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
Legal Ţ Education Ţ Recruitment Ţ Wellbeing
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CONTENTS FEATURES
08
Injury Mitigation in Team Sports. Part-2: The risk management approach Colin W. Fuller
29
What to do and When to do it? The Tricky Question of Specialisation in Youth Football Laura Finnegan
11
Injuries in Football: It’s Time to Stop Chasing the Training Load Unicorn Franco M. Impellizzeri, Aaron J. Coutts, Maurizio Fanchini, Alan McCall
33
Training the Semi-Professional Footballer Daniel Bernardin, Dylan Mernagh
36
Karen Carney A Pioneer for the Women’s Game Sean Carmody
39
Wrist Injuries in Goalkeepers Raj Bhatia, Adam Esa, Sam Haines
45
Neurodegenerative Disease Mortality Among Former Professional Soccer Players – Summary Emma Russell
49
Job Insecurity: Reducing Its Negative Effect on Your Wellbeing Caroline Marlowe
50
FMPA Register
17
ABOUT
Cautious Return to Play Could Prevent Muscle Injuries in Professional Football Håkan Bengtsson, Jan Ekstrand, Markus Waldén, Martin Hägglund
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Generalised Joint Hypermobility – Why should it be screened for within a football setting? Adam Johnson
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FMPA Conference 2020
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Understanding and Developing Relationships in the Modern Football Hierarchy Dr Daniel Parnell, Professor Barry Drust
Football Medicine & Performance Association 6A Cromwell Terrace, Gisburn Road, Barrowford, Lancashire, BB9 8PT T: 0333 456 7897 E: info@fmpa.co.uk W: www.fmpa.co.uk FMPA_Official Officialfmpa fmpa_official LinkedIn: Football Medicine & Performance Association FMPA_Register FMPARegister fmpa_register Chief Executive Officer Eamonn Salmon eamonn.salmon@fmpa.co.uk
Design Oporto Sports www.oportosports.com
Executive Administrator Lindsay Butler admin@fmpa.co.uk
Photography PA Images, FMPA
Project Manager Angela Walton angela.walton@fmpa.co.uk
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
Print Media Village www.media-village.co.uk
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
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feature
GENERALISED JOINT HYPERMOBILITY WHY SHOULD IT BE SCREENED FOR WITHIN A FOOTBALL SETTING? FEATURE / ADAM JOHNSON What is Generalised Joint Hypermobility? Generalised Joint Hypermobility is a term that is used to describe the capability of joints to move beyond their normal limits. Patients who are deemed “hypermobile” are the ones who have excessive levels of joint mobility. Adam Johnson First Team Performance Physiotherapist Brighton & Hove Albion Football Club @PreventionPhys
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Generalised Joint Hypermobility (GJH) is usually a hereditary condition, however, it may also be acquired as a result of sporting performance through activities requiring excess mobility, such as ballet. To be classified as having GJH there must be five or more joints involved. Acquiring hypermobility through athletic performance in one joint only (for example, knee hypermobility) would not be enough to be classified as having generalised joint hypermobility. The more appropriate term to use would be “localised joint
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hypermobility”, as per the Ehlers Danlos Society’s definition. GJH is a part of a wide spectrum of hypermobility disorders (Figure One). GJH, accompanied by musculoskeletal manifestations, provides a diagnosis of generalised hypermobility spectrum disorder. This may also potentially encompass Elhers Danlos Syndrome. If an athlete is suspected to have GJH, it is important to understand the screening tests that can be used. Figure One: The Hypermobility Spectrum taken from https://www.ehlers-danlos. com/what-is-hsd/ Key To Figure: G= Generalised, P= Peripheral, L= Localised, H= Historical, JH= Joint Hypermobility, HSD= Hypermobility Spectrum Disorder, hEDS= Hypermobile Ehlers-Danlos Syndrome.
football medicine & performance
Type
Beighton score
Musculoskeletal involvement
Asymptomatic GJH
Positive
Absent
Asymptomatic PJH
Usually negative
Absent
JH typically limited to hands and/or feet
Asymptomatic LJH
Negative
Absent
JH limited to single joints or body parts
G-HSD
Positive
Present
P-HSD
Usually negative
Present
JH typically limited to hands and/or feet
L-HSD
Negative
Present
JH limited to single joints or body parts
H-HSD
Negative
Present
Historical presence of JH
hEDS
Positive
Possible
How do we screen for Generalised Joint Hypermobility? The most commonly utilised hypermobility screening tool is the Beighton Scale. This tool encompasses a battery of tests that assess the range of movement in the little fingers, thumbs, elbows, knees and lumbar spine flexion. The Beighton Scale provides a score out of nine, with a score of 5 or greater seen as a positive indicator of GJH in pubertal men and women up to the age of 50 (JuulKristensen et al., 2017). The cut off score used to define a hypermobility changes with age, with children requiring a higher score of 6/9, and subjects over 50 requiring 4/9. The Beighton Scale has been widely used within published literature, and forms one criterion of the wider assessment for Hypermobility Spectrum (Figure One). The screen is easy and quick to perform and requires no specialist equipment. It has also been deemed valid and reliable (JuulKristensen et al., 2017). On the other hand, if we are looking at footballers specifically, then only one element of the Beighton Scale assesses lower limb laxity, and this is only in a single plane of movement. The Lower Limb Assessment Score (LLAS) (Ferrari et al., 2005) may therefore be a more appropriate tool to use when screening footballers for GJH. The LLAS includes twelve multi-planar assessments of the hip, knee, ankle and foot. A recent study has now validated the LLAS within a football setting (Johnson, Ward & Simmonds, 2019), and suggested that a cut off of 4/12 is appropriate for an adult footballing population.
Why is screening for Generalised Joint Hypermobility important in football? The first high quality epidemiological study which aimed to address this question within an elite football environment was completed by Collinge & Simmonds (2009). The study recorded injury rates and rehabilitation periods in a second-tier first team squad. The injury rates between the hypermobile and non-hypermobile players were then compared. The study identified that the hypermobile group presented with very similar rates of injury through the season when compared to the nonhypermobile group (6.2 vs 6.3 injuries per 1000hrs respectively). Despite these similar rates, the hypermobile group demonstrated a greater number of training days missed (71 vs 31 days) as well as a greater number of competitive games missed (12 vs 5 games) over the course of the season. The authors concluded that although the hypermobile players were not more prone to injury, they were perhaps prone to more significant injuries. It is important to note that these findings were not statistically significant. A larger cohort study performed by Konopinski et al. (2016) looked at three different second-tier clubs injury rates over the course of a season. Their study reported a slightly greater risk of injury within the hypermobile populations at the three clubs, however, this finding was also deemed to be “suggestive but not conclusive”. This lack of statistically significant findings within the two studies highlights the need for further research into the influence of hypermobility and football injuries. Furthering work in the area utilising the Lower Limb Assessment Tool may also provide different, and more specific, answers to the current questions.
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Notes
In reading this article, there may now be more awareness that current research has identified that approximately a quarter of football squads would be classed as “hypermobile” (when using a 5/9 Beighton Scale cut off). This is a large percentage of athletes within football squads for whom it is not yet fully understood how to best manage. It may be that hypermobile players potentially require more proprioceptive input, or strengthening through extreme ranges than the non-hypermobile athlete, in order to help reduce their risk of injury. However, until further research is done in the area, we cannot simply make assumptions surrounding their management.
Collinge & Simmonds (2009). Hypermobility, injury rate and rehabilitation in a professional football squad- A preliminary study. Physical Therapy in Sport, 10, 91-96. Ferrari, J., Parslow, C., Lim, E. & Hayward, A. (2005). Joint hypermobility: The use of a new assessment tool to measure lower limb hypermobility. Pediatric Rheumatology, 23, 413-420. Johnson, Ward & Simmonds (2019). The Lower Limb Assessment Score. A Valid Measure of Hypermobility in Elite Football? Physical Therapy in Sport, 37, 86-90. Juul-Kristensen et al. (2017). Measurement properties of clinical assessment methods for classifying generalised joint hypermobility- A systematic review. American Journal of Medical Genetics Part C (Seminars in Medical Genetics), 175C, 116-147. Konopinski et al. (2016). The effect of hypermobility on the incidence of injury in professional football: A multi-site cohort study. Physical Therapy in Sport, 21, 7-13.
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