The official magazine of the Football Medicine & Performance Association
football medicine & performance
Issue 31 Winter 2019/20
Feature
Karen Carney A Pioneer for the Womens’ Game In this issue Injuries in Football: It’s Time to Stop Chasing the Training Load Unicorn Cautious Return to Play Could Prevent Muscle Injuries FMPA Conference 2020 Neurodegenerative Disease Among Former Footballers
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CONTENTS FEATURES
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Injury Mitigation in Team Sports. Part-2: The risk management approach Colin W. Fuller
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What to do and When to do it? The Tricky Question of Specialisation in Youth Football Laura Finnegan
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Injuries in Football: It’s Time to Stop Chasing the Training Load Unicorn Franco M. Impellizzeri, Aaron J. Coutts, Maurizio Fanchini, Alan McCall
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Training the Semi-Professional Footballer Daniel Bernardin, Dylan Mernagh
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Karen Carney A Pioneer for the Women’s Game Sean Carmody
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Wrist Injuries in Goalkeepers Raj Bhatia, Adam Esa, Sam Haines
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Neurodegenerative Disease Mortality Among Former Professional Soccer Players – Summary Emma Russell
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Job Insecurity: Reducing Its Negative Effect on Your Wellbeing Caroline Marlowe
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ABOUT
Cautious Return to Play Could Prevent Muscle Injuries in Professional Football Håkan Bengtsson, Jan Ekstrand, Markus Waldén, Martin Hägglund
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Generalised Joint Hypermobility – Why should it be screened for within a football setting? Adam Johnson
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FMPA Conference 2020
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Understanding and Developing Relationships in the Modern Football Hierarchy Dr Daniel Parnell, Professor Barry Drust
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Contributors Colin W. Fuller, Franco M. Impellizzeri, Aaron J. Coutts, Maurizio Fanchini, Alan McCall, Håkan Bengtsson, Jan Ekstrand, Markus Waldén, Martin Hägglund, Adam Johnson, Dr Daniel Parnell, Professor Barry Drust, Laura Finnegan, Daniel Bernardin, Dylan Mernagh, Raj Bhatia, Adam Esa, Sam Haines, Emma Russell, Caroline Marlowe
Marketing/Advertising Charles Whitney 0845 004 1040
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Administration Assistant Amie Hodgson amie.hodgson@fmpa.co.uk
COVER IMAGE England’s Karen Carney during the FIFA Women’s World Cup Third Place Play-Off at the Stade de Nice, Nice. Richard Sellers/PA Wire/PA Images
Football Medicine & Performance Association. All rights reserved. The views and opinions of contributors expressed in Football Medicine & Performance are their own and not necessarily of the FMPA Members, FMPA employees or of the association. No part of this publication may be reproduced or transmitted in any form or by any means, or stored in a retrieval system without prior permission except as permitted under the Copyright Designs Patents Act 1988. Application for permission for use of copyright material shall be made to FMPA. For permissions contact admin@fmpa.co.uk
feature
INJURY MITIGATION IN TEAM SPORTS PART-2: THE RISK MANAGEMENT APPROACH FEATURE / COLIN W. FULLER Introduction Part-1 of this series1 reviewed models used for developing sports injury mitigation programmes. Three major weaknesses were identified in the ubiquitous sequence of prevention (SoP); namely, the model focussed on reducing numbers of injury rather than injury burden, ignored associated injury management issues, and has not been operated in real-world situations. It is surprising, therefore, that SoP has provided the focus for sports injury mitigation research when there is an alternative, proven model available. Risk management has been embedded within UK health and safety legislation since publication of the Health and Safety at Work etc Act 1974. Section 2 (General duties) of this Act states “It shall be the duty of every employer to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all his employees.” Regulation 3 (Risk assessment) of The Management of Health and Safety at Work Regulations 1992 clarifies how this duty should be completed: “Every employer shall
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make a suitable and sufficient assessment of the risks to the health and safety of his employees to which they are exposed whilst at work.” The risk management approach was discussed in Royal Society reports in 19832 and 19923. Fuller4 discussed the implications of the risk management approach for sport in 1995 and published a sport-specific risk management model in 20045,6. The aim of this paper is to discuss the risk management model in the context of injury mitigation. Risk Management (RM) Model The sport-specific RM model, with players presented as the stakeholder of interest, is summarised in Figure 1: the original research papers should be consulted for a detailed explanation of each aspect of the model5,6. There are three important general features of the RM model that should be noted: ~ Injury mitigation interventions are not automatically mandated in RM: the need for risk mitigation is determined by
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whether stakeholders consider current risk levels acceptable or unacceptable; ~
Situations should be reviewed when new risks are identified, new information about existing risks becomes available or stakeholder perceptions about existing risks change;
~
The model is underpinned by quality management principles.
Risk factors and the context of risk The complex way that risk factors define situational context has been described as7: “Risk must always be placed in a particular context. The context of risk is related to the stakeholders, the location, the equipment, the process, the weather, the time of day, the organisation, and the sector in which the risk occurs. In addition to the physical context, one must also consider the cultural, social and political context of the risk, as these aspects also affect the decision-making process of risk assessment.” Context is therefore of paramount importance and to ignore it during the development of injury mitigation procedures would be a mistake.
football medicine & performance
Player-specific factors
Facilities, equipment, activities, setting, etc
Figure 1. Sports injury risk management model (adapted from Fuller (2007))
Risk factors Preventive interventions
Epidemiology
Risk estimation
Risk mitigation
Stakeholders’ risk perceptions
Therapeutic interventions Risk evaluation
Unacceptable level of risk
Acceptable level of risk
Communicate information to sports community
Fuller described the importance of context in sport-related situations as6: “the risk experienced by each athlete is affected by his/her intrinsic risk factors and by the way in which these personal factors interact with the sports environment”. It is essential, therefore, that the specific context for which an injury mitigation programme is intended and the context in which the programme was examined be stated, so that application boundaries are transparent. In the RM model, risk factors are grouped into two sets, which together define the overall context. Factors such as athletes’ gender, body mass, joint flexibility, previous injury and risk-taking behaviour are included within the ‘playerspecific’ set, while factors such as laws of the game, weather, equipment and game activities are included within the ‘facilities, equipment, activities and setting’ set, as they impact on all players. Risk assessment Risk assessment is the cornerstone of RM and epidemiological studies within the risk assessment process provide the evidence to support RM decisions. An important outcome from epidemiological studies should be the identification of causation factors in general terms, such as acute/gradual onset and contact/non-contact activities, and in specific terms, such as whether the player was running, tackling or kicking the ball when injured. Clearly, injuries sustained in unpredictable events are likely to require different mitigation approaches to injuries sustained in controllable events. In order to evaluate injury mitigation procedures, pre- and post-intervention levels of incidence, severity and nature of injuries are minimum requirements. Evaluating injury mitigation procedures based on incidence alone does not provide sufficient information: the RM approach also entails measuring injury severity to determine whether there has been a reduction in injury burden5-10.
Risk mitigation (injury burden reduction) If the risk assessment process indicates a level of injury risk that stakeholders consider unacceptable then mitigation measures that might reduce the level of risk to an acceptable level should be identified and evaluated. The RM model defines injury burden by two parameters: incidence and severity of injury. Therefore, teams have two strategies available for risk mitigation (Figure 1); viz., preventive (reducing number of injuries) and therapeutic (reducing severity of injuries). Unfortunately, SoP has focussed attention on the prevention of injuries and opportunities to reduce injury burden through other strategies have been largely overlooked. There are, in addition to preventive measures, many therapeutic interventions that could be explored, such as timely removal of players from the pitch when first injured11 and developing player-specific12, sportspecific13 and injury-specific14 treatment and rehabilitation protocols. If an injury mitigation intervention does not reduce the risk to a level that is acceptable to stakeholders, revised or new mitigation processes are examined in the repeating RM cycle. When injury risk has been reduced to acceptable levels, the cycle follows a different course and takes researchers, governing bodies and clubs down the risk communication route to ensure that all relevant personnel are made fully aware of the mitigation procedures being adopted. Several governing bodies, including FIFA15, have adopted this approach. Conclusions The risk management model does not suffer from the weaknesses associated with the SoP model. This opens new possibilities for improving the quality of risk mitigation research, which will be discussed in Part-3 of this series.
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1. Fuller CW. Injury mitigation in team sports. Part-1: a review of current dogma. Football Med Perform Assoc J 2019;30 (Autumn). 2. Royal Society. Risk assessment – a study group report. Royal Society; London: 1983. 3. Royal Society. Risk: analysis, perception and management. Royal Society; London: 1992. 4. Fuller CW. Implications of health and safety legislation for the professional sportsperson. Br J Sports Med 1995;29:5-9. 5. Fuller CW, Drawer S. The application of risk management in sport. Sports Med. 2004;34:349-56. 6. Fuller CW. Managing the risk of injury in sport. Clin J Sport Med. 2007;17:182-7. 7. Fuller CW, Vassie LH. Health and Safety Management. Principles and Best Practice. Harlow; FT Prentice Hall: 2004. 8. Drawer S, Fuller CW. An economic framework for assessing the impact of injuries in professional football. Safety Sci 2002;40:537-56. 9. Fuller CW. Injury risk (burden), risk matrices and risk contours in team sports: a review of principles, practices and problems. Sports Med 2018;48:1597-1606. 10. Fuller CW. Assessing the return on investment of injury prevention procedures in professional football. Sports Med 2019;49:621-629. 11. Fuller CW. “Recognize and remove”: a universal principle for the management of sports injuries. Clin J Sports Med 2018;28:377-381. 12. Fuller CW, Walker J. Quantifying the functional rehabilitation of injured football players. Br J Sports Med 2006;40:151-157. 13. Della Villa S, Boldrini L, Ricci M, Danelon F, SnyderMackler L, Nanni G, Roi GS. Clinical outcomes and return-to-sports participation of 50 soccer players after anterior cruciate ligament reconstruction through a sport-specific rehabilitation protocol. Sports Health 2012;4:17-24. 14. Mendiguchia JE, Martinez-Ruiz E, Edouard P, Morin J-B, Martinez-Martinez F, Idoate F, Mendez-Villanueva A. A multi-factorial, criteria-based progressive algorithm for hamstring injury treatment. Med Sci Sports Exerc 2017;49:1482-1492. 15. Fuller CW, Junge A, Dvorak J. Risk management: FIFA’s approach for protecting the health of football players. Br J Sports Med 201;46:11-17
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