H, Xavi; FC Barcelona, Real Madrid
Tobler, M Lawless, M Vaso, A Weber. C.F., FC Bayern Muenchen, Chelsea F.C., Manchester
City FC, Olympique Lyon, Corinthians Sao Paulo, Fla-
mengo Rio, Inter Mailand, Atletico Madrid.
FIFA Member Associations
Bendiksen M, Bennike S, Benson BW, Beuck S, Bianchi Klügl M, Knoepfli-Lenzin C, Kolbe J, Kramer E, Krebs
F, Binnet M, Bishop JD, Bizzini M, Bjørneboe J, Black- D, Kreutzfeldt M, Krug H, Krumbholz A, Krustrup P,
well J, Blair SN, Boccard J, Bomberger I, Börjesson M, Kurdak SS, Kutcher JF, Kutcher JS, Kuuranne T, Lam-
Bortolan L, Botha M, Botre F, Boutellier U, Branco P, precht M, Langevoort G, Larsen MN, Lea T, Leach
Brasso K, Brinkmeier P, Brito J, Brittberg M, Broad RE, Lee HH, LeiperJ, Lepers R, Leunig M, Levine B,
N, Brophy RH, Broséus J, Bruun DM, Budgett R, Lindenskov A, Lislevand M, Ljungqvist A, Loland S,
Bugbee WD, Bull F, Bunc V, Bungu-Kakala J, Burke Loucks A, Lundby C, Lütscher A, Lüscher T, Maddocks
L, Butch A, Cantu B, Cantu R, Caplan A, Carlsen D, Maffiuletti NA, Magwende G, Mahajan V, Mak-
KH, Casartelli NC, Castagna C, Castellacci E, Cas- dissi M, Malina RM., Mandelbaum B, Manniche V,
tillo F, Chabane S, Chagonda E, Chalabi H, Chamari Mannion AF, Manzi V., Marclay F, Marques-Vidal P,
K, Chaouachi A, Cheung K, Cheung SS, Chilvers C, Mateus-Avois L, Matheson G, Maughan R, Mayosi B,
Christensen JF, Christensen KB, Chtourou H, Chu Mazzarino M., Mboup S, Mc Guinness I, McAdams T,
CR, Clarke J, Clothier B, Connes P, Constantinou McCall A, McCrea M, McCrory P, McIntosh AS, McK-
D, Coppo V, Corlette J, Correia L, Costello M, Coyle ay C, Meeusen R, Meeuwisse W, Meier U, Meijboom
E,Cunningham K,D´Hooghe P, da Silva ME, Davis G, E, Meyer T, Midtgaard J, Millard-Stafford M, Mith-
de Andrade JL, de Ceuninck M, de la Torre X, de Silva oefer K, Modena R, Mohr M, Molloy M, Moreno A,
A, de Sousa MV, de Windt TS, DeCelles J, Della Villa Mortensen J, Mota J, Motaung S, Mountjoy M, Muli-
S, Dellal A, Derman W,Deutsch C, Di Paolo FM, Dick Musiime F, Müller S, Müller W, Mussack T, Mykle-
RW, Dolle G, Donald J, Donath L, Donati F, Dorasami bust G, Nassis GP, Nicoli R, Nielsen CM, Nielsen G,
R, Draper C, Drezner J, Drust B, Dungl P, Durkin P, Nielsen HP, Nielsen JJ, Nieman D, Nilstad A, Nybo L,
Durussel J, Echemendia RJ, Edouard P, Eiles M, Ekb- O’Brien C, Odendall M, Oksa J, Olsen OE, Orntoft C,
lom B, Ekstrand J, Elbe AM, Ellenbogen R, Emery C, Ortega P, Ottesen LS., Özgünen KT, Pambo P, Pánics
Engebretsen L, Ersöz G, Eterovic I, Evans R, Faude O, G, Patricios J, Pedrinelli A, Pedrinelli LF, Pellegrini B,
Feddermann-Demont N, Felix S, Finch CF, Fitzpatrick Pelliccia A, Pereira RM, Peterson L, Petrou M, Peytavin
D, Flenker U, Flores M, Frandsen C, Frandsen U, Frey A, Pfäfflin F, Pineda G, Pipe A, Pitsiladis YP, Platen P,
WO, Friedmann B, Friedrich K, Fukui R, Fuller CW, Pohlig R, Powers S, Pralong F, Provvidenza C, Purcell
Gál T, Gaoua N, Gardner A, Garnier PY, Garrett WE L, Putukian M, Rabin O., Racinais S, Raftery M, Rahli
Jr., George J, Geraint GS, Gersoff WK, Geyer H, Geyer A, Ramkurrun J, Randers MB, Rasmussen LS, Raut-
L, Gfrerer L, Gianotti S, Gittens R, Giza E, Gleeson M, enberg C, Rebelo A, Rechsteiner R, Rêgo C, Reichel
Gliemann L, Gobbi A, Goldstein MA, Gore C, Görtz C, Reider B, Reilly T, Reis I, Renström P, Reuter H,
S, Grantham J, Graw M, Greenhaff P, Gregson W, Richalet JP, Robinson N, Rodchenkov G, Rodrigues
Grimm K, Grosse J, Grossen R, Guddat S, Günter H, AC, Roelands B, Roky R, Romiti M, Rørth M, Rösch
Guskiewicz K, Gutzwiller F, Haddad M, Hägglund M, D, Rosenbloom C, Rössler R, Rufer W, Ryynänen
Hambly K, Hammes D, Hänggi P, Hangody L, Hansen JAI, Saltin B, Saris D, Saudan C, Saugy M, Sawka M,
L, Hansen PR, Harcourt PR, Hargreaves M, Hasler H, Sayegh S, Schamasch P, Schänzer W, Schena F, Schmalz
Hawley J, Helge EW, Helsen W, Hernandez AJ, Herrera R, Schmeling A, Schmidt JF, Schmidt S, Schmidt W,
CP, Herring S, Hespel P, Hewett T, Ho D, Hodgson R, Schmied CM, Schneider KJ, Schulz R, Schweizer C,
Hodgson L, Holder J, Holdhaus H, Holland R, Holm Schweizer T, Schwellnus M, Scopp J, Seabra A, Segura
PM, Holme I, Hoppeler H, Hornstrup T, Horton J, J, Sekajugo J, Sennhauser C, Serratosa L, Serwadda
Houllier G, Howman D, Huber S, Huguet J, Hume P, D, Shewchenko N, Shireffs S, Siegenthaler U, Sills A,
Hussain AW, Hutchison B, Illig C, Impellizzeri F, Insler Silva PR, Silvers H, Singh DG, Smalley M, Søgaard
S, Isola V, Iverson GL, Jackman SR, Jakobsen MD, Jan- P, Soligard T, Spielvogel H, Sprumont D, Stamm H,
kelowitz R, Jenoure PJ, Jensen CJ, Jochum M, Johans- Steadman RJ, Steffen K, Steffen R, Steinacker J, Stein-
en L, Johnson JM, Johnston K, Jordan B, Jørgensen wachs MR, Sterk S, Stone M, Strahm E, Straumann D,
NR, Kaijage R, Kang J, Kaputa J, Karli U, Karlsson J, Straume-Naesheim TM, Stray-Gundersen J, Suetta C,
Kautiainen H, Keller DI, Kerper O, Kesti M, Khan K, Sundstrup E, Tahmi M, Tator CH, Terrel B, Theodosa-
Khouaja F, Kilzer T, Kindermann W, King C, Kirk- kis J, Theron N, Thevis M, Thiele E, Thiele ES, Thieme
endall DT, Kissick J, Kjaer M, Klameth S, Kloeck W. D, Thom C, Thomas A, Thomassen M, Thünenkötter
248 ACKNOWLEDGEMENT | FOOTBALL MEDICINE PROJECTS
T, Timme M, Tipton K, Toigo M, Tombides D, Tovar tella G, Dingiso P, Dladla S, Eenhoorn B, Etter I, Fan-
G, Tscholl PM, Tschopp M, Turner M, Urwin J, Uth J, chini M, Fladberg Grøv S, Gattoni C, Gomide Leite M,
van der Ende M, van Mechelen W, Vanscheidt W, Var- González M, Grasshoff G, Guzula N, Item-Glatthorn
gas E, Vásárhelyi G, Verhagen E, Vernec A, Verroken J, Keller O, Knobel A, Koch F, Kollaritsch A, Konopka
M., Vieth V, Viret M, Voight M, von Grebel C, Vouil- K, Lacloche AMM, Liu Yuk Pat-Agathe MJ, Lund SS,
lamoz M, Vuddamalay A, Walden M, Wallace S, Wan- Lutuli M, Madondile D, Mafi lika L, Magqwaka X,
der J, Watson K, Watson P, Weihe P, Weiler R, Weston Makay T, Malgas Z, Marquardt B, Martin-Schmitt S,
M, Wiget C, Wikman JM, Williams AM, Williams C, Mathieu N, Mathiso N, Matiwane N, Mbaleki S, Mdle-
Williams III RJ, Wittschieber D, Wong del P, Wong F, leni M, Mkhontwana N, Mkita H, Mondi G, Mondli-
Wyss H, Zaslav K, Zebis MK, Zenobi-Wong M, Zer- wa X, Morf C, Mottier P, Mselele H, Müller R, Ndi-
guini Y, Zidema D, Zorzoli M. weni LBM, Netto D, NeumannS, Nhokombi S, Nickel
F, Okoth GT, Pfeffer R, Pfennig A, Morf C, Rodo A.
Rosenheck T, Ryffel-Fehlbaum E, Sala F, Samsel T,
Physicians Savoldelli A Shumane V, Sibeko N, Sidzumo L, Solem
Mwikaria M, Sowamber S, Steiner R, Streng M, The-
all team physicians of all FIFA competitions and the iss J, Tjongarero T, Töndury S, Troncana M, Tuali N,
football tournaments of the Olympic Games, andA- Wellauer V, Wolfensberger S, Zwahlen A.
guilar M, Annan P, Asanin I, Atchou G, Atravia Arias
G, Babwah T, Bahtijarevic Z, Bassett D, Baumann
M, Benchebha H, Benkhelifa D, Berkovskiy V, Biegel Research assistants
M, Boldt J, Bonin B, Borges S, Borras G, Bouglali M,
Boukhalfa R, Boumeridja M, Boumeridja S, Brjesson M, Anyango B, Aoina J, Bahorun R, Baier C, Blum J,
Brukner P, Brunner U, Campos N, Celada OL, Cha- Bunce J, Cervantes G, Chong S, Dvořák D, Gaillard A,
bane S, Christopoulos H, Coleman L, Colla F, Cota J, Geng H, Grasshoff G, Hanacek R, Hartenbach K, Hart-
Dah C, Dawson T, Eirale C, Emmanuel A, Engmann mann M, Ilic Z, Jelassi H, Joe G, Juma Wilberforce B,
M, Erhart D, Fischer V, Fousek J, Gatteschi L Geert- Karambu Muthee J, Kariuki J, Kariuki W, Karuku Gitau
sema C, Goudswaard GJ, Greuter R, Gruhler R, Grzy- J, Kemboi J, Khouaja A, Kiefer J, Kolmer M, Krámek V,
wocz J, Hagne C Haknchol R, Hanna C, Hasek R, Krauer S, Kreisl D, Lewis G, Lunga O, Mahler R, Mat-
Holtzhausen L, Hospodar V, Hyun-Chul K, Isler A, eva R, McCammon C, McFarlane K, Meyer J, Muigai
Jones JJH, Jowett A, Kaalund S, Kafunek M, Kammouai Irungu D, Musango P, Musembi Muindi S, Muthiah
H, Khalifa R, Khanlari P, Knezek J, Krejci P, Krupa D, J, Mweene L, Nyangila M, O’ Riordan D, Onyango
Kubes R, Lowndes S, Luiz Runco J, Makhlouf L, Mal- Okoth E, Oriko A Papác J, Purbhoo M, Rakotoarimino
kus T, Marti F, Martin UP, Martinez AMartinkova D, Schmidt J, Schuler R, Sonntag C, Specker HJ, Sti-
J, Mbuwi J Medina R, Mladenovic M, Montans AP, neear C, Stuart G, Wagner M, Walker K, Wambui S.
Montes C, Morikawa T, Müller F, Murphy I, Mutiso V
Nematswerani E, Novak Z, Onyeudo P, Paclet JP, Pan- Players, coaches, team physicians, physiotherapists, man-
grazio O, Paterson G, Radames G, Robles E, Roche B, agers and representatives of all the clubs and school teams
Rosetto M, Ruff P, Runco J, Russell J, Ryser J, Sadji S, that volunteered to participate in our studies.
Sager M, Schläpfer M, Schneider W, Schubert J, Sekfali
R, Seob Song J, Serranno Diaz J, Shimizu K, Siemssen
T, Simon A, Slim M, Sward L, Titah D, Titah O, Val- Should we have forgotten to specifically name
entin A, Vanecek L, Verner J, Villani D, Vogrin M, anyone of our numerous supporters, please
Walter R, Zeroual T. accept our sincere apologies, and be reassured of
our utmost gratefulness!
Publisher
Fédération Internationale de Football Association
Content
)HŪ´#UNŪ¨J, Astrid Junge
Photos
Authors of the respective publications, Prof. )HŪ´ #UNŪ¨J
Graphic Design/Layout
Andreas Lütscher, Schulthess Clinic, Zurich
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galledia ag, Switzerland
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